AMERICA'S HEALTH CARE SYSTEM BE IN 5 YEARS
Our presidential election is only days away, 48 million
people in America are uninsured and health care costs are rising 2 to 3 times
faster than our nation's GDP. Where will America's health care system be in 5
years. Welcome to ReachMDs monthly series to focus on Public Health Policy.
This month we explore the many questions facing health care today.
Health Care Policy, Medical Professionalism, is this a
unique idea? You are listening to a special program on Health Care Policy on
ReachMD XM 157, the channel for medical professionals. I am Dr. Bill Rutenberg
your host and with me today is Aaron Carroll. Dr. Carroll is an associate
professor of pediatrics and Director of the Center for Health Policy and
Professionalism Research at Indiana University School of Medicine in
Indianapolis. Today, we are discussing the center for health policy and professionalism
research at Indiana University School of Medicine.
Welcome, Dr. Carroll. It is great to have you with us
Thank you for having me.
The press release I read said quick turnaround research of
hottest topics of the day related to health policy, medical professionalism,
medical education, and physician practice is the goal of the center for health
policy and professionalism research or CHPPR that sounds like ReachMD.
A little bit, yes.
How quickly can your center analyze a problem and offer a
solution. Can you give us a concrete example or two?
It depends on the type of problem and exactly what answer
you are looking for. If it is a question of how does the public feel about
something or you know what is the general sense that how the public would
accept from them when you are looking at survey, we actually are building infrastructure
and having out to do quick turnaround phone and mail service. So we are
talking around, you know weeks actually if we need to. To do medical research
in general takes much longer than that to get it published and previewed, so what
we are trying to do is try to create the infrastructure and ability to give
rapid turnaround answers for policy makers and even to other medical
researchers in a much quicker fashion.
Can you give us an example of a project that is done
recently in terms of say a survey format?
Sure, 5 years ago, we got interested in the idea of how do
doctors really feel about National Health Insurance because we hear all the
time when people talk about health reform that doctors would revolt that there
is no way that they would actually accept any type of big huge reform and we
realize that you know that is an answerable question and so we did a mail
survey 5 years ago and found some interesting results that really there was
some ambivalence, but not nearly the opposition you had expect and then since
this was an election year, we decided well be nice to check again and so we
conducted another survey of physicians to see would they support or oppose
government legislation to establish National Health Insurance and what we found
actually again in general we surveyed 5000 physicians and had excellent
response and we found that actually 59% of physicians stated they would support
or greatly support government law to establish National Health Insurance, which
is quite a surprise I think to a lot of people and less and less <_____>>
doctors would actually oppose this. We published that in the early April issue
of Annals Internal Medicine and it got a fair amount of press at that time and
that is the kind of step we want to do where it turns out that there is a lot
of questions in policy where you can actually provide answers instead of
debating one way or the other and arguing not based on fact, but based on I
just believe it so. There are times in health policy where we can actually
quantify and answer and that is what we would like to do.
With the National Health Care, did you look it any reasons
why doctors either favor or oppose National Health Care?
We did not ask them directly, but we asked them for a fair
amount of demographic and practice and private characteristics to see if we can
analyze and see which kind of doctors or which types of practices might favor
it or oppose it more. By specialty, we found that those in greatest support
were pediatricians, pediatric subspecialist, family practice doctors actually
quite high up now, medical internist, and psychiatrist as well, but even you
know majority of general surgeons. The groups that opposed that the only
specialty that do not have a majority in support were anesthesiologist,
radiologist, and surgical subspecialist. We also looked at you know man versus
woman and turns out female doctors are more likely the support it, doctors
practicing in an urban environment who see more uninsured patients are more
likely to support it, but we did not get into the details of why they would or
would not support it because again that would to some extent take a much more
in-depth study that would take more time and our goal was actually to try to
get a snapshot of what was going on in a timing manner, so it could be outlined
before the election.
Will you fray that this might be used into a broader sense
and otherwise are you in favor of it, sure I am in favor of it because I
believe you only asked 2 questions as opposed to how much control would you
like to see the government have. You are worried that the press, the public
might take doctors' supports National Health Insurance overwhelmingly,
two-thirds did. Does that bother you a little bit?
No, it does not because when we published the results, we
only state the question and the answer, so we do not take this to say like hey
you know two-thirds of doctors say vote democrat that is not what they said.
Two-thirds of doctors said that they support government legislation to
establish National Health Insurance and that is what we said and we asked the
second question you right said, would you support or oppose more incremental
reform such as what people keep opposing and it turns out less doctors said that
they supported incremental reform than National Health Insurance and it is hard
to look it those two questions in favor what they actually more likely to
support National Health Insurance than incremental reform and which can strew
that as a greater support for something that truly is not there. Especially
since we asked the same questions 5 years ago and we were sure within every
single specialty that we measured in 2003 and in 2008 support for National
Health Insurance went up and so why I would certainly hesitate to take this and
go further with the data then the question actually asks and answers. I feel
quite comfortable on saying, 59% of doctors support legislation to establish
National Health Insurance.
Now that we know there is this much support, what gives you
nightmares about National Health Insurance?
Well, you know as always in any kind of big type reform
there is the potential for damage and danger and you know it needs to be done
right and it needs to be done in such a way that costs are controlled and that
we to some extent make sure that everybody gets the care that they need without
sort of breaking the bank. The big concern is always money, but _____ money as
we speak. Certainly, we spent you know 2 to 3 times per person already what
any other country really in the world spends on health care and if you look at
almost any metric of the quality of health care system we are doing quite
poorly. So it is hard to imagine it is doing worse. What we could do worse of
course is always we could spent more money and with the economy in the danger
that it is right now, we certainly need to keep our eye on the ball with respect
to cost and so that would be the issue. Knowing how policy often gets past not
on objective data, which is our goal, but on anecdote and sort of personal
preference, there is the potential with a big sort of new government
bureaucracy that it can get pushed to put a lot of money in the areas where it
does not need to go, we would absolutely need to keep our eye on that.
Cost obviously is a big number. Has your center done any
policy work on cost containment. In other words, if you can make say a 3-point
or 5-point plan to the candidates, here is how we think we can provide health
care at a reasonable cost. Have you done any work there and what have you come
We have not actually done any like actually what I would call
research. Certainly, we discussed the issue amongst ourselves and we had had
many debates and arguments and we have definite thoughts on how we can
proceed. Certainly there is the model of what other countries have done. What
interesting about this is that pretty much every other industrialized nation in
the world has gone toward the National Health Insurance System and we should
not ignore that. What we should do is look at them and what succeeded and what
has failed and you know some countries have done a much better job with the
National Health Insurance System and in containing cost than other countries.
They have all done better job in containing cost. I should say that in it
almost all of them have spent you know one-third to one-half, as much as we do
per person, which is remarkable.
Well, a lot of it comes down to some extent through
administrative overhead and that their systems are much more efficient. Some
of it comes down to fact that they spent less on some technologies and
pharmaceuticals because they can collectively bargain as large groups. Some of
it comes down to the fact that the physicians are very well paid in this
country higher as compared to all other people than in other countries and some
of it because they spend money more effectively be it on preventive care or on
things that might actually prevent illnesses as opposed to having to pay much
more money on the back end and when you add all that up together it actually
winds up being significantly less money. Here the other thing that we should
not ignore and I do not like to deaminase the private health insurance industry
is that there is no profit in the National Health Insurance System and so you
know all the money that sort goes into the system to some extent either goes
into a tiny bit of administrative overhead or into actual care. None of it
gets diverted off into profit or to dividends or anything else, which also
saves quite a bit of money and so most of those countries should operate in a
bigger more efficient scheme. So, looking in this country how it might happen
is that you know your average non-profit private insurance company in this
country operates somewhere about less than 15% overhead. While the investor on
Blues are up in the order of 20% to 25% overhead. Medicare operates just over
about 3%, meaning that 97 cents at every dollar put in to Medicare goes into
actual patient care and yet in general, people feel the Medicare is terribly
inefficient. Actually if you think of efficiency as how much money instead
wasted on non-medical stuff, Medicare’s by far the most efficient Healthcare
System in this county.
Well I will respell that Healthcare has no business trading
on the New York Stock Exchange.
I would agree with you there and I think a lot of doctors
agree with you. Of course, many will disagree as well and if certainly
something that we should talk about, but I think the important thing is that we
actually do talk about it and have an open public debate and actually discuss
how much or how little of the money should go into different things. That is a
lot of how they do cost containing in other country. It is very public. It is
very open. You know where is the money is going. You know where it is being
wasted because it is the government, they have to tell you. A private
insurance company is a black book. It is a black box I believe. You know you
cannot see what in it and know where the money is going or how and without sort
of the pressure of knowing where the things are going, it is impossible really
to make a change.
One of my favorite articles I have ever read is your article
on medical myths. <_____ >We talked about preventive care as a cost
I had an opportunity to interview Dr. Jeffrey Joyce from the
And they published a study showing that if we are effective
in preventive health care, people will live longer because they are healthier
and it will cost us same amount of money. We really would not save anything.
Ya, I think actually that I would almost on the side of
saying we are going to spend worse. Preventive care, is not see this is an
interesting argument, I am glad you brought this up. Preventive care to some
extent is not as much about cost containment as it is about you know doing good
about improving outcomes. Because lets be quite honest here, the quickest way
to reduce cost in the United States is if every smoker die tomorrow because
then we would never have to pay for their bills any more.
No actually scariest thing is what I heard proposed recently
by one of the insurance companies and that is we cut off care in the last 6
months of your life. The only problem is, when is the last 6 months.
But that is scary.
It is very scary, but in the United States to some extent we
have made I think a collective agreement that cost is not our main concern
because we spend money like crazy.
Ya, we just have more.
If cost is not our main concern, why do not we make access
often. Why do not we actually improve the outcomes. We have already sort of
agreed to cost, we are just going to let it go. I agree and that I do not
think that preventive health is the way that you actually decrease cost over
the long term. I do think; however, that preventive health care is the way
that we actually improve outcomes, that we improve life expectancy, and there
might be reduced secondary cost as we become a more profitable society and
people in general can function better, but they are absolutely correct, making
people live longer is likely in the longer going to cost as more money in
general. I still say that is good and it worth the money.
I would like to thank Dr. Aaron Carroll who has been my
guest for the special program on health care policy on ReachMD XM 157, the
channel for medical professionals.
I am Dr. Bill Rutenberg and we were discussing the center
for health policy professionalism research at the Indiana University School of
I invite you to listen to our on-demand program library
by visiting us at reachmd.com. If you have questions or suggestions call us at
Thanks for listening. Until next time, I wish you good
day and good health.
You have been listening to Public Health Policy in
America a special ReachMD XM 157 interview series with our nation's top thought
leaders in public health. This month ReachMD XM 157 will be discussing the
many issues challenging public health policy in America. For a complete
schedule of guests and programming information visit us at reachmd.com.