Epib654/Summer2010/Policy/NEJM Shattuck 2008 US Health Policy.Pdf

The NEW ENGLAND JOURNAL of MEDICINE

Perspective august 21, 2008

SHATTUCK LECTURE Health of the Nation — Coverage for All Americans Charles D. Baker, Arthur Caplan, Ph.D., Karen Davis, Ph.D., Susan Dentzer, Arnold M. Epstein, M.D., Bill Frist, M.D., Robert S. Galvin, M.D., Ruben J. King-Shaw, Jr., Thomas H. Lee, M.D., Jonathan B. Oberlander, Ph.D., Sara Rosenbaum, J.D., Steven A. Schroeder, M.D., and Reed V. Tuckson, M.D.

On May 10, 2008, the Journal and the Mas- sachusetts Medical Society brought together 13 panelists — physicians, academics, and business, insurance, and political leaders — for a seminar on U.S. health policy and health coverage. In a discussion moderated by Ar- thur R. Miller, J.D., of the New York Univer- sity School of Law, the participants identified important challenges to the U.S. health care system and debated possible solutions. The group addressed the dissatisfaction among physicians in general and primary care providers in particular and considered its relationship to a reimbursement system that rewards high-tech procedures rather than cog- nitive work and time spent with patients; various approaches to payment reform were proposed. The discussion also covered the growing need for major investments of time and money in information technology and the payoff that other countries have seen. Sev- eral participants expressed concern about the disproportionately high costs of new drugs and end-of-life care in the United States and broached the topics of negotiation of drug prices, cost-effectiveness analyses, and rationing. After some consideration of the political, social, and economic obstacles to achieving universal access to care, the seminar concluded with remarks on the politics of health care reform and speculation about change under a new ad- ministration.

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Downloaded from www.nejm.org by DR. J JAIME CARO on February 7, 2009 . Copyright © 2008 Massachusetts Medical Society. All rights reserved. PERSPECTIVE Health of the Nation — Coverage for All Americans

A video of the seminar is available at And that means, in addition to poseful, directed conversation with www.nejm.org. What follows are ex- fee for service, a monthly panel his or her patients on a regular cerpts from the discussion. fee for being a medical home. basis. It’s a blended system of payment, Arthur Caplan: [The average physi- which has worked very well in Steven Schroeder: There is an ele- cian’s perspective is this:] I went Denmark, where people have phant in the living room that to medical school. I’m loaded with well-established relationships with we’re not talking about. All these debt. I’ve got an office full of peo- primary care and compensation comments presume the persistence ple pushing paperwork every day. for primary care is on a par of a vibrant primary care system. I don’t have time to talk to any- [with] or even higher than com- But if [physicians are] telling [their] body. No one in Washington pensation for specialty care. sons and daughters not to go into seems to care what I think. I can’t medicine, those that go into med- function this way. I don’t get re- Thomas Lee: The theme is team icine know for sure they don’t want imbursed enough. care these days. We obviously need to go into primary care. They teams for the really sick people, want to go on what they call the Charles Baker: Primary care needs but [also] for the not-sick people. “ROAD” to happiness — radiol- to be treated with a lot more re- The sick people who need help ogy, ophthalmology, anesthesia, spect by the payer community, with their weight and their blood dermatology, or emergency med- generally, and by Medicare in par- pressure and smoking cessation icine. They want to do that be- ticular, because Medicare sets the — it shouldn’t be [the physician] cause they’re coming out with huge debts. Because unless we fix the payment system, they’re not going to get the kind of income that they’d like. They’re more at- tracted to shift work, so they don’t have to worry about patients after they leave. And they don’t like all the hassles. Unless we do more fundamental surgery on making primary care a more compelling field, I think in the future primary care will be practiced by others than doctors. Reed Tuckson, Steven Schroeder, Karen Davis, Arnold Epstein.

rules of the game for everybody who’s following up to see if they Sara Rosenbaum: When you have else. And Medicare is procedure stopped smoking. And [a physi- patients with very garden-variety driven. It’s technology driven. And cian’s] whole practice has to get conditions that require certain it doesn’t pay for time. It pays paid in a way that it can support kinds of garden-variety interven- for transactions. a team around them. We need tions, and the patients can’t af- physicians to trust nonphysicians ford them, the dilemma for a phy- Karen Davis: We need to give to do things. sician is: Do I even start to counsel [physicians] the option of being patients on the kinds of treatment a patient-centered medical home. Ruben King-Shaw: The crux of mak- options I would recommend? Be- A practice should be rewarded for ing the difference here is not to cause this patient really doesn’t taking accountability, for making destroy the fee-for-service system have any of these choices. sure that patients are getting ap- but to add to it, to make it a propriate counseling, they’re up to valuable use of a physician’s time Arnold Epstein: [Spending too date with their preventive care. to have an intimate, relevant, pur- much on care at the end of life]

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come a debate over insurance. Insurance is one way to finance health care for a population. It is not the only way.

Jonathan Oberlander: If there’s one lesson that we’ve learned about health reform in the last few decades, [it’s that] being right doesn’t count for very much. We can come up with lots of stories to evoke moral outrage. And it’s not just about the uninsured. Jonathan Oberlander, Charles Baker, Sara Rosenbaum, Bill Frist. There are many Americans with insurance who have inadequate is a big problem. The numbers protection and who file for bank- I’ve seen put it at something like ruptcy every year because they’re $130 billion a year. The quip is Sara Rosenbaum: [Access to care underinsured. But if we’re going that the U.S. is the one country is] the most basic ethical issue to fight this battle for health re- in the world where they think of all. But it is a national deci- form on moral grounds, we’re death is optional. And we act that sion on our part. It’s not the fed- going to lose. way. I think we have to start to eral decision; it’s not the state deal with that. And the time to decision; it is a national social Reed Tuckson: When you live in a deal with it is not at the bedside. decision. And we’ve been very community with people who are It’s with a broader group trying bad about this. uninsured, you are being affect- to think about standards and ed through the inadequacy of the piecemeal efforts where we can Steven Schroeder: I think that a public health system, the diver- put things out of bounds. I don’t country should be judged by how sion of resources. You’re being know if that means we say that it treats its less fortunate. In that compromised because of the ef- people don’t get dialyzed when respect, I’m ashamed of our fects on the hospitals and physi- they’re 97, or bring it back to 95 country. cians in your community. All of or 92. Or that certain medica- us are in the boat together. tions when the cost per adjusted Ruben King-Shaw: It’s a failure on life-year is $500,000, we say that the part of America to provide Bill Frist: You’re paying a premium we’re really not going to cover for adequate health care for all of $235 every month for your pri- them. And we try and change the of its citizens. Now that has be- vate health insurance — $70 of culture.

Karen Davis: We spend twice what every other country spends. The U.S. is subsidizing prescription drugs in other countries because we accept whatever pharmaceu- tical companies charge, rather than having a system of assess- ing the cost-effectiveness of those drugs, devices, and procedures and negotiating on the part of the entire population to get de- cent prices. Thomas Lee, Ruben King-Shaw, Susan Dentzer, Arthur Caplan.

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that goes directly to the uninsured, individuals — everybody has got coverage?” the answer can be yes. right now. The American taxpay- their own 18-point plan. And [This applies to] the whole de- er [is already paying] $50 billion what we have learned, over and bate about health care in the for the uninsured. Because we over again, when people get wed- U.S. for the past 20 or 30 years, have legislation that if [you go] ded to those fundamentals, is you with the possible exception of to the emergency room, you’re never get to the calculus of actual the Medicare Modernization Act, taken care of. So we are already legislation that can get passed. where, whether you like it or not, paying for a lot of care for the the president basically said, “I’m uninsured in a very indirect, un- Susan Dentzer: All [the presiden- going to stake my presidency on transparent, inefficient way. tial candidates’ health] plans have this, and it will happen.” And as a substantial element of unreality a result, it did. That’s what you Jonathan Oberlander: The price tag to them. Part of it is either Dem- need a president to do if you’re for universal coverage really is ocratic or Republican holy writ going to get the coverage ques- not that much. If you talk about that is being recycled from past tion resolved. adding the uninsured to the ex- debates. Part of it is fantasy based isting system, you’re talking about on a lack of understanding about Mr. Baker is president and chief executive officer of Harvard Pilgrim Health Care, roughly $100 billion a year. We how things really work now. We Wellesley, MA. Dr. Caplan is a professor of already spend over $2 trillion, will have to wait till after the bioethics at the University of Pennsylvania, so it’s a mark-up but not much. election — see how things settle Philadelphia. Dr. Davis is the president of the Commonwealth Fund, New York. Ms. When we cut taxes in 2001 and out. And then engage in a realis- Dentzer is the editor-in-chief of Health Af- 2003, we found the money to do tic discussion about how to pick fairs, Bethesda, MD. Dr. Epstein is chair of that. When we passed the Medi- this up together. the Department of Health Policy and Man- agement at the Harvard School of Public care Prescription Drug Benefit Health, Boston, and an associate editor of in 2003, we found the money to Robert Galvin: I think business is the Journal. Dr. Frist is a former U.S. sena- do that. When we went to war as willing to get out of what it’s tor (R-TN) and a visiting professor of inter- national economic policy at Princeton Uni- in Iraq, we found the money to doing now as it’s been since I re- versity, Princeton, NJ. Dr. Galvin is the do that. So this is a question of member. Even more than the ear- director of global health care at General priorities. And the uninsured are ly ’90s, simply because the costs Electric, Fairfield, CT. Mr. King-Shaw is chair and chief executive officer of Mansa not a political priority. continue to compound. So unless Equity Partners, Tallahassee, FL, and Car the Congress can work together lisle, MA. Dr. Lee is network president at on access and cost at the same Partners HealthCare System, Boston, and an associate editor of the Journal. Dr. Ober- Reed Tuckson: If you want to actu- time, it’s going to be difficult to lander is an associate professor of social ally get something done in Con- sway the business community medicine and health policy and administra- gress, what it’s going to require into believing what’s on the oth- tion at the University of North Carolina, Chapel Hill. Ms. Rosenbaum is a professor are multiple different stakehold- er side is not going to be worse of health law and policy at George Washing- ers who are all prepared to go for than [what we have] today. ton University, Washington, DC. Dr. their second choice. What is frus- Schroeder is a professor of health and health care at the University of California, trating is once you get beyond Charles Baker: [The presidential San Francisco. Dr. Tuckson is executive vice the moral outrage, what happens candidates’ health plans are] po- president and chief of medical affairs at is that every sector — the pri- litical bromide — put out there UnitedHealth Group, Minneapolis. vate insurers, the manufacturers, so that if somebody says, “Do you Copyright © 2008 Massachusetts Medical Society. small business, the advocates for have a position on health care

Health of the Nation — Coverage for All Americans To watch the video, vote, and add your comments, go to www.nejm.org/perspective/health-of-the-nation-video.

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