The Doctor Weighs In

By Dov Michaeli MD, Ph.D

I am not a health care policy wonk, or a wonk of anything, to tell the truth. But having observed the heated arguments, the indecipherable terms and acronyms, and the general sense of helplessness in breaking the political logjam, I asked a naїve question: how do others deal with the issue?

 I looked at the British system, which I know quite well. I also looked at the Japanese system, which I knew from my visits to the country and contacts with Japanese doctors, professors, drug companies, and just plain folks. Finally, I looked at the Taiwanese system, which I think is an unsung hero that deserves more recognition.

The British system

The Brits are very much like us economically, politically and culturally. They have a much more cynical attitude toward government than we do, if you can imagine that.

So here are, in general outline, the salient facts about their system.

· The “macro economic” aspect: the percentage of gross domestic product (GDP) spent on health care: 8.3

· Average family premium: None; funded by taxation.

· Co-payments: None for most services; some co-pays for dental care, eyeglasses and 5 percent of prescriptions. Young people and the elderly are exempt from all drug co-pays.

· The British system is "socialized medicine" because the government both provides and pays for health care. Britons pay taxes for health care, and the government-run National Health Service (NHS) distributes those funds to health care providers. Hospital doctors are paid salaries. General practitioners (GPs), who run private practices, are paid based on the number of patients they see. A small number of specialists work outside the NHS and see private-pay patients.

· How does it work? Because the system is funded through taxes, administrative costs are low; there are no bills to collect or claims to review. Patients have a "medical home" in their GP, who also serves as a gatekeeper to the rest of the system; patients must see their GP before going to a specialist. GPs, who are paid extra for keeping their patients healthy, are instrumental in preventive care, an area in which Britain is a world leader.

· What are the concerns? The stereotype of socialized medicine -- long waits and limited choice -- still has some truth. In response, the British government has instituted reforms to help make care more competitive and give patients more choice. Hospitals now compete for NHS funds distributed by local Primary Care Trusts, and starting in April 2008 patients are able to choose where they want to be treated for many procedures.

Finally, The brits love to gripe about everything: traffic, the schools, the weather, and yes--the NHS. But try to suggest  that health care should be privatized and you will be met with hostility, as I witnessed personally, and as the Conservatives found out to their dismay in the following election.

The Japanese system

· Percentage of GDP spent on health care: 8

· Average family premium: $280 per month, with employers paying more than half.

· Co-payments: 30 percent of the cost of a procedure, but the total amount paid in a month is capped according to income.

· Japan uses a "social insurance" system in which all citizens are required to have health insurance, either through their work or purchased from a nonprofit, community-based plan. Are you listening Barack? Those who can't afford the premiums receive public assistance. Most health insurance is private; doctors and almost all hospitals are in the private sector. Take that, free market zealots.

· Japan boasts some of the best health statistics in the world, no doubt due in part to the Japanese diet and lifestyle. But also due to superbly trained physicians and surgeons. And due to almost fanatical emphasis on preventive medicine. To wit: Japan has  the highest rates of stomach cancer in the world. But almost every Japanese undrgoes an annual gastroscopic examination. Consequently, most stomach cancers are detected at stages 0 and 1 (in other words, very early). This results in a low, and decreasing mortality rate. On the other hand, in the U.S gastric cancer is detected mostly in stage 4, sometimes in stage 3--either way too late for curative surgery. Mortality rate--close to 100%.

Unlike the U.K., there are no gatekeepers; the Japanese can go to any specialist when and as often as they like. Every two years the Ministry of Health negotiates with physicians to set the price for every procedure. I have been privy to some aspects of these negotiations. The government gets into the minutest detail of the charges for procedures and drugs. Because Japanese culture abhors confrontation and fosters consensus, these negotiations are long, arduous, but at the end of the day everybody signs on. This helps keep the cost down.

· What are the concerns? In fact, Japan has been so successful at keeping costs down that Japan now spends too little on health care; half of the hospitals in Japan are operating in the red. Having no gatekeepers means there's no check on how often the Japanese use health care, and patients may lack a medical home. These are of course policy concerns. But I had the occasion to ask several colleagues and some regular people I met, what their concerns were.  Almost universally the answer was: none. Not a scientific poll, but telling nontheless.

The Taiwanese system

· Percentage GDP spent on health care: 6.3! This should be music to the ears of liberals and conservatives, Democrats and Republicans alike.

· Average family premium: $650 per year for a family for four.

· Co-payments: 20 percent of the cost of drugs, up to $6.50; up to $7 for outpatient care; $1.80 for dental and traditional Chinese medicine. There are exemptions for major diseases, childbirth, preventive services, and for the poor, veterans, and children.

· Taiwan adopted a "National Health Insurance" model in 1995 after studying other countries' systems. Like Japan and Germany, all citizens must have insurance, but there is only one, government-run insurer. Working people pay premiums split with their employers; others pay flat rates with government help; and some groups, like the poor and veterans, are fully subsidized. The resulting system is similar to Canada's -- and the U.S. Medicare program.

· Taiwan's new health system extended insurance to the 40 percent of the population that lacked it (sounds familiar?) while actually decreasing the growth of health care spending. The Taiwanese can see any doctor without a referral. Every citizen has a smart card, which is used to store his or her medical history and bill the national insurer. The system also helps public health officials monitor standards and effect policy changes nationwide. Thanks to this use of technology and the country's single insurer, Taiwan's health care system has the lowest administrative costs in the world.

· What are the concerns? Like Japan, Taiwan's system is not taking in enough money to cover the medical care it provides. The problem is compounded by politics, because it is up to Taiwan's parliament to approve an increase in insurance premiums, which it has only done once since the program was enacted.

Some naїve questions

· Why don’t we hear more about the Japanese and Taiwanese systems in the media, in the political debates, in congress, in health care forums debating ad nauseam how to fix the system?

· Are we so hopelessly captive to commercial and political forces that have a stake in the status quo, that nothing can be done to change it?

· Why can’t we do it? Are the Taiwanese so different from us? Are they smarter? Are we so dumb?

So please, all you policy mavens: please enlighten this naїve layman; why do we need to reinvent the wheel? It has already been invented in Japan and Taiwan. And it works!

If you’re like me, your medical records are scattered all over your home region. (In my case, that’s lovely coastal Northeast Florida.) Over the years I’ve had several doctors: primary care physicians and specialists. I’ve been a hospital patient, and I’ve had outpatient procedures at doctor-owned facilities. I’ve had workups at several diagnostic centers and labs.

The problem is that it’s health care Babel out there. No organization has my complete history because few if any of these organizations can share my medical records. Currently less than one-quarter of doctors store their patients’ information in electronic medical records that can be traded. And even if they did, the industry hasn't defined standards for records yet, so most systems can’t talk to each other. Until recently we couldn’t grab all the pieces of a patient’s record strewn throughout a region and drop them into a single medical chart.

If I landed in an emergency room tomorrow, even if the doctors knew my name, they wouldn’t be able to retrieve my records and then factor my history into their diagnoses and treatment decisions. Instead, they’d quickly order expensive batteries of tests and, with still relatively limited information, take their best shots. No matter how skilled and dedicated they are, their clinical results would be compromised by what they don’t know. The lack of full information would drive the cost up substantially as well.

The waste associated with our inability to easily pull this information together is huge, and becomes apparent when you consider how many doctors patients see, and how little coordination among them there is. Many seniors, for instance, have regular visits with a variety of doctors. A recent national study found that, annually, the average Medicare patient saw seven different doctors in four different practices. Five were specialists.

As you'd expect, sicker patients see even more doctors. About 40 percent of seniors have seven or more chronic conditions, and typically saw 11 doctors in seven practices. The sickest 25 percent went to 16 or more doctors in at least nine practices.

Probably none of these doctors currently has access to a complete patient record. Unaware of what they don’t know, they might prescribe drugs that conflict with the patient’s other drugs, They may repeat tests recently performed elsewhere. The possibilities are endless, but the results are clear. Incomplete patient information produces poorer clinical outcomes at higher cost.

The problems I’ve described affect nearly all of us; they’re not restricted to the uninsured or the poor. Only if you receive all your care through an integrated health system, like a Mayo Clinic or Kaiser Permanente, will all your records reside in a single place. Even then, getting access to that information can be difficult if you suddenly need care elsewhere, like the emergency room of another organization.

For all these reasons, a group of community-minded individuals in my home town has been working to build a regional health information exchange. The Northeast Florida Regional Health Organization, or NEFRHO (pronounced NEF-row), would be a not-for-profit community health care utility, dedicated to a single idea: facilitating better health care information that helps everybody who touches health care – patients, employers, doctors, hospitals, health plans, our city and county officials – make better health care decisions.

NEFRHO is a Regional Health Information Organization, or RHIO. There are now RHIOs under development all over the country, simply because what they're trying to accomplish makes sense. But there are enormous challenges in getting them going. One is getting the different health care leaders within a region - they have historically been adversaries - to collaborate. The other is finding a financing model that makes it sustainable. The Healthcare IT Transition Group has a great blog that tracks the progress of these efforts around the country at http://blog.hittransition.com/rhio_regional_health_information_organization/index.html.

Several very affordable tools – we got great deals from two organizations eager to show what their tools could do when implemented community-wide - would make NEFRHO effective and financially sustainable. Carefx is a commercially available tool that translates between different electronic medical record systems around the region. A doctor types in a name and, like Google, it immediately assembles all available record information about that patient. He can see a note, a medication list, an image gathered from all the systems on the network. 

Think of the impact! Doctors throughout Northeast Florida would have better patient information to make better, more cost effective treatment decisions, without duplicating recently performed tests.

Another tool would help patients make better decisions about their own care, particularly important for patients responsible for an ever larger burden of their health costs. WorldDoc is an accurate and easy-to-use Web-based diagnostic tool – its being used effectively by some very progressive health plans, like Heritage, based in Houston – that helps patients determine whether they should visit their physician and what other steps are appropriate, given their symptoms. There is a personal health record, a medical encyclopedia, a tool for evaluating lifestyle health risks, comparison tools for hospital quality and drug cost, and much more.

Like any utility, NEFHRO would be sustained by very modest dues paid by its primary funders: businesses, health care organizations and local government. That support would build on our existing health care resources to create even better care than is already available in our community, and better care than is in most other communities. Imagine how companies interested in relocating would respond, in addition to our region’s many other blessings, to demonstrably better, lower cost health care.

The trick here is that we’ve designed NEFRHO to be financially self-sustaining without government or philanthropic assistance. In large part, we hope to get leverage business’ interest in WorldDoc’s capabilities to get annual dues of $15 per employee (or $1.25 per employee per month). That would make it go. In return, though, we need to document and show the returns on investment that accrue to the community and the employers.
This project already has the support of many of our hospital and physician leaders. To make it happen, all it really needs now is vision and leadership from Northeast Florida’s business and government communities.

If you are involved in a RHIO effort in your community, post a comment describing you experience.   Let's learn from each other.

Brian Klepper, PhD