What Health IT Won't DoBy M.L. Baker | Posted 11-27-2005
The U.S. has 46 million uninsured people. It also leads in the fraction of its citizens who forgo care to save money, according to a study by the Commonwealth Fund that surveyed thousands of "sicker adults" across six developed countries. Americans who do get care pay more. Thirty-four percent of U.S. patients surveyed had spent more than a thousand dollars; no other country aproached this rate. Australians and Canadians came closest, with 14 percent paying as much.
As far as health care dollars go, we are doing less with more. We spend about 15 percent of our GDP on health care; that's twice as much as the UK and 1.35 times as much as Germany, according to the Organization for Economic Co-operation and Development (OECD). Despite this spending, the U.S. has worse metrics for longevity and infant mortality than many other developed countries. In the Commonwealth study, the U.S. scored the highest on all seven measures of patient-reported medical, medication, and lab error rates, though not all differences were statistically significant. Americans even have to wait longer to get a regular doctors' appointment. (We come in a close second to Germany for the shortest wait times for specialist appointments and for elective surgery.)
Costs are getting worse, particularly for individuals. Employer health insurance premiums went up by 11.2 percent last year , up 59 percent from five years ago, and family premiums are now approaching a year's salary for a fulltime worker earning minimum wage, according to the Kaiser Family Foundation. The automotive and airline industries are threatened with bankruptcy partly because of health care costs for retired workers.
Runaway costs are blamed on a variety of factors: lack of competition among insurance companies, overutilization, medical malpractice lawsuits, the copious administrative costs involved in filing and disputing claims. Insurance companies don't seem to be suffering: Aetna, Wellpoint, and UnitedHealth reported earnings increases of 25 percent or more from a year ago.
Health information technology, done right, could help knit a fragmented health care system together, bring down costs, and improve access, but it is policy, not technology that is needed to cure U.S. healthcare ills. Indeed, some policy changes are essential to clear the way for technological benefits.
The pay-for-performance movement, though its success is still unproven, is a good example. Instead of paying doctors per procedure or diagnosis, a practice that rewards overutilization, it rewards doctors for sticking to clinical guidelines. That's a change in policy, not technology. Yes, technology is involved in documenting doctors' practice, but the biggest hurdles involve policy. Doctors don't want their incomes to drop if they perform poorly, or if they happen to treat sicker, less compliant, or simply more atypical patients than their peers; optimal clinical guidelines are disputed, as are appropriate measures of performance. (Some programs reward doctors simply for using health IT rather than trying to assess its benefits. That misses the point.)
Although few politicians and fewer executives dare to admit it, the policy change that both employers and patients need most is an alternative to employer-provided health insurance. Tying insurance to employment stifles entrepreneurship, that quintessential American characteristic. I'd wager that nearly everyone knows someone plodding away in an unfulfilling job for fear of losing health insurance. I know two couples who decided to get married because a partner needed health insurance.
Insurance companies have every reason to shun unhealthy workers. A recently released Wal-Mart memo famously shows how these motivations are passed on to employers. Among other strategies, managers were advised to make sure that every single job included physical activity. This was not to help employees get exercise, it was to make sure only reasonably healthy people could stay on the payroll.
The insurance companies that determine how much employers pay for their employees' health care have little incentive to preserve people's long-term health. On average, a particular insurance company will cover a particular worker for only about two to four years, so why should an insurer invest in programs that could save money for its competitors? Part of the rationale for the Medicare prescription drug benefit is that it could keep seniors healthier and save money by cutting hospitalizations. But steps to establish a healthier senior population should start well before its members turn 65.
Unfortunately, there's little market for that kind of foresight.