The future of American health care dominates politics this year, but a high-profile team of experts suggests the current debate will not be the prescription to fix the country’s entire ailing system.
On Tuesday, the National Academy of Medicine released Vital Directions, a series of critical reports created by more than 150 scientists, doctors and policymakers who have been working together for the past 18 months, since long before the Trump administration’s push to repeal Obamacare. They hope policymakers will use the report as a blueprint to make American health policy great again.
The United States spends an enormous amount of money on medical treatment as a country, but the care isn’t great, the report suggests. The system is at a “critical juncture” at which there are record medical advances but the system itself will stop Americans from benefiting from them, according to the report.
Fixing the system is not impossible. Structural barriers that lead to fragmented care, inefficiency, mistakes and fraud need to be removed to enhance the value Americans get for what they spend, the experts conclude.
“Americans are facing challenges that go beyond coverage provisions in (the Affordable Care Act) and the proposed (American Health Care Act),” said Victor J. Dzau, co-chairman of the team and president of the National Academy of Medicine. “For coverage to have value, our health care system has to work towards attaining its full potential.”
No. 1, and not in a good way
In 2015, US health care spending grew 5.8% to $3.2 trillion — 18% of our gross domestic product — making it some of the most expensive in the world, and yet Americans get worse outcomes than other countries, studies show. For example, the US ranks 37th, behind less wealthy countries like Costa Rica and Morocco, when it comes to efficiency, according to one World Health Organization report (PDF).
Demographics make the need for improvement urgent.
The US population is getting older, and older people tend to be sicker. By 2060, the number of people over 65 will more than double to 98 million (PDF).
The population is also fatter. More than a third of Americans are obese, and with obesity comes health problems. There are high rates of chronic disease, as well: About half of American adults struggle with at least one chronic condition that needs regular care.
Americans are more accident-prone: The US leads the industrialized world in the rate of car crash deaths. And about 111,000 Americans get shot each year, with about 77,200 of those surviving and needing follow-up care, making the US the world leader in mass shootings and in gun deaths.
That’s not to mention the ongoing opioid epidemic. Drugs are the leading cause of accidental death in this country.
The sickest individuals, who tend to be poor, disproportionately get the worst medical treatment, the report said.
“Our nation is spending more than $10,000 per person on health care, and yet we are failing to achieve better outcomes,” Dzau said.
A fractured health system
One of the main failings, these experts believe, is the fragmented nature of American medicine. It’s a problem Congress’ debate doesn’t address, they say. Doctors and researchers work in silos and are disincentivized to collaborate.
Most government health care and private insurance pay doctors per service. Volume, rather than value, of care gets rewarded more, the new reports argue.
“It is a model that has made all the wrong decisions in terms of caring for patients,” said Sheila Burke, a member of the panel and an adjunct lecturer in public policy at the Malcolm Wiener Center for Social Policy at Harvard’s John F. Kennedy School of Government.
A fee-for-service system means your doctor gets paid more to order tests rather than spend quality time giving medical advice. Technology is available for doctors to consult with patients via the internet or phone, but that doesn’t typically get reimbursed. Neither does the doctor get reimbursed for educating a patient’s family so they can help create that community of care.
“Fee-for-service payment, is in fact, at the heart of (these) problem(s),” said panel member Michael O. Leavitt, former governor of Utah and former secretary of the Department of Health and Human Services under President George W. Bush. “Coordinated care is substantially better.”
That also means that medical professionals need to be trained to work in teams and that training needs to be incentivized, the report says.
The importance of data
Patients need more access to their own data so they can better understand their health, the papers argue. Currently, your records stay with your doctor and don’t follow you through life. Electronic records have made data sharing easier, but it’s often difficult for doctors to share due to incompatible systems and time constraints.
With specialization in medicine, patients with the most maladies often have the most doctors. Rarely do these patients have someone who looks at all these records and coordinates their care. That leads to redundancy, waste and medical mistakes, the reports show.
At a research level, because of patient privacy laws, there is no access to real-time data. If doctors could share individual patient data while protecting privacy, researchers could get a better handle on what treatments work. They could also catch outbreaks and adverse reactions sooner.
At a drug level, big health data are there, but with technical, regulatory and cultural barriers, data sharing is “neither simple, nor an established norm in health care and clinical research,” the report said.
Most data generated by a clinical trial goes unpublished. New laws and financing should encourage data sharing, the experts say. To encourage more precision medicine, standards may need to shift, since government-required randomized clinical trials for drug approval may not work because it’s difficult to get enough data.
At an approval level, drugs need a better chance to make it to market, the report argues. Only about 50% of all drugs make it to the final clinical drug trial stages. It costs about $2.6 billion to bring a new drug to market. There need to be more ways to evaluate real-world evidence, the papers argue, and the government’s “cumbersome and outdated regulatory review process” needs to change.
What else can be done?
Not all answers on how to improve American health lie within the medical system itself, the report argues.
Only 10% of premature deaths overall happen due to shortfalls in medical care, it points out. Genetic predisposition, social circumstances and individual behavior and environment play a much bigger role in someone’s health.
The experts call for investment in social service programs and for neighborhood infrastructure to be built with health in mind. Walkable neighborhoods, accessible parks, stores that sell fresh and affordable produce and improved public safety can all help a community’s health, studies have showed. Affordable child care, public transportation and job training all can improve people’s overall health, the papers said.
“Solutions will not be quick. These will take a long-term committed response across the board,” said Thomas Daschle, former U.S. senator from South Dakota.
Daschle argued that bipartisan support will be key in making these changes. “We did not see it with the ACA. If we do not see it at this time, I guarantee you, we will be back in two years or three years, having this debate and this discussion all over again. Vital Directions — it gives us an opportunity to say we can avoid this.”
