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The Nuts and Bolts of Reform Proposals
Date:6/22/2009

Suggestions range from greater emphasis on preventive care to universal electronic records

MONDAY, June 22 (HealthDay News) -- U.S. legislators continue to debate the details of what many hope will be the blueprint for a transformation of the nation's health-care system. While no fully formed proposals have emerged so far, here are some key elements:

Evidence-based guidelines.

During a speech to the American Medical Association last week, President Barack Obama said that "less than 1 percent of our health-care spending goes to examining what treatments are most effective."

"There's a big gap between what we know the problems are and knowing exactly what are the best treatments for them, and there's another really important gap between knowing the most effective treatments and having those put into standard practice," said Thomas R. Oliver, an associate professor of population health sciences at the University of Wisconsin School of Medicine and Public Health.

What really happens today is that quantity of care is rewarded over quality: Those health professionals who order the most diagnostic tests and prescribe the most drugs get a bigger piece of the financial pie, according to advocates for change.

"We have spent far more money on research of new diagnostic techniques and new medications and not enough money on how to identify the best treatments," said Dr. Nancy W. Dickey, president of the Texas A&M Health Science Center.

This part of the reform effort would allocate more resources to determining which treatments work the best and how to implement them. The Recovery Act of 2009 has already earmarked $1.1 billion to this type of research, according to the White House Office of Management and Budget.

The evidence-based approach would offer the added benefit of protecting doctors who follow new, agreed-upon treatment guidelines from devastating malpractice lawsuits, while still leaving some avenue for people with legitimate medical claims. This would eliminate the need for caps on medical malpractice awards, advocates for change claim.

Universal adoption of electronic record-keeping.

Hospitals and other health-care organizations are transferring paper records to electronic ones, but in a piecemeal fashion. Once an electronic system is in place across the country, patients would no longer have to repeat their medical history or recite their prescriptions (what they can remember, anyway) to each new doctor.

This would mean lower administrative costs, partly by eliminating unnecessary repeat tests. But it could also potentially prevent life-threatening medical errors. "It would save money over the long run if people had electronic medical records and if everybody had some sort of medical home in charge of medical care," said Linda Fentiman, professor of law at Pace Law School in New York City. "But it might take 10 years for that to be implemented."

Greater emphasis on preventive care.

The goal here is to devote more money to programs to combat preventable problems such as obesity and smoking-related illnesses, and to encourage vaccinations and disease-screening tools such as mammography and colonoscopy. "This is one of the reasons that managed-care health-care costs are so high," Fentiman said. "Most people change plans pretty frequently, so if a managed-care company knows it's only going to be covering people for two to three years, it doesn't have the financial incentive to provide high-quality preventive care. We don't yet have a system that will pay physicians for taking good care of the patient over the long run."

Effective management of chronic illness is another piece of the puzzle, said Mary Mundinger, dean of the Columbia University School of Nursing in New York City. That means steps like making sure that people take their blood pressure medications, cut down on salt, and exercise to prevent heart attack or stroke -- problems that will end up costing billions to treat. "Personal responsibility for one's health care has not been built into the American system before," she said.

Prevention also reduces many problems associated with social inequalities. "Income and health disparities can be reduced significantly by getting everyone access to good primary health care," Oliver said.

Covering the Uninsured.

This may be health-care reform's biggest question: how to provide coverage to the estimated 46 million Americans who are uninsured. Answers here seem especially elusive. It's virtually certain that employer-provided insurance would remain. Obama has proposed that it could be supplemented by a federal "health insurance exchange" -- a kind of large pool that individuals could use to comparison shop for health insurance.

Changes to Medicare reimbursement.

Not for the first time, proponents of health-care reform are advocating streamlining the unwieldy Medicare reimbursement system, making sure doctors and institutions aren't overpaid for care, instituting a competitive payment system, curbing abuse, and keeping increases in reimbursements in line with economic gains.



SOURCES: Thomas R. Oliver, Ph.D., associate professor, population health sciences, University of Wisconsin School of Medicine and Public Health, and associate director, health policy, University of Wisconsin Population Health Institute, Madison; Linda Fentiman, professor, law, Pace Law School, New York City; Mary Mundinger, Dr.PH, dean, Columbia University School of Nursing, New York City; Nancy W. Dickey, M.D., president, Texas A&M Health Science Center and vice chancellor, health affairs, Texas A&M System; White House Office of Management and Budget fact sheet


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