These days, Democrats and Republicans have a relationship that’s about as amicable as the Steelers and Ravens in January. Everyone is sick of gridlock-inducing Beltway politics, which were on ignominious display during recent health care reform debates. It would be too easy to conclude there’s no path forward. But all of us involved in health care delivery and policy owe it to the American people to make bipartisanship a reality, rather than a cliche. Otherwise, the harm that our health system inflicts on patients and the economy will only worsen. Let’s ask our legislators, D’s and R’s, to pass some legislation that matters to us.
It is — or should be — a cause of shame to both Democrats and Republicans that Americans are in poorer health than people living in any other Western country, even though our health care is the most expensive in the world. We spend nearly a fifth of our gross domestic product on health care. Yet compared to other industrialized countries, the United States has shorter life expectancy, higher rates of chronic disease, obesity and cancer, and higher rates of alcohol and substance abuse. Yes, America is exceptional — unfortunately, in this case, for standing out as a horrendous outlier.
Whether your fashion sensibilities lean more toward pantsuits or red baseball caps, there is a plan for creating a high-quality, affordable and accountable health system that everyone can get behind. Let’s stop arguing about universal health coverage. Just bring down the ridiculously high cost of care and the country could afford to do the right thing. We are all looking at the wrong problem; no wonder our solutions are so unsatisfactory.
Bring down the unit costs of care
To drive down unnecessary, unsustainably high health care costs, we need to attack the root causes. Here are two big ones:
• Waste: Between 30 percent and 40 percent of all U.S. health care spending is wasted through unnecessary treatments, preventable complications, inefficiencies and errors. Burning through that much cash would shutter the doors of any other industry, to say nothing of the resulting aggravation and suffering felt by patients. Let’s strengthen provisions in Medicare and Medicaid that refuse to pay for unproven treatments, unnecessary diagnostics, drugs with generic/low-cost equivalents — the whole basket of “unnecessaries.”
We need policies that create a culture of discouraging waste. Let’s require professional health schools that receive public subsidies to develop a new curriculum that teaches waste reduction, lean methods and patient education in the dangers of overtreatment. Let’s fund a commission to study overuse of drugs: antibiotics, opioids and other. At the same time, we should require every insurer to reimburse clinical pharmacy costs so that people taking several medications can have their drugs assessed. It is not impossible that 75 percent of diabetics and 90 percent of people with chronic lung disease are on the wrong medications. That would cut down on waste and make people healthier. Speaking of drugs ...
• Drug prices: From price spikes on previously cheap generics to innovative new treatments that cost as much as a house, patients are getting hammered financially. If lifesaving drugs aren’t affordable, they’re not lifesaving. We have much to learn from countries that pay far less for their drugs. Britain and Israel, for example, focus heavily on the clinical efficacy of drugs and possess negotiating power that’s sorely lacking in the United States.
We also must learn from American innovators. Think of Dr. Vivian Lee at the University of Utah. She realized that spending by her health system on the EpiPen was wasteful and unreasonable. She also realized that nurses could fill a syringe. She created EpiKits, which saved her system more than $30,000. Imagine if that sort of ingenuity were replicated across the country, and not just for EpiPens. That commission will have plenty to do.
Stop making excuses for medical errors
Each year, about 250,000 people in the United States die from preventable medical errors, according to a 2016 study in The BMJ, a medical journal. The National Patient Safety Foundation puts the number at 400,000. To put that in more understandable, Pittsburgh terms, that’s enough casualties from avoidable infections, surgical and medication errors, and other gaffes to fill Heinz Field, PNC Park and PPG Paints Arena to the rafters — two or three times. You can assume that maybe four times that number suffer costly and needless harm.
We need to ensure that there’s accountability on the part of medical providers and health systems, train health professionals to be champions of safety and quality — and reward them for those efforts. Some of the critical steps required to address rampant medical errors, such as ensuring that providers wash their hands and follow safety checklists, don’t require new investments. They require leadership and enforcement — and much stiffer penalties for preventable errors.
Put our bodies and minds back together
For years, we have practiced and paid for health care as though the body and brain were disconnected. Yet research has shown that 20 percent to 50 percent of adults with a chronic disease have coexisting depression, that depression can impair patients’ ability to manage their chronic disease, and that almost half of those with depression don’t receive treatment. This translates into absenteeism and downstream medical costs.
We at the Pittsburgh Regional Health Initiative — a non-partisan regional collaborative of medical, business and civic leaders organized to address health care safety and quality improvement — have proved the value of screenings to detect problems requiring treatment. We should make screening universal for behavioral health concerns in primary care: the first line of defense to prevent, detect and treat problems that become more serious down the line. Such screenings might also extend to school health clinics and employee assistance programs.
It also means addressing an acute shortage of mental health professionals and in-patient beds that leaves patients and families in crisis waiting weeks for treatment. This “crisis of unmet crises” makes suicide, homicide and even mass casualties more likely. This requires funding, policy change and will.
Create the workforce that we need, not the one we inherited
We need to ensure that every health care professional is working at the top of his or her licensure. We shouldn’t, for example, have physicians performing tasks that medical assistants or licensed practical nurses can capably handle or have psychiatrists fulfill roles that don’t require a medical degree. We also need to embrace new and transformative workforce roles, such as community health workers who can help seniors and other vulnerable populations remain well in the community and avoid hospital and nursing home admissions.
In Rwanda, there’s a Good Samaritan army of iPhone-equipped community health workers who help HIV-positive individuals navigate medical and social services and coordinate maternal and child care. This may require that we adjust policies to make sure that professional guilds aren’t blocking entry-level health workers from adding value to health teams. We also need more flexible attitudes toward licensure and certification. But we can do it.
Demand transparency in cost and quality
Let’s say that you need a knee replacement. Want to know how much the procedure will cost, and who excels at performing that procedure? Good luck. While some progress has been made, health care data on cost and quality remains opaque, at best. I can pull out my smartphone and access a plethora of information that helps me choose wisely on where to eat dinner, what car to buy or which plumber to hire. Why can’t we bring that level of transparency and actionable information to finding a doctor or choosing a hospital?
Come on, legislators. It’s time to require cost and price transparency, as well as quality. Why can’t we shop around for the high-value provider, particularly if you want us to assume more of the cost?
Advance local innovation
Another nexus of health care innovation may well be at the state and regional level if funding is available for experimentation. Everything doesn’t depend on positive federal policy — though it sure would be helpful. Local leaders understand their constituents’ particular health concerns, and they still cross party lines to get things done. There’s a network of multi-stakeholder groups poised to demonstrate ways to improve quality and drive down costs at the local level, including the Pittsburgh Regional Health Initiative. This won’t happen by reducing funding for innovation.
The PRHI is part of a larger national network of more than 30 regional health improvement collaboratives called the Network for Regional Healthcare Improvement. PRHI has guided efforts to reduce hospital-acquired infections, strengthen the skills of the health care workforce and transform care delivery and payment through research and demonstration projects.
We’re learning what works. For example, a project called COMPASS demonstrated that screening patients for depression in primary care, and linking them to a care manager and mental health specialist, can improve outcomes for those suffering from depression and diabetes and/or cardiovascular disease. Another initiative, the Primary Care Resource Center, reinvented community hospitals as one-stop shops for coordinated outpatient care for patients who have chronic conditions such as COPD and heart failure. And yet another initiative, RAVEN, is showing promising results in helping nursing home residents avoid preventable trips to the hospital and ER and reducing cost.
But regional and state efforts are aided or curtailed by federal legislation. Make no mistake: Our high costs of care and delivery system glitches need a national tweak. No matter your political stripes, it’s clear that our health care system is failing many Americans.
In these hyperpartisan times, we need a coalition of responsible legislators, providers, insurers and informed consumers who can translate our vast medical and technological talents into a truly exceptional health care system. Please consider the above suggestions and act now! Surprise us.
Karen Wolk Feinstein is president and CEO of the Pittsburgh Regional Health Initiative.
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