Pursuing Comprehensive Health Coverage in the U.S. One of the largest issues facing politicians in the 2008 presidential race is the topic of health care. Experts discuss what steps could be taken to improve health care access. How do other nations approach the issue — and what can be learned from their programs?
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Pursuing Comprehensive Health Coverage in the U.S.

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Pursuing Comprehensive Health Coverage in the U.S.

Pursuing Comprehensive Health Coverage in the U.S.

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Candidates on both sides of the political divide promised to overhaul the American health care system. And it seems like the only thing they all - Republican or Democrat - can agree on is that our system is broken. But how do you fix it? Several candidates think we should have a market-based approach to health care. At least one is calling for a voucher system to help pay for insurance. There's a call for a single-payer system, presumably with Uncle Sam writing the checks.

This hour, we're going to take a look at heath care in the U.S., help you understand what the issues are; what are the pros and cons and price tags of the different approaches. Plus, we're going to spend an enormous amount of money on health care more per person than most industrialized nations - how can we get more for our dollar and bring more of the uninsured into the system?

For example, why does the VAD, Veterans Administration, pay 60 percent less per drugs than the Medicare system? What's going on here? And why are doctors prevented from carrying out preventive medicine that might cost more money upfront but pay bigger savings in care later on?

For example, have you ever tried to get an EKG at a checkup? Chances are your HMO won't pay for it, so your doctor has to cheat. He or she has to ask you: Are you having chest pains? And then she can do the EKG and get that covered. Why not pay for that test now and find the problem before it gets worse and cost more later?

Hopefully, we'll get some answers to these questions this hour and look at comparison of other health care systems around the world and how we might adapt what is going on in some of those countries. If you'd like to give us a call, our number is 1-800-989-8255, 1-800-989-TALK. You can also log on to "Second Life" and meet other avatars talking about this topic at our outdoor auditorium in Science School.

Let me introduce my guests. Uwe Reinhardt is the James Madison professor of political economy at Princeton. He's also a member of the editorial board for The Journal of the American Medical Association and a member of the Institute of Medicine.

Thanks for being with us today, Dr. Reinhardt.

Dr. UWE REINHARDT (Political Economy, Princeton University): Okay. Thank you for having me.

FLATOW: You're welcome.

Fred Ralston Jr. is the chair of the Health and Public Policy Committee of the American College of Physicians. He's also a practicing physician. And he joins us from Fayetteville, Tennessee.

Welcome to SCIENCE FRIDAY, Dr. Ralston.

Dr. FRED RALSTON Jr. (Chair, Health of Public Policy Committee, American College of Physicians): Good afternoon.

FLATOW: Donald Berwick is the president and chief executive officer of the Institute for Healthcare Improvement. Dr. Berwick is a medical doctor and a clinical professor of pediatrics and health care at Harvard Med School. He's also on the editorial board for JAMA.

Welcome back to SCIENCE FRIDAY, Dr. Berwick.

Dr. DONALD BERWICK (President and Chief Executive Officer, Institute for Healthcare Improvement): My pleasure.

FLATOW: Dr. Reinhardt, how do we begin to talk about this? I mean, where do you begin, you know? It is so much to talk about.

Dr. REINHARDT: We have to begin to understand the health system, think of what a health system has to do. There has to be the financing of health care. Somebody has to pay for it originally, and that is all those households. So somebody has to gather the financing. That could be the government or it could be a private insurance company.

Then, somebody has to purchase the health care from the delivery system and discipline the providers to make sure the prices are not too high and the quality is good. That can, generally, be either only the government or some private insurance company, although now you have a new dogma out there that says the individual consumer - patient, sick people - can be the prudent buyer of health care, which many of us doubt can be done. And then, finally, somebody has to produce the health care.

And once you break it down this way, it's actually rather simple for financing. At the moment, we have about 50 percent of it is tax finance. The government sucks the money out of our pockets and either buys health care directly for us like traditional Medicare or gives the money to private insurance company to buy on our behalf. That's Medicare advantage, for example. It could be the employer who sucks the money out of out paychecks and buys insurance for us, or we could do this ourselves and by our own insurance.

Now, when it comes to purchasing, by and large in this country and the rest of the world, it is thought that private insurance companies can be made to be very prudent purchases. They have big data banks that can negotiate with doctors. And I think the world is moving more and more in that direction and the delivery system can be anything. It can be government-owned hospitals, private nonprofit. It can be for-profit. All medical practices are for-profit. So the delivery system is okay, what we now have, even Canada has private for-profit health care delivery.

So the real issue in America now that we need to debate is: Who should collect the financing? Should it be government or should it be private insurance companies? And then, secondly, who should purchase health care on our behalf? Should it be government or should it be private insurance companies? And that's really it. And every health plan you hear about is just a variation around this theme. And I would make this preposition: There is no new health care idea being proposed today that hasn't been proposed already in the last 40 years.

FLATOW: And so why are we stuck with a broken system then?

Dr. REINHARDT: Well, first of all, the system really isn't broken, for the bulk of Americans, when they get sick, they go to the doctor; they go to the hospital, they have their operation, whatever. They come home, they convalesce, and somehow it's paid for.

Is that the most efficient way to do it? No. Is it always the best quality? Our quality expert, Don Berwick, would certainly not agree that it is always the highest quality. But more or less, it works. It's just for the uninsured, some 40 to 50 million and growing, that the system has broken down. And then, again, as Dr. Berwick will tell us, we could get this health care a lot more cheaply with much better quality than we now get.

FLATOW: Let me go to you then, Dr. Berwick. Tell us how we might do that.

Dr. BERWICK: Well, Professor Reinhardt has described the economic structures correctly, of course, but overall, we're spending far too much and getting far too little for it. And we have so many factors in where our system is built that drive costs up without any value, and a lot of defects in care that we don't have the proper incentives or structures in place to get out of the system.

FLATOW: Mm-hmm. Tell us about some of those. What are some of the defects and what are - what incentives are lacking?

Dr. BERWICK: Well, the Institute of Medicine in 2001 put out a report that listed this six improvements we need. The improvements were safety. Lots of people get hurt by health care, many more than the public understands. When you're going to care, we give you problems in addition to those you bring to us.

Safety was the first effectiveness, which means promising people scientifically grounded care. We know what science should do. We know how to treat congestive heart failure. We know how to prevent a pressure ulcer, but we just don't do it. Patient centeredness is the third variable. People lose dignity. They lose voice. They lose power. They lose time in the health care system, and that's not necessary either.

Timeliness was the fourth dimension. We waste time. Anyone knows how long they wait in the waiting room. And ask any nurse how much time she's wasting in senseless tasks instead of taking care of patients. Efficiency was the fifth variable. And the final one is equity, which is probably are going to be listed first because it's still true that race, minority race, especially being black in our country, is the strongest critique that we have about health.

FLATOW: Mm-hmm. What about the over prescription of treatments that people really don't need. But doctors who don't think they're making enough money prescribe so they can get a little bit more money back?

Dr. REINHARDT: I don't think that's the reason that overuse exists. We had tremendous overuse of medicines, tests, hospital beds. But these are built into the system. I think doctors, on a whole, are trying hard to do the right thing, but we have direct-to-consumer advertising that's trying to convince people to take drugs they don't need. We're - we have - we use very expensive drugs, sometimes, when simpler ones would do. Even your opening example, Ira, of an EKG at a checkup - well, most EKGs at checkups are not necessary, and we need a public that's very sophisticated about knowing that more is not better in health care. In fact, often, more is worse.

FLATOW: Mm-hmm. So no one has proven, in other words, that an EKG, the annual checkup is - will make you live long.

Dr. BERWICK: That's right. We can't connect that, except for certain cell populations, to anything good that happens to the person and it sure cost a lot of money.

FLATOW: Mm-hmm. What about plans that are in other sides of the world, in other countries? I'd like Dr…

Dr. BERWICK: We have performed in the U.S. and we've got to realize that there's a myth that we have the best health care in the world. We have the best technology in the world. Our advanced health care is absolutely wonderful.

But when you look at the system as a whole, it's extremely wasteful compared to a lot of other systems that are spending a lot less money than we are. They're more integrated; they use doctors differently. They're much smarter about the use of nurses and they don't overinvest in supply. They're frugal. And if they decide they want to have home health care or outreach or education instead of another cardiologist, they can do it.

FLATOW: Dr. Ralston, you agree?

Dr. RALSTON: Yes. I think we all have a little bit different perspectives, but I certainly haven't disagreed with anything said so far. On behalf of American College of Physicians, the second largest physician group in the country, we took a look at U.S. health care and tried to compare it to 12 other industrialized countries.

And as you mentioned earlier, most of the listeners wouldn't be surprised to hear that we had the highest health care cost, generally about twice per person of most of the other countries analyzed. They might be more surprised to find out that we had the lowest life expectancy and the highest infant mortality among those countries.

And we feel that there are a number of areas of improvement in delivery. And I think that people can have different perspectives on payment for this, but the inefficiencies in the delivery are there. And the key practices that we saw in other countries was really that they had more of a system. And I think that's the key that everyone should agree on.

Everyone in those countries, for all practical purposes, had health insurance. They generally had electronic health records and they focus on care coordination by a personal physician but involved in a medical team in the best practices. And, you know, there are proposals to do this within the United States. There's a business coalition working with the American College of Physicians, family physicians and pediatricians. And, you know, we have some potential for improvement, but there's some more obstacles to this.

FLATOW: Mm-hmm. 1-800-989-8255 is our number. We're talking about health care and then coming up with some new ideas, looking at different ways for health care.

Let me reintroduce my guests. Uwe Reinhardt is the James Madison professor of political economy at the Princeton University. Fred Ralston, chair of the Health and Public Policy Committee, American College of Physicians. Also with us is Donald Berwick, president and chief executive officer of the Institute for Healthcare Improvement. Our number: 1-800-989-8255.

We have to go to a break. We'll come back take lots of your calls because this is the topic, which is only good for this time of the year, the political season. The candidates have come up with some ideas of their own. Maybe you have one that you'd like to suggest. Also, up here in "Second Life," we'd like to hear from your questions also.

Stay with us. We'll be right back after this short break.

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FLATOW: You're listening to TALK OF THE NATION: SCIENCE FRIDAY. I'm Ira Flatow.

We're talking this hour about health care policy and how we might achieve universal health care in this country, with Uwe Reinhardt, Fred Ralston and Donald Berwick.

Dr. Ralston, you're a practicing physician. Tell me about the wastage of your time and resources in your office and how you might want to streamline that.

Dr. RALSTON: Well - and I'd certainly agree with Don Berwick's comment about the EKG for patient without symptoms. I'll give you a better example. There's very good evidence now that screening colon exam or colonoscopy above age 50 is beneficial for long-term health.

And I recently had an insurance agent who literally was unable to find out whether his own policies, told by the company that he works for, cover the screening colonoscopy, a simple yes-no question. And to me, it's that type of wastage of time.

I mean, there are some statistics that suggest that a diligent physician, really, with an average patient panel, will take over seven hours a day to provide all recommended, preventative services to his or her patient panel, and additional 10 and a half hours a day to provide high-quality chronic care. And it's pretty clear - and this is something that really - it makes me understand, first of all, why I'm behind all the time, but it also makes me understand why I'm frustrated that there is more that can be done. And it's pretty clear that a streamline system - I sometimes refer to our non - to our health care, non-system.

FLATOW: Well, tell me what a streamline system means, to the lay person.

Dr. RALSTON: Well, if you had more time in an office visit or you had better communication with patients, where you didn't have to spend an awful lot of time on administrative or regulatory burdens, patients often see it from their side, in filling out insurance forms and then claims. But we said if there are two or three similar medicines of similar prices, it often takes us a great deal of time to find out which one is covered under a plan. That - in this age of technology, that's really unforgivable.

FLATOW: Right.

Dr. RALSTON: There ought to be an easy Web site to punch a couple of buttons, find out that formula, where it would be able to tell the patient how much and move on to medical issues.

FLATOW: Wouldn't a plan that covers everybody create that kind of central database?

Dr. RALSTON: Oh - but you have to have someone to set that database up.

FLATOW: Right.

Dr. RALSTON: I mean, we have an electronic health record in our office. We have one in our hospital. And the way that those two communicate is I log on to the office from the hospital when I have a patient there and vice versa.

In Britain, for example, as a government, they spend $192 per person per year as a public investment in health information technology. We spend 43 cents per person per year. That's inexcusable in a country spending as much on health care. I mean, we need to figure out things that will help us provide more effective care. And there are a lot to be learned from a lot of different people.

FLATOW: Dr. Reinhardt, you write in the JAMA that it's been estimated that we spend so much time. We have a gazillion insurance plans that each doctor has to deal with 25, sometimes up to 60 different insurance contracts, claiming reimbursements from the insurers. It's unbelievably complicated and expensive.

Dr. REINHARDT: That is true.

FLATOW: How do we get around that?

Dr. REINHARDT: Well, it is totally wasteful because, I think, when you're a doctor, just keeping track of the bills is impossible. This is why doctors now hire consultant companies that actually help them write the bills that will not be rejected by the insurance carriers because it doesn't fit their format.

I don't know how you get around it unless you have a strong government that simply dictates you must all use the same nomenclature. You must all use the same billing forms. You can issue only maybe 10 different types of insurance policies rather than, literally, 1,000 different types of insurance policies, where a doctor - I'm not a doctor. But imagine when you prescribe a medicine and you don't have a clue whether that drug is or is not covered in that particular patient's particular insurance company…

FLATOW: Mm-hmm.

Dr. REINHARDT: …how you actually practice sensible medicine under that system? I cannot imagine.

FLATOW: Dr. Ralston, is there a country - you've studied them all, or a good number of them - that has a system that might work for us better?

Dr. RALSTON: There is something in Denmark that appears to be going right. IBM has been nudging a number of their friends in the business community and those of us in the medical community to look in that model. And they have close to what we're proposing in the U.S. of a patient center with medical home, where there is an ability - you know, I obviously can't spend 18 hours a day doing all of those recommended things for my patients. There are many things, with a team approach, we can do.

For example, in my elderly patients, if I help deal with issues of incontinence difficult with - difficulty with bladder control and deal with issues of fall prevention - those are two areas where you can improve the quality of life as people age and actually save money for the health care system, and also improve people's dignity. To me, that's a win, win, win. And we need to all move in that direction.

But we can't simply do it the way the current system is structured. It's - you know, I just was told to resell eight prescriptions because probably for a few cents per month, a company had changed their pharmacy benefit manager. Fortunately, our group has invested in the electronic health records so it wasn't as hard as it would be for somebody else. But there are an awful lot of times of busy work where we're not really being productive in improving people's health.

FLATOW: 1-800-989-8255. Let's go to the phone, to Tom(ph) in Washington, Missouri.

Hi, Tom.

TOM (Caller): Good afternoon. I'm a first-time caller here.

FLATOW: Mm-hmm.

TOM: I enjoy your show.

FLATOW: Thank you.

TOM: Can you hear me?

FLATOW: Yes, go ahead.

TOM: Well, in reference to what you're - I - 35 years ago, I had an appendectomy in France. And they have, at least I understood, at that time a two-tier system taken care of very well. What I can't understand is they eliminate a lot of these things that your doctors have just been referring to since it's government-controlled, so to speak.

FLATOW: Mm-hmm.

TOM: But I think the ultimate difference is their government is into people. Our government's into corporations. I mean, there's - generalizing when you broadcasting the thing here, but we are not a people-oriented government. And until, like, Germans do, like French do, like Denmark, all of the research - they look at it first. If it's going to harm the population, they stop it. They're not getting a lot of bad chemicals into their countries like we are, so on and so forth. I don't know if that makes (unintelligible) for you…

FLATOW: Let me get…

TOM: …but if it's something that they should…


TOM: …that we need to consider.

FLATOW: Dr. Reinhardt, any comment?

Dr. REINHARDT: I mean, there is certainly something to the difference between our style of democracy and the parliamentary systems of Europe and Canada. We're, for example, lobbying, as we know it, which is purchasing legislative favors for money. It's just illegal in those countries. And I think the interest groups there are listened to, but they don't run the show, while here, as you know, we've all read that environmental and energy legislation was literally written by the industry; the language or the legal language was written by the industry. You wouldn't have that in this country. And I do believe it could be said that their democracies are a little bit more representatives of what people want…

FLATOW: Mm-hmm.

Dr. REINHARDT: …than ours. Our democracy essentially says every four years, you get to elect an elite. And once that elite is in power, it works for the interest groups rather than to people, by and large. I don't think you will have that as much in the other countries.

FLATOW: Mm-hmm. Dr…


FLATOW: I'm sorry, go ahead.

Dr. REINHARDT: But, I mean, there, too, of course. No one - and, say, take Germany, I asked the minister of health of Germany, what is the source of power of the pharmaceutical industry in Germany given they can't bribe you, so to speak? And she says, oh, it's not that. But they threaten me with - by pulling out their research base into other countries, and that's the leverage they have over me. So the interest groups - they do have power over government through persuasion, but it isn't through money.

FLATOW: Mm-hmm. Dr. Berwick, do you think our politicians can overcome this and understand the real problems of the health care system?

Dr. BERWICK: It's really hard to move a $2-trillion system. There's a lot of political momentum - a lot of political will in the status quo, but we really should change. There's a call - I love the caller's term, people-oriented care - that's what we need.

People-oriented America would be - would promise everybody health care. It's just not right that people here can't get insurance or care. It would promise transparency so you'd know what happen to you. If you got hurt, there'd be an apology. And we promise to end that kind of risk. We wouldn't waste people's time. We wouldn't agree to complications in care that we know we can get rid of but that are still on the system. That's what people-oriented would look like.

And I don't know if the political structures have the will to take that on right now, those big changes, if we're going to do that.

FLATOW: We've had two candidates, I think, Obama and Edwards have called for a single-payer system. Do you think anybody who actually promises anything like that can actually do it once they get into office?

Dr. BERWICK: Well, it's related to what I said before. My colleague, Steve Spears(ph) says we're spending too much and getting too little. We can spend less. We can have everything we want for far less money than we spend today, but only if we're willing to make the changes to make this system reliable and equitable. In other words, better care will be lower - will be much less costly than the care we have today, but that will involve changes.

FLATOW: What would be your single biggest change to do that?

Dr. BERWICK: I'd integrate care across the continuum. Ten percent of our people, the chronically ill, spend about 70 percent of the money that we spend on health care and they - ask them what it's like. They get dropped as they get passed from one place to another. They get forgotten. We have research literature that shows that 85 percent of readmissions for people with heart failure could be avoided. It's the largest reason for admission in Medicare is going to the hospital with heart failure. That's a million admissions a year. Forty percent of those people, when they go home, are going to bounce back into the hospital on 90 days. We could do away with 85 percent of that readmission rate. But who's going to do it?

FLATOW: How would you do away with that?

Dr. BERWICK: Well, you do it with coordinated care: Reach out to the home, educate the patient, provide home health nursing, have early warning signs when the patient starts to gain weight or get worse. In other words, don't wait for the trouble, intercept it. But that requires care across the continuum, integration, and we don't have those structures in America. The medical home that the American College of Physicians is calling for is sort of like that, that there is an integrator in the picture, someone that's got your back and is going to be with you no matter where you journey in the health care system. We lost that in America, and people pay a high price in money and health.

FLATOW: Sounds so simple.

Dr. BERWICK: Doesn't it?

(Soundbite of laughter)

FLATOW: Dr. Reinhardt, tell me the fact of life about this.

Dr. REINHARDT: The fact of life about what?

FLATOW: About why we don't have an integrated health care system as you…

Dr. REINHARDT: Well, in part is the reason has already been stated that we have so many interest groups. And everyone has an idea of how to fix the system, but as my - a friend, Stuart Altman, has once put it, everyone's second best plan is to stay this close. So they defend what we already have. We have integrated systems. For example, the Kaiser Permanente health plan, which is integrated - wouldn't you agree, Don?

Dr. BERWICK: Absolutely, yes.

Dr. REINHARDT: It is. And there you have a data system that can actually integrate across all of the specialists that might touch a patient, and they have an electronic personal health care record, where at midnight a patient could tap into the Web site, see the tests he or she got, get those tests interpreted with pointers to the literature. They can make appointments with doctors. These systems exist. As a matter of fact, I would argue the U.S. invented these systems as we often invent good ideas. We just don't apply them. We export them.

FLATOW: We're talking about health care this hour on TALK OF THE NATION: SCIENCE FRIDAY from NPR News.

What do you all think of the Massachusetts experiment requiring everybody to get health care? California is trying to work that way. Is that a good example? Anybody want to jump in on that?

Dr. REINHARDT: Well, I mean, the Massachusetts - I call it sort of the all-American health plan. It basically keeps in place the public programs, Medicare and Medicaid, and expands them a little bit. And then it gives people - it mandates people you must be insured, but it also organized the health insurance market. So there is like a farmer's market - they call it the connector -through which you can buy insurance so that when you have a preexisting condition, you're not totally out of the picture.

And there are attempts to control health care cost a little better, although that's iffy. And there are subsidies for lower - middle-class people who cannot afford the premiums. What the problem of the Massachusetts plan will be is that it will cost more money, more government money, than Governor Romney had anticipated. I think he knew it, but just didn't say it. And I wouldn't have either. You don't scare people with a plan like this. You run into it and then you explain to people why it costs more.

But I think that is a doable plan. As I understand, the Hillary - Senator Clinton's plan, it is really very much like the Massachusetts plan except for the nation as a whole. And Governor Schwarzenegger's plan is also like that, which means you keep most things in place as they now are and fill in the gaps, which is quite different from radical plans like Victor Fuchs and Ezekiel Emanuel, who basically want the government to do all of the financing and then you get a voucher to buy your own private health insurance. And I think Dr. Kotlikoff also has a similar plan.

Those plans have actually been around since 1972, when Paul Elwood first proposed it to President Nixon and the - read in at Ann Summers(ph) at Princeton at that time proposed similar ideas. The idea government raises our taxes, gives you a voucher and you can buy with it at your own private health care purchaser and regulator. That is a private insurance company.

FLATOW: Now, you don't agree with that plan?

Dr. REINHARDT: Oh, no, no. It - I mean, my own feeling is the right-wing economists will scream bloody murder when they hear how much you would have to raise in taxes because you literally would have to raise $2.5 trillion in taxes versus what we now do as about half of that.

FLATOW: What would it cost per year to implement something like that?

Dr. REINHARDT: Well, I mean, if you run it very efficiently, it should be cheaper than what we have now. But I think you, you know, you would need an additional trillion dollars of taxes a year.

Dr. RALSTON: I would say the Massachusetts' plan is an act of moral commitment, moral courage. There are 300,000 people who are covered in Massachusetts now who weren't before that plan was put in place. It's terrific. But it does call the question because - I don't know if Uwe agrees, but it's - we're going to have to face the music. If we really want to do what's moral, which is cover everybody, we're going to have to swallow hard and change care so it becomes affordable.

Dr. BERWICK: And we feel that we're going to have to have more primary care doctors to actually handle that delivery, and we're going to have to redesign the delivery system. That way, you have an opportunity to blend more people in the system without raising the price tag quite as much as we might fear.

FLATOW: That's another topic. We'll try to get back to that a little bit later. Do we have enough doctors? Do we have enough doctors to move the system in a different direction? Good question. Our number: 1-800-989-8255 is the number if you'd like to call us and get in on the conversation.

We're talking about the future of health care, trying to come up with some new ideas and talk about the old ones, see what's shaking in the political system. So stay with us. We'll be right back after this short break.

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FLATOW: You're listening to TALK OF THE NATION: SCIENCE FRIDAY. I'm Ira Flatow.

A brief program note coming up on Monday in this hour: Neal Conan looks at the brutal warfare that started again in Congo. Why it's happening again? Plus the Opinion Page, that's Monday on this hour on TALK OF THE NATION.

We're talking this hour today about health care policy, and looking at how we might achieve universal health care in this country.

My guests are Uwe Reinhardt from Princeton University, Fred Ralston of the American College of Physicians, Donald Berwick of the Institute for Healthcare Improvement

Interesting op-ed piece in the Wall Street Journal today by Merrill Matthews, who talks about why can't people buy policies across state lines, saying that if there's a great health insurance policy in one state, why can't someone else from another state - why don't we have a law that allows you in another state to purchase health care insurance? And there's a bill in Congress by John Shadegg of Arizona, an Arizona Republican, who has suggested making this into law. It seems like in everything that we're seeing today, whether it's air pollution or global warming and now health care - the states are taking the leads. You know, why can't I side - why should I not be able to buy that Massachusetts policy if I want to?

Dr. RALSTON: Ira, the - we're finding in the U.S., there are tremendous differences in malpractice climates among states, and also there are states that have higher numbers of primary care physicians, for example, and have lower costs. If you're an insurer selling a policy in one of those friendlier lower-cost states, I'm not sure you would want a resident of one of the higher cost states purchasing that policy. And then once again, that would add to the incredible number of policies already in sort of the jumble that physicians have to deal with on a daily basis.

FLATOW: Well, shouldn't we leave that up to those insurance policies and those states to decide if they want to take on these extra people?

Dr. REINHARDT: You know, I sometimes wish we would do it just to put this baby to bed, and nothing would happen.

(Soundbite of laughter)

Dr. REINHARDT: I must - the reason is quite clear, and every one of us who studies it knows it. Health care, the way it is practiced, varies enormously from region to region. Massachusetts has an extremely expensive style of practice in medicine, so does Texas. While, if you go to Minnesota or Wisconsin, they practice a more conservative style mainly because they use primary care physicians more.

Those data has been assembled by Dr. Jack Wennberg and his associates at the Dartmouth Medical School for at least two decades, and we know also states spending per capita on health varies enormously. So if healthcare is cheap, you can get it cheap health insurance policy in Wisconsin. The reason that it's cheap is they buy health care in Wisconsin. If that same Wisconsin insurance company had to buy health care in Boston or in Philadelphia, their policies would cost pretty much what a policy costs in Blue Cross Massachusetts or in Blue Cross Pennsylvania.

I have heard Newt Gingrich advocate why can't we purchase health insurance across state line, and I wish the Congress would just say, all right, go ahead.

Dr. RALSTON: I agree with you, but you know, it…

Dr. REINHARDT: The Americans would learn nothing would happen.

Dr. RALSTON: Changing it - we have to simplify insurance. That's the basic insurance problem we have, not making it more complex…

Dr. BERWICK: Yeah.

Dr. REINHARDT: Correct.

Dr. RALSTON: Well, let's go ahead and try it. But the problem is in the delivery of health care. The data that Uwe is citing, here is how it goes. If you divide America into fifth, all the market areas, the difference between a lowest fifth of expenditure and the highest fifth of expenditure is $3,000 or $4,000 a year. The Dartmouth Group that Uwe is referring to has studied quality and asked the question, well, what do you get for the extra 3 or $4,000. Well, what you get is worse quality.

Dr. BERWICK: Right. That's…

Dr. RALSTON: With the highest expenditure areas, the system performs far worse.

FLATOW: Why? Why does it perform far worse?

Dr. RALSTON: There's access - they call it supply-driven demand, when you build a bed or build an angiography suite or add at specialists back that's used, even though it doesn't contribute to health or health status. The - more is not better.

Dr. REINHARDT: There was a study by a senior economist on President Bush's White House staff. She is now at Harvard. And they looked at the quality rating of states, the ranking and the health spending of states using these Jack Wenberg data. And they found an inverse relationship, which means where we spend a lot, the quality of care was actually lower. And the argument was it deemphasizes primary care there; people wait too long until they get too sick, and then you have super specialists who do ever-conceivable tests and charge a lot. And so the irony is that the cheaper care, as Dr. Berwick said, is actually better care. And Dr. Ralston made that point as well when he said we need more primary care doctors.

Dr. RALSTON: And sadly, if you look at the Dartmouth data, it seems like we ought to be producing more primary care doctors as a nation. Yet, if you look at the senior survey that the American Association of Medical Colleges does every year, there's been a dramatic decline in increase in internal medicine, family medicine and pediatrics at least in the general scale. And we need to be figuring out ways to redesign the system to move toward those high-quality, low-cost models of delivery that Dartmouth has so effectively pointed out.

Dr. BERWICK: One of them…

FLATOW: Do we have fewer doctors because they hear of these horror stories about becoming a doctor and dealing with the health care system?

Dr. RALSTON: Well as a full-time generalist, I will certainly say that there are many positive things about my work. The relationship that I have with patients is absolutely priceless.

But when I walk out of that exam room door and deal with the complex environment that we live in, it makes you think twice. And the generation of medical students going into practice are looking and they're making lifestyle choices.

Now, I would argue in when I speak to medical students - I can - that there are many wonderful things in primary care, but we're going to have to make the system more effective so people won't feel so frustrated.

FLATOW: Well, let me ask you…

Dr. BERWICK: All the strong-performing systems in the world are very strong in primary care, and very good use of nursing. I think the two keys are primary care.

Dr. REINHARDT: And nursing. There's…

FLATOW: Right.

Dr. RALSTON: And a team approach to health care. There are many things that practices can learn and can delegate duties and have other people within the office, not a physician, help patients, and that's certainly fine. And what we need to do is look at best practices from whether it's the U.S. and the V.A., Kaiser Permanente, Denmark. We need - as I explained to my children, we need to form an all-star team of the best practices. We don't have to copy any one particular system.


FLATOW: So, let me ask you this question. Is the reason why they are doing better and doing it more cheaply because they have a single unified system in each one of those countries?

Dr. BERWICK: I believe yes. Fragmentation is the enemy here. And anything that unifies effort, the teamwork; the idea of working in teams, as Dr. Ralston said, is sole key.

One of the ironies here, and one of the political problems is that we sort of had the answer briefly: The best of the early HMOs, the one of the few that's still endure sort of had closer to the right answer that we've ever had in America because there were integrated systems, they had a limited budget, which is a good thing, and they were able to allocate resources where patients needed it. And when we - what we find systems that are able to do that kind of integration, they do perform better.

Dr. REINHARDT: And, Don, you would agree, they use more primary care doctors relative to specialists.

Dr. BERWICK: Every high-performing system.

Dr. REINHARDT: I think they do. Now, the issue here is Ira raised this question, do we have enough doctors? Overall, we may or may not - depends on how we use them, but there is no question, we are running into a shortage of primary care physician.

In over Dartmouth, Massachusetts, it's very hard to get a good primary care physician now, right, because we do not pay primary care physician enough money relative to what physicians can make being radiologist or oncologist. And so if you have young persons coming out in medical school with a bundle as that, and there face a choice of being in a low-paid primary care of pediatrics or geriatrics or internal medicine or GP, or becoming a radiologist, of course they're going to, more likely, take the highest-paying specialty.

Here, I blame government. Medicare has to be the leader in paying better for primary care, even if it had to come at the expense of controlling a little more what gets paid to the specialist. And the government hasn't done it.

Dr. BERWICK: We have a research project in our work, which we call a triple aim, where we're saying what we really need is the actors that can do three things at once - improve health care, make it far better - like we're talking about on the phone now - improve health status, because we haven't talked much about prevention, smoking, accidents, injuries, depression, violence, and reduce per capita cost. We need stakeholders in America that have all three in line at once. And we can do it then if there's somebody that's at our custody of all three at once.

FLATOW: 1-800-989-8255 is our number. We're talking about health care this hour on TALK OF THE NATION: SCIENCE FRIDAY from NPR News.

I said before that Barack Obama had advocated a single-payer system and I misspoke.

(Soundbite of laughter)

Dr. REINHARDT: Yes, yes, you did.

FLATOW: I did. His stance is - I'm reading from a paper in the New York Times says he require children to get insurance, aims for universal - aims for universal coverage, and he would roll back President Bush's tax cuts for people earning over $250,000.

Dr. REINHARDT: Ira, I'll give your listeners a Web resource.


Dr. RALSTON: If you go on to www.acponline.org, we actually are taking the health positions of all the presidential candidates and putting them on our Web site, and we're tying to link them to some of our recommendations for high-performing system to make our members aware of the choices that they face. But this is also open to the general public.

FLATOW: Mm-hmm. It's very complicated in this, you know, this season to keep track of just where everybody stands on these issues.

Dr. REINHARDT: Yeah, these Web sites, though, of the ACP and then the Kaiser Family Foundation. it's www.kff.org. They also have a beautiful side-by-side comparison of all the plans that before us. So as citizens who wants to be informed can either go to ACP or to the Kaiser Web site, and find it there. And there's still other think tanks who have it, too, but those are two great sources.

FARLOW: Mm-hmm.

Dr. BERWICK: I look for four things on any candidate's Web site, which is are they promising universal coverage as quickly as we can get there; are they committed to integrated care; are they - is going to strengthen primary care and do they have a reasonable plan for changing health care so that the cost fall.

FLATOW: Mm-hmm. Also, I mentioned John Edward's position. I'll read something out of the Times.

(Soundbite of laughter)

FARLOW: He's - according to the Times, his position is to require everyone to get insurance subsidized by employers and the government. So that's…

Dr. REINHARDT: Well, there are some plans. For instance, the Committee of Economic Development recently came out with a plan that had been substantially written, I think, by our colleague, Alain Enthoven, at Stanford. And he had always looked to employers to be the major sponsors of health insurance, but this plan, he now proposes, doesn't have employers in it.

It is, basically, again, a voucher plan where the government would raise the financing, and then people would have vouchers to pick different competing HMOs. I mean, basically, he's persuaded to the prepaid group practice model, the integrated system Don Berwick talked about. And I think more and more people are coming to the realization that 10 years from now that the role of employers in American health care will be much diminished.

Smaller business units will be simply out of it. Only the huge corporations like G.M., G.E. will probably still be in the game. Why? Because businesses just simply can't cope with this complex system anymore.

FLATOW: We're talking about health care this hour in TALK OF THE NATION: SCIENCE FRIDAY from NPR News. I'm Ira Flatow.

In fact, they're begging for help on these things from the government because they - it drives the price of their cars up in comparison to Toyota (unintelligible) in National Health Insurance and has paid by the people rather than buying cost of the car.

Dr. BERWICK: Yeah, sure. When the country, Sweden, is spending 3 or $4,000 per capita, and we're spending 6 or $7,000, you can imagine the difference in our economic viability and global market place.

Dr. REINHARDT: And this is - Americans just have to get used to the idea that in the coming decade, the role of government in financing health care in America will inexorably grow no matter who runs the show - number one.

Now, you may use private insurance as purchasers. As most of these health plans - Senator Biden, Senator Edwards, Senator Clinton, Senator Obama - they all use private companies as purchasers, but there will be heavy government regulation, because government is not a patsy. They will insist on performance, including quality measurement and reasonable prices. So people who dreamed to get government out of health care, they are dreaming. Government will increasingly intrude no matter who runs the country.

FLATOW: And if Republican gets president?

Dr. REINHARDT: Same thing. It's just the - there's no choice. Smaller business would say, we can't deal with this anymore. And whoever that president is -we'll have an impoverished lower middle-class impoverished by health, and those people vote.

FLATOW: Uwe, do you think that the health care is going to move to the top of the political issue this season?

Dr. RALSTON: It needs to.

Dr. REINHARDT: I think it could happen. It depends what happens in the Iraq. If Iraq come down - I mean, my forecast - I've actually wrote an op-ed piece -says the long run view in Iraq is we'll be there forever with 60,000 to 80,000 troops inside big bases. That was, in fact, the whole idea of this war is to have these bases, so we'll be there forever. But as long as there isn't a huge slaughter and not a lot of the American troops get hurt or killed, I think health care, domestic issues will rise to the top again.

Dr. BERWICK: I think it will, too, in the next few years. The good news is there are answers. We'd know how to make care better at lower cost. Now, we just have to have the guts to do it.

FALTOW: Mm-hmm.

Dr. RALSTON: There's a lot of exciting work being done. One of the things that really intrigues me is the whole idea of comparative effectiveness. Just because something appears to an improvement, you need to compare it to other sayings and get the biggest bang for your buck. And that really needs to transcend political philosophies.

FLATOW: But do you think we have the guts to do this?

Dr. RALSTON: We're hearing more and more people from all persuasions concerned about the American health care system.

Dr. BERWICK: If you want an integrated system that has your back, that knows were you are and can trace you through your journey in health care, then you're part of a latent majority. The number of different state cultures that we'll be better off is enormous. It overwhelms those who want to preserve the status quo. Politically, what we need is to find a way to forge that coalition because it's the vast majority of us that will be better off in a reformed and integrated health care system.

FLATOW: Okay, we've run out of time. I've got to thank all of my guests. Uwe Reinhardt, professor of political economy at Princeton; Fred Ralston, chair of the Health and Public Policy Committee, the American College of Physicians; Donald Berwick, president and chief executive officer at the Institute for Healthcare Improvement.

Gentlemen, thank you all for taking time to…

Dr. BERWICK: Thank you, Ira.

FLATOW: You're welcome.

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