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With a new White House occupant on the way and signs of a day of financial reckoning looming for Medicare, experts at Johns Hopkins say changes in national health policy may finally be in the offing — if only we could figure out how to make them happen.

By Michael Anft

With a new White House occupant on the way and signs of a day of financial reckoning looming for Medicare, experts at Johns Hopkins say changes in national health policy may finally be in the offing — if only we could figure out how to make them happen.

To get at the story of health care in the United States, look past the individual sagas you've read about in newspapers. Don't think about patients losing their homes to medical bills, or of people watching a child or spouse or parent die because they can't afford care. While you're at it, put aside the medical attention you receive, which you're generally happy with, according to most surveys. Instead, immerse yourself in the harrowing statistics: The United States spends $2.1 trillion a year on health care. More than 30 percent of that — about $700 billion — has nothing to do with improving people's health. Instead, it goes to administrative costs and for tests and treatments that aren't necessary. About half of all patients don't receive proper treatment. Fifty-seven million Americans struggle to pay their medical bills, and around 46 million have no health care coverage at all. A study by the Institute of Medicine found that 18,000 Americans die each year because they don't have health insurance.

If the American health care system were a patient, such vital signs would suggest that it is very sick, and that the disease is spreading to the body politic. Indeed, despite spending nearly $7,000 per person a year on health care — around twice as much as most other developed countries — the United States ranks 42nd in the world in life expectancy. Try reading all those numbers without focusing on one word: crisis.

"The best of the best of our health system is the best in the world," says William R. Brody, president of Johns Hopkins University, who will retire from his post at the end of the year. "But the average is not so hot. We need to do better."

But you probably know that. More than 80 percent of Americans think it's time to overhaul the system, according to survey results released in August by the New York health care research group Commonwealth Fund. A poll published in April in Annals of Internal Medicine suggests that nearly six in 10 physicians prefer a "single-payer" plan like Medicare, which the federal government runs with relative efficiency. Both major political parties have made changing the way we manage health care a plank in their platforms. So, if everyone agrees national health policy needs a makeover, why hasn't it happened?

"It really comes down to power and money," says Jonathan Weiner, a professor of health policy and management at the Bloomberg School of Public Health. "This issue is also about individual rights versus social responsibility, the role of governments versus the role of individuals. If the whole thing wasn't any bigger than health care, we would have solved it already."

Others, including Brody, say that though Americans say they want change, many are satisfied with their own care and lack the collective political will to force a large-scale upgrade because of it. Still, the inaction can be bewildering. How can the richest nation on Earth allow 15 percent of its population to play Russian roulette with its health, as well as with its finances, by having no insurance? Why should the effective but overstressed Medicare program be allowed to run in the red and be threatened with bankruptcy in the coming decades as 77 million baby boomers hit retirement? And why do Americans as a group accept subpar care for all they spend to keep themselves healthy?

Such vexations are particularly relevant at Johns Hopkins. "We're fully hedged on health care," says Brody. "We educate people about medicine, we insure our employees, and we're also a large provider of health care. We can have costs rising on the one hand, and still lose money on the other. It's a real tangle." The university is a regular presence in Washington, testifying before congressional committees and offering expert insight to staffers there who focus on health policy. But getting politicians to engage in discussion on the issue has been nearly impossible. For much of the past year, Brody has tried to corral presidential candidates to talk about health care for a series of prerecorded television programs. "Most of them didn't want to get near it," he says, suggesting that though many candidates talk about health care on the stump, the issue is simply too thorny for them to sit down and discuss in a deep or specific way. Brody also lacks faith in Congress' ability to break its long-standing gridlock on the issue.

Still, others inside and outside of Johns Hopkins see the coming change at the White House as a sign that health care might finally receive a much-needed policy transplant, no matter who wins. (At press time, the presidential election had yet to be decided.) The economy willing, 2009 could be the year. "These days, Congress is looking to do something — and something big," says Ellen-Marie Whelan, a former assistant professor at the School of Nursing, and now staff director for the Senate Subcommittee on Retirement and Aging and an aide to Senator Barbara Mikulski (D-Md.). "It takes a lot of effort to change even the small things regarding health care. So, the thinking is, if we're going to make the effort, why not do something large?"

There is no easy comprehensive answer to the health care crisis. But Johns Hopkins people spend a lot of time living the issue and thinking about it, and some have developed programs to make health care better and cheaper. In an attempt to understand what shape health care in the future might take, we asked Hopkins administrators, economists, physicians, and researchers six questions central to the health of a system Americans entrust to keep them healthy:

Can universal health care work?

Nearly 60 percent of Americans who are privately employed have some sort of employer-supported private health insurance, though that number has decreased by 5 percent since 2000. The government covers another 28 percent of Americans through Medicaid, Medicare, and other programs. The rest are on their own. Lacking access to the primary care that could keep them healthy, they may resort to expensive emergency room visits they often can't pay for. Or they may put off seeking care until their conditions worsen, requiring more extensive treatment. That's bad for them, but it's also bad for everyone else because the law requires hospitals to give emergency care treatment (see "Red Alert"), and those costs are borne by hospitals and taxpayers. Not only does the cost of hospital care for the uninsured drive up the price of care for everyone, in some states, including Maryland, insurance companies must help cover the cost of hospital care for the uninsured. Those factors contribute to higher private insurance premiums, which have skyrocketed by 87 percent since 2000.


Red Alert
High-cost emergency rooms reflect a health care system out of control.


Some people who study the coverage issue at Johns Hopkins think that health insurance should be like a kid's swim party: Everybody into the pool. By having each insured participant taking on the health risks of everyone else, and constructing a system that guarantees everyone is covered, money would flow into the pool more consistently, and everyone could receive basic medical care. A so-called universal health care system might go a long way toward lowering the costs that the uninsured bring to bear on the system, and to lower the likelihood of medical catastrophe that often results from not being able to pay for care, says Gerard Anderson, a professor of health policy and management at the Bloomberg School.

But others say that universal coverage, while desirable, is no panacea for what ails health care. Weiner, for instance, suggests that continuing rises in health costs might make universal coverage unworkable. And there's the question of whether there are enough primary care doctors to treat 300 million people. A recent study by the National Association of Community Health Centers estimates that as many as 60,000 more primary health care providers would be needed to handle the crush. "To make this work, we'd need to have more physicians' assistants, nurse practitioners, and others to do more primary care," says Edward Miller, dean of the School of Medicine. "We'd also need to increase incentives for primary care physicians to care for populations of patients, and not just to treat ailments."

"Universal coverage is certainly a worthy goal, but it's not an answer," adds Patty Brown, chief executive of Johns Hopkins Health Care, which runs insurance plans for Hopkins' 44,000 employees and some Medicaid and military patients. "To get to that answer, we'd have to address the environmental aspects of our health culture, such as people who smoke, or can't get produce where they live, or who live in neighborhoods where there's no place to exercise. There's no magic wand for this."

How will we pay for it?

A plan with the government acting as the sole insurer — a single-payer system — could save as much as $350 billion per year, according to the Physicians for a National Health Program, an advocacy group in Chicago. But a majority of Johns Hopkins administrators and professors say the single-payer idea would never get out of the legislative box. For one thing, drug and insurance industry lobbyists simply have too much clout in Washington. What appears more likely is a government guarantee of health care but with private insurance options.

One possible solution, offered by Anderson, would be a health plan available to the unemployed, the currently "uninsurable," and healthier workers and their employers — a plan he calls Medicare Part E(veryone), which he and others announced in a recent paper published by the Brookings Institution, a nonpartisan think tank in Washington. The plan would be mandatory for those without public or private insurance. Those who preferred to buy private insurance still could, but the federal government would guarantee at least a minimum of coverage to the entire U.S. population. Using a sliding-scale system based on an individual's income, the government would kick in part of the cost of coverage, as would the individual and his or her employer. Such coverage has the potential to eliminate the wide disparities in health care across the country, while giving employers and individuals who buy private insurance a lower-cost insurance option, says Anderson. Also part of the political debate is health savings accounts or tax credits. Most researchers and health care providers at Johns Hopkins, however, show little enthusiasm for such options, skeptical whether they will go very far in helping families pay the $12,000 on average that private health insurance currently costs them.

How can the richest nation on Earth allow 15 percent of its population to play Russian roulette with its health by having no insurance? With health care seemingly stalled in Washington, some states, including Massachusetts and Oregon, have taken stabs at making health care more affordable for their residents. In 2001, six faculty members at the Bloomberg School, including then dean Alfred Sommer, SPH '73, worked with the Maryland Health Care for All! Coalition to develop a program to close the insurance gap in Maryland, to be funded by a 2 percent tax on all state businesses and increased levies on alcohol and tobacco. "We saw that the feds haven't had the stomach to deal with health care — it was the same with tobacco — and that states would have to ramp up their own ideas," says Sommer. "We decided that it was consistent with the school's mission to help them. It is in all of our best interests to have a good, strong system for everybody." So far, the group has succeeded in expanding Medicaid to cover more Marylanders.

The coalition, which unveiled its plan for a statewide guarantee of insurance at the Bloomberg School this month, is headed by Vincent DeMarco, A&S '79, '82 (MA), who now also has an appointment at the School of Medicine. "There's a consensus out there that some level of government has to do something," he says. "The public has wanted health care to be more rational. This is a sane way of improving access to health care without giving in to the vested interests of the private insurance industry or the single-payer extremists."

Will we have to ration care to afford it?

Other Western or Westernized countries with government-run health systems, including Canada and the United Kingdom, limit the number of tests and treatments they'll pay for. Yet those countries still have longer life expectancies and lower infant mortality rates than the United States. Because more people are seen regularly for checkups, complaints, and vaccinations, populations in those countries are healthier and generally happier with the health care they receive than Americans are, according to surveys.

However, Americans, raised to value choice and availability of a full range of services, might not buy into a similar program. "The prospect of not rationing worries me more than rationing," says Brody. "Part of the problem with health care is that Americans think they should be able to get any kind of services at any time they want. How do you tell them that they can't?"

Without question, rationing would require tough choices. Take, for instance, end-of-life care. According to one widely publicized though controversial source, the Dartmouth Atlas Health Study, health care spending at hospitals during the last two years of life typically costs about $50,000 per patient. According to that study, costs at Johns Hopkins Hospital — which tends to attract extremely sick patients — were significantly higher. "If we ration, does that mean that no one over 80 gets their aorta fixed, or that we take them off of dialysis?" asks Miller. "We might be able to do more palliative care, or move people to hospice earlier, but it's never an easy call."

Nevertheless, some kind of limits on services might be necessary to bring fiscal sanity to a system that has gone mad, says Weiner. "We've got to identify things that work, things that don't, then draw a line — there has to be a budget. It's the most pressing ethical question we face."

To make those calls, says Ronald R. Peterson, president of Johns Hopkins Hospital and Health System, health care providers need input from many sectors. "We need ethicists, clergy, whomever to lead us in a broader conversation in this country," he says.

For some, the answer comes easier. "In other developed countries, they've figured out how to offer a modicum of health care for everybody," says Barbara Cook, president of Johns Hopkins Community Physicians, a 17-site group that handles 450,000 visits off-campus each year. "If people want more than that, then they can seek it out and pay for it on their own."

How can we make health care more affordable?

The system is rife with what economists call "inefficiencies": Uninsured patients who visit emergency rooms for primary care, or who show up for care only after becoming seriously ill. Doctors who prescribe expensive, often unnecessary tests. Specialists who charge the system more for their services than primary care doctors. Hospitals that must process bills and medical claim forms for over 700 private insurance providers — as Johns Hopkins does — each with its own procedures and guidelines, while maintaining an expensive bureaucracy to deal with them all.

How to deal with such inefficiencies?

Uninsured people and others who can't pay their bills cost the system about $30 billion each year, but that's only part of the problem. The payment system rewards high-cost specialists by approving fees for diagnostic tests and surgeries (which goes a long way toward explaining why there's a lack of lower-paid primary care doctors). Brody and others at Johns Hopkins say that the fees-for-services system used in the United States could be reworked to include a pay-for-performance model that rewards those who treat entire populations and who practice good medicine. "Right now, doctors are paid to do more things — not better things," Brody says. "If there's one thing we know it's that, no matter what the rule is, people will follow incentives. We need to put incentives in place for doctors to give the right kinds of care."

Patient advocates worry that such a system, handled in the wrong way, could be used by doctors to deny treatment to patients with dire prognoses. But some researchers point to systems like the one in the United Kingdom, where primary care physicians who work in a government-financed system receive incentives for care coordination and prevention. Because every Briton is included in the system, no one — even those in poor health — can be turned away. In the name of keeping its population and coffers healthy in the future, the British government several years ago wanted to make sure that more than 55 percent of children at age 2 had been vaccinated. "At first the doctors said that the British people were too conservative to get the vaccination rate up," Sommer reports. "Someone high up in the health system then told them that if they could get the level up to 70 percent in their region, they'd get paid an extra amount in pay per year." In a short amount of time, an even higher percentage of infants in England and Northern Ireland were vaccinated.

If such incentives are to work in the United States, others say, there should be disincentives for prescribing unnecessary or redundant tests. Expensive, high-tech imaging machines are notoriously overused in the United States. The fact that each hospital or medical center feels that it needs one of each machine is a sign of dysfunction, some observers say — a luxury the system can no longer afford.

People who can't pay their bills cost the system $30 billion a year, but that's only part of the problem. Technology can become a problem for the opposite reason: a lack of availability. Information technology that could automatically deliver electronic medical records through a coordinated, nationwide system to emergency rooms, hospital wards, and private physicians is still a pipe dream for most health administrators. Because of it, records must be created each time a patient makes a visit, which means there must be more staff on hand to process the forms — and to pay. "We haven't done as good a job of using computers as other sectors," says Peterson. "We would be able to dramatically decrease our cost burden if we didn't have to reinvent the wheel every time someone enters the health care system."

Brody suggests that automation might save as much as 10 percent of the total annual outlay on health care, which would mean billions of dollars. But that day is a long way away: Less than 40 percent of family physicians have the ability to use electronic medical records, and no one knows for sure who would lay out the piles of cash necessary to get such a national system up and running.

Can we improve quality while driving costs down?

As contradictory as the notion might seem, there is a precedent for doing better work at a lower cost. "The thing that is so hard for people to understand, but that was proven in the auto industry, is that when you focus on cutting costs, you automatically reduce quality. But when you focus on increasing quality, as we've done with safety measures here at Hopkins, you almost always reduce cost. It's counterintuitive," Brody says.

One way to attack the cost issue while treating patients better is to re-emphasize primary care. Barbara Starfield, a professor at the Bloomberg School, found that when primary care physicians lead medical teams, health improves and costs fall. The more physicians there are, the more mortality is reduced. A shortage of primary care physicians means that people in some regions, especially rural parts of the country, get less care and suffer worse outcomes. Some residents of counties along the lower Mississippi River, for example, live nine to 11 years less on average than do people in suburban Connecticut.


Check That
A simple checklist for intensive-care-unit doctors results in fewer infections and deaths.


Another way to reduce costs is to reduce the number of medical errors. Peter Pronovost, a critical care professor, has devised ways to standardize hospital care across the staff, and has reduced mortality rates by implementing a checklist that standardizes the handling of IV lines in patients. His clinical research has led to a much lower infection rate in the intensive care unit at Hopkins and elsewhere — and has saved millions of dollars. (See "Check That".)

Brody and others also make the point that medical care is inconsistent across the country. When people get the wrong treatment, they don't get better and often cost the system more in the long term. According to the Institute of Medicine, the delivery of medical and preventive care is consistent with scientific evidence only about half the time. A bill introduced to Congress this summer to implement effectiveness standards here — already a fait accompli in England — has garnered little attention, however.

Brody says methods used in other countries could be applied in the United States. For example, gastroenterologists in Japan oversee a staff of technologists who perform colonoscopies at about one-third the cost. Anderson adds that other countries can become models of prevention as well, perhaps pointing the way toward curtailing the costs of chronic illnesses. Within the last 15 years, Brazil has gone a long way toward reducing its obesity problem by making people aware of how fat they're getting, providing more outdoor space for exercise, and making gyms more available in urban areas, he says. Russia has gotten the word out on hypertension with some corresponding improvement in the numbers of people who suffer from the disease, and Uruguay has been out in front on smoking awareness and cessation.

How do we provide better care to the elderly and save Medicare?

Medicare, the universal system of coverage for people 65 and older, faces financial deficits that threaten its future. However, physicians — who are actually paid more per treatment by private insurers — are loath to disband a system that chews up much less money in administrative costs (and can make up a substantial part of a physician's income). Experiments in privatizing the program, such as the Medicare Advantage managed care plan, have ended up costing more. Without the relatively efficient government-run program, physicians reason, people on fixed incomes would seek out care much less often and receive fewer necessary treatments.

Many health providers and researchers are looking for ways to more efficiently spend Medicare's money. Much of the research emphasis at Johns Hopkins has been on ways to reduce the cost of treating a population that is growing more elderly by the minute. Scientists here are banking on the idea that lowering the costs for the neediest segment of the population could go a long way toward making health care better and less expensive.

The United States ranks number one in the world in the rate of people who suffer from chronic diseases, such as asthma, hypertension, and kidney disease. Of the 125 million people who fall in that category, more than half suffer from more than one chronic ailment, and most are elderly. All told, more than 70 percent of Medicare's annual budget of around $450 billion goes to provide care for elderly people who are chronically ill. One Johns Hopkins program in development, called Senior Strategy, would create a "continuum of care" for patients who come into Bayview Medical Center for treatment — matching patients with teams of doctors who could consult jointly about their condition, prepare the patient to return home, and offer house calls and earlier palliative care for those who are terminally ill, thereby reducing the length of expensive stays in hospital beds.

Another developing program at Hopkins is led by Charles "Chad" Boult, a professor at the Bloomberg School's Center for Integrated Health Care. Boult's team is investigating whether so-called Guided Care — in which a registered nurse works closely with three to four primary care physicians to provide comprehensive care for patients with several chronic conditions — can improve quality and lower costs at the same time. A study involving 900 chronically ill patients found that those who received Guided Care rated their care more highly and used hospitals, skilled nursing facilities, and home health care less often than those who received "usual care," resulting in a net annual savings of $1,600 per patient. "We already know that Guided Care improves the quality of chronic care, and it appears to save money for Medicare and private insurers too," says Boult. "We've built this around primary care doctors. We're hoping it rejuvenates primary care."

Many who study health care say such programs represent much-needed change for the health care system. "But we need to do more than just switch money around to deal with the chronic care crisis," says Anderson. "We need a 50-year plan." In 1950, he explains, the United States moved from a system that had been focused on preventing infectious diseases, such as polio, to one that concentrates on acute illnesses, such as heart attacks and strokes. Somewhere around 2000, the transition from acute to chronic illnesses began.

But the wheelchair of change moves slowly — a metaphor for the entire medical system. The vast majority of grants still go toward research that is acute care–based. "We still train our physicians one body part at a time instead of thinking about the patient holistically," Anderson says. "It's going to be a real challenge taking the chronic disease focus very far very fast."

The same might be said for treatment of the ailing patient that is American health care. Whether a new president facing a crisis in international finance will have the economic and political wherewithal to change the system quickly and widely is the $2.1 trillion question.

Michael Anft is a senior writer at Johns Hopkins Magazine.

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