Straight Talk: The Continuing Struggle to Make Health Care Affordable
The Martin Luther King holiday provided an opportunity for many of us to see at least parts of the presidential inauguration. My major interest was not in the contest of which designer's dress the First Lady would wear or even the highly advertised singers of our various national anthems. I actually wanted to hear what President Obama would choose to say in his inaugural address.
The address was much more specific than many pundits had expected, and even though the reaction to statements on climate change, immigration and civil rights (including gay rights) were expected, I was interested in what would be said about medical care as well. On one hand, what he said about strengthening commitments to Medicare and Medicaid will be interpreted by some as doing nothing to stop the growth in entitlement programs; but, on the other hand, he clearly signaled the necessity for compromise.
Regardless of the stand of political extremes, the imperative to address the budget deficit does not seem to have escaped the President or his hope for a legacy. It is not just his admission that Medicare and Medicaid must be addressed, but the reality that these are the big gorillas in the budget deficit formula. I believe the Affordable Care Act was a step forward as a developed country must provide health care for its citizens. The challenge now, however, is to make it affordable.
The Deficit Reduction Debate and Health CareThere are many initiatives that will be fought over between the parties, but deficit reduction is now an issue with the wind at its back. The arguments will center on how much is to be gained from revenue and how much from cuts. Be sure that cuts are coming — substantial cuts will come with consequences, but they will come in private insurance reimbursement as well. Last month, Doug Morris, MD, director of the Emory Clinic, and I teamed up to reflect on what could be done to contain costs by controlling waste.
Waste was defined as health care spending that can be eliminated without decreasing quality of care. It is great to talk of eliminating waste, but I am reminded of what the mail carrier told my wife when she complained about all the junk mail in our mailbox. He said, "There is no such thing as junk mail — that's what pays our salary." I am afraid this may also apply in medicine, especially as more physicians become employees of hospitals. Eliminating waste will be good for the payer, but will it be good for the providers? I think somehow we have to make it so. The threat of major cuts may become the "necessity" that is the mother of invention. We can react in one of two ways: one is to cry that no cuts are appropriate and defend the current expenditures; the other is to recognize the need to prioritize and work with payers and others to ensure that the resources are spent wisely.
It will be important that incentives are aligned in a way to reward best practices. The ACCF/AHA guidelines have been developed over many years of diligent reflection on the evidence. Our guidelines, for example, now make a major issue of treating only ischemia-producing lesions, at least when acute coronary syndromes are absent. Will reimbursement schemes be in sync with these recommendations?
The recently implemented payment codes for percutaneous coronary intervention (PCI) reflect a change. As I understand it, reimbursement for single-vessel stenting has gone down (again), but the codes now allow additional charges for five arteries and up to two side branches per vessel. If extensive multivessel interventions are warranted, then it is proper that the reimbursement reflect that. On the other hand, the incentive will encourage performing PCI on lesions of borderline severity. These kinds of incentives, although entirely appropriate for the work done in most cases, will necessitate careful scrutiny of what we are doing. Remember that, in addition to overuse of medical resources, the Institute of Medicine includes "failure of execution of care processes and fraud" among the components of medical waste. If the number of lesions treated per patient goes up substantially in a hospital, I suspect someone will be watching.
I believe that quality of care is improving, and cardiologists and surgeons are becoming increasingly aware of what is needed as evidence continues to inform us. The heart team approach to decision making is a safeguard against snap judgments and unconsidered options. If resources become limited, this multidisciplinary reflection about choices of therapy will become even more important.
Many areas of cost are outside of physician control, but it is encouraging that in some systems, knowledgeable physicians are being recruited to work toward rational cost control. I hope that more of this can occur because our patients are counting on us to become engaged in finding solutions.
Spencer B. King, III, MD, MACC, is president of the Saint Joseph's Heart and Vascular Institute and Professor of Medicine Emeritus at Emory University School of Medicine in Atlanta. He is also editor-in-chief of JACC Cardiovascular Interventions. He has been a pioneer in interventional cardiology, directing the first trial of angioplasty versus surgery.
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