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(HealthNewsDigest.com) – Successful health reform should lower medical care costs, improve quality-of-life, and measurably increase value for money spent on health care. These objectives, however, might not be achieved even if health insurance were available for everyone.
Today, many Americans already have comprehensive coverage, yet they often fail to obtain high quality health care when measured by compliance to approved standards for preventive care and chronic condition management. Universal access to health insurance, therefore, will not by itself result in a successful outcome of reform, if such outcome is measured by improved national health status. Coverage itself does not guarantee that patients will obtain the preventive and chronic care they need.
Recent articles by Fuchs1, Hartzband2 and Inglehart3 precisely describe the politics and special interest barriers to health care reform. Fuchs correctly asserts that health care reform is an essential part of reducing national indebtedness. Hartzband highlights the lack of alignment of physicians with their patients and a reimbursement system that prevents a sustained culture of health in America. Inglehart explains the political realities that will have to be dealt with in order for President Obama to achieve successful reform. Despite the contributions of these and other authors, what is most needed is a clear path for health care reform that can be embraced by physicians, patients, and insurers, including the federal government.
Today’s Health Challenge
Most recommendations for preventive care and chronic and acute disease management have not been well adhered to by doctors and patients. Yet they do not know this. In fact, the perception of doctors and patients regarding the quality of their compliance belies the evidence. For example, mammography is known as a highly recommended and effective screening method for female breast cancer. However, in our pooled sample (~576,000 persons) obtained from hospitals, large and small companies, and union health plans, including fully insured and self insured entities, the rate of mammography is just 42.7% with a standard deviation of 14.2%. Recent data from the American Cancer Society indicated the probability of developing breast cancer is 1 in 24 for females aged 40 to 59, and 1 in 26 for females aged 60 to 694. At the level of compliance measured, many cancers are not being detected at precisely the time when intervention would be most effective. Moreover, it is well known that late stage cancer costs much more than early stage cancer (in our sample, $72,300 per patient per year for late stage versus $12,800 per patient per year for early stage). As cancer expenditure is always one of the most expensive disease categories in health plans, early detection of cancer using low-cost screenings is extremely effective in reducing high-cost, late stage cancer treatment. Yet early detection is not effectively practiced by patients and their physicians.
Diabetes is a condition that exemplifies the lack of compliance with accepted care guidelines for the identification and treatment of a chronic illness. Many times, this condition is neither identified nor treated appropriately, thus contributing to extraordinary pain and suffering and associated medical expense. According to the American Diabetes Association, 23.6 million children and adults, making up eight percent of the U.S. population, have diabetes. However, only 17.9 million people have been diagnosed with diabetes by physicians and/or other health care professionals. A staggering 5.7 million people have this condition and do not know it.5
In the same pooled population we studied, the prevalence of diabetes is 4.2%±1.2%, indicating that there are many plan members with undiagnosed diabetes. In addition, the cost of treatment for first-time diagnosed diabetic patients with severe complications, such as stroke, heart attack, kidney and other circulatory complications is $12,000 more per year than a patient with newly diagnosed diabetes without complications. Early identification of diabetes, therefore, is important in lowering medical expense and increasing quality-of-life for diabetic patients.
Multiple interventions for high-risk individuals with type 2 Diabetes in England6 suggested that well-defined diabetes intervention programs can reduce the risk of cardiovascular and other vascular events by 50%. However, in our pooled population, only 70.1% of the members with diagnosed diabetes had received at least one Hemoglobin A1c test; meanwhile, for known members with hypertensive diabetes, only about 40.0% of them (STD: 10.8%) complied with the recommended guideline for use of ACE/ARB to treat their hypertension. Even though 65.2% (STD: 14.4%) had used these medications at least once after hypertension was diagnosed, many of these patients eventually discontinued use of prescribed medication. In this same diabetic population, compliant members spent ~$10,670 per year, compared with ~$16,581 for the non-compliance users and ~$12,429 for patients who took no medications. This evidence supports the notion that early diagnosis and long-term interactive compliance is an optimal way to control cost and improve population health.
Health Care: A New Definition
In order to achieve successful health care reform, the meaning of “health care” needs to be refocused on the continuous improvement of a population’s health status, which can be measured by the rate of compliance with accepted high quality standards of care. It is precisely this focus on health status improvement that needs to become the national objective for health care reform. Not all people feel sick, but all people need to have reasonable access to acknowledged standards of care in order to achieve optimal health status. These standards of care include preventive health guidelines for healthy people as well as care for people with chronic and acute medical conditions. By focusing on efforts to achieve improved health status–compliance–for everyone, enormous amounts of healthcare expenses can be eliminated.
In his article, Fuchs1 refers to Machiavelli’s observation that “there is nothing more difficult to manage, more dubious to accomplish, nor more doubtful of success…than to initiate a new order of things. The reformer has enemies who profit from the old order and only lukewarm defenders in all those who would profit from the new order.”1
In order to overcome many years of failure to achieve the promise of lower cost and higher quality care, a new paradigm of risk assessment is required. Insurance rates and benefits need to be based on what should occur to keep high health status, not only on what has occurred to people with poor health status. Health plans today must include benefits that are medically logical for each plan member, and benefits must be contingent upon compliance with these standards by physicians and the people they care for.
Achieving Reform
The linking of plan benefits to compliance with known high quality standards of care is a simple low-tech, low-cost method of lowering health care expense by encouraging quality care. Despite health plan members and their physicians already behaving in a manner that suggests that coverage (benefits paid for in a health plan) determines what care people should receive, health benefit plans all too often do not appropriately relate an individual plan member to his or her need for care. Therefore, the linking of benefits to nationally accepted care standards would be a simple step to achieving the alignment of interests among physicians, plan members, and health plans. Such alignment is the critical step to achieving the sort of reform that leads to optimal health status.
STEPHEN A. KARDOS, D.O., F.A.A.P.
Chief Medical Officer
Dr. Kardos founded Health Network America in 1991 and served as CEO until 2008. Prior to that, he held the positions of Senior Vice President and Chief Medical Officer at Blue Cross Blue Shield of New Jersey and Chief Executive Officer and Board Chairman of Blue Cross Blue Shield of New Jersey’s first network HMO.
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