Sunday, July 19, 2009

Health care reform - will Dr Obama be able to cure the US Health System?

Let’s pretend that President Obama is actually Dr Obama, and that his job is to diagnose and treat the US Health System. What will he find, how will he go about it, and what will be the outcome?

The process of diagnosis is relatively straight forward. Everyone acknowledges that the system is broken and that there are a number of agreed on symptoms of this disorder. Firstly the system is far too costly, consuming almost twice as many dollars per capita as health systems in other Western countries. And this expense is also poorly focused, with over thirty per cent being spent on administrative non-patient care costs (such as insurance companies costs and profits, and excessive administrative costs for providers), almost twice as much being spent on medications as other countries, and reimbursement inappropriately targeting piece rate medicine and rewarding doctors who perform interventions, (such as surgeons and radiologists) instead of prevention and the treatment of chronic illness (such as primary care physicians). Of course the existence of 47 million uninsured is a disgrace and a huge problem, as is the relatively poor quality of overall care provided nationally for the money spent. And finally the whole system is very patchy, with excellence provided relatively cheaply in some areas, and the opposite in many others, and this occurring in the setting of relatively little investment in electronic medical records and modern information technology, which could certainly improve the system.

So what should Dr Obama do? If he addresses some of the problems above, then the task becomes clearer. It is absolutely necessary to introduce some form of national public insurance program, both to insure the currently uninsured, and to provide competition for the excessive number of health insurance companies to make them reduce their rates, increase their cover, and provide better value services. It is likely that this process will lead to many of the insurance companies going out of business, and that is fine, because there are way to many at present, and it would be more rational for us to have fewer larger health insurance operations. At the same time the cost of pharmaceuticals has to be addressed – there needs to be a nationally negotiated formulary for core essential drugs that are paid out of the public purse. At the same time the payment structure for providers needs to be changed, and more emphasis paid for services for chronic illness and prevention, and less for interventional medicine, while also encouraging, as is happening, the use of electronic medical record systems and other health information technology initiatives. A single dramatic enhancement would come if he insisted on the introduction of a national health identifier number as this would greatly enhance the ability of providers to exchange health information when necessary, and would greatly simplify billing and administrative processes.

Many other things have to happen, of course, but will Dr Obama and his team be up to this task? We currently have a bloated and inefficient health system, and in any such system there are winners and losers. The winners in today’s health system are insurance companies, the pharmaceutical industry, and large numbers of providers who are used to receiving excessively high incomes for interventional services. The losers are patients, and the country. When looked at broadly, the diagnosis and treatment of our health system are actually relatively straightforward, but it has to be accepted that today’s “winners” will not necessarily remain in that position long term, and that there will be a number of losers as we change the system. Let’s just hope that Dr Obama, and his multidisciplinary team in Congress, are able to push through the reforms the US health system needs so that the patient is no longer the loser.

Peter Yellowlees MD has recently published “Your Health in the Information Age – how you and your doctor can use the Internet to work together”. It is available at and most online bookstores.

1 comment:

  1. Hi,

    This is the assistant editor for which is a medical publication offering hospital news, information and reviews. We also cover a wide variety of medical topics, some of these articles being relevant to Health Care reform as you will see from the homepage of our site. We are in the process of updating our health care news section with dozens of articles on the reform and other relevant issues. If possible I would like to be included within your blog roll, offering our information as a resource to your readers and essentially building a relationship between our sites. Please let me know if this addition can be made, Thanks!

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    Mary Miller,