USA’s healthcare reform: challenges and opportunities

I think it’s safe to say that our healthcare system is in deep trouble. In fact, it is about to bankrupt our economy. Costs continue to escalate as the USA spends close to US$2.5 trillion every year on healthcare. Of each dollar spent on healthcare in the USA, 31% goes to hospital care, 21% goes to physician services, 10% to pharmaceuticals, 8% to nursing homes, 7% to administrative costs and 23% to other categories, such as diagnostic laboratory services, pharmacies and medical device manufacturers [101]. Medical debt is the principal cause of personal bankruptcy in the USA [102].

There are just a couple of problem areas that have lead to this debacle. In my previous editorial I mentioned medical malpractice and health insurance as the main problem areas [1], and stated that Congress does not adequately address these root causes of our healthcare problems in the bills currently under consideration. Thus, the USA’s Health Care Reform will not work because it amounts to applying band aids to a gaping wound that requires major surgery. In this editorial I suggest ways to address the root causes of our problems. On the one hand, I have nothing to gain or lose because I am not involved in politics and am retired. However, on the other hand, I do have a lot to gain or lose because I am a patient relying on the USA’s healthcare system for my medical care.

This is truly a crisis situation; we need to have a sense of urgency. The system must be transformed and this will require fundamental change.

Malpractice litigation

A keyword search of the current proposals for ‘malpractice litigation’ does not yield a single hit. There are two or three hits for ‘malpractice’. The most relevant is the statement that individual states should be “encouraged to develop and test alternatives to the existing civil litigation system” [103]. Clearly the proposal does not embrace or even identify any fundamental change in malpractice litigation and sidesteps the issue by relegating it to the individual states.

Ways must be found to prevent frivolous malpractice suits. When a frivolous suit occurs, both the lawyer and the person suing should be severely penalized. In those cases where malpractice has occurred, the monetary awards should be proportional to the physical damage suffered by the patient and capped at a reasonable amount. Lawyers should not receive a percentage of the award (currently ∼35%, plus expenses) but should be remunerated on a reasonable hourly or fixed-fee basis.

Companies providing malpractice insurance should not be allowed to settle suits out of court as an easy way out. They should be required to pursue all suits in court so that innocence or guilt is clearly established and a reasonable award imposed. Congress should be able to address these issues; after all, most of them are lawyers. But then, maybe that is why they choose not to tackle these problems.

Health insurance

A capitalistic system that values free enterprise should allow for the continued existence of public companies that provide health insurance policies. A healthy competition between such companies would lead to reasonable premiums for the clients (patients). The government, other than the Medicare Program for the elderly, should not be in the business of providing health insurance and competing with public companies. Companies providing health insurance should not interfere with physicians’ decisions as to what is best for the patient regarding diagnostic tests, surgical procedures, or treatment in general. However, for this to work, physicians need to practice medicine in a way that benefits the patient without creating unjustified costs in the way that defensive (litigation pre-emptive) medicine does. Thus, insurance companies have their responsibilities but physicians have very important responsibilities too.

Practice of medicine

We need to undergo a major transformation of how we practice medicine. We must return to patient-oriented medicine. For a couple of generations we have practiced defensive medicine. This must stop. Defensive medicine has become embedded in our medical guidelines, textbooks and medical school curricula. There are at least two generations of physicians that only know defensive medicine, and do not understand patient-oriented medicine.

We should emphasize clinical diagnosis. A good history and physical exam should be relied upon for many diagnoses. The question should then be what additional tests are necessary to confirm the clinical diagnoses? And not how many additional tests should be performed to avoid malpractice litigation? Physicians have been conditioned to prescribe according to a list of insurance company-approved drugs. We must go back to prescribing what is best for the patient. Insurance companies have also established the duration of treatment and length of hospitalization that they will approve. These limits are based on studies that determine what is sufficient for the average patient. In this situation 50% of patients will be undertreated and discharged too early from the hospital. Patient treatment and length of hospitalization should be individualized. Again, insurance companies have their responsibilities but physicians have very important responsibilities too. Medical Societies, Licensing Boards and Review Committees have to take an active role, together with medical schools and training programs, to ensure that we do transition smoothly and rationally from defensive, malpractice litigation pre-emptive medicine to patient-oriented medicine. Current medical guidelines, textbooks and other teaching tools will have to be thoroughly revised.

I look forward to the day when every patient gets a thorough history and physical exam before a MRI is ordered; when every physician is free to order the medication best suited to his patient without having to ask for the insurance company’s permission; when a patient is discharged a couple of days earlier or later than the median as justified by medical rather than statistical reasons; when common sense and good medical science rather than arbitrary regulations prevail. A serious crisis requires fundamental change. Band aids alone will not do. The fundamental changes, the transformation that is required will not be simple or painless and yet it must occur, as the alternative is not acceptable.

In December 2009 the Senate’s version of the Health Care Reform bill was approved by a vote of 60 versus 39 with all Democrats voting for and all Republicans voting against. By the time this editorial is published Congress will have approved some form of the bill. A clear example of partisan politics with Senators showing little concern for what is best for the citizens of this country.

In my next editorial I will address some other root causes of the healthcare debacle, such as drug prices, the role of pharmaceutical companies and the US FDA.

Financial & competing interests disclosure

Antonio J Grillo-López is a member of the Board of Directors of ONYX Pharmaceuticals and of the Board of Trustees of the Hope Funds for Cancer Research. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.