Health-care system must be fixed, speaker says

Fixing issues related to health-care costs and coverage in the United Stateswill not be easy, but something must be done, said Roger C. Herdman, MD, to attendees at anevening guest lecture March 6 at the American Glaucoma Society annual meeting.

Dr. Herdman, director, Board on Health Care Services, Institute of Medicine (IOM), NationalAcademy of Sciences, shared facts and statistics to provide a view of where things stand. Hestressed that his talk represented his views, not necessarily those of the IOM.

Despite the large variation across the country in the costs associated with providing medicalcare, little variation exists in outcomes, he said. Also, only half of the care meetsrecommended standards; 30% is redundant, ineffective or inappropriate, Dr. Herdman said. TheUnited States has the highest rate of medical errors among six developed nations, headded.

Racial disparities exist related to quality of care provided, Dr. Herdman said, and the costsrelated to Medicare keep increasing to such an extent that the program could be insolvent by2019.

Safety-net provisions-voluntary hospitals, academic health centers, public health clinics,community health centers, free care, and emergency departments-have prevented the health-caresystem from collapsing.

"But all of these are in distress now," Dr. Herdman said. "The fact of the matter is, [thesystem] is slowly imploding."

Costs have increased because of improving technology, care associated with obesity and aging,the fact that supply generates demand, commercialization, risk selection, cost shifting,resource allocation, and other reasons, he said. The short-term implications are thatreimbursements are lowered; the use of technology is controlled; patients pay higher co-pays,co-insurance, and deductibles; pay-for-performance and physician profiling measures related tocosts are undertaken; and other steps are taken as well, he said.

Despite all of these issues, and with shortages and high attrition rates for nurses and otherdirect-care workers, most patients in the United States indicate that they are satisfied withthe current health-care system, although they are worried about it, Dr. Herdman said. He notedthat surveys indicate that Republicans are more likely to be satisfied with the system than areDemocrats.

When asked whether he had solutions to the challenges facing the health-care system, Dr.Herdman said, "Many of the people I talk to say that we could fix the system very easily,[that] all we need is a will to do it, and what they're really talking about, of course, is asingle-payer system. That's certainly one approach, but it certainly has its detractors."

The average American believes that centralized, governmental health-care systems such as thosein Canada and much of Europe are "terrible," Dr. Herdman said. In actuality, emergency-roomwaits in England and the United States are comparable, he said.

"I don't have a solution to the problems of the health-care system, but it seems to me thatMedicare was a pretty good program, and it might not be a bad idea to try to pursue somethingalong those lines," Dr. Herdman said.

He said he is skeptical that the United States government ever will move to using costeffectiveness analysis as part of its system.

"It seems like a gloomy situation. What I've tried to do is tell you some of the facts," Dr.Herdman said. "We will need to meet these challenges."

When it comes to the presidential candidates, Dr. Herdman said that the health-care plansproposed by Sen. Hillary Rodham Clinton (D-NY) and Sen. Barack Obama (D-IL) are very similar;one difference is that Sen. Clinton's plan would require everyone to obtain health-carecoverage, whereas Sen. Obama's would not. Democrats, in general, he said, are more likely tofavor more spending, more government involvement, more coverage, and more cost controls.

Opponent Sen. John McCain (R-AZ) would seek to reform the tax code so that health-care coverageis not tied to employment, Dr. Herdman said; instead, Sen. McCain would seek tax credits tohelp individuals pay for health-care coverage.

In response to a question from the audience, Dr. Herdman said that the candidates may addresstort reform on their Web sites but that he hasn't heard much talk about it in speeches.