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Homes with Heart

Experts discuss the issues surrounding the current health care crisis in the U.S.

By Amy Albo and Christopher Nelson

The topic of health care reform is deeply contentious, laden with political, economical, philosophical, and emotional landmines. (Just ask Sen. Hillary Clinton about her 1993 initiative.) There is one point, however, on which everyone agrees: Itís a complex issue with no quick fixes. Yet itís clear that health care reform is reaching a tipping point. Some of Utahís most informed individuals on the subject recently participated in a roundtable discussion for Continuum:

Brent C. James
Brent C. James
Leigh Neumayer
Leigh Neumayer
Richard J. Sperry
Richard J. Sperry
Susan Terry
Susan Terry
Norman J. Waitzman
Norman J. Waitzman
Kim Wirthlin
Kim Wirthlin

Brent C. James BSí74 (computer science) BSí76 (medical biology) PhDí78 MStí84, executive director of the Institute for Health Care Delivery Research and vice president, Medical Research and Continuing Medical Education at Intermountain Health Care; adjunct professor at the University of Utah School of Medicine, Department of Family and Preventive Medicine; member of many national taskforces and committees that observe health care quality and cost control

Leigh Neumayer, M.D., M.S., professor of surgery at the University of Utah School of Medicine; general surgeon

Richard J. Sperry BAí79 (economics) BAí79 (chemistry) MDí83 MSí94 PhDí95, associate vice president for health sciences at the University of Utah, professor of anesthesiology at the U of U medical school; holds the Governor Scott M. Matheson Chair in Health Care and Health Management, one of the few interdisciplinary professorships in the country

Susan Terry, M.D., FACP, medical director, University Health Care Community Clinics; a primary care doctor for 25 years

Norman J. Waitzman, Ph.D., professor of economics at the University of Utah and co-director of the Behavioral Science and Health Program, focuses on health care economics and policy, and the relationship between socioeconomic status and health

Kim Wirthlin BAí86 MPAí02, vice president, Government Relations and associate vice president, Health Sciences Public Affairs & Marketing; has tracked health care issues on a state and federal level for the past 10 years

Following are excerpts from the discussion:

CONTINUUM: How would you characterize the current state of health care and health care coverage in Utah? And how does Utah stack up in comparison to the rest of the country?

SPERRY: I could begin by mentioning the data published by the Utah Department of Health. The most recent information about the uninsured in Utah is that in 2007, 10.6 percent of Utahís population was deemed to be uninsured, which equates to about 287,000 people. The uninsured group covers all age groups although it is largest by far in the 18 to 34 age group, where 17.8 percent of Utahís population reports being uninsured. And Utah does not buck the national trends of the ethnic data: About one-third of all Utah Hispanics [like those nationally] report being uninsured. The Department of Healthís report suggests that 35 percent of adults living below 150 percent of the federal poverty level [roughly $10,000 per one-person household] lack health insurance. To be fair, different surveys count people differently. So there is a bit of controversy as to what the actual numbers are. But I think thereís probably a consensus that the numbers are too high and that the trend is upwards.

WAITZMAN: Thatís an excellent point. Whether Utah does better than the nation in terms of health insurance coverage is something that would be difficult to definitively assess at this point. But the trends from both the state survey and the national survey basically see an increase in the uninsured. So, we have to start to think about what is going to drive the trend.

WIRTHLIN: One thing that really puts a personal face on this is the recent study that was done by Families USA [a nonprofit consumer health care advocacy organization]. It said that 150 Utahns die annually because they donít have access to health insurance. Nationally, two to three times as many people die from lack of access to health insurance than from homicide. And I think, Wow. Thatís in this state, in this country where we have this belief that you can get health care if you need it.

JAMES: But it turns out that nationally and internationally Utahís health care system as a whole stacks up pretty well. The Organization for Economic Cooperation and Development measures global mortality amenable to health care. Although the U.S. as a whole scores quite poorly, about 16th, if you break out Utah, we do quite well. A young population and LDS lifestyle are the big drivers, because two major challenges to health are smoking and alcohol.

WAITZMAN: Thereís a lot of evidence that Utah is exceptional in certain respects, and that the nation and the world can learn from us in terms of the delivery and organization of care here. But there are ways in which we are not exceptional. The rate of uninsured in the state is rising similar to [that of] the nation. Our average employer-provided premium for health care is also statistically similar. And for a family plan, weíre a little higher than the nation, largely due to the fact that we have larger families. The degree to which we have out-of-pocket payments here compares unfavorably, particularly for the family plan relative to the U.S. For the lowest wage quartile of workers in Utah, we do worse than the nation as a whole, and the disparities are unfortunate in that regard. Certainly thereís room in Utah to do better.

JAMES: I think youíre absolutely right: This really is ‘the cream of the crap.’ The evidence is overwhelming that we could do much better.

NEUMAYER: One of the things that we lack in Utah is a good, obvious safety net, which is available in other cities and counties similar in size to some of ours, especially Salt Lake City. Iím talking specifically about a county hospital whose primary job is to care for the indigent and uninsured. Without that, people go for a long time without seeking care. I had a patient who had a mammogram at a health fair and found out she had a breast mass, but she didnít pursue it further because she didnít have insurance. A year or two later, when she got insurance, she came to see me. And now she has metastatic breast cancer, which has spread to her meninges [membranes that envelop the central nervous system], bones, lungs, liver. And itís tragic, because had this been treated when she first noticed the mass a year or two ago, it would have been in a much more curable situation. If you have no insurance in Utah, there is no place to go to get any level of care except showing up in the ER.

JAMES: Except there are 130 million dollars in pre-identified charity care. Our policy at Intermountain is that if someone shows up without insurance, they are given care. The University plays that role, too, and itís not just showing up in an ER.

NEUMAYER: But it has to do in part with patients feeling like they donít have access.

WIRTHLIN: I agree. The average person has no idea that the University and IHC both have charitable care systems in place. What they Ďknowí is that they are not insured and so have no access. The health care system, as we all know, is so complex that even when you have insurance, sometimes itís difficult to access the care that you needólet alone, when you donít have insurance, which creates this huge financial barrier. And going through that process of qualifying for the charity care . . .

NEUMAYER: . . . is embarrassing.

WIRTHLIN: Exactly. You know youíre going to have to lay out your assets. And what if they say that, actually, you do have a way, over the course of many years, to pay for this care?

SPERRY: Any business eventually reaches a limit to how much charitable care or bad debt it can provide. Margins are thin for everyone, and if institutions arenít able to keep their doors open, which is already happening in other parts of the country, access will be dramatically limited. Uninsurance stresses us now, but ultimately it could break the bank.

JAMES: Weíre very clearly heading in to a major national health care crisis around money. The United States is currently about 46 trillion dollars in debt in the sense of commitment to U.S. citizens through entitlement programs beyond current or projected levels of taxation. Itís about the net value of the United States of America. And two-thirds of the shortfall is Medicare, which is about 30 trillion dollars in the red for people currently alive. To get this in perspective, the social security debt is just 5.7 trillion.

As a result of rising health care costs, we see employers abandoning health insurance. Itís a bottom-up phenomenon where the little guys bailed first and now the big companies are shifting more and more of the financial burden onto their employees. Twelve years ago, over 85 percent of all Americans had health insurance through their place of work. Currently, fewer than 60 percent are now insured through their employer, and that rate continues to drop.

WAITZMAN: This is a critical part of the health care dilemmaówhether employer-provided insurance can be sustained in the new era. Whatís partly responsible for the decline is a very rapid increase in health insurance premiums. In the last seven years, weíve had over 100 percent increase in insurance premiums and only a 27 percent increase in earnings. Much of this cost increase has been shifted onto employees, but a lot of it has been held by the employers as well. ĎWhatís driving cost?í is an interesting question. It gets to the core of how weíre going to deal with the health care problem beyond just covering more people.

JAMES: Thereís a phenomenon called Ďrescue care,í which is this almost overwhelming feeling we have as human beings to help someone whoís suffering or facing death. When it comes to the Ďrescueí world, the United States is by far the best. About half of all health care expenditures in the United States are incurred in the terminal episode of life that ends in death. You end up not prolonging life, but prolonging dying. Itís a huge investment, and most people donít want it. But we donít know where the boundary is and we canít pull back.

WIRTHLIN: Where we draw the line is a very complex question. And it happens at the beginning of life as well.

WAITZMAN: And hospitals are reimbursed to provide that type of care. The NICU [Newborn Intensive Care Unit] is a huge profit center.

JAMES: Thatís right. Our payment system is optimized to provide rescue care. When you compare the United States to Sweden, their infant mortality rate is about half. As soon as you risk-adjust for gestational age, the difference disappears. What that says is that the Swedes are classifying premature infants differentlyóas stillbirthsówhile weíre classifying them as salvageable infants, and weíre going to pull out all the stops to try to save them.

NEUMAYER: This really requires a huge paradigm shift in the U.S. populationóbecause we are all about rescue care, and as soon as thereís something that needs to be rescued, we go there.

CONTINUUM: So in regard to whether our health care system is broken or not, it seems that it reflects what we value in society.

JAMES: Thatís exactly correct.

WIRTHLIN: It does reflect the values of society in some ways except when it comes to the nature of competition within the health care system.

JAMES: Letís be up front about this: Itís not a system. Itís never been designed as a carefully organized system. But itís evolving. And the biggest change is happening at the level of clinics and hospitals. Itís the idea of coordinated team-based care and reflects the changing demographics in our physician makeup, where now more than half of our medical school enrollees are female. It has to do with lifestyle choices, too, and proves that when youíre a member of an effective team, you donít have to destroy the rest of your life to practice good medicine. This is a fundamental, profound shift.

WIRTHLIN: But to what extent do you see insurance reimbursing differently to support that kind of coordinated care?

JAMES: Itís clear that primary care does more for total health than does rescue care. So far the insurance hasnít made the transition, but it has to, and itís starting to.

TERRY: The team is absolutely essential, because there is no way that I can go into an exam room with a patient and in 15 minutes accomplish every single thing thatís supposed to happen. Even with insurance, and regardless of how wealthy you are, you still only get 50 percent or less of the health careópreventive services and suchóthat you should get when you see the doctor.

WIRTHLIN: Yet the insurance companies donít reimburse for the cycle of care that Susan [Terry] would like to provide patients.

JAMES: Care coordination embedded in a primary care office works far more effectively than disease management or care coordination embedded in an insurance plan. Which is exactly whatíd you expect if youíre familiar with those systems. And I see that evolving quite nicely. This is a bottom-up approach that organizes everything around value-added, front-line work processes. Iím actually a lot more sanguine about the possibility of building something rational than Iíve been in a long time.

WAITZMAN: While thereís great innovation thatís occurring within IHC, the University, and other integrated health care systems, thereís also growing awareness that our system is broken with respect to the overall coordination of rules that guide delivery and insurance. There are vast disparities. The access to the system is awry. And insurance is structured so that we reimburse in a backward way.

CONTINUUM: In what ways do you see opportunity for health care reform? Do we blow up the system and start anew? Or work within the current system?

TERRY: Itíll blow itself up.

NEUMAYER: Do you think thatís happening right now?

SPERRY: I donít think itís there yet. The system functions well for some peopleóprobably for those people who control most of the resources and have the political power. So I donít know if the crisis is deep enough that the people who are in positions of power will either by force or by choice be willing to make the changes.

NEUMAYER: Itís not there yet, butÖ I think [that point] is coming sooner than we think. We need a lot of help outside the health care system, or the non-system, so that people understand how much their behaviors contribute to the overall crisis.

JAMES: So hereís the underlying problem, and itís a philosophical debate: Do you regard health care as a free market, which is what insurance is designed to deal with? Or do you regard it as a shared social benefit?

WAITZMAN: Right. The question really is how the individual market is structured to allow the incentives that arise from the flow of market forces, and how much government is going to regulate it to preserve that shared benefit to the community. Both Republicans and Democrats indicate that theyíre ready for health care reform. Part of the division is over the poles that Brent [James] indicated and whether we try to preserve aspects of the employer-based system, which both the left and the right want to destroy for different reasons. The left wants to move toward a fully government-run single-payer system. And the right wants an individual insurance market, which gives individuals much more choice. But thereís also a group that believes we should preserve aspects of this employer-based system as we transition to a new system. For example, I like the fact that the University of Utah is a big organization and can negotiate with insurance providers. If I were an individual trying to insure myself, Iíd be going up against a very large power. It gets complex fast, unfortunately, but I agree, this tension between market and government provision is certainly there.

SPERRY: Should we focus on states changing their system state by state, or is it something that should be left to the federal government?

JAMES: Itís a very complex problem with no clear solutionónot just in the United States but in all Western democracies. One idea is to run a series of experiments at a state level and find out what works. We are much more likely to craft a workable solution in Utah than we are at a national level. If we canít do it here, I have no idea how theyíre going to pull it off there. This is the crucible of the states.

WAITZMAN: So whatís the impediment for our state to become the crucible? Weíre an ideal state to do it, so why donít we do it?

JAMES: We are doing it in some sense. I see innovation on two or three different levels. We have a legislative task force thatís trying to address this issue and get the debate on the surface. But I think that change will happen down at the level of real people and real hospitals and real insurance plans facing real problems and coming together to find solutions. The reason we will succeed as a state is because we are small enough and have the necessary humanitarian attitude. The nation needs just a few concrete good examples that can be built on.

SPERRY: Are you optimistic or pessimistic about the system and its future?

NEUMAYER: The whole system needs to be rearranged, and it may take a crisis to get that to happen because people are not willing to give up what they have right now, both on the provider side and the access side. The current system is limping along, and if it continues to exist in its current state, Iím pessimistic that it will provide me with health care in 20 years. But Iím optimistic about the opportunities there are for change, especially in Utah. We have a unique population and a cohesive group of physicians, even though weíre not terribly organized. We could serve as the template for what could happen across the country. Although we donít deal with some of the unique situations of giant cities that have huge numbers of uninsured and underinsured people, what we learn here could be applied elsewhere.

TERRY: Iím optimistic because, as Brent [James] was saying, I see a lot of change happening at the front line. Our system is working hard on a grassroots level to create coordinated teams and to bring the relationship closer between specialty services and primary care. I also see improved coordination between Intermountain and the University, which covers the bulk of the health care in the state, and Iím encouraged by that.

WAITZMAN: Thereís a clear trajectory moving us toward seriously considering reform on both the state and national level. Weíre swept up in an increasing uninsured population, rising costs, chronic illnesses, more treatments for those illnesses, an aging population, scarce financing, changes in the labor market, and international competition squeezing us. All of these factors will push us more and more toward intervention and discussion about reform and policy. Utah is an exception in many ways, but with respect to the trajectory, weíre basically right in line. And weíre a bit behind the ball with respect to the task force that is in place. Maine, Vermont, and Massachusetts have made attempts to move toward universal coverage and have instituted innovative structures that span the market to government health care reform. There are 12 other states that are involved in seriously pushing in that direction. If weíre going to take advantage of our exceptionalism, we have to integrate reform in a more serious way.

JAMES: I agree that the current system is unacceptable. At the same time, Iím optimistic that change is happening. Itís multi-factorial and is going to require a fundamental shift in the way we think of ourselves as physicians and nurses and as an organized system of caregivers. We know enough about how the system performs or doesnít perform and the exact causes of the failure, which gives us an opportunity to talk about how we structure our public policy. And now there are some emerging solutions. Utah is widely regarded as one of the best examples in the world. If we canít do it, nobody can. So letís go do it.

SPERRY: I agree that the current system is not acceptable. At the same time, there are a lot of good things to be said about health care and how itís delivered in the United States, and certainly in Utah. But there are enough problems with our system, or non-system, that we donít have much choice but to change it, and Iím actually optimistic. The topic of health care reform isnít something that is just discussed by health policy experts and health care economists. Some action is being taken in so many arenas that I have to believe there is momentum building for change; hopefully it will be sustained. I think that it will . . . because it has to be.

— Amy Albo is a writer and editor for University Health Care, and Chris Nelson is the director of public affairs, University Health Care.

For an extended transcript of the discussion, click here (pdf file).

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