Rx for Reform

Iowans contribute to the national debate on the ailing healthcare system.

No gift exceeds that of an able body. Good health is the wish we make for ourselves and our families in the glow of birthday candles. It is the toast we make before the holiday feast. In the face of a really bad day, in times when all seems lost, if we are healthy—then we are grateful.

Yet, at one point or another, our bodies or minds fail us and we must seek help. Health care affects us all.

In recent months, top politicians, medical providers, and patients across the country have hotly debated how to restore the crippled U.S. healthcare system. In America, of course, anyone can go see a doctor or visit the nearest emergency room. However, not everyone can pay the resulting bills. At the crux of the impassioned healthcare debate lies the issue of how to provide affordable coverage while controlling skyrocketing healthcare costs that, left on their present course, will likely bankrupt the U.S. economy.

Although the U.S. last year spent more than any other nation—$2.1 trillion or about 17 percent of the gross domestic product—on health care, it only places 37th on the most recent public health survey of all World Health Organization member-nations, a survey that takes into account data such as life expectancy and infant mortality. It's an unsettling ranking for a country that boasts the world's most sophisticated medical services and therapies.

As politicians grappled with ways to improve the system, healthcare experts in Iowa stepped forward. The Iowa Committee for Value in Healthcare, a group of leaders from the University of Iowa and across the state, developed guidelines (see sidebar on p. 20) to assist members of Congress and other elected officials in their reform discussions. Here, some committee members, along with other UI alumni and experts from various healthcare specialties, offer their thoughts on the right prescription for health care in America.

Maximizing Resources

We have a moral obligation to make quality, community health care accessible to every citizen in this country. We now have more than 40 to 45 million people without insurance, who often end up in emergency rooms where the care is fragmented, lacks follow up, and is extremely expensive—and we all pay for that. The question is not one of access; it's one of cost and distribution. This country has the resources—the biggest question is whether we have the will to make the right choice and make sure no one is left out.

The culture of this nation will demand that we keep a private insurance system. A combination of public and private options would preserve competition and decrease costs. Whatever happens, the system should prioritize prevention and should not penalize someone for a pre-existing condition. I also see a bigger role for physician assistants and nurse practitioners to play in health care—they provide a high level of service to patients at a lower cost compared to primary care physicians. The UI happens to have the U.S. News & World Report No.1-ranked physician assistant program.

Here at UI Hospitals and Clinics, we're trying to improve patient safety and coordination of care. Earlier this year, we launched the Epic clinical information system so that healthcare providers can view a patient's records simultaneously. No one has to engage in a paper chase for charts, records, or medical history; it's all right there on the computer screen. Soon, affiliated physicians in clinics across the state will be able to access the records of patients who have been treated here, so that they can make better care decisions in their home communities. Also, we will test a new program called "My Chart" that gives patients access to their secure, online medical records. With electronic records, we can streamline services, reduce errors, avoid duplication, and educate patients about their health conditions.

Value for Money

The costs of medical procedures and interventions should be transparent, so people know what health care really costs. The goal should be the least invasive intervention possible that provides the best result in the most cost-efficient manner. Value is essential. We can cut a lot of fat in the system without hurting care, simply by investigating all options and getting the most "bang" for our buck.

I remember my 84-year-old grandmother with multiple chronic conditions, extreme obesity, chronic heart failure, and in the end stages of kidney failure. Her doctors considered moving her from Mason City to University Hospitals and Clinics in Iowa City (three hours via ambulance) for further diagnostics in a specialty MRI machine capable of handling obese patients. Heroic interventions for her kidney failure would have offered very little improvement over the long run, and she was not interested in such intensive and futile care. Without me and my uncle present as her advocates, she may likely have endured this expense and hassle. She died 36 hours later (luckily surrounded by family members living in the local area), but she should have received information about palliative care years earlier given her multiple chronic and ultimately fatal conditions.

Finally, a word about Medicare. It's the single largest financier of health care, but dedicated revenues for the program cannot keep up with spending. We are on a track toward fiscal chaos; one that could squeeze support for other domestic priorities such as education and the environment. We must make sure that care is provided efficiently and that those who need help the most receive it. As taxpayers, we all have a stake in preserving Medicare (and Medicaid) at an optimal level. Without urgent structural changes, this critical program will collapse.

Access & Affordability

Dentistry is an area of health care that tends to be elective—you rarely die of tooth decay; you can just ignore it until it becomes painful, even though good oral hygiene has a major impact on general health. Our big problem is giving lower socioeconomic groups access to affordable dental care. We have poor distribution of dentists in places that really need services, such as rural areas. But even if there's a dentist available, often a patient can't afford to go. Unlike doctors, dentists don't have to accept Medicaid; most won't treat patients with this coverage because the reimbursement rates just aren't worth it.

Commercial health insurance is an oxymoron. You can't make money insuring a service that everyone needs; it's like selling flood insurance in a flood plain. To make money, you must exclude or drop people, put limits on coverage, or levy excessive charges. Socialized medicine isn't necessarily the answer, but we do need a governmentsupported program to ensure access and affordability. If government should not be involved in health care, then why is it involved in education? If basic education is a right, then why isn't health care? You don't choose to be sick or get cancer. It happens to you.

In my classes, I discuss with students how the concept of global health is no longer a oneway street. The image of the U.S. shipping off physicians and antibiotics to poor countries is only part of the story. We can learn a great deal from other countries that are doing a much better job with health care.

Improved Communications

The New York Times recently identified Cedar Rapids as one of the top ten U.S. communities that represent healthcare systems headed in the right direction—places that deliver effective health care in a less costly way.

One criticism of American healthcare is that we don't coordinate care well; that, despite our advanced technologies, our system is inefficient. In Cedar Rapids, we've adopted electronic systems to improve the communication among physicians at our two main hospitals, Saint Luke's and Mercy, to benefit patient care. We need sophisticated IT systems and monetary incentives for physicians to share information. Mayo Clinic is often held up as the model for unity and cohesiveness. At Mayo, physicians work for a salary instead of individual reimbursement and they communicate through a unified service system.

Physicians want to use treatments, techniques, and approaches that are both beneficial to patients and save money. Also in Cedar Rapids, we researched the overuse of CAT scans to see where we can reduce unnecessary and potentially harmful radiation exposure—not to mention cut costs. Many doctors would like to see more national research on treatment plans that work best for various conditions.

With regard to insurance reform, I support universal coverage that does not exclude anyone for a pre-existing condition. The policy should move with a person from job to job. However, I don't think there should be a government-backed insurance option. In our state—one of the best in the nation in terms of quality and at the bottom for Medicare/Medicaid reimbursement rates—a public option would not provide adequate pay to Iowa providers. Compared to public programs, private insurers pay us in a much fairer way. We need a more equitable system.

Simplified Coverage

Overall, health insurance is far too complicated for the average person to understand. We need to simplify coverage choices, make them user-friendly.

Pharmacists deal constantly with a layer of management that most people don't know about—a fourth party in the mix among the pharmacist, the patient, and the insurance company. Pharmacy benefits managers, or PBM s, process millions of claims for insurance companies each day. PBM s possess a lot of power; they decide what drugs are approved and how much reimbursement the pharmacist will receive. Often, these reimbursements are inadequate to cover pharmacists' costs, let alone make a small profit. But, like executives in insurance and pharmaceutical companies, these managers can make millions of dollars a year.

As pharmacists take on a bigger educational role in health care, we spend huge amounts of time with our patients—without reimbursement. If we were compensated for this time, we could only further improve the health and care of our patients, reducing their need to use the system in the first place. Insurance companies offer reduced co-pay incentives for using mail-order pharmacies, but I can't tell you how many times we've bailed out people because they didn't receive their orders or got the wrong thing or don't know how to use their medications. Often, we must haggle with insurance to figure out what we can get approved for a patient; meanwhile, critical days can go by when a patient needs to be taking that medication.

Personal Responsibility

The cost of health care is growing faster than any other sector of the economy. We have an increasingly aging population with emerging conditions of chronic disease and disability. Over the next 25 years, the number of Americans aged 65 and older will grow from 13 percent to almost 20 percent. Our health system is the Titanic and Baby Boomers are the iceberg.

We can all do our part to preserve the health of this country. We can take personal responsibility for the choices we make. Modern medicine allows us to address disease; however, we do have some control on the conditions that produce illness. Good public health practices of disease prevention and health promotion can prevent the development of infectious disease, as well as reduce or minimize the effects of chronic disease. We can limit the costs of health care with these steps—and improve the quality of life for every individual.

The College of Public Health was established in 1999 to support just this kind of broad-based engagement in health policy. The emergence of health reform as a national priority establishes a fundamental responsibility for our college to act, a responsibility we have addressed in the formation of the Iowa Committee for Value in Healthcare and the nonpartisan, informed, comprehensive recommendations it produced.

Health reform requires more than government and the passage of laws. It involves leadership and societal commitment to topics of prevention, equity, and morality. Indeed, our fundamental challenge in health reform is defining who we are as a nation—and what we wish to be.