Making Sense of Health Care Reform

The debate about health care reform has emerged as the nation's most contentious issue, as the current proposals to change the system have been met with confusion and fear. Fear of loss of choice, fear of rationing, fear of governmental control, fear of increasing taxes, fear of burgeoning government debt and fear of nothing getting done. Although there is general agreement that we need to broaden health insurance coverage and rein in skyrocketing costs, what's strangely missing is a reasoned discussion of what we really want from a reformed health care system. We've heard that our current system is the best in the world as well as deeply flawed, but which is it? Why does our current system cost so much, yet is unable to cover 47 million Americans or to prevent chronic diseases? Getting health care reform right requires a clear understanding of the strengths and weaknesses of how health care is delivered today and how to make it better. This understanding starts with a real story about James.

James is 49-years old and self-employed. He makes a modest living working from home, and he can't afford health insurance. James enjoyed what he considered to be good health until a year ago when, after lunch, he developed severe discomfort above the pit of his stomach. He thought it was indigestion, but the discomfort persisted and he began to sweat profusely. His wife saw James crumple to the floor, and she called 911. Within 15 minutes, an EMT arrived and found that James had a barely detectable pulse and low blood pressure and concluded that he was having a heart attack. He was rushed to the local hospital on life support.

When James arrived in the emergency room of the community hospital, he was semi-conscious. The diagnosis of a heart attack was made and James was given Activase, a bioengineered thrombolytic agent which is used to dissolve clots in coronary arteries. James's clinical condition remained unstable, however, and signs indicated that he might die without more advanced treatment. The decision was made to transfer him to a major regional academic medical center where the latest technologies were available.

James was transported there by helicopter, was quickly evaluated by the cardiovascular team and sent to their angiography laboratory for direct visualization of his coronary arteries. Several obstructions were noted as was severe dysfunction of his heart contraction as a result of the blocked blood flow. The decision was made to open Jim's coronary blockages by placing stents where the obstruction existed. Skilled cardiologists placed the stents accurately via a catheter inserted in an artery in James' leg, and coronary artery blood flow was quickly restored.

Nonetheless, the function of James's heart muscle remained severely abnormal, indicating that damage had occurred. More ominous was James's low blood pressure, indicating that he was in "cardiogenic shock" - a life threatening condition. To keep him alive, the cardiovascular team implanted an advanced heart assist pump that compensated for his heart's diminished work. James remained in the cardiac intensive care unit for three days then transferred to a "step down" facility and finally to a regular hospital unit. Following eight days in the hospital, James's heart function recovered sufficiently for him to go home.

After discharge, James was maintained on powerful and expensive medications to improve his cardiac function, protect his kidneys, and decrease the likelihood of a life-threatening cardiac arrhythmia. After three months, James gradually increased his level of physical activity to where he was able to walk approximately a mile, but if he walked uphill, he became severely short of breath. On follow-up visits to his cardiologist, James's heart function, as measured by ultrasound, revealed injury to his heart muscle that made him susceptible to "sudden cardiac death syndrome" from a rapid, irregular heart beat due to damage of his heart's electrical conducting system. Following the advice of his cardiologist, James had an intracardiac defibrillator implanted to protect him from such an event.

It has been a year since James's heart attack. He is back at work, and able to garden, a hobby he greatly enjoys. The fact that James is alive, moderately active, and has a positive outlook on life can be considered to be a miracle. Many of the technological advances that allowed James to survive were developed in the US within the last decade. It is unlikely that James would have had this outcome in any other country in the world.

But all is not well. The cost of James's care has been well over $300,000. James lost his health insurance when he became self-employed and could not afford an individual policy. Since James is uninsured, he does not receive the deeply discounted medical rates that are negotiated by big insurance companies. Because James has had to bear these extraordinary costs, he is on the verge of bankruptcy. Moreover, he now has a pre-existing condition that will make future health insurance even more difficult to obtain. On top of this, as a consequence of the severity of his heart attack, James may ultimately develop congestive heart failure, a debilitating chronic disease further limiting his health and requiring expensive long-term coordinated care.

And if this blow to James's future health and financial well-being are not distressing enough, there is yet another aspect to this story which is even more disturbing - James's destructive and nearly fatal heart attack might have been prevented!

James, born in rural North Carolina, recalls that his father died at the age of 46 from a heart attack. Several uncles had heart attacks, many dying before the age of 60. James ate salty and fatty foods and smoked nearly a pack of cigarettes a day from the age of 14 until he quit in his early 40s. He has been overweight since his late teenage years and rarely exercised. Before his heart attack, when he had insurance, James was told by a physician to lose weight, stop smoking and decrease the amount of salt he ate, but there was no comprehensive discussion regarding his great risk for heart disease based on his family history, physical condition and lifestyle. Nutrition, exercise, and stress reduction are all mainstays of prevention and are effective at reducing risks, yet there was no meaningful discussion or initiation of these strategies. There was no follow-up or support to help James make needed changes. James was a walking time bomb for a life-threatening condition that was preventable, but our country's health care system failed to help him prevent his debilitating heart attack.

James's experience illustrates that our country's approach to health care is world class in dealing with disease events, but it is ineffective in preventing and managing chronic disease. It has been estimated that one-half of all deaths in the U.S. from chronic disease can prevented. True health care reform would deal with health enhancement and prevention of chronic diseases, which consumes three-fourths of every health care dollar. Fortunately, effective reform can be built on the strengths of our current system.

As a consequence of rapidly emerging predictive power, we are developing increasing capability for early detection and prevention of many major chronic diseases long before severe manifestations occur. We are each born with different susceptibilities to diseases that develop over time as a consequence of what we are exposed to and what we do. We typically begin developing an underlying disease long before we become aware of it. Once symptoms occur, the disease has progressed substantially. In James's case, the initial clinical onset was a catastrophic heart attack. While commonly recognized symptoms may appear late, it is usually possible to identify one's susceptibility and initiation of the disease process before major damage occurs.

These principles apply to most chronic diseases including diabetes, pulmonary diseases, cancers, musculoskeletal diseases, and others.

We can rationalize our health care system by providing individuals with an understanding of their health risks and the education and support they need to minimize disease; and by providing them an ongoing relationship with a primary care physician and/or health coach to develop individualized health plans and track progress so that interventions, when needed, are available. Such approaches have been termed "prospective care," "patient-centered care," "integrated care," or "personalized medicine" and can build on our existing system to revolutionize health care as we know it.

With prospective care, James's physician would have formally evaluated his risks for major chronic diseases and identified his high risk for a heart attack. A personalized plan for James would have been developed to lessen his risks and to track progress. James would have had access to a cost-effective health care coach to advise, encourage and track progress. James might have chosen to engage in regular aerobic exercise, dietary strategies, management of blood pressure and stress reduction. The addition of cholesterol lowering and other medications might have been indicated as well as a stress test to anticipate the risk of a heart attack. Such preventative approaches are far more cost-effective as they prevent needless trips to the hospital or emergency room. The saying "an ounce of prevention equals a pound of cure" holds true -- health care costs are less when appropriate interventions are taken before a catastrophic event occurs. By integrating personalized, preventative approaches with care for catastrophic disease-events such as James's heart attack, we can make our health care system the best in the world.

Key factors in health care reform:

Universal Access - A rational approach to health care requires that all Americans have access to the fundamental resources and insurance needed to maintain health and prevent and treat disease. Universal access to care also makes financial sense as it would eliminate the high costs of treating the uninsured in emergency rooms and hospitals, which are currently passed on to payers, contributing to the burgeoning expenses.

Education and Personal Empowerment - Valuing the importance of health should be a societal focus. Smoking cessation, minimization of driving while drinking, the importance of saving the environment - these are examples of movements that have been advanced by comprehensive education and community actions. Developing a full blown "going healthy" movement could focus our nation on the importance of health as a resource and a shared responsibility. Such a movement would benefit from broad coalitions of businesses, schools, communities, consumer groups, social and religious organizations, public health groups and the government. Key to any rational health care movement is individual empowerment to improve one's health.

Personalized Prevention and Strategic Health Planning - Understanding that chronic diseases develop over time leads to abundant opportunities for personalized prevention and management of disease progression to minimize adverse consequences. Strategic health planning, based on one's health risk, is a rational approach. Such approaches are already being implemented and provide models for care. Individual strategic health plans based on the person's risks for preventable diseases along with appropriate tracking and early intervention are crucial to this strategy.

System Integration - Creating strategic approaches to care requires a provider system with which the patient has an ongoing interaction with a point of care, such as a primary care physician or health mentor. The delivery system must give the patient the level of care they need when they need it. Services should be focused on the patient's holistic needs and integrated to maintain continuity from health promotion to disease event care. Health information technologies, along with more rational and transparent reimbursement systems, can make this goal attainable.

Reimbursement - We are getting what we pay for in health care. Reimbursement now financially rewards interventions for disease events such as James's heart attack, so our system is skewed to providing this type of care instead of helping James to prevent a heart attack. What's missing is a coherent reimbursement approach for prevention, early intervention, and effective long-term management. Changing reimbursement strategies to pay for continuity of care and better outcomes is essential. Of all the impediments to universal access, changes in reimbursement may be the most difficult to attain as there is so much money at stake and thus much resistance to change. Nonetheless, reimbursing providers for integrated preventative approaches and better clinical outcomes will have the greatest leverage in fostering better models of care.

Better Approaches - While the concepts described here are sound, and indications of effectiveness are already apparent, it will be important to determine what works best and what provides the greatest consumer satisfaction. Within the general principles of care outlined herein, there are many possible approaches. It will be necessary to develop and learn from those that work best. Whatever models are chosen, individual choice is critical, as is transparency of information regarding outcomes and patient satisfaction. To stimulate competition and ingenuity for creating the best models of care, demonstration projects funded by the government and private insurers should be established. Outcomes could be monitored and overseen by credible non-biased entities such as the Institute of Medicine. The best strategies could be adopted by insurers and by government-funded programs such as Medicare or Medicaid.

Political Focus on the Right Issue - Unfortunately, the current health care debate shows little indication of changing our current ineffective, uncoordinated, and extremely expensive approaches to care. To make effective change, the debate should shift to a focus on rational health care delivery. As a start, it is critical to envision and design comprehensive approaches to personalized health planning along with strategic and coordinated health care. A sustainable and effective approach to care can be built on the strengths of our current system.

Ultimately, we must affirm our commitment as a Nation to a reasonable and practical level of health care as an individual's right. With this in mind, access to health care for all is required, but such care must be directed toward enhancing personal involvement and empowerment to improving health along with systems to support this. Personalized, predictive, preventative and coordinated strategies will not only provide better health promotion and disease prevention, but will rationalize the current approach which focuses on disease events. It is clear from James's experience that our country's approach to health care is the best in the world in dealing with life threatening disease events yet inadequate in preventing disease. Resolving this contradiction is at the crux of what it will take to initiate meaningful and sustainable health care reform in the United States. By doing this, our health care system will be far more effective and more affordable. With an understanding of this outcome in mind, we can create health care reform to attain it.

Dr. Ralph Snyderman is Chancellor Emeritus Duke University, past president and CEO of the Duke University Health System, past chair Association of American Medical Colleges and president of the Association of American Physicians.