Civic Criteria for Major Health Care Reform
A Checklist:
1. Clarify the Ultimate Goal 2. Identify the Means for Reaching the Goal 3. Control and Fund Health Care Costs 4. Introduce Complex Improvements Carefully 5. Improve the Allocation of Resources 6. Improve the Collection and Use of Professional and Consumer Health Information 7. Enhance Quality, Comprehensiveness and Accessibility of Care Delivery 8. Rebalance the Cultures in Health Care Systems 9. Reject Covert Rationing
Discussion:
1. Clarify the Ultimate Goal. It is easy to confuse ends and means. It helps to recognize that various interests often have a mix of motivations. But from CQC's civic viewpoint, the ultimate goal is clear: better health for all. (See Attachment A for information about CQC.)
2. Identify the Means for Reaching the Goal. To reach the goal requires many things: (a) better quality of care, (b) better access to care, (c) better coverage by health insurance, (d) research and training on better means of prevention, diagnosis and treatment, (e) better communication among doctors, hospitals, other providers, and patients, (f) better allocation of needed resources for care, including preventive and primary care, (g) better public health programs for safer food, medication, and environment, and (h) better public education on health-related lifestyles and on utilizing health care resources. These necessary things require adequate public support and funding.
3. Control and Fund Health Care Costs. Important as it is, health care is not the only public or personal requirement. Controlling health care costs is important for fiscal soundness, global competitiveness, other national needs, and a well-rounded standard of living.
Yet quality health care for all, particularly in a nation which could put a man on the moon, is increasingly recognized as a must for a civilized society. And although it will not be cheap, it is affordable.
The sources of waste in present health care systems are fairly well known. A decade ago, CQC's handbook on health care policy asked, "Can we separate good and bad methods of health care cost controls?" and gave examples of each. (See Attachment B.) Today even more kinds of waste have become prominent. In fact, 30% of spending on health care does not go to the actual delivery of health care. For example, the cost of TV advertising of prescription medications may warrant attention. But reducing health care costs by such methods as subjecting military or other retirees to new or higher deductibles or co-pays raises serious questions. Do we really want to balance the budget on the backs of the sick or elderly? If we feel that persons who are rich or in above-average circumstances should bear greater shares of our nation's needs, the remedy should be in our revenue system, not in our health system.
Reducing waste in present health care systems is essential, but may not produce sufficient savings to achieve quality care for all, particularly with an aging population and growing needs for long-term care without impoverishment. We should consider additional funding, in part by reducing the current waste of money, time and talent in other sectors of our economy, perhaps including some parts of transportation, energy, financial services, commercialized recreational gambling, etc. A review of history and practices in our past and in other advanced nations should suggest other sources of revenue. In addition, technology has greatly reduced the percentage of national income formerly required for food, releasing resources for fields with growing capabilities and needs like health care. For all these reasons, we should not fear some long-term increase in the percentage of GOP de'voted to quality health care for all. And since health care is a labor-intensive sector, its growth should help alleviate the burdens of unemployment on individuals, on the economy, and on governments.
4. Introduce Complex Improvements Carefully. This refers to such things as better health information technology (HIT) and "best practices" protocols for doctors and hospitals.
There is much potential merit in these approaches to better and less costly care. Organizations like Kaiser Permanente and the Department of Veterans Affairs are leaders in better HIT to improve communication and access to records in delivering health care efficiently. But expanding HIT to all doctors, hospitals and some others should take care to avoid the wasteful hassles that have bedeviled many other IT users: consumers, businesses, even government agencies. In health care, computerization should be carefully standardized, stabilized and simplified to protect both providers and patients from technical, security, or other troubles. (See, e.g., Business Week of May 4, 2009, "The Dubious Promise of Digital Medicine;" see also Outlook in Washington Post of Aeril 26, 2009, at p.3.)
As to "best practices," most doctors and patients will welcome such information provided it is accurate, not overstated, and free from conflicts-of-interest, and provided further that it is free from financial pressures that seem to take a "one size fits all" approach. All patients with a given condition are not the same, and the doctor's judgment of what is in the patient's best interests should be respected. In the past some insurers, even including government insurers, have rejected successful new procedures as "not proven" or "not covered." In those rare situations where a doctor regularly disregards established standards of care without justification, other corrective measures are available.
5. Improve the Allocation of Resources. There is a great need for preventive care, and for primary care practitioners, not only to provide better health but also achieve long-term reductions in costs. Young doctors are disproportionately driven into specialties because insurers pay them at higher rates, helping them to cope with their heavy debt burdens accrued during medical education. There are also shortages of registered nurses, and of qualified nurse practitioners, physicians' assistants, and other clinical and auxiliary personnel, including emergency care and transportation providers in rural areas. There is ample precedent for public programs to fund training of health professionals.
6. Improve the Collection and Use of Professional and Consumer Health Information. The collection and dissemination of "best practices" information to providers should not be limited to domestic sources. The government should promote regular exchanges with providers in other countries for mutual benefit.
As to consumer health information, government health agencies should encourage professional health groups to support dissemination of useful health information to the public. In addition, health agencies should develop strong channels for close cooperation with education agencies to assure that all school students know basic human biology, basic health-related lifestyle practices, and also know when and how to consult doctors. Health illiteracy is a significant cause of preventable and costly illnesses.
7. Enhance Quality, Comprehensiveness and Accessibility of Care Delivery This means that (a) caregivers should be available, qualified, and with the resources they need to do their work, (b) transportation should not be an obstacle to delivery of care, (c) care should be comprehensive, covering illnesses, injuries, disability, and prevention, (d) patients' rights of choice, informed 'consent and confidentiality should be respected, (e) care and its delivery should not be denied or interrupted by changes in employment, residence, family status, prior illnesses, or the insolvency of providing or paying organizations, (f) care should not come at the price of impoverishment, and (g) care should include applicable improvements in medical materials and technology.
8. Rebalance the Cultures in Health Care Systems. Present health care systems embody a mixture, and sometimes a clash, between the cultures of market behavior and the cultures of professional callings which stress service to others and the integrity of science. From a civic viewpoint, both types of cultures have a place in various parts of the total health care sector. Yet we believe that the dominant culture in health care, somewhat like that in fields like education, military and other public service, and in professions like the clergy and journalism, should be the culture of service to others.
Our economy has plenty of sectors where the dominant culture is a profit-driven market competition, with or without regulation, which can enrich both competitors and society: food, clothing, shelter, transportation, communication, construction, recreation, publishing, financial services, etc. But in health care the dominant culture should be generally similar to that in the other service-oriented professions.
This means giving attention to those sectors of our present health care system where market behavior is dominant, such as manufacturing and marketing mediications and medical equipment, and the provision of commercial health insurance. These important sectors should achieve reasonable compatibility with our overall national health system goal in one way or another: by effective regulation, or by yardstick demonstrations, or other means. Other means could include bona fide non profits, either as providers or as insurers, as was the case in the early days of Blue Cross Blue Shield. But the history of health insurance as described in Dr. Geyman's 2008 book "Do Not Resuscitate", suggests that reviving nonprofit health insurance might be challenging. Demonstrations of public health insurance might focus on defined groups, such as persons between 55 and 65, or veterans who are not cov«~red as such, or persons of limited means who are not covered by Medicaid.
Precedents for effective reforms in health care can be found in ele!ctric utilities, which first were subjected to rate regulation and then, after they failed to provide service to rural families and elsewhere, were supplemented but not supplanted by REA and TVA. Providing adequate health care for all is as important as providing electricity was then. Moreover, REA and TVA did not destroy privately-owned utilities. Even in a field in which government was dominant, postal services, private businesses have grown, as shown by United Parcel Service, Federal Express, and Email.
9. Reject Covert Rationing. We cannot support the tacit, everyday rationing of health care common even in advanced countries. In the United States, care is often denied because a patient lacks adequate health insurance and is not covered by Medicaid. Such patients, if still alive, may be treated in an emergency room, but such care may be too late, and may cost more than timely care would have cost.
In other countries certain procedures may be denied or delayed because of age or a failure to fund some kinds of care. According to an April 2009 article in the Annals of Internal Medicine, a group in the United Kingdom health service that evaluates new medicines rejected four new cancer drugs used in other nations as not cost-effective. Protests caused a partial reversal. But some leaders in health insurance seem to favor a similar kind of cost-benefit approach called QALY (quality-adjusted life years). This weighs the price of a drug against the probable increase in the patients' life expectancy, not in calendar years but in years adjusted downward if the quality of life is judged to be substandard. Obviously such a standard is likely to deny care to persons who are quite sick or quite old. Alternatively, the growing custom of patients documenting their instructions for their end-of-life care may both improve care and reduce costs.
We support the rationing of health care in urgent battlefield situations with unexpectedly high casualties, or in comparable emergencies, where rationing in the form of triage is necessary. But we oppose any other rationing of health care, whether by intent or in effect. Any failure adequately to fund a category of needed care, including long-term care and care for the mentally ill, is a form of rationing.
ATTACHMENT A
Citizens for Quality Civilization, Inc. ("CQC)" was founded in 1989 as a civic group under IRC section 501(c)(3). COC's mission is to improve civic responsibility through better public understanding of national policies. We are active in education policy, health care policy, transportation policy, and globalization. In each area, we create readable, objective civic handbooks.
In 1999 we issued our handbook on health care policy; in 2004 our transportation handbook on traffic congestion; in 2008 our handbook on education policy, and in 2009 we will issue our globalization handbook.
COC operates (a) with informality, (b) by using the expertise in the Washington region, and (c) by never publishing drafts until we have comments from a variety of experts.
Robert L. Gilliat chairs CQC's Health Policy Group. For 18 years he was Deputy General Counsel of the Department of Defense for Personnel and Health Policy. His responsibilities included the worldwide system of health care for members of the armed services and their families. Recently he counseled the United Seniors Health Cooperative on long-term care and the Senior Health Insurance Assistance Program for Montgomery County. He was heavily involved in helping seniors enroll in Medicare's new drug benefit (Part D) and with all aspects of health care. He also was president of his local civic association.
William Bechill, recently deceased, was an Emeritus Professor at the University of Maryland's School of Social Work. He was the U.S. Commissioner on Aging and Chief of the Division of Medical Care of the California Department of Social Welfare. He developed a program of rehabilitation services at the University of Michigan, and was a consultant for the Kaiser MotorsUAW/CIO Social Security Fund. Mter retiring he chaired the Maryland Commission on Aging (1996-2003) and the Advisory Board for the Center on Global Aging at the Catholic University of America.
Deborah Schumann, M.D., earned a B.A. in chemistry from Smith College, studied pharmacology at Yale, earned her M.D. at University of Maryland, and completed four years of post-graduate training in ophthalmology. She practiced ophthalmology for over 20 years in four states. Currently she is an advocate for accessible, affordable, high quality health care for all Americans and is a co-founder of Montgomery Health Care ACTION, a grass-roots organization for health care reform. In addition Dr. Schumann studied health care statistics, policy and economics at the George Washington University.
Robert L. Saloschin is a lawyer, retired naval officer, community leader, commercial pilot, and founder of CQC. He practiced law on Wall Street, in urban renewal programs, and in the Civil Aeronautics Board. For 20 years he was a director of St. Luke's House which provides rehabilitation for the mentally ill. At the Justice Department from 1958 to 1981, in the Office of Legal Counsel and as Director of the Office of Information Law and Policy, he worked with leaders including Robert Kennedy and William Rehnquist, and developed initiatives in civil rights, communication satellites, and immigration. For 10 years he counseled all federal agencies on Freedom of Information requests for their records, including records in healthrelated programs.
Chronology of CQC's Work on Health Care Policy: In 1993, when Hillary Clinton began work on health care reform, CQC created a short checklist of civic criteria to help evaluate any reform proposal and distributed it to government offices.
In 1995, when it appeared that Congress might greatly curb Medicare, CQC produced a defense of Medicare and distributed it to media and other groups.
In 1997, when only incremental improvements in health policy were in prospect (such as the well-intentioned but ineffective Kennedy-Kassebaum law on portability of health insurance), CQC established an informal group to survey the situation. We decided that a civic handbook to improve public understanding of health care systems would help build support for future legislative improvements.
In 1999 CQC published its health policy handbook (which can be accessed on our website). Our draft was vetted before publication by Professor William Baumol who advised Senator Moynihan on health care economics. The handbook was distributed to key individuals in 80 national organizations concerned with heath care policy.
From 2001 to date, CQC has monitored efforts to move beyond the consensus on the problems in health care toward a consensus on what to do. These efforts included the bipartisan WydenHatch survey, some private sector coalitions, and some state-level initiatives. Nevertheless, in our view, progress has clearly been insufficient. This not only afflicts much of our citizenry with care that is inadequate or unaffordable, but also weakens us as a nation in an increasingly competitive world.
ATTACHMENT B
(Extract from CQC's 1999 handbook on health care policy)
Can we separate good and bad methods of health care cost controls?
Answer: Generally, the answer is yes, although the separation is not always clear-cut.
The generally affirmative answer is based upon two broad premises: first, that the test of whether any method of cost control is good or bad depends less on the extent to which it cuts costs than on whether or not it adversely affects the quality of care, and second, that given the skill-intensive nature of most health care services, quality care requires respect for the professional judgment of caregivers including some scope for professional errors.
Examples of generally good methods of cost control include: 1) effective investigation of fraud, waste, and conflict of interest; 2) effective anti-trust investigation of price-fixing; 3) adequate rewards and full protection for whistleblowers who report fraud, price-fixing and other abuses; 4) regular examinations of health care systems in other nations to find improvements for possible use here; 5) establishment of yardstick projects to develop and test more efficient forms of health care; 6) the use of traditional deductibles and co-payments by consumers, which could be reduced or eliminated for preventive care and increased for aggravating factors like smoking, drunk driving, :failure to use seat belts, etc.; 7) the reduction of excessive paperwork imposed upon doctors and hospitals by intermediaries; and 8) a reduction or elimination of the share of health care funding by payers that is not spent on care of patients but is retained by intermediaries for administrative costs and profits. In addition, legislators might give attention to investigating and controlling situations of apparently extreme overpricing that affects health costs; for example, the recent report in the September 1998 issue of Health Letter that pharmaceutical companies are charging several times as much for certain drugs sold in the United States as they charge for the same drugs sold in other countries.
Examples of generally bad methods of cost control include: 1) pressuring doctors to skimp on care by paying them according to the number of patients they sign up instead of by the amount of time and service they provide called "capitation"); 2) pressuring doctors not to refer patients to specialists, not to discuss costly options for diagnosis or treatment, and not to prescribe drugs they think best where cheaper ones are available; 3) agreements between intermediaries and hospitals or other providers resulting in patients being assigned to a more distant emergency room or to inconvenient times or places for services; 4) financial pressures on patients may not only suffer pain and anxiety but even a poorer prognosis; 6) intermediary payment policies hospitals to replace registered nurses with lower paid and less qualified personnel; 5) delays by intermediaries in authorizing diagnostic or treatment services during which that curtail the ability of teaching and research hospitals to continue those functions; and 7) making decisions between inpatient and outpatient services, or on the duration of hospital stays, on the basis of costs to the intermediary rather than the patient's best interests.