WASHINGTON, DC-At a time when 47 million Americans lack health insurance, the US medical system is suffering from the wrong kind of incentives and should be organized differently. That was one of the conclusions at a news briefing here sponsored by the American Medical Association.
Michael E. Porter, PhD, MBA, the Bishop William Lawrence University Professor at Harvard Business School, presented his ideas for health system reform at a news briefing here sponsored by the American Medical Association, held in conjunction with the publication of a theme issue on access to care in the March 14 issue of the Journal of the American Medical Association. Dr. Porter's article, How Physicians Can Change the Future of Health Care, was coauthored with Elizabeth Olmstead Teisberg, PhD, MEngr, MS, of the University of Virginia Darden Graduate School of Business
So much of health care reform is coming from outside, Dr. Porter said at the briefing. We believe the only way things will change will come from within, from doctors themselves. Insurance is just the beginning; we need to fix the delivery system…. We have 21st-century technology delivered with a 19th-century delivery system.
Figure. Michael E. P...Image Tools
Instead of the current overall system of fragmented, episodic physician visits and tests at different silo sites, Dr. Porter said his research leads him to believe medicine should be restructured and organized around medical conditions and cycles of care. And, he said, risk-adjusted outcomes and costs for each medical condition should be measured.
Payment should be for a cycle of care, he said, not for each discrete service. Today you can get a single price for an organ transplant; this price covers everything, he noted.
We believe this is something only physicians can do, he remarked of this new organizational approach to health care. Physicians have to get out of the bunker; it's time for physicians to lead…. We hope that if we get the physician community leading this effort, we will have a real chance of something happening. If we don't do something, we get on the dangerous path to rationing.
Example of Different Organizational Approach
As an example of organizing medical treatment by medical condition, Dr. Porter cited care at an institution such as the University of Texas M. D. Anderson Cancer Center. He noted that a breast cancer patient will likely have all of her medical care in one area, and that her treatment will likely be coordinated by her primary oncologist. She will not have to trek from hospital to radiology center to physician office to physician office to get her treatments and x-rays. She will be in one integrated system, he noted.
Asked if cancer care can be looked to as a model for the kind of restructured health care system he envisions, Dr. Porter, coauthor of the recent book Redefining Health Care, said yes. Cancer care is much more integrated, he said in an interview. M. D. Anderson is particularly far along…. I think cancer care is ahead, particularly in some of the major cancer centers.
Change Needed in Not Just the Process, but an Overall Restructuring
Dr. Porter said some of the current health reform initiatives, including pay for performance (P4P), focus only on the process of health delivery, not on an overall restructuring he believes is necessary.
Asked by OT to comment on quality-improvement programs of specialty groups, which come from within a medical discipline, Dr. Porter said, Most provider organizations are measuring process measures, not outcomes measures.
Due to outcomes-based health research at Dartmouth University and others, I think we now have a proof of concept on outcomes measures. Outcomes measures, he noted, include: Did the patient survive? How long did recovery take? Were there complications of recovery? In cancer care, he said, outcomes measures are especially important because a cancer survivor may develop complications of treatment years after receiving therapy.
Other speakers at the AMA news briefing also stressed that health system reforms are needed to preserve patient access to quality care. The uninsured often receive less medical care and take longer to improve after being diagnosed with a new chronic condition such as cancer, heart disease, or diabetes or after suffering an unintentional injury such as a fall, fracture, or sprain, according to the study in the same issue of JAMA (2007:297:1073-1084) by Jack Hadley, PhD, Principal Research Associate with the Health Policy Center of the Urban Institute in Washington, DC, and a Senior Fellow at the Center for Studying Health System Change.
Included under new chronic conditions in the study were cancers of the digestive and respiratory tracts; bone; skin; genitourinary organs; and other neoplasms.
Dr. Hadley analyzed data on non-elderly patients from the Medical Expenditure Panel Surveys (1997-2004). He studied 20,783 cases of unintentional injuries and 10,485 cases of the onset of one or more chronic conditions.
He found that uninsured people were 53% less likely to obtain care for unintended injuries, and uninsured people with a new chronic condition were 55% less likely to obtain any medical care. Dr. Hadley said he was particularly concerned about the data on uninsured people with chronic conditions, because chronic conditions need chronic care-Once something like this happens, it can lead to a death spiral. Similarly disturbing results of being uninsured have been reported by the Institute of Medicine, among others.
Underinsured
Even if people are insured, they may be at risk for adverse outcomes because they are underinsured, said Harlan M. Krumholz, MD, the Harold H. Hines, Jr., Professor of Medicine and Epidemiology and Public Health at Yale University School of Medicine.
In his study in the JAMA theme issue, Dr. Krumholz and colleagues found that heart attack patients with financial barriers to health care have a poorer recovery, a poorer quality of life and a higher risk of re-hospitalization than those without such barriers.
According to data in the article (first author is Ali R. Rahimi, MD, MPH), more than 16 million Americans avoid health care because of its costs or have trouble affording their medications despite having health insurance.
Dr. Krumholz and his coauthors found that of those patients who reported financial barriers to health care services, fully 68.9% were insured, and of those who reported trouble paying for their medications, fully 68.5% were insured.
I think this is one of the most important findings of my study, Dr. Krumholz said. Even insured people have trouble paying for care…. These patients are experiencing their recovery in a different way from those with no financial barriers. He added, To me it's a very stark decision point. We're talking about getting people proper insurance and appropriate insurance.
Catherine D. DeAngelis, MD, JAMA Editor-in-Chief and the moderator of the news briefing, noted that the United States spends some $2 trillion on health care, about twice as much as Canada, and yet has 47 million uninsured citizens.
In a statement, AMA Board Member Jeremy Lazarus, MD, called the effort to extend health care coverage to all Americans an urgent need. He said, Sadly, as employer-sponsored coverage continues to decline among modest-income families, more hardworking parents find themselves unable to provide health care coverage for themselves and their children. Covering the uninsured is a top priority for the AMA, and covering America's children is the first step.
The AMA supports reauthorization of the State Children's Health Insurance Program (SCHIP), which covers about six million children whose parents cannot afford health insurance but make too much to quality for Medicaid. Millions more US children are eligible for SCHIP, but are not enrolled.
Survey Reveals Need for Standardized Oral Chemotherapy Prescribing
Despite the widespread use of prescribing safeguards for infusion chemotherapy, few of those measures have been implemented with oral chemotherapy, according to a study by researchers at Dana-Farber Cancer Institute.
In the Jan. 13 issue of the British Medical Journal, Saul N. Weingart, MD, PhD, Vice President for Patient Safety, and his colleagues report that a survey of NCI-designated comprehensive cancer centers found few organizations with standardized prescribing practices for oral chemotherapy.
Given how quickly oral chemotherapies have become standard care for a growing number of cancers, we were not surprised to find variations in how organizations prescribe and monitor the use of these agents, Dr. Weingart said in a news release.
It was surprising, however, that few of the safeguards used with infusion chemotherapy have been adopted for oral chemotherapy.
The researchers sent a survey on the current practices for prescribing, coordinating and monitoring, dispensing, and educating patients about oral chemotherapy to 54 NCI-designated comprehensive cancer centers, of which 42 centers responded.
Dr. Weingart said the survey revealed significant variations in the way that prescriptions were generated at most centers and in the amount of information required to complete them.
Nearly 70% of the centers (29) used handwritten orders for the majority of oral chemotherapy prescriptions, 5% (2) used preprinted paper prescriptions, and 14% (6) used computed-based prescription order entry systems.
An analysis of the information required to order prescriptions for six oral chemotherapies found that few centers mandated the inclusion of the patient's diagnosis (26%), the treatment's schedule and duration (9%), or the patient's body surface area, and only 21% of the centers required a second physician to review and approve the chemotherapy order.
More than half of the centers had no required elements for oral chemotherapy prescriptions.
The respondents also reported that between 2004 and 2005 at least one serious adverse drug event related to oral chemotherapy occurred at 10 centers, and 13 centers experienced a serious near miss.
The research was supported by the Center for Patient Safety at Dana-Farber and the Agency for Healthcare Research and Quality
© 2007 Lippincott Williams & Wilkins, Inc.