personal perspectives Health care reform: the differential diagnosis

Economic and political experts appear mary care providers who will be required has to include improvements in diagnosis to agree that the US health care system is a in a new, more efficient health care system. and effectiveness of health care delivery horrible mess, and there is no consensus as This will require increased efforts by US achieved using electronic medical records. to how to fix it. The differential diagnosis medical schools to recruit and train pri- The costs of implementing electronic is that our health care system: (a) is dying mary care providers. To promote preven- patient records should be shared among because of hopelessly opposed political par- tive care, all insurers should be required the medical schools, as a single format ties and greedy insurance companies or (b) to refund a portion of insurance costs to would meet the needs of all. Similarly, as has a treatable illness. I believe that the a first step toward a single-payer plan, illness is treatable, if we adhere to sev- all insurance providers should be eral guiding principles. These include required to use the same form, which (a) universal access to compassion- The physician’s voice would largely be filled out automati- ate health care, (b) improved health cally using the electronic record. This care through scientific advances, and The reality is that everybody now has would drastically reduce administra- (c) reduced administrative and legal tive costs associated with insurance costs. Establishing these three goals, access to health care, but the uninsured and billing. Additional cost savings and introducing a series of changes primarily use the most expensive forms of could be achieved by meaningful tort designed to achieve them, can result in reform that protects the legal rights meaningful health care reform. health care (e.g., the emergency room), of patients but reduces frivolous law- Goal number one: universal, compas- boosting the costs. suits. This could be facilitated by an sionate coverage. The first goal should enhanced system of case review by be the easiest to achieve. Initially, experts, prior to initiating costly legal through a combination of private and proceedings. Further cost regulation public options, everybody should have patients who undergo their annual physi- should include compensating all physi- some form of health insurance. I believe cal examinations. The discussion about cians with salaries, which would remove that the ultimate goal should be a single- health care has to refocus on how to pro- incentives for unnecessary procedures. payer system, but that need not be the first vide access for all to a physician who is well The diagnosis is clear: our health care step toward universal coverage. Achieving trained and cares about patients and who system is in critical condition. However, universal health insurance today would works in a system that is humane and no its strengths include the world’s best sys- require the government to provide cov- longer treats patients and physicians like tems for training health care providers and erage for that portion of the 15% in the commodities. biomedical researchers. The quality and United States who are currently uninsured Goal number two: scientific advances in medi- effectiveness of the administrative com- and cannot afford health insurance and to cal knowledge. America has the best biomed- ponents of our health care system must be make health insurance a requirement for ical research infrastructure in the world. improved so that they enhance the health those who can afford it. The reality is that However, this great national treasure is of the patient, rather than destroy it. everybody now has access to health care, fragile and must be continually supported but the uninsured primarily use the most in order to develop new, more effective and Andrew R. Marks expensive forms of health care (e.g., the affordable diagnostics and therapies. Sus- emergency room), boosting the costs. Cost tained increases in support for biomedi- Columbia University, New York, New York, savings from regulating physician income cal research are an essential component of USA. E-mail: [email protected]. and from administrative and tort reform health care reform. could be used to pay for universal cover- Goal number three: reducing costs. Any dis- J. Clin. Invest. 119:2853 (2009). doi:10.1172/ age. A bigger challenge is training the pri- cussion of meaningful health care reform JCI41022.

An academic, apolitical approach to health care reform

The United States is on the verge of of this great country should have access relating to how to pay for those presently addressing one of the most important to excellent health care. To accomplish uninsured. Opponents are concerned that issues facing the country, its health care this, universal health insurance must be a this will require increased taxation and/ system. An underlying premise of the component of any plan. Many controver- or decreased support for those presently need for reform is a belief that all citizens sial issues have arisen in the debate, most insured. The only acceptable solution will

The Journal of Clinical Investigation http://www.jci.org Volume 119 Number 10 October 2009 2853 personal perspectives be one in which the cost of covering the including academics, the health care indus- perhaps there is a better system, with pan- uninsured derives from improved efficien- try, think tanks, government, and industry. els of trained judges making these deci- cies in the delivery of health care. They should operate in an environment sions rather than juries with little under- Everyone accepts that there is much free from politics and develop conclusions standing of the nuances of health care. inefficiency in our present system, driven that are based on a critical analysis of data. These issues and others must be seriously by a complex set of misaligned incentives, While participants should bring differ- debated, and the debate must include an ent perspectives to this problem, analysis of their effects on health care they must all be committed to quality and cost. the program’s success and must Last, the development and education leave their parochial interests and of the health care workforce must be conflicts at the door. In the end addressed strategically as part of the solu- The physician’s voice this could be the most impor- tion to the problem. The ultimate solution tant accomplishment in health can never be achieved without a workforce The establishment of Medicare in the care during our lifetime, and the that is aligned with and serves the critical opportunity to contribute must components of health care. This process 1960s marked a transformation in how trump self-interest. has been left to individual universities and this country would take responsibility for Third, very little about this has thus lacked any direction driven by a the care of its elderly. One can argue that debate is black and white. I have national health care strategy. heard too much rhetoric express- This is a propitious moment in the the system was not set up perfectly and ing extreme views from both sides history of health care. The establish- costs have increased beyond expectations, of the aisle in Congress. There is ment of Medicare in the 1960s marked no component of health care that a transformation in how this country but we did the right thing. We now are is evil. Most participants work would take responsibility for the care of presented with an opportunity to once in health care to make people its elderly. One can argue that the system healthier, and they derive satis- was not set up perfectly and costs have again do the right thing. We must do so, faction and reward from their increased beyond expectations, but we and we must get it right. efforts. This includes physicians, did the right thing. We now are present- allied health providers, hospital ed with an opportunity to once again do administrators, universities, the the right thing. We must do so, and we pharmaceutical industry, the must get it right. insurance industry, and prob- We must provide optimal health care ably even malpractice attorneys. to all members of our great country. We but the question is how to address this. Are there conflicts with personal gain? must do this in a way that controls the While it is perhaps easier to identify the Certainly. Like everyone else, health care costs of health care. And we must not opportunities for improvement than the workers have families to support and wish allow this to lower the quality of health solutions, it is of the utmost importance to do that well. Like the rest of industry, care that our presently insured patients that this be done correctly, and thus I pharmaceutical companies and insurance receive. Addressing these three priorities offer a few guiding principles from my companies have stockholders to answer together is not a trivial exercise. The good perspective. to. This does not make other industries news is that it does not violate the laws First, the specifics of the plan cannot be evil, and it should not be viewed as mak- of thermodynamics, and thus it is theo- driven by politics. While a certain num- ing these companies immoral or malevo- retically possible to achieve all. However, ber of votes are needed to pass a bill, we lent. The costs of drug development are the path to success is difficult, and we cannot allow this to be the dominant enormous and could not be solely sup- must use every tool available to achieve process that determines our future health ported by government or nonprofit foun- our goals. I believe that the process will care system. Perhaps the bill should lay dations. It is the profits generated by the be aided greatly if members of the aca- down a plan to develop a plan rather than pharmaceutical industry that provide the demic community and of the ASCI play define it. Such a bill could prescribe time necessary support to sustain drug devel- a pivotal role. lines that must be met and milestones at opment, and we should be very careful which actions must occur, such as extend- that we do not weaken this process. Robert Alpern ing insurance to all. Our current health Fourth, nothing can be off the table. care system is exceedingly complex and Successful reform may require radical Yale University School of Medicine, New will be difficult to fix. However, time is of change. Perhaps primary care doctors Haven, Connecticut, USA. E-mail: robert. the essence, and failure to pass a health should make more money than highly [email protected]. reform bill would be devastating. Sad- specialized surgeons. This concept is dling a reform effort with too many limi- foreign to our health care system, but it Conflict of interest: Robert Alpern is direc- tations driven by political realities will should be considered. There has been a tor of Abbott Laboratories and a member of doom it to failure. noticeable silence regarding tort reform. the Scientific Advisory Board of Relypsa. Second, this process should be guided by It has been argued that patients who have the greatest minds in health care. Partici- been mistreated should be able to reap a J. Clin. Invest. 119:2853–2854 (2009). doi: pants should encompass a broad group, financial reward. I do not disagree, but 10.1172/JCI40997.

2854 The Journal of Clinical Investigation http://www.jci.org Volume 119 Number 10 October 2009