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WHERE WILL AMERICA'S HEALTH CARE SYSTEM BE IN 5 YEARS

Our presidential election is only days away, 48 million people in America are uninsured and health care costs are rising 2 to 3 times faster than our nation's GDP. Where will America's health care system be in 5 years. Welcome to ReachMDs monthly series to focus on Public Health Policy. This month we explore the many questions facing health care today.

Health Care Policy, Medical Professionalism, is this a unique idea? You are listening to a special program on Health Care Policy on ReachMD XM 157, the channel for medical professionals. I am Dr. Bill Rutenberg your host and with me today is Aaron Carroll. Dr. Carroll is an associate professor of pediatrics and Director of the Center for Health Policy and Professionalism Research at Indiana University School of Medicine in Indianapolis. Today, we are discussing the center for health policy and professionalism research at Indiana University School of Medicine.

Dr. RUTENBERG:

Welcome, Dr. Carroll. It is great to have you with us today.

DR. CARROLL:

Thank you for having me.

DR. RUTENBERG:

The press release I read said quick turnaround research of hottest topics of the day related to health policy, medical professionalism, medical education, and physician practice is the goal of the center for health policy and professionalism research or CHPPR that sounds like ReachMD.

DR. CARROLL:

A little bit, yes.

DR. RUTENBERG:

How quickly can your center analyze a problem and offer a solution. Can you give us a concrete example or two?

DR. CARROLL:

It depends on the type of problem and exactly what answer you are looking for. If it is a question of how does the public feel about something or you know what is the general sense that how the public would accept from them when you are looking at survey, we actually are building infrastructure and having out to do quick turnaround phone and mail service. So we are talking around, you know weeks actually if we need to. To do medical research in general takes much longer than that to get it published and previewed, so what we are trying to do is try to create the infrastructure and ability to give rapid turnaround answers for policy makers and even to other medical researchers in a much quicker fashion.

DR. RUTENBERG:

Can you give us an example of a project that is done recently in terms of say a survey format?

DR. CARROLL:

Sure, 5 years ago, we got interested in the idea of how do doctors really feel about National Health Insurance because we hear all the time when people talk about health reform that doctors would revolt that there is no way that they would actually accept any type of big huge reform and we realize that you know that is an answerable question and so we did a mail survey 5 years ago and found some interesting results that really there was some ambivalence, but not nearly the opposition you had expect and then since this was an election year, we decided well be nice to check again and so we conducted another survey of physicians to see would they support or oppose government legislation to establish National Health Insurance and what we found actually again in general we surveyed 5000 physicians and had excellent response and we found that actually 59% of physicians stated they would support or greatly support government law to establish National Health Insurance, which is quite a surprise I think to a lot of people and less and less <_____>> doctors would actually oppose this. We published that in the early April issue of Annals Internal Medicine and it got a fair amount of press at that time and that is the kind of step we want to do where it turns out that there is a lot of questions in policy where you can actually provide answers instead of debating one way or the other and arguing not based on fact, but based on I just believe it so. There are times in health policy where we can actually quantify and answer and that is what we would like to do.

DR. RUTENBERG:

With the National Health Care, did you look it any reasons why doctors either favor or oppose National Health Care?

DR. CARROLL:

We did not ask them directly, but we asked them for a fair amount of demographic and practice and private characteristics to see if we can analyze and see which kind of doctors or which types of practices might favor it or oppose it more. By specialty, we found that those in greatest support were pediatricians, pediatric subspecialist, family practice doctors actually quite high up now, medical internist, and psychiatrist as well, but even you know majority of general surgeons. The groups that opposed that the only specialty that do not have a majority in support were anesthesiologist, radiologist, and surgical subspecialist. We also looked at you know man versus woman and turns out female doctors are more likely the support it, doctors practicing in an urban environment who see more uninsured patients are more likely to support it, but we did not get into the details of why they would or would not support it because again that would to some extent take a much more in-depth study that would take more time and our goal was actually to try to get a snapshot of what was going on in a timing manner, so it could be outlined before the election.

DR. RUTENBERG:

Will you fray that this might be used into a broader sense and otherwise are you in favor of it, sure I am in favor of it because I believe you only asked 2 questions as opposed to how much control would you like to see the government have. You are worried that the press, the public might take doctors' supports National Health Insurance overwhelmingly, two-thirds did. Does that bother you a little bit?

DR. CARROLL:

No, it does not because when we published the results, we only state the question and the answer, so we do not take this to say like hey you know two-thirds of doctors say vote democrat that is not what they said. Two-thirds of doctors said that they support government legislation to establish National Health Insurance and that is what we said and we asked the second question you right said, would you support or oppose more incremental reform such as what people keep opposing and it turns out less doctors said that they supported incremental reform than National Health Insurance and it is hard to look it those two questions in favor what they actually more likely to support National Health Insurance than incremental reform and which can strew that as a greater support for something that truly is not there. Especially since we asked the same questions 5 years ago and we were sure within every single specialty that we measured in 2003 and in 2008 support for National Health Insurance went up and so why I would certainly hesitate to take this and go further with the data then the question actually asks and answers. I feel quite comfortable on saying, 59% of doctors support legislation to establish National Health Insurance.

DR. RUTENBERG:

Now that we know there is this much support, what gives you nightmares about National Health Insurance?

DR. CARROLL:

Well, you know as always in any kind of big type reform there is the potential for damage and danger and you know it needs to be done right and it needs to be done in such a way that costs are controlled and that we to some extent make sure that everybody gets the care that they need without sort of breaking the bank. The big concern is always money, but _____ money as we speak. Certainly, we spent you know 2 to 3 times per person already what any other country really in the world spends on health care and if you look at almost any metric of the quality of health care system we are doing quite poorly. So it is hard to imagine it is doing worse. What we could do worse of course is always we could spent more money and with the economy in the danger that it is right now, we certainly need to keep our eye on the ball with respect to cost and so that would be the issue. Knowing how policy often gets past not on objective data, which is our goal, but on anecdote and sort of personal preference, there is the potential with a big sort of new government bureaucracy that it can get pushed to put a lot of money in the areas where it does not need to go, we would absolutely need to keep our eye on that.

DR. RUTENBERG:

Cost obviously is a big number. Has your center done any policy work on cost containment. In other words, if you can make say a 3-point or 5-point plan to the candidates, here is how we think we can provide health care at a reasonable cost. Have you done any work there and what have you come up with?

DR. CARROLL:

We have not actually done any like actually what I would call research. Certainly, we discussed the issue amongst ourselves and we had had many debates and arguments and we have definite thoughts on how we can proceed. Certainly there is the model of what other countries have done. What interesting about this is that pretty much every other industrialized nation in the world has gone toward the National Health Insurance System and we should not ignore that. What we should do is look at them and what succeeded and what has failed and you know some countries have done a much better job with the National Health Insurance System and in containing cost than other countries. They have all done better job in containing cost. I should say that in it almost all of them have spent you know one-third to one-half, as much as we do per person, which is remarkable.

DR. RUTENBERG:

But why?

DR. CARROLL:

Well, a lot of it comes down to some extent through administrative overhead and that their systems are much more efficient. Some of it comes down to fact that they spent less on some technologies and pharmaceuticals because they can collectively bargain as large groups. Some of it comes down to the fact that the physicians are very well paid in this country higher as compared to all other people than in other countries and some of it because they spend money more effectively be it on preventive care or on things that might actually prevent illnesses as opposed to having to pay much more money on the back end and when you add all that up together it actually winds up being significantly less money. Here the other thing that we should not ignore and I do not like to deaminase the private health insurance industry is that there is no profit in the National Health Insurance System and so you know all the money that sort goes into the system to some extent either goes into a tiny bit of administrative overhead or into actual care. None of it gets diverted off into profit or to dividends or anything else, which also saves quite a bit of money and so most of those countries should operate in a bigger more efficient scheme. So, looking in this country how it might happen is that you know your average non-profit private insurance company in this country operates somewhere about less than 15% overhead. While the investor on Blues are up in the order of 20% to 25% overhead. Medicare operates just over about 3%, meaning that 97 cents at every dollar put in to Medicare goes into actual patient care and yet in general, people feel the Medicare is terribly inefficient. Actually if you think of efficiency as how much money instead wasted on non-medical stuff, Medicare’s by far the most efficient Healthcare System in this county.

DR. RUTENBERG:

Well I will respell that Healthcare has no business trading on the New York Stock Exchange.

DR. CARROLL:

I would agree with you there and I think a lot of doctors agree with you. Of course, many will disagree as well and if certainly something that we should talk about, but I think the important thing is that we actually do talk about it and have an open public debate and actually discuss how much or how little of the money should go into different things. That is a lot of how they do cost containing in other country. It is very public. It is very open. You know where is the money is going. You know where it is being wasted because it is the government, they have to tell you. A private insurance company is a black book. It is a black box I believe. You know you cannot see what in it and know where the money is going or how and without sort of the pressure of knowing where the things are going, it is impossible really to make a change.

DR. RUTENBERG:

One of my favorite articles I have ever read is your article on medical myths. <_____ >We talked about preventive care as a cost saving.

DR. CARROLL:

Yes.

DR. RUTENBERG:

I had an opportunity to interview Dr. Jeffrey Joyce from the Ryan Corporation.

DR. CARROLL:

Yes.

DR. RUTENBERG:

And they published a study showing that if we are effective in preventive health care, people will live longer because they are healthier and it will cost us same amount of money. We really would not save anything.

DR. CARROLL:

Ya, I think actually that I would almost on the side of saying we are going to spend worse. Preventive care, is not see this is an interesting argument, I am glad you brought this up. Preventive care to some extent is not as much about cost containment as it is about you know doing good about improving outcomes. Because lets be quite honest here, the quickest way to reduce cost in the United States is if every smoker die tomorrow because then we would never have to pay for their bills any more.

DR. RUTENBERG:

No actually scariest thing is what I heard proposed recently by one of the insurance companies and that is we cut off care in the last 6 months of your life. The only problem is, when is the last 6 months.

DR. CARROLL:

Exactly.

DR. RUTENBERG:

But that is scary.

DR. CARROLL:

It is very scary, but in the United States to some extent we have made I think a collective agreement that cost is not our main concern because we spend money like crazy.

DR. RUTENBERG:

Ya, we just have more.

DR. CARROLL:

If cost is not our main concern, why do not we make access often. Why do not we actually improve the outcomes. We have already sort of agreed to cost, we are just going to let it go. I agree and that I do not think that preventive health is the way that you actually decrease cost over the long term. I do think; however, that preventive health care is the way that we actually improve outcomes, that we improve life expectancy, and there might be reduced secondary cost as we become a more profitable society and people in general can function better, but they are absolutely correct, making people live longer is likely in the longer going to cost as more money in general. I still say that is good and it worth the money.

DR. RUTENBERG:

I would like to thank Dr. Aaron Carroll who has been my guest for the special program on health care policy on ReachMD XM 157, the channel for medical professionals.

I am Dr. Bill Rutenberg and we were discussing the center for health policy professionalism research at the Indiana University School of Medicine.

I invite you to listen to our on-demand program library by visiting us at reachmd.com. If you have questions or suggestions call us at 888MDXM157.

Thanks for listening. Until next time, I wish you good day and good health.

You have been listening to Public Health Policy in America a special ReachMD XM 157 interview series with our nation's top thought leaders in public health. This month ReachMD XM 157 will be discussing the many issues challenging public health policy in America. For a complete schedule of guests and programming information visit us at reachmd.com.