Physicians in the United States have a unique appreciation of the tremendous successes and even greater potential of our health care system, yet we also endure firsthand its woeful deficiencies. In the ongoing debate about how to improve the current health care structure in the United States, our individual voices have been all too quiet. No single health care organization, nor its spokesmen, speaks for the broad range of physicians’ opinions. Rather, doctors must make every effort, and indeed have an obligation, to speak forcefully as informed participants in this important process.
Jonathan A. Epstein, Laurence A. Turka, Morris Birnbaum, Gary Koretzky
Submitter: Irene M. Spinello | firstname.lastname@example.org
David Geffen School of Medicine at UCLA, Kern Medical Center, Bakersfield, CA
Published October 19, 2009
There are two groups of people for whose healthcare the federal and/or the state governments are already responsible for. The first group is the Native Americans. The Federal Government is obligated by treaties to provide health care to all Native Americans, but has not kept its promise. The news is full of horror stories about the inadequacies of the care provided on the reservations and appalling medical care due to lack of facilities, lack of equipment, and lack of qualified personnel. How could we think that the government can run healthcare for all?
The second group of people the government is responsible for are the prisoners. At the time when we are all resource conscious, our local, state, and federal prison system assigns one and quite frequently two prison guards 24/7 to a hospitalized, comatose prisoner on life support machines. The prisoner is not going anywhere – he is in a coma; but the guards are on overtime. Moreover, in the recent several months, the inadequacies of the prison medical care, especially in California, were exposed in the news. California government was mandated to improve the healthcare condition for the prisoners. The solution was to release some 57,000 of them back into the society. Out of sight, out of mind; and it will look great on paper.
How can we still trust the government with our health – the government that breaks its promises and manipulates numbers in order to create an illusion of correcting the problem? Why should we not think that if government-run healthcare passes, the same solution would not be used again by deciding on a group to eliminate or take off the books? The most sacred relationship between the patient and his doctor, between the healer and the sick will no longer exist. It will now be up to a bureaucrat with quota requirements and a set political agenda.
Have we forgotten Tuskegee? It was the Public Health System that started and sponsored the study for 40 years. For participating in the study, the men were given free medical exams, free meals and free burial insurance but no medicine that could have cured them. And the doctors did not find that unethical, nor did they find that illegal. They did not rebel; they were quiet. They forgot Primum non nocere – First, do no harm. They were working for the Government! The present system is not perfect. A large number of physicians practice defensive medicine to avoid malpractice suits. Surely that increases the cost. We can and should fix that first.
But supporting a government run or regulated healthcare will transform a physician from a servant of the patients’ healthcare needs to the serfdom of the governments’ agenda. This is a dangerous road to take.
Submitter: F.P. Schena | email@example.com
Renal, Dialysis and Transplant Unit. Department of Emergency and Organ Transplant. University of Bari
Published October 5, 2009
Every year the percentage of country’s gross domestic product (GDP) in the industrialized countries increases because of the high cost of medical services (diagnostic tools, new drugs and surgical procedures), which are in continuing expansion.
The per capita cost of health care in the United States is about twice that in other major industrialized countries, but more than forty-five millions of people remain without health insurance and many other individuals have inadequate insurance for their sickness.
The free market of health insurance influences largely the health policy and the world cannot forget episodes of health care difficulties of US citizens who moved outside of the country for drugs and health assistance as shown in Michael Moore movie (Sicko).
The Obama health care reform proposes a public assistance, probably in competition with the current private insurance. But other solutions are in progress by some Senators and Parliamentarians.
The false alarm that this reform may reduce the salaries of physicians is not true because salaries of the public healthcare system as in Britain and Italy are not so high, but decorous.
I think that the most important aspect of the problem is the continuing expansion of the cost which depends on new diagnostic tools, new drugs and new surgical procedures. But the copayment form is necessary because there is no possibilities that the government assistance may furnish all medications, laboratory tests or preventive care; perhaps this strategy should be adjusted for income age and disease.
In Italy and Britain where a national health service is functioning by more than 50 years the government determines expenses, negotiates salaries of the personnel and controls the use of expensive technologies.
The strength of these two systems is the continuous operating activity of general practitioners and pediatricians for primary care. The results of this policy is NHS in which patients have great trust in the family doctor. By contrast in US this first step is relatively weak. The possibility to increase the doctor-patient relationship should be one of the fundamental milestone of the Obama reform.
Submitter: Daniel Batlle | D-Batlle@Northwestern.edu
Northwestern University, Feinberg School of Medicine
Published September 25, 2009
The health care debate has appropriately centered on how to extend medical coverage to all Americans and control the ever increasing cost of health care. As part of the debate, we should also examine our system and seek ways to improve quality of care. As a kidney specialist, the care of patients with end-stage renal disease (ESRD) comes to mind as a paradigm that invites us to reflect on both the success of a federally funded program and its shortcomings. In 1972, the U.S. Congress amended the social security act to provide $173 million initially to support people suffering from irreversible kidney failure. From this point on, the care of patients with ESRD has been covered in much the same way that Medicare provides universal coverage for people over the age of 65. The approximate cost is $34 billion per year and there is intense pressure to reduce costs.
In the early 80s in the United States and the late 80s in England and other European countries, an ESRD committee at each hospital determined who would benefit the most from dialysis such that elderly people or people with too many co-morbidities would usually not be offered dialysis. For the last three decades, all Americans have had unrestricted access to dialysis. In fact, it has become “un-American” to die from kidney disease. Octogenarians and older currently account for close to 20% of patients on dialysis . According to the latest USRD report , the ESRD population reached a new high in 2007 with 527,283 patients of whom, 368,544 were on dialysis and 158,739 were transplant patients.
The Centers for Medicare and Medicaid Services (CMS) is expected to start “bundling” soon as a way to cover a given patient with advanced kidney disease on an annual basis. While this change in coverage for patients with ESRD may prove cost effective or, at least, more predictable, it may decrease the quality of care if there is too much emphasis placed on limiting procedures to stay profitable. There are rumors that the large dialysis companies are interested in providing health insurance and at the same time providing the medical care of patients with ESRD. We must remember that health insurance is a for-profit industry, and that the dialysis companies are also for profit organizations.
Coverage for ESRD care is universal in the United States, yet the clinical outcomes have been in some ways disappointing. Mortality rates in particular have remained high for many years at around 20-24% annually, which is in contrast to the lower rates observed in Europe and Japan . The root cause for lower survival rates in the United States is not fully understood. For instance, the mortality rate in Italy (under 12%) appears to be half that found in the United States .
Some aspects of the delivery of care in Italy that are unique when compared to the United States include: involvement of the nephrologists beginning in the stages pre-ESRD, their involvement in the placement of dialysis vascular access, and their physical presence requirement during dialysis sessions . While these factors may be less tangible, one important difference is the much higher use of AV fistulae (>85%) in Italy than in the United States (<40%). This is a clear reflection of delivery of care differences because there is no medical disagreement that AV fistulae are the preferred mode of access for chronic dialysis.
Why are our colleagues in Italy having a greater success using AV fistulae? I surmise that this difference reflects the involvement of the nephrologist in the care of these patients early on and the continuous care that follows early referral. By contrast, in the United States, patients often have dialysis access placed while they are in the hospital where the circumstances favor the placement of a central line for dialysis, which adds to the expense and later leads to increased morbidity because of associated infections and increased inflammatory burden. In fact, only one in three patients who started ESRD therapy in 2007 has seen a nephrologist for a year or less, according to the 2009 USRDS Annual Data Report, which was just released in September .
For practical purposes, early referral in Italy means “surrendering” care to the nephrologist early on in the course of kidney disease. It then becomes a natural part of management of advanced chronic kidney disease (CKD) to create an AV fistula in a timely fashion. This form of disease management for CKD that has evolved in Italy is both cost effective and delivers good clinical outcomes.
While our federally funded ESRD program is something to be proud of as it has saved hundreds of thousands of lives ,and has inspired the rest of the world to utilize state of the art technologies in dialysis, it is also clear that the clinical outcomes must improve. As part of the debate about healthcare reform, we should look at ways to ensure that patients are seen by nephrologists early and ideally in specialized CKD clinics . Taking note of other countries whose systems for ESRD care delivery is more efficient, less costly and, most importantly, yields better clinical outcomes, seems a logical thing to do.
Submitter: Norman H. Edelman | firstname.lastname@example.org
Preventive Medicine, Internal Medicine, Physiology & Biophysics Stony Brook University
Published September 24, 2009
As we watch health care legislation work its way tortuously through the Congress one cannot help but wonder why achieving universal coverage is so difficult in the United States as compared to other industrialized nations. The reason, I believe, is that in those countries health care is treated as a system, that is, a means of delivering a basic necessity at the public expense. There, the imperative is to deliver quality with equity [universal coverage] at the lowest cost, as in our public education systems. On the other hand, we may have had the option to mold health care into a system as late as in the 70s or early 80’s but since then we have encouraged it to become an aggressive profit seeking industry, regulated [somewhat] and publicly subsidized [extensively] to be sure, but an industry nevertheless. In a country which believes in the free market and respects the successful entrepreneur, downsizing or limiting the growth of a huge, highly successful industry in order to pay for equity, especially when the failure of most other industries has caused a major recession, is likely to be difficult; and it has proven to be so.
In the US health care is a uniquely successful industry. It grows in good times and bad. From this point of view it contributes rather than “costs” 2.2 trillion dollars [or 17percent of GDP] to our economy each year. Virtually all of its products are useful, some are lifesaving, there is very little overseas outsourcing and, critically important, fully 70 percent of the expenditures are for the salaries of middle class and working class personnel who are a mainstay of the economy of many communities. Nationwide the industry employs 12 percent of our workforce. Accordingly, the “efficiencies” which some think are obtainable, if rapidly realized, would increase our unemployment rate by from by one to two percentage points. One person’s efficiency is another’s job. In addition, it is unique among industries in that the potential demand for its products is infinite. We may, at some time, have enough cars, food and housing but we will never have enough health care because people will always want to live longer in good health. We have the technology to meet that demand and, I believe that, given the opportunity, the majority of Americans would put this item at the top of their list for discretionary spending.
So what is the real problem? It clearly is the cost to the public sector. In our tax-adverse society neither the federal nor state governments can sustain further increases in demand for publicly supported health care. The proper approach, in my view, is not to try to put the genie back in the bottle and try to make health care into a system, which because of the industry’s great economic power may be futile or even economically unwise at this time, but to recognize that it is an inordinately subsidized industry and focus on reforming government subsidies. There are two parts to this, both admittedly difficult. First, in order to pay for universal coverage we must decrease the subsidies to the privileged and well off. There are many pieces to this, most already articulated. Suffice to say that the privileged include high earners who benefit most from the tax exemption of employer based health insurance, well to do Medicare recipients whose out of pocket costs for health care are little more than those with incomes marginally above Medicaid eligibility levels, and of course, powerful industries such as the pharmaceuticals.
The second involves providing a universal coverage system which does away with the fiction that we can deliver “the best possible care” to all. All people are entitled to “decent” care, which, of course, has to be continually redefined. But some new technologies will simply be too expensive and not sufficiently cost effective to merit public subsidy. From a free market as well as an equity perspective, these should be available for purchase by those who can pay and available to all when they become cost effective. There are a variety of mechanisms which have been proposed to provide decent care for all. These range form “Medicare for all” the concept of which is embodied in the proposed new public insurance entity, to expansion and improvement of Medicaid with Federal support, which some think may be more palatable politically, to simple vouchers, reminiscent of food stamps, which is favored by fiscal conservatives.
Why is this approach better than the current approach to achieving equity by expanding the current system and paying for it with “efficiencies”? I believe that there are at least three reasons. First, I think the well off will see the inherent fairness of decreasing subsidies and be more like to accept that approach than unspecified “efficiencies” or a broad increase in their income tax rate. Second, given the certain, and desirable, explosion of expensive health care technology it is essential that we establish and articulate the principal that publicly subsidized health care must be fair and decent but cannot be unlimited. Many systems in the industrialized social democracies do so by providing the opportunity for people to purchase insurance to supplement their decent but not unlimited basic public plans. Finally, we should take care not to demonize and put the breaks on what may well be our most creative, dynamic and successful industry.
Submitter: John Balint | email@example.com
Albany Medical College, Albany NY
Published September 20, 2009
I was educated and trained in the UK during the first 10 years of the National Health Service and have always supported Universal access to care and still do. As was elegantly demonstrated by “Sick Around the World” on PBS, there are multiple ways to provide that. For the USA to achieve that goal we need some major adjustments to increase efficiency and control costs and basic philosophy.
1. We need to train many more primary care physicians (PCP) – potentially 45-50 thousand in the next 10-15 years. This will need national financial support for their education, which should be available for all doctors as in most developed nations.
2. PCP’s should be trained in and encouraged to take on the role of “Captain of the Ship” and coordinate cases for their patients.
3. Current income differentials between PCP’s and specialist need careful reevaluation in this context.
4. Electronic health records will be important to allow these changes. But we need much improved security for the patient data and we need a new culture of proof reading such documents to protect patient welfare.
5. Currently all of our institutions and us in academic or private practice have to deal with large multitudes of insurance carriers each with their own billing programs. We should reduce this huge cost burden by insisting that all insurers use one billing system – perhaps Medicare or something new.
6. If we allow continued function of private for profit health insurers we should impose limits on profits as happens in several countries such as Germany.
7. There should be consideration for limits on direct to patient advertising in all its forms. The savings should be passed on to patients in the form of lower costs.
8. We must also address the issues concerning Graduate and Post Graduate Medical education, it should be our professional obligation to fund it.
9. Most importantly physicians and Medicine must reestablish our dedication to the profession as expressed in our professional oaths on entry in to medical school and at graduation. Health care should be regarded as a public good and not a commercial enterprise.
I hope we can get these
Submitter: William R. Hazzard | William.Hazzard@va.gov
Division of Gerontology & Geriatric Medicine. University of Washington.
Published September 20, 2009
As members of ASCI we have all traversed a path of intensive clinical research to a level of recognition allowing our election to this prestigious society. For me this began during a subspecialty fellowship 40 years ago in Endocrinology and Metabolism, where our focus at the University of Washington (UW) was on patients at increased risk to premature CVD attributable to their diabetes and/or genetically determined hyperlipidemia, and our locus of activity was the General Clinical Research Center, where we could conduct carefully-controlled metabolic research on the pathophysiology of their disorders. We were young, eager, naïve, and most of us were not unduly burdened with heavy debts from medical school when tuition was only about 5% of present levels or distracted by personal or family concerns in our professional dedication to medicine and science at that stage in our lives. Since those halcyon days my career, like that of many of my colleagues from that era, has proceeded serially through phases of increasing breadth and educational and administrative responsibility, including service as a Medicine residency director and department chairman even as I maintained a continuing focus upon a challenging opportunity that had first been placed before me in 1975 by my chairman, Bob Petersdorf, : to initiate a division of Gerontology & Geriatric Medicine at the UW at the dawn of this new field in American medicine. And in this transmogrification I migrated from one of the narrowest medical subspecialties, Endocrinology and Metabolism, focused almost solely at the UW on its research mission with generous funding from the NIH, to that very broadest of specialties, Geriatrics, one that best thrives when working in collaboration with every medical, surgical, and related health care discipline in joint efforts to meet the health and social care needs of our progressively aging population.
And as a geriatrician I can only applaud the audacity of hope that fuels our current movement in the ASCI and other professional organizations to re-engineer our health care system in order to meet the compelling needs of our aging citizens for more accessible, timely, efficient, coordinated, and appropriate care for their multiple, predominantly chronic, and most complicated array of health and social care needs. And also as a geriatrician --- and acutely aware of the painfully few internal medicine and family medicine residents who elect our single year of clinical fellowship training for board certification in our specialty --- I applaud the consensus among academic faculty that health care reform must reverse the growing imbalance between primary care (which includes geriatrics) and that provided by other medical and non-medical specialties and subspecialties. However, central to this essay is my appreciation of how difficult this reversal will be, especially because academic medicine in the US has become captive to economic, scientific, and professional forces that have driven us to sub-sub-subspecialize evermore narrowly in order to sustain our focus within manageable boundaries that allow us to remain abreast of and indeed lead our disciplines as clinical investigators while increasingly dependent upon extramural research funds in an era of intense competition and NIH budgetary constraints. So I have to acknowledge that I have contributed to the genesis of this problem throughout a blissfully stimulating and satisfying career, managing to negotiate that career astride the traditional 3 (or 4)-legged stool of clinical, educational, investigational, and administrative achievement even as I have reinforced this progressive fragmentation of attention, resources, and effort that is at its most extreme in the academic health center by offering its centrality and power in American medicine as the most promising, efficient, and most certain route to respect and support for geriatricians and recruitment of the best and the brightest to our field by anchoring our efforts in those centers throughout the US.
And I have also come to realize that the economic underpinning of our academic, superfocused model of professional activity and career development has been a major generator of the expensive, inefficient, and often redundant care that threatens the integrity and economic viability of the American health care system. Even more uncomfortable for me to acknowledge is the easy relationship I have enjoyed at each stage of my career between me as a clinical investigator and educator and the pharmacological and medical device industries and their representatives who support our research and its drive toward evermore exciting but also evermore expensive care of the diseases that afflict our evermore aging patient populations (a cozy relationship that is on required display before every grand rounds or sectional conference in the lists of potential conflicts of interest of the presenter, a measure of uncertain effectiveness adopted to manage this problem).
In other words, as academic physicians we are not only part of the problem but perhaps at its very center!
So what should we do about this? For starters I would suggest the following as specific key elements of a comprehensive health care reform effort:
Submitter: Laurence Jacobs, M.D. | firstname.lastname@example.org
University of Rochester School of Medicine and Dentistry
Published September 16, 2009
To the editors:
The many dysfunctional aspects of our health care system are well known: unsustainable costs on an ever-increasing course; uninsurance for nearly 50 million and severe underinsurance for many millions more; the lack of flexibility in both work and personal relationships entrained by employer-based insurance and fear of its loss; our abysmal metrics for infant and maternal mortality and for longevity, related, in part, to our imbalance between primary care physicians and specialists; medical debt-related personal bankruptcy, growing rapidly and virtually unknown elsewhere; and over 20,000 needless annual deaths due to uninsurance.
In such a complex system, it is naive to expect a single diagnosis or treatment to be a comprehensive cure; yet, costs drive a huge portion of our problem. And a key underpinning of our costs is the infiltration of the profit motive into health care. When corporations in health care insurance put profits and shareholder returns above any concern about patient care, when physicians selectively and excessively refer patients for imaging, dialysis, or hospitalization to for-profit facilities in which they are co-owners, how can health care not suffer?
Regarding costs, we need to reverse the 1997 FDA decision that allowed direct-to-patient advertising of pharmaceuticals, which now saturate our media. We need to remove the for-profit elements from health care, and re-focus on health care as a human right, and not as a commodity. A single-payer system, an improved Medicare for all (as in HR 676), would save enough ($ 400 billion per year, roughly) to insure all our currently uninsured without putting another dime into the system.
We need to re-think financial incentives which have perverse results, including how medical education is financed and the resulting huge debt loads, which clearly influence career choice. We also have pressing need to reconfigure reimbursement formulae to reward primary care activities and reduce interventional emoluments. We have to move away from fee-for-service and toward salaried systems for physicians. Properly done, these steps should help insure that physicians will be there for the larger number of patients seeking primary care.
Research needs to be protected and nurtured, in universities and industry. Since R and D budgets are about half of marketing and advertising budgets, the latter should not be a problem. But we also need to think about how to make careers in clinical and translational research more attractive to young physicians; the near-void in these areas in NIH R01 funding has resulted in the gap being filled with many non-hypothesis oriented clinical trials, funded by drug companies.
Our health care can be incredibly effective and life-saving, and our research enterprise is the envy of the world, but we have to find ways to limit our waste and fraud, provide incentives to make primary care more attractive to our students and residents, and reimburse physicians for the quality and not the quantity of the care they provide.
Submitter: Alan M. Krensky, M.D. | email@example.com
National Cancer Institute
Published September 16, 2009
Thank you for your Editorial and the various Personal Perspectives. I propose the following:
First principles for health care reform
Submitter: Arthur Bank | firstname.lastname@example.org
Published September 16, 2009
The most controversial issue in the health care wars is the value of the "public option" for health insurance. Is it really necessary for meaningful health care reform? In my opinion, it is crucial. Without it, there will be no impetus for HMOs and other private insurance providers to lower their costs, and premiums and uncovered costs will continue to escalate. President Obama is exactly right. We need a public option to keep HMOs and insurance companies in check. These are profit-making businesses which have substantially higher administrative and share-holder expenses than any public plan. They are afraid they will go out of business with a new public option. And I hope they eventually will if they can't change their ways. Medical insurance should not be a profit-making business, Medical care is a right, not a privilege.
The public option is also the only sane way to enforce the fact that all Americans be covered by health insurance, by providing insurance at reasonable costs. Even much of the middle class cannot afford the premiums of private insurers today. We need competition. The senators who are against the plan are politically motivated. They want to satisfy their constituencies, mainly older voters.
I am 74 years old and a retired physician-scientist, and I believe a public plan is the least we can do to try to cover everyone with medical insurance and lower costs. I believe that seniors who are against the public option are selfish, self-centered hypocrites who are already benefiting from a public plan designed for them, Medicare. They can't see past their own self-interest. They don't seem to understand or care that their children and grandchildren deserve the best medical care as much as they do, at affordable costs. The AARP is waffling again on the public plan just as it did 10 years ago when it prevented the passage of catastrophic health insurance, which would have saved us all lots of money and might have helped avert the current crisis.
Of course, we also eventually have to change health care re-imbursement. We must increase re-imbursement to primary care physicians, the key to the health care system and to pediatricians and obstetrician-gynecologists, also primary care physicians. They are our primary doctors, on the front lines, who need to be properly re-imbursed. At the same time, we must lower re-imbursements to medical sub-specialists, surgeons, dentists, ophthalmologists, radiologists who are making way too much money for their services. The medical profession has done much too little to regulate doctors' fees. It should now do much more, or the government must regulate for them. Medicine should not be a big business. It is a right, and should be available to all at reasonable prices.
The health care scandal in the United States grows worse with each passing day and is treated by our politicians as just another political football while more of our citizens continue to suffer and die needlessly from the lack of adequate care. This is truly an American tragedy with no end in sight. Health care is a right of all Americans, all human beings, and yet we, the richest country in the world, bail out banks and financial institutions with billions of dollars and yet cannot feel enough for our fellow countrymen to insure that they receive treatment when they are sick. How perverted and immoral is that?
No one group is to blame for how we have reached this state of emergency. Doctors, we the care-givers, have largely ignored our responsibility in the political arena for too long to help solve this problem. Many of us were feeling like we were doing God's work at the same time that we were making enough money to continue to live well, and that was enough. More recently, with Medicare and Medicaid reimbursements low, many physicians have also contributed to the problem by becoming businessmen more than physicians, and colluding with drug companies and HMOs to increase their incomes, while also increasing the cost of medical care.
But the real villains in this piece are our government and special interests, especially the drug companies and HMOs. Medicine is a profit-making business for them, and boy are they ever making profits. In addition to increasing profits, did you know that right now it is illegal for Medicare or Medicaid to negotiate lower drug prices with drug companies? The government should have the right to negotiate for lower drug prices with drug companies. And we should have the right to sue HMOs. Did you know it is illegal to sue HMOs?
We also have a largely dispassionate Congress, many beholden to the drug companies and the HMOs and to other private business interests for campaign contributions and other perks.
Eventually, we need government run universal health care, perhaps as an extension of Medicare and Medicaid. Everyone must be covered. The program should be paid for by higher taxes. Yes, higher taxes on those of us who can afford to pay them and all of us to some extent. The HMOs should become more reasonably priced or put out of business as quickly as possible by any new plan.
At its base, the solution to health care really requires an increased feeling of empathy by many more of us for our fellow Americans, perhaps requiring an impossible change in our collective human nature from self-interest to a belief in the health and well-being of all. We are the only supposedly "civilized" country without universal health care. Health care is a right, not a privilege. Not a business. Except in the USA. The health care scandal is a shame on America that needs to be addressed soon.
Submitter: J.L. Mehta, MD, PhD | email@example.com
University of Arkansas for Medical Sciences
Published September 16, 2009
Here are suggestions to reduce the healthcare costs. Some of these suggestions may not be palatable to physicians, hospitals, pharmaceutical industry and device manufacturers, but implementation of these suggestions will have an immediate effect on healthcare costs.
Medical care must not be for-profit, but as much a human right as food and shelter.
Submitter: Gerald S. Levey, M.D. | firstname.lastname@example.org
David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Published September 16, 2009
The debate over healthcare reform has exposed wide-ranging differences of opinion among members of Congress, various special interest groups and the American public. The debate has focused largely on a government run health plan, insurance reform and making Medicare and Medicaid more efficient. There has been a significant absence of discussion regarding the training of physicians for the new healthcare system that might emerge from comprehensive healthcare reform; there has not been any serious discussion of how to sustain a vigorous biomedical research effort in the United States including the development of an adequate number of physician scientists.
Biomedical Research: It is evident that the best way to achieve a significant decrease in medical spending envisioned by any healthcare reform plan is development of methods to prevent human disease and finding cures for medical diseases. For example the identification of individuals possessing the genetic abnormalities that make them more susceptible to developing lung cancer if they smoke and then counseling them throughout their lives about their predisposition and the need for them not to smoke is preferable to no effort to prevent the disease and having to treat an already developed lung cancer requiring major medical interventions. Disregarding politics a simple ban on smoking in the United States would save untold billions and ultimately trillions of dollars of healthcare costs.
Cost of Training of Physicians: As we try to develop a more culturally diverse physician population it is important to rethink the way medical student education is financed. Right now the mean for individual student debt is approximately $140,000 for a public medical school and $190,000 for a private medical school. This is an unacceptable burden especially given the relative scarcity of scholarship money for many of our students. Any comprehensive healthcare reform must initiate an overall review of funding for medical education and a reconsideration of governmental support for medical student education. Although this might be unacceptable to those who are not supportive of a substantial role of government in medicine it would surely make certain that medical education is affordable to those who want to enter the profession of medicine in the United States and help create a culturally diverse physician workforce.
Comprehensive healthcare reform must also initiate a reconsideration of the funding for graduate medical education and resolve the decades-long workforce controversy about how many generalists and how many sub-specialists are necessary. Recent commentary on the physician workforce suggests that there is need for an expansion of the numbers of physicians being trained and that sub-specialists will continue to have a necessary and critical role in delivery of healthcare because there is a shortage of sub-specialists as well as generalists.. The numbers of generalists who will be required however, is complicated because it must in large part reflect the type of healthcare system we construct. The role of the primary care physician would most likely be vastly different in a prevention based system which could utilize nurse practitioners and/or physician assistants. Geographic distribution of physicians must also be considered; the underserved populations in our inner cities and rural areas deserve the quality of generalists and sub-specialists that are so necessary in an age when medical knowledge grows in volume and many physicians cannot sustain the complex knowledge base required in each of the sub-specialty areas of medicine.
Mechanisms for a Stable and Sustainable Funding of Training and Research: Since the 1980’s I thought it was a mistake to have Medicare and Medicaid participate in a substantive way financially to fund the training of residents and fellows (graduate medical education). The government needs to develop a mechanism of funding, possibly an appropriations model similar to NIH or a trust fund originally proposed by the late Senator Daniel Moynihan. The dollars spent on healthcare i.e., Medicare and Medicaid should be spent on healthcare and not the training process. These alternative models to provide financial support would remove a burden on Medicare and Medicaid.
The National Institutes of Health is the major source of support for biomedical research in the United States. Too frequently over the past half century the academic community has been faced with the unreliability in the funding sources for NIH grant sponsored research. There needs to be stability and planned growth so the numbers of grants provided can be relied upon by universities and the individual investigators without altering the quality of the research being performed. We have a situation now in the country where there is a continued scarcity of physician scientists and the pay line for NIH grants most years is unacceptably low. Failure to correct this in the future may result in cutting the lifeline for medical advances that produce the cures and preventive measures that are the key to lowering healthcare costs.
In conclusion these critical issues including provision of financial support for medical student education, more appropriately financed post-graduate medical education, and recognition that the ideal way to lower healthcare costs are by prevention and cures of diseases through biomedical research must be discussed as soon as possible as key pieces in the healthcare reform debate. Failure to do so will impair the successful transformation of the American healthcare system.