Carolyn Bevan MD
Faculty Peer Reviewed
With health care spending increasing at an unsustainable rate while an estimated 46 million Americans live without insurance [1], the urgent need for healthcare reform in the US is clear. Much less obvious, however, is how to go about it. At the beginning of the month, President Obama addressed Congress in a political call to arms, emphasizing that Americans must come together to address this important issue. This week, many of the major medical journals weighed in on the debate.
For those of us who have been unable to keep up with the healthcare debate this week, it may be helpful to start with a brief overview of a few key developments. The main piece of legislation under debate at the time of the president’s speech was the Affordable Health Choices Act, which would incorporate reform of existing insurance structures while introducing a “public option” for individuals who are unable to obtain private insurance [2]. While the bill represents an important step forward in healthcare reform, according to preliminary estimates by the Congressional Budget Office (CBO), it would increase the federal budget deficit by $1.0 trillion over the ensuing decade and expand coverage to only 16 million previously uninsured Americans [3]. In response to these and other concerns, Senator Max Baucus, chairman of the Senate Finance Committee, introduced “The Baucus Bill.” Made public this week, the bill would, among other things, mandate some form of insurance coverage for most Americans, without a new public option, while incorporating insurance industry reform and implementing strategies to control cost [4]. According to the CBO, the Baucus Bill would actually lower the federal deficit by $16 billion over the next decade, while expanding coverage to 29 million previously uninsured Americans [5]. Still, some Democrats are concerned that mandating insurance will put even more strain on middle income families, while some Republicans call the bill “a back door to the public option.” [6] As Congress continues to fight it out, the editors of the major medical journals have been monitoring the debate, and this week, they focused on the dollars and cents of US healthcare reform.
This week’s New England Journal of Medicine features a perspective article entitled System Wide Cost Control – the Missing Link in Healthcare Reform, in which co-authors Jonathan Oberlander, Ph.D., and Joseph White, Ph.D. question the efficacy of regulating costs by cuts in federal spending alone. Their main concern is that isolated federal cost cuts would limit cost control to Medicare, which would ultimately result in cost shifting to private payers rather than resulting in real cuts in healthcare spending. To address this issue, they advocate for a system of “all payer regulation,” which they define as meetings of insurers with government agents to negotiate regional standardization of payment schedules and fees for medical care reimbursement. Such systems are already used by Germany, Japan, and the Netherlands – all countries featuring multiple insurers rather than single payors. In these countries, all-payer systems have been shown to reduce prices, avoid cost shifting, simplify billing, and allow private and public insurers to, not only coexist, but work together to contain healthcare spending. The authors conclude that any healthcare legislation will have to address cost control while avoiding significant disruptions in care, and they assert that this cannot be achieved by focusing on federal systems alone [7].
The Journal of the American Medical Association also featured a commentary on cost control by Stephen M. Shortell, PhD, MPH, MBA, from the UC Berkley School of Public Health. Dr. Shortell echoes the concern that the cost of expanding insurance coverage will not be adequately offset by the cost control strategies currently under discussion. He suggests a method of “bending the cost curve” to address the underlying causes of skyrocketing healthcare costs. Firstly, he advocates changes at the community level, including focus on disease prevention initiatives. He cites physical activity, nutrition, and smoking cessation as three targets that have shown excellent return on resource investment, both in terms of cost savings and patient welfare. Secondly, he highlights the need for changes at the hospital and physician level, mainly through changes in organizational structure. He suggests the establishment of “Accountable Care Organizations” (ACOs): groups of physicians, hospitals, and other players in the health care industry who would come together to maximize efficiency in controlling healthcare resources. He also recommends that a Center for Comparative Effectiveness Research be founded to collect data and make recommendations about which treatments, interventions, or health promotion strategies are most cost effective and efficient. These concepts seem to echo the “all payer regulation” referred to in the NEJM article, and perhaps highlight a general feeling among public health authorities that providers must increase collaboration and work together to gather evidence to control the costs of healthcare [8].
And what to physicians think about all this? The NEJM reports on a cross-sectional study conducted earlier this year to gauge physicians’ opinions on healthcare reform and cost control strategies. In the study, surveys were sent to 2000 practicing physicians in all specialties. Participants were asked to indicate their level of agreement or disagreement with three statements regarding health care ethics and policy. The statements were as follows (1) “Addressing societal health policy issues, as important as that may be, falls outside the scope of my professional obligations as a physician.” (2) “Every physician is professionally obligated to care for the uninsured and underinsured.” (3)”I would favor limiting reimbursement for expensive drugs and procedures if that would help expand access to basic health care for those currently lacking such care.” They were then asked to indicate whether they had “no” “moderate” or “strong” moral objection to “using cost-effectiveness data to determine which treatments will be offered to patients.” In addition to general demographic information, the physicians were also asked to identify their specialty and classify themselves as conservative, moderate, or liberal on “social issues.” The response rate was 51%, with some variance by region and age category, but not by sex or specialty. Results showed that 78% of respondents felt obligated to address health policy issues, 73% felt obligated to care for the uninsured or underinsured, and 67% would favor limiting reimbursement for expensive interventions in exchange for expanded access. Physicians expressed less comfort with allowing cost-effectiveness studies to determine treatment: a slim majority of 54% did have a moral objection to using cost-effectiveness analysis “to determine which treatments will be offered to patients.” Researchers suggest that physicians may feel unsure of how to incorporate this type of analysis into their practice, while they may also have concerns that an emphasis on cost might disrupt the physician-patient relationship. Based on these data, researchers concluded that while physicians are willing participants in the healthcare debate, they may be slightly more resistant when it comes to implementing many of the currently proposed cost containment strategies. These concerns will need to be addressed if the current health care reform proposals are to be successful [9].
Clearly, the debate on healthcare reform is far from over. In addition to the economic challenges of meaningful reform, as highlighted in the journals this week, there is a deep obligation to secure and uphold high quality patient care. Given the demands of practicing in America, it is difficult for many physicians to participate in the healthcare debate, but it is important for them to lend their unique perspective on the realities of implementing new systems, and to be champions of the ideals of beneficence and nonmaleficence this profession holds so dear. Changes will be difficult, but it is obvious that maintaining the status quo is simply not an option. In the words of President Obama, “we did not come here just to clean up crises. We came here to build a future.”
Dr. Bevan is a 1st year internal medicine resident at NYU Medical Center.
Reviewed by Michael Poles MD, Associate Editor, Clinical Correlations, Assistant Professor of Medicine, NYU Division of Gastroenterology
1. DeNavas-Walt C, Proctor JD, Smith JC “Income, Poverty, and Health Insurance Coverage in the United States: 2008” [Internet]. Washington, DC: U.S. Census Bureau, Housing and Household Economic Statistics Division. 2009 September. 74p. Available from: http://www.census.gov/hhes/www/hlthins/reports.html
2. Elmendorf, D “Preliminary Analysis of Major Provisions Related to Health Insurance Coverage Under the Affordable Health Choices Act” [Internet]. Washington, DC: Congressional Budget Office; 2009 June 15 [cited 2009 September 21]. 10p. Available from: http://www.cbo.gov/doc.cfm?index=10310&zzz=39036
3. America’s Affordable Health Choices Act: Quality Affordable Health Care: Summary. [Internet]. Washington, DC: House Committees on Ways and Means, Energy and Commerce, and Education and Labor. 2009 July 1 [cited 2009 September 21]. 4p. Available from: http://www.opencongress.org/bill/111-h3200/show
4. “Half a Loaf, or Half-Baked?” The Economist. 2009 September 17. Available: http://www.economist.com/world/unitedstates/displayStory.cfm?story_id=14460017&source=features_box3
5. Elmendorf, D “Preliminary Analysis of Specifications for the Chairman’s Mark of the America’s Healthy Future Act” [Internet]. Washington, DC: Congressional Budget Office; 2009 September 16 [cited 2009 September 21]. 24p. Available from: http://online.wsj.com/article/SB125320046917319855.htmlhttp://www.cbo.gov/doc.cfm?index=10572&zzz=39579
6. Hitt G “Baucus Will Tinker with Health Bill to Mollify Critics” The Wall Street Journal. 2009 September 18, Page A4. Available:
7. Oberlander J, White J “Systemwide Cost Control – The Missing Link on Health Care Reform” N Engl J Med. 2009 Sep 17;361(12):1131-3. Epub 2009 Sep 2. (http://healthcarereform.nejm.org/?p=1627&query=home)
8. Shortell SM “Bending the Cost Curve: A Critical Component f Health Care Reform” JAMA. 2009 Sep 16;302(11):1223-4. (http://jama.ama-assn.org/cgi/content/short/302/11/1223?home)
9. Antiel RM, Curlin FA, James KM, Tilburt JC “Physicians’ Beliefs and U.S. Health Care Reform – A National Survey” N Engl J Med. 2009 Sep 14. (http://healthcarereform.nejm.org/?p=1785&query=home)
10. Obama, Barack. “Remarks by the President to a Joint Session of Congress on Health Care.” U.S. Capitol. Washington, D.C., 9 Sep. 2009. Available: http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-a-Joint-Session-of-Congress-on-Health-Care/