Friday, October 23, 2009

Four Pillars of Healthcare Reform Needed in America

Dr. David Nash, Professor of Health Policy and Medicine at Jefferson Medical College of Thomas Jefferson University in Philadelphia was in an interview with Marti Moss-Coane of WHYY Radio, Philadelphia talking about the American healthcare system. Here is the podcast link. He has experienced it from his lofty perch as a national health policy leader as Founding Dean of the Jefferson School of Population Health, as an Internist, as well as from the point of view of caregiver to his aging father.

He has decided, after much experience, that it's "fragmented and poorly-designed."

He says that in the case of his father's palliative care, a new medical specialty that is about chronic care management, new strategies would have been helpful. Moderated discussions with healthcare professionals as far as utilizing resources, care at the bedside, and pain management issues should have been implemented.

What can be done?

Four Pillars of Healthcare Reform

1) Create Value in the System. We're spending the most and we don't get much for it. America isn't currently ranking in the top 30 countries in the world with the best healthcare. It's "as dysfunctional as it can get" he says.

2) Cover and Insure Everyone. "How" we do so is negotiable. Real reform of healthcare financing is what the country needs. He suggests bundling money given to hospitals. He thinks that a public plan is something the government pulls into the discussion at will, as a power play, but that it might add to the mess, because it could put the whole system at risk. When asked if it would force competition by lowering costs and require companies to improve, he says real changes in the way doctors and hospitals are paid are needed. For example, true costs could be clarified before procedures happen.

3) Promote Prevention and Wellness. The financial incentives now are at the high end, for fashionable big-ticket expenses, such as financing heart surgery and more helicopters. He says that only 3% of the population can say they practice all the following: 1) they don't smoke 2) wear a seatbelt 3) eat variety of fruits and vegetables and 4) are the appropriate weight. He says we are all paying for diabetic care and for smoker's care. One third of all healthcare dollars are being spent on diabetes, he says.

4) Coordinated Care. Healthcare now is piecework. There are 18,000 billing codes and none for coordinated care. He says that doctors would do it immediately if they were paid to do it. They obviously must be forced to change with financial incentives. There should be more sharing of information electronically. Since solid science is behind only one in five medical decisions, the need for coordinated care is obvious. There needs to be more investment in primary care, and coordination of related medical professionals in offices and follow-through of medical conditions.

Dr. Nash says the insurance system could improve if we focus on what matters and keep the system patient-centered. Medical errors are serious problems and the error rate needs to be lowered. Since medical care will never be perfect, the focus has to be on being harm free, if not error free.

Also, Dr. Nash says resources are overutilized in some zipcodes. He says there is already rationed care in this country because of the "knuckleheadedness going on in Washington."

He doesn't hear the President saying "Let's do a better job coordinating care and practicing prevention." He says it didn't happen around the country with managed care. There is a lack of coordination and communication. Financial incentives are headed in the wrong direction. He says that care is a complex process and tools can be brought to bear in this technological day and age.

Here's the podcast link, at WHYY National Public Radio (

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