References and Notes
1. Physicians’ Plan for a Healthy
Minnesota. The MMA’s Proposal for Health Care Reform. The Report of the
Minnesota Medical Association Health Care Reform Task Force. January
2005. The most powerful determinants of population health are personal
health behaviors and the physical, economic, and social condition of the
communities in which people live. Costa Rica spends less than 10 percent
per capita of what the United States does for medical care. Yet, life
expectancy in both countries is virtually identical. Costa Rica has
one-half the rate of tobacco use, and a four-times lower lung cancer
death rate than the US; a fraction of the car ownership rate, which
results in lower accidents and higher exercise rates; and dramatically
different dietary patterns contributing to much less obesity, diabetes,
and heart disease.
2. Reducing the Costs of Poor-Quality Health Care
Through Responsible Purchasing Leadership. Midwest Business Group on
Health in collaboration with Juran Institute, Inc., The Severyn Group,
3. Assuring Health Care Coverage For All. A plan by the
American Academy of Family Physicians. October 2001.
4. Len M.
Nichols. Outline of the new America vision for a 21st century health
care system. New America Foundation Health Policy Program. Despite
spending twice as much as other developed countries on healthcare,
longevity for Americans ranks 24th among these countries, and the
performance of the healthcare system ranks 37th.
5. James F. Fries,
C. Everett Koop, Jacque Sokolov, Carson E. Beadle, and Daniel Wright.
Beyond Health Promotion: Reducing Need and Demand For Medical Care.
Health Affairs. v.17, no. 2 pp70-84,1998.
6. The Health of Nations.
Phillip J. Longman. .
in healthcare spending is driven by (1) increased use of healthcare,
especially expensive new medical technologies, by all age groups, (2)
general price inflation, (3) inflation in the prices of medical services
beyond general price inflation, and (4) aging of the population. Only
the first factor can be influenced by consumer behavior. That would
require motivation to manage one’s health budget account, an option most
people do not have since they pay for health insurance rather than for
medical expenses out of their pocket. Individual human behavior has the
greatest impact on healthcare costs, making promotion of healthy
behavior the primary goal of reform. Spending more cannot solve the nine
leading causes of disease attributed to unhealthy behavior. Obesity and
inadequate exercise may be the major results of unhealthy behavior that
have the greatest impact on escalating medical care costs. Recent
figures show that obesity is responsible for 20 percent of healthcare
costs in the U.S.A. Overweight individuals present an additional
contribution that raises this percentage. The use of tobacco is
estimated to have an economical impact on medical costs that is of a
similar magnitude. Alcohol and drug abuse also contribute significantly
to medical care costs. Preventable illness representing eight of the
nine leading causes of death (heart disease, cancer, stroke, pulmonary
diseases, accidents, pneumonia/influenza, diabetes, and suicide) makes
up approximately 70 percent of the burden of illness and its associated
costs. Coverage for everyone must implement plans to reduce preventable
illness influenced or directly caused by communicable diseases,
violence, physical fitness problems (inadequate exercise, obesity,
dietary indiscretions, and nutritionally incomplete diets), media
influences, tobacco and substance abuse, environmental safety (air and
water quality, food safety, waste management and accident prevention).
Such plans can have a profound effect on improving the health of
individuals and communities. Financial incentives must be implemented to
reduce the consequences of individual behaviors responsible for health
7. Elliott S. Fisher, H. Gilbert Welch. Avoiding the
Unintended Consequences of Growth in Medical Care. How Might More Be
Worse? JAMA February 3, 1999, vol. 281, no. 5. p446-453. Promises for
“cures” where none is possible often leads to disregard for the oath to
“do no harm.”
8. Essential Health Care Services.
9. John E. Wennberg, Elliott S. Fisher, and Jonathan S. Skinner.
Geography and the Debate Over Medicare Reform. Health Affairs 13
February, 2002. W96-W114. Healthcare spending could be reduced by 30
percent to the level of the benchmark of low-cost regions (Minneapolis)
without affecting quality of healthcare and life expectancy. Budgetary
caps would be necessary which would require patients and their
primary-care givers to make the decisions how their budget would be best
spent, or better invested in their best interests. Providing
cost-effective and essential quality care requires changes to: (1)
eliminate under-provision of effective care; (2) establish patient
safety; (3) reduce scientific certainty through outcomes research; (4)
establish shared decision making for preference-based treatments,
chronic disease management, and end-of-life care; (5) establish
accountability for capacity; and (6) promote conservative practice when
greater care is wasteful if not harmful. Strategies are required to
effectively and fully use all provisions for quality healthcare that are
cost effective, always justified, not harmful, and maintain low rates of
morbidity and mortality. Outcomes research is essential for determining
what is best for the patient and so that unproven and ineffective
diagnostic and management protocols are not followed, usually for
generating income and giving patients hope where little hope can be
10. Ibid. Medical professionals must be accountable to
accurately assess patient needs and recommend appropriate and effective
care through the use of established protocols. In addition, physicians
must be more committed to practicing in the kind of interdisciplinary
care teams that are needed to manage complex and chronic conditions,
something that most physicians do not do. These professionals have a
major responsibility to achieve measurable improvements in health, most
importantly through patient education. They are also most responsible
for exercising stewardship over collective healthcare resources,
especially for patients’ financial resources that are needed for present
and future healthcare. Medical professionals are morally responsible for
promoting health literacy among patients and the entire population.
Health policy currently places far too little emphasis on
population-wide prevention approaches, primarily through education, that
can help reduce risk factors for disease. That requires creating and
maintaining continuous health education for all peoples. Physicians must
provide the leadership for making public health paramount.
ability of people to sue medical professionals and facilities would be
drastically reduced. New medical diagnostic technology and treatments
have driven healthcare costs more than anything else. Many of these
innovations have been used without scientific studies to prove any new
or additional benefits on life expectancy or better health outcomes.
Evidence-based medicine must be practiced; research must demonstrate
effectiveness for all medical treatments supported by a health security
plan; technology must remain experimental and in research settings until
it can show proven value. Doctors who follow establish protocols in
practicing evidence-based medicine will have few justifiable pressures
to practice defensive medicine.
12. Ibid., Effective
care comprises services whose use is supported by well-articulated
medical theory and strong evidence for efficacy, as determined by
clinical trials or valid cohort studies. The category is further
restricted to interventions that virtually all patients should want as
part of the contract they make with their healthcare systems. If the
costly “state of art” care today is effective why has the average U.S.
life expectancy from age eighty-five been constant at 6.0 years since
13. The Dartmouth Atlas of Health Care.
Healthcare costs are highest in
geographical regions having the most physicians, especially specialists,
diagnostic laboratories and the highest number of hospital beds. The
regional differences are largely independent of beneficiaries’ need for
services. The number of visits to specialists by patients during their
last six months of life can be twelve fold greater in some areas
compared to other parts of the country. For this group of people the
average number of days spent in a hospital can be less than five in one
part of the country to over 21 in another. These differences are also
seen in the number of days such patients spend in intensive care units.
Greater spending does not buy better quality and more effective medical
care. Many referral needs could be managed by communications not
requiring a visit to a specialist. For example, electronic
communications can transmit information to specialists quickly and often
just as effectively as through an additional office visit. The only
thing that the specialist will not be able to do is a physical
examination. Physicians are trained to perform physicals, however, and
it is unlikely that the specialist will find something new in most
cases. The specialist will have time to evaluate more problems and the
overall costs to patients will be reduced. Survival rates and life
expectancy are the same regardless of whether a patient lives in a
high-intensity or low-intensity care region. There is no evidence that
there are differences in the quality of life in one region compared to
14. Reducing the Costs of Poor-Quality Health Care
Through Responsible Purchasing Leadership. An estimated 30 percent of
all healthcare spending nationally goes for care that is either not
indicated, not effective, or not up to current community standard. The
researchers reached the startling conclusion that Americans receive
effective care (defined as appropriate care based on medical evidence
and practice guidelines) for acute and chronic conditions only about
half the time. Professional care providers should develop best-practice
models and protocols with which all care-givers could use to design
their care for individual patients. These would be readily available
through internet use of websites detailing recognized standards. Use of
these protocols would guarantee payment for the medical costs incurred.
Patients would be informed that ignoring the protocols to follow a
care-giver’s own program would consume a patient’s medical budget and
jeopardize payment of unjustified tests or management. Thus, part of
expected consumer behavior would be to oversee a patient’s medical
budget and prevent waste so nothing would be left for forthcoming
essential medical care. (Chronic care management must be guaranteed as a
part of, or included in, any major costly procedure.) This would insure
against overuse of diagnostic procedures, hospitalizations, and ICU
stays. In addition, health professionals and their organizations can be
rewarded for following the accepted protocols. Patients would also learn
which groups will be the most reliable in protecting both their
financial and medical interests.
15. Assuring Health Care Coverage
16. Reducing the Costs of Poor-Quality Health Care Through
Responsible Purchasing Leadership. In spite of the technological
advances of the past 50 years, the quality of healthcare remains
inadequate and highly variable, with errors occurring far too frequently
and advances in clinical knowledge finding their way into practice far
too slowly. Minorities appear to be disproportionately affected by
quality problems within American healthcare. World-class competitiveness
in manufacturing requires system error (or defect) rates of 230 or fewer
per million opportunities. Fewer than five out of a million financial
service transactions result in an error. Yet most processes within
healthcare experience 6,000 to over 300,000 defects per million
opportunities. In other words, error rates within healthcare are orders
of magnitude higher than in other industries. The six-sigma approach to
quality improvement suggests that all industries should strive for error
rates of no more than 3.4 errors per million opportunities.
individuals must not be disregarded in medical care decisions. Obtaining
healthcare information eliminates the care-giver as the only one in any
decision-making process. Therefore, a high priority of consumer behavior
must be to become and stay informed. That behavior depends on providing
patients with unbiased information on possible diagnostic and management
choices. Patients now have an input and this enables a cooperative means
for making joint decisions. Numerous high-quality websites on the
internet offer all the information a patient needs to help make informed
decisions. Medical organizations and facilities can also provide this
information through video instruction and printed material. Educating
the consumer so that more informed decisions are made decreases the
frequency with which certain procedures are performed. One result is
less demand for intensive care and fewer surgeries. Another is reduced
demand for expensive diagnostic procedures—especially imaging
procedures. (Shared decision making is not popular because of providers’
fears about loss of autonomy and income.) Multiple studies have also
demonstrated that providing medical consumers with information and
guidelines for self-management can lower service use 7 to 17 percent at
very low cost. These approaches appear to work through two mechanisms:
better consumer information and increased confidence (personal
self-efficacy) that much illness can be effectively treated at home. For
example, data from The Dartmouth Atlas which analyzes the central
concept that self-care, when appropriate, is to be preferred to
professional care and that individuals can determine when professional
care is required if provided with relevant information. Elderly people
needing healthcare choose care to be least intensive as possible when
death approaches. They do not cling to life at any cost and desire a
need for healthcare to sustain their life as long as possible—in most
cases such existence is of poor quality.
18. Employers will no
longer pay for health insurance unless some employees choose to have
"supplemental" insurance. The 9 percent health security tax will be less
when individuals will no longer pay the taxes they pay for Medicare and
Medicaid. No longer will individuals be paying the 18 percent for health
insurance now costing them, even if this is paid for by an employer.
Employers can increase wages from savings from health insurance costs
that they are no longer obligated to pay.
19. Examples of taxes
include: a fixed sales tax amount on every gallon of automobile fuel
sold; a value-added tax on food and drinks that are high-calorie dense
and nutritionally not balanced (advertisements for such products should
state that a value tax has been added); a sales tax imposed on all food
and drinks sold in a restaurant; a value-added tax imposed on all
alcoholic beverages. All these taxes would go directly into the funds
supporting the healthcare program. None would go into any general funds.
When the government is working to promote healthy behaviors, it is
counterproductive to give the poor food stamps and allow them to
purchase any kind of food or beverage. Their use must be limited to
“healthy” foods. Also the government is not doing needy individuals a
favor by giving away surplus foods that are by themselves not
nutritionally the best for them.
20. Steffie Woolhandler, David
Himmelstein. Transparency or fig leaf? http://news.yahoo.com/s/usatoday/transparencyorfigleaf&printer=1
21. The responsibility for healthcare costs must become fairer and
must be shared proportionately by individuals with unhealthy behaviors
that contribute to the leading causes of disease. Individuals who
control their behavior in order to prevent and delay the onset of the 70
percent of medical problems caused by behavior can claim a rebate of the
health security tax they have taken out of their wages. Individuals not
overweight or obese can have their Body Mass Index (BMI) determined and
verified by a licensed medical practitioner. Rebates for normal-weight
individuals can be claimed on their income tax returns. Nonsmokers
(verified by normal tests for serum continine) can claim a rebate.
Individuals with drinking or substance-abuse problems or behavior
resulting in automobile accidents can claim no rebates. It is believed
that only financial incentives will motivate people to change behaviors
that increase their risk for needing healthcare. Coverage for everyone
will be promoted by financial advantages for Americans who select a
family physician who they visit at least once a year for physical
examinations, medical care and for receiving information on disease
22. Sacramento Healthcare Decisions. Just Coverage.
Citizens define the limits of ‘basic’ healthcare.
www.sachealthdecisions.org The Just Coverage project was designed to
learn what consumers believed are the elements of basic coverage within
a budget representing approximately 2/3 of the cost of a typical
employer-based health plan. The basic coverage must be (1) affordable to
all and to those with extensive healthcare needs and (2) as
comprehensive as possible to address life-threatening situations;
prevent or delay illness, disease, or disability; and restore vital
functions. The criteria for restrictions included the following:
Eliminate coverage of healthcare needs that are not critical to
essential human functioning.
Employ strict limits on provider choice
and use of specialists.
Expect adherence to clinical guidelines and,
whenever possible, prescribe the least-costly interventions.
coverage of unproven, ineffective or expensive and marginally-beneficial
Exclude coverage of costly treatments for conditions that
could be avoided or remedied by change in personal behavior.
“Implementing this model of basic coverage would be challenging. It
holds providers and patients to standards of treatment efficiency and
effectiveness that are not used now or not applied consistently. It
reduces the authority of physicians and patients in deciding which
providers can be used and when. As well, foregoing coverage of
non-essential needs acknowledges that communal resources should not be
used to remedy all healthcare problems. Despite these restrictions, most
participants regarded this as appropriate for a basic plan and one they
could accept for themselves.” Changes to provide healthcare for all must
built on the current knowledge that “Unfortunately, an employer-based
health insurance premium usually costs more than is politically feasible
for expansion programs financed with public and private monies.”
population surveyed was instructed to (1) make their basic coverage
affordable, (2) meet the healthcare needs of many, (3) emphasize
prevention, (4) provide good value, (5) serve the best interest of
society, and (6) show compassion.
A model for coverage was based on
the following limitations to define the parameters of basic coverage:
(1) Eliminate coverage of healthcare needs that are not critical to
essential human functioning. (2) Employ strict limits on provider choice
and use of specialists. (3) Expect adherence to clinical guidelines and
whenever possible, prescribe the least-costly interventions. (4) Exclude
coverage of unproven, ineffective or expensive but marginally-beneficial
treatment. (5) Exclude coverage of costly treatments for conditions that
could be avoided or remedied by change in personal behavior.
Americans believe that healthcare coverage must be provided to everyone,
but they do not want to be limited to a standard they regard as minimal
and do not want restrictions on what they can purchase with their own
dollars. “Minimal” does not mean a restriction of essential care. Rather
it has removed the waste inherent in the system which amounts to a third
or more of healthcare costs. Just Coverage’s of a basic plan is built
on: (1) Use well-functioning, cost-conscious primary care providers. (2)
Deny coverage for less essential needs. (3) Exclude high-cost, low-value
interventions. The majority of survey participants concluded on the
following needs and the most appropriate response:
Care—Treatment of unexpected, severe illness or injury, such as sudden
liver failure from food poisoning or massive injuries from an accident:
All emergency remedies are covered to try to save the person’s life and
establish basic functioning. Treatments are those proven to be
effective. If these treatments do not work or no such treatment exists,
supportive care is covered.
Complex Chronic—Treatment of serious
long-term conditions – such as diabetes, heart failure, arthritis – if
they have worsened over time and require extensive medical care to keep
patients as functional as possible: Doctor is required to follow
established guidelines for the least costly ways to manage complex
chronic illness. Though the covered tests, treatments and drugs are
effective for most people, they may not work quite as well as more
costly alternatives. May also covers very costly treatments that may
improve patients’ health or functioning, like knee replacement if
arthritis makes walking impossible.
Dental/Vision—For preventing and
treating dental problems; testing and correcting for problems with
eyesight: Cleanings and x-rays yearly without co-payment. Basic dental
services are 80% covered; maximum coverage is $1,000 yr. Vision Care,
which includes vision testing (refraction) once a year, if needed.
Covers $75 towards glasses every 2 years but not contact lenses.
End-Of-Life Care—For patients who have a terminal condition, when
medical treatment is no longer effective and who are expected to die
within the next few months: Hospice is covered in the home or hospital
to provide good pain control, treat other symptoms, and give emotional
and spiritual support. Coverage is not provided for further medical
attempts to delay a patient’s death from the terminal condition.
Episodic Care—Treatment (office visits, tests, drugs, etc.) for common
problems, such as a sore knee, constipation, recurrent cough, heart
burn, persistent skin rash, etc., and short-term urgent problems like
appendicitis: All emergencies and urgent care are dealt with quickly.
When the problem is not urgent, patients may wait several weeks or
LONGER for medical appointments, tests or surgery.
Behavioral Health—For detecting and treating mental illness. May also
cover behavioral health problems such as smoking and substance abuse,
and unhealthy conditions like obesity: For severe mental health
disorders (such as bipolar disease, severe depression and anorexia)
covers inpatient and outpatient therapy and drugs. Covers less severe
mental health problems, as well as behavioral health problems, with
out-patient therapy and medications.
monitoring and treatment of chronic conditions (such as asthma, high
blood pressure, diabetes) when they are newly diagnosed or
uncomplicated, to maintain good health and avoid worsening of condition:
Doctor is required to follow established guidelines for the least costly
ways for managing chronic illness. Though these tests, treatments and
formulary drugs are effective for most people, they may not work quite
as well as more costly alternatives. If treatment is not sufficient,
also covers more expensive tests, procedures and formulary drugs. Doctor
is required to follow established guidelines for using these treatments.
Maternity—For care of women during pregnancy and childbirth; includes
care of the newborn: Covers routine pre-natal and post-natal office
visits, tests, drugs and procedures that meet national standards for
preventing, detecting or treating problems. Covers childbirth, any
complications, and the first day of hospital stay for normal birth.
Prevention—To help prevent many diseases or illnesses and to identify
medical problems as early as possible: Covers wellness exams, screening
tests and immunizations. These must meet national standards for being
most effective, such as flu shots, PAP tests at a certain age, colon
exam at age 50, cholesterol screening and others.
Quality of Life—For
problems in function, appearance or comfort that are not seriously
disabling but impact personal quality of life. Examples: Injuries
affecting athletic performance; infertility; impotence; nail fungus: NO
Restorative—For restoring or improving ability to do basic
daily activities such as walking, speaking, personal care and critical
work-related functions. Often needed after strokes, joint replacements,
amputations, etc.: Covers all necessary rehab services (such as physical
therapy) to improve essential functioning. Covers artificial limbs but
not in-home patient equipment.
Improving healthcare quality has not
motivated individuals to demand changes. Costs will be the driving force
for change. With healthcare costs directly driven by human behavior,
only financial incentives for individuals to make changes in unhealthy
behavior can motivate people to reduce their healthcare costs.