Coming together on health care

If America’s health care system were a patient, its doctor might declare “code blue.” Our health status is vulnerable at best: The United States spends more per capita on health care than other industrialized nations yet performs poorly–37th in the most recent World Health Organization ranking–in many key outcomes, such as obesity and infant mortality.

If our health care system were a patient, its care-givers would diagnose its problems, weigh solutions and prescribe treatment. We need to take that same team approach in “treating” the system. We need to define the relationship between good health care and good health. We need to engage patients and providers in optimizing health. And we need to treat dysfunctional incentives in the system that generate skyrocketing costs and poor health results.

For Patients

Give patients some skin in the game

We need to explore ways to educate the public about the benefits of proper nutrition and staying active, incentivize healthy choices or at least attempts at healthy choices, and hold people accountable.

Meaningful health reform must address how we improve the health of the American population, or costs associated with chronic disease will continue to spiral out of control. Preventing diseases resulting from poor health choices (using tobacco, inactivity, improper nutrition) will save costs to our health care system.

Optimum health would include not only a source of payment for health care services, but also knowledge and understanding among patients of the risky behaviors or personal choices that can lead to disease or illness. There must be resources within a community to support healthy behaviors. This would include such things as bike paths, sidewalks and access to healthy eating choices including fresh fruits and vegetables.

Appointed director of the Iowa Department of Public Health in April 2007, Thomas Newton, M.P.P., oversees its five divisions: acute disease prevention and emergency response; behavioral health and professional licensure; environmental health; health promotion and chronic disease prevention; and tobacco use prevention and control.

Do the Four Right Things

For many years I have been a proponent of health care insurance companies supporting preventive measures to promote and ensure health. Even though insurance companies pay for sick care and not health care, there is much that we can do to promote and preserve our own health. There are four simple measures that can make dramatic changes in our health and well-being.

1. Nutrition and healthy eating
Food choices are integral in promoting health. Five nutritional foods you may add to your diet are oatmeal and oat bran, good sources of fiber that reduce the absorption of cholesterol in the intestine; walnuts, almonds and other nuts that may decrease risk of heart disease; fish and omega-3 fatty acids that reduce the risk of heart disease by lowering cholesterol, reducing blood pressure and the risk of blood clots; extra virgin olive oil, instead of other oils, to decrease the bad (LDL) cholesterol and increase the good (HDL) cholesterol; and foods fortified with plant sterols, which may reduce LDL cholesterol.

2. Weight loss
Weight is a balancing act between intake and energy output. The simplest approach is to cut calories in food and drinks and increase calories burned through physical activity.

3. Fitness
Being physically active can decrease risk of chronic disease, improve balance and coordination, help weight loss and increase self-esteem. Committing to a reasonable activity program is necessary for each of us.

4. Stress management
Stress is an inherent part of 21st century life. We are always on alert for stressors. Learning to manage stress can help reduce our internal alarm system and decrease the risk of serious health problems. This can be done by taking time to relax, meditate, pray, contemplate and have thoughtful discussions with loved ones.

Jacqueline M. Stoken, D.O.’90, is a physician with Heartland Holistic Health, Des Moines, and a member of the DMU Board of Trustees. She is a fellow of the American Academy of Physical Medicine and Rehabilitation.

For Providers

Back to Basics: Accessible, Coordinated, Evidence-Based Care

Before we implement a lot of new reforms, we need to get back to and improve a few fundamental principles. Giving more people access to primary-level health care is much more cost-effective than waiting until the problem has gone from something easily treatable to something requiring hospital and specialized care.

Secondly, although the days of the general practitioner taking care of his community from cradle to grave may be a thing of the past, the general principles behind such care shouldn’t be abandoned. Developing a system that tracks and reports a person’s tests, results and interactions with different practitioners would facilitate coordination of care.

Lastly, Americans with access to health care need to be more realistic in their expectations, and their care providers need to be more evidence-based in their approach. Those with coverage have become accustomed to having immediate access to high-level tests. We don’t tend to give the body time to do something it is often inherently capable of doing–to heal itself.

Jodi Cahalan, Ph.D., M.S.’93, M.P.H.’01, is dean of DMU’s College of Health Sciences.

Provide Carrots for Primary Care Physicians

The nation faces a critical shortage of primary care physicians, a shortfall that can only be remedied by medical schools convincing our graduates of the societal needs and rewards associated with careers in primary care. Without strong medical school leadership, long-term health care reform will never happen.

The shortage of primary care providers and those in some specialties, including general surgery, psychiatry and obstetric-gynecology, is not just about the total number being trained but equally about the mal-distribution. This can only be solved at the federal level, by paying providers more money to go to under-served areas or having mandatory service requirements for all students who receive federal loans.

Graduates could receive a lower interest rate (or none) on their loans to practice in a designated shortage area versus a significantly higher interest rate for those who practice in non-designated areas. Loan repayment and tax incentives also play potentially big roles. This is an area that obviously would be controversial, particularly for politicians trying to get re-elected, but we all need to be a part of the solution to our health care crisis.

Kendall Reed, D.O., FACOS, FACS, is dean of DMU’s College of Osteopathic Medicine and professor of surgery.

Give Providers, Students a Louder Voice

I would encourage health care providers and students pursuing a career in the health professions to work with their professional associations and legislators to identify the challenges they are currently facing or anticipate will occur that interfere with their ability to deliver quality cost-effective medical services. These are the individuals and groups that need to be heard more than other special interest groups who influence how medicine is practiced and how medical services are reimbursed.

If health care is a fundamental right for every American, then a hybrid health care system comprised of both private and governmental programs should coexist to meet this pledge. A framework for both is currently in place. Decision

-makers should work to correct the obscene inefficiencies within each of these systems that have contributed in making medicine a big business for non-medical personnel. Directing the majority of dollars directly to patient care rather than administrative bureaucracy will result in a higher probability of quality health care for all Americans while providing health care providers with fair and reasonable compensation.

Any change in health care delivery must empower patients and health care providers to make decisions through frank communication founded on evidence-based outcomes, costs, realistic expectations and the virtue of the health care provider/patient relationship. Doing what is best for the patient, without the influence of litigation lacking evidence of negligence, is critical to the success of health care reform.

R. Tim Yoho, D.P.M., FACFAS, is dean of DMU’s College of Podiatric Medicine and Surgery.

For the System

Communicate, Coordinate

The solution to improving health care may be generations ahead as we likely will have to change our entire concepts of giving and receiving medical care. A strong effort to promote primary care, especially family practice, would be a good place to start. This needs to be the base for the patient-centered medical home, where the primary care doctor works with the patient to coordinate the entire health care package.

It will also be important that evidence-based medicine be used to even out the field of treatment and develop quality and safety measures. Once established, the protocols would define a therapeutic plan.

Cost control would be easier with electronic medical records so that testing results would follow the patient. Far too many tests are done because previous test results are not known by the doctor.

Tort reform is also needed. A large amount of money is wasted on testing done for the sole purpose of protecting the physician and others in the health delivery system from litigation. We must remove the need for the doctor to do every test imaginable to avoid becoming involved in litigation.

Max McKinney II, D.O.’69, is a retired physician in Farmington Hills, Mich., and a member and immediate past chair of the DMU Board of Trustees.

Define Benefits, Attack Waste

Health care reform is a three-legged stool of 1) access to care, 2) benefits that are covered and 3) the efficiency of the health care community.

Defining the list of covered benefits is the way many countries control costs. Certain procedures or diseases fall outside of the benefit package. Without defining a core set of benefits for society, an expectation is created that health care coverage is infinite.

Currently in the United States, consumers expect access to the broadest benefit package at the lowest cost–the best care someone else will pay for. As the United States is learning, health care can become a tremendous burden on the economy.

There are tremendous waste and overutilization in the delivery of health care. Some estimates are that 30 to 40 percent of overall health care cost is due to waste and duplication. Through redesigned processes and improved collaboration, the health care community can reduce the waste, fragmentation and overutilization of services.

Thomas C. Evans, M.D., is president of the Iowa Healthcare Collaborative, a provider-led and patient-focused nonprofit organization dedicated to promoting a culture of continuous improvement in health care in Iowa.

Explore Private-Sector Best Practices

America is not getting good value for the $2.6 trillion it spends on health care each year. High costs are putting care out of reach for millions of families and individuals. Our nation can avoid the emergency room by first addressing the rising cost of health care. By bending the curve on medical costs, more Americans will be able to access the care they need when they need it.

Modernization of our health care system is needed. Americans want a system that is more accessible to all, more affordable, more effective and efficient, simpler and more responsive. Coverage expansions and cost containment are two sides of the same coin and should be pursued in tandem.

Every American must have access to quality and affordable care. To achieve this important goal, we need to:

  • Build upon the foundation of employer-based coverage that more than 160 million Americans currently rely on
  • Reform the individual insurance market
  • Target expanded public funding for low-income individuals and families
  • Modernize Medicare and Medicaid
  • Make better use of technology to improve health care quality and efficiency.

A key take-away from UnitedHealthcare’s work and experiences serving more than 70 million Americans is that many lessons can be learned from the innovations and successes emanating at an increasing pace from the private sector. Reform does not require wholesale change. Rather, by taking advantage–on a broader scale–of what is working today to reduce costs and improve quality, we can build a better, more effective health care system that responds to each of our needs.

Dan Kueter, M.B.A., is president and chief executive officer of UnitedHealthcare, Iowa and Central Illinois. The company is part of UnitedHealth Group, the largest single health carrier in the United States.

Use Incentives, Analytics to Drive Behavior, Drive Down Costs

There are no silver bullets in improving our health care system. As we look at it from a business perspective, we have to focus on keeping people healthy. That’s the major paradigm shift in health care. Our company uses health screenings that categorize people on level of risk. We want to move them to low-risk; if they’re already there, we want to keep them there. We put more benefits money in preventive care and have added incentives for people to take their medications.

We need a system of analytics to show ways to motivate healthy behaviors, drive down costs and avoid unnecessary medicine. Let’s develop national standards and measures so we can assess outcomes and control costs. Let’s regionalize expensive, high-tech lab equipment and services to reduce duplication. And let’s expect people to pay at least a little for their health care so they think about their behavior.

If we run a lot of product down our assembly line, we can realize some efficiencies, but we can’t raise our product prices too much or we’ll price ourselves out of the market. That’s not the way it works in medical care. There’s not enough competition in pricing, and we don’t go hard enough on cost reduction.

Karin Peterson is vice president for human resources at Pella Corp., a privately held designer/manufacturer of residential and commercial windows and doors. Headquartered in Pella, Iowa, the company employs approximately 8,600 people in 13 states and Toronto. Peterson also serves on the Iowa Committee on Value in Health Care and represents her company on the Iowa Healthcare Collaborative.

The state of our system

  • Three out of every four dollars spent on health care are directly spent on treating chronic disease. Seven out of every 10 deaths in the U.S. are the direct result of chronic disease. (Source: Centers for Disease Control and Prevention)
  • The 2008 “America’s Health Rankings” reported the health of Americans had failed to improve for the fourth consecutive year, based on rising obesity, increasing number of uninsured people and persistence of risky health behaviors. Vermont led as the nation’s healthiest state in all factors; Louisiana replaced Mississippi as the least healthy state. (Source: United Health Foundation)
  • The U.S. is the only advanced nation with a large fraction of its population uninsured, 46 million, or underinsured, 25 million. (Source: Council on Foreign Relations)
  • National health spending is expected to exceed $2.5 trillion in 2009, accounting for 17.6 percent of the gross domestic product (GDP). That’s more than $8,000 per every man, woman and child in the U.S. By 2018, national health care expenditures are expected to reach nearly $4.4 trillion–more than double 2007 spending. (Source: Centers for Medicare & Medicaid Services)
  • The World Health Organization stated in 1946, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
  • In 2009, the average annual premium for a family using employer-sponsored health insurance is $13,375, a 131 percent increase from 1999. On average, covered workers contribute 27 percent of the total premium for family coverage. (Source: Henry J. Kaiser Family Foundation)
  • The U.S. spends 44 percent more per capita than Switzerland, the country with the second highest expenditures. (Source: Council on Foreign Relations)
  • A 2009 study by the nonprofit Research Triangle Institute reported that medical spending averages $1,400 more a year for an obese person than for someone who’s normal weight. Overall obesity-related health spending totals $147 billion, 9.1 percent of all medical spending and double what it was nearly a decade ago.
  • Obesity in American adults has increased by 60 percent within the past 20 years; obesity in children has tripled in the past 30 years. One-third of American adults are obese, and obesity-related deaths have climbed to more than 300,000 a year, second only to tobacco-related deaths. (Source: Centers for Disease Control and Prevention)
  • In just three years, the Medicare and Medicaid programs will account for 50 percent of all national health spending.
  • A study reported in the American Journal of Medicine found that 62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Of those who filed for bankruptcy, nearly 80 percent had health insurance.
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