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Improve care, lower costs

More primary-care physicians, treatment standards and electronic medical records would help.

July 13, 2009

Americans like to complain about the healthcare system, but they're unnerved by many of the proposals for improving it. More than 90% of those surveyed last fall by the Deloitte Center for Health Solutions said that healthcare costs are a threat to their personal financial security, and 80% gave the system a mediocre grade or worse. Yet less than half favored measures to promote electronic medical records, the use of scientifically proven treatments or more monitoring of the safety and effectiveness of drugs. Evidently, we'd rather live with the shortcomings we know about than risk more severe ones.

One encouraging thing about healthcare reform, however, is that improving the quality of care can help slow the debilitating increase in costs. It's good for all. And although the changes required won't be easy, they're essential to the crucial third piece of the healthcare reform puzzle, which is providing coverage to all Americans.

Healthcare providers, academics, analysts and insurers agree that the starting point to improving quality is in adding to the ranks of primary-care doctors and giving them a more proactive role in maintaining their patients' health. According to the American Academy of Family Physicians, other industrialized nations have found that adding one primary-care physician for every 20,000 people decreased the number of unexpected premature deaths by 9%. It also decreased hospitalizations and reduced the amount of care required for many ailments. It's not enough, though, just to have more of these doctors; they also need to expand their contacts with patients, promoting healthy behavior, managing chronic conditions and coordinating the care delivered by specialists, clinics, hospitals and other parts of the healthcare system. Such coordination is rare outside of tightly integrated providers such as the Mayo Clinic, and quality suffers as a result.

The main reason for the shortage of primary-care doctors is that Medicare, Medicaid and private insurers don't pay enough for the work they perform. The current system generally reimburses providers for what they do to their patients, not how well their patients stay, which means it undervalues immunizations, routine checkups and other services that can ward off or mitigate ailments. As Dr. Ted Epperly, president of the family physicians group, has noted, insurers will pay a lot to amputate the leg of a diabetic patient, but not so much to provide the services that might have prevented the amputation. Consequently, the U.S. has a lower percentage of primary-care physicians (about 30%) than other industrialized nations. Worse, the number of med-school graduates choosing primary-care fields is declining rapidly, dropping by half since 1997.

The current reimbursement regime also gives primary-care doctors an incentive to spend less time with patients in order to rush more of them through their offices. They order more tests and call in specialists more frequently than they would if they could afford to spend more time on diagnoses. That's another reason why a bigger investment in primary care should lead to savings in the overall system.

A second step toward higher-quality care is developing treatment standards to guide doctors, clinics and hospitals. This is a controversial move because of the fear that Washington would use the standards as a pretext to limit spending on expensive drugs or interventions near the end of life. Yet even if medicine remains an art as well as a science, it seems foolish not to look at the results of different treatments to try to discern which ones work best under various circumstances. Too little is known about the best way to respond to too many ailments.

The point isn't just to alert doctors to the industry's best practices. It's also to help patients choose among treatment options, especially if the research on comparative effectiveness were to be accompanied by data on how much the approaches cost. Even patients with insurance can face significant out-of-pocket expenses, so information about cost and effectiveness would help them weigh their doctors' advice against experiences from across the industry.

Having physicians lead the research would help reassure the public that the primary goal is to improve care, not to save money. To give those treatment standards teeth, however, they should influence reimbursements -- for example, insurance companies could offer higher payments to doctors and hospitals that meet them.

A third step is to promote the use of information technology in tracking patient care. There are many reasons to switch from paper to electronic medical records, but the most compelling is that it gives healthcare providers better tools for managing patient care. These include systems that guide which medicines are prescribed, what dosages are ordered and when they are to be administered -- three of the most common sources of medical foul-ups. Such technologies have cut errors by half or more.

In addition to averting potentially lethal errors, these systems can help doctors make sure patients pursue the follow-up care they often neglect after they leave the office, much to their own detriment. Software can also help physicians diagnose ailments and adhere to industry standards for treating them. Today, however, electronic medical records are the exception, not the rule. The high cost of converting to these systems is daunting, especially for smaller medical practices (which is why Congress provided about $20 billion in subsidies for electronic medical records earlier this year). Other challenges include the lack of a standard format for sharing electronic records among healthcare providers, and the privacy risks posed by putting such sensitive data into electronic form. Yet the improvements in quality and physician productivity are more than enough to justify making the switch, and doing it soon.

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