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Confronting the brutal facts in health care

      The United States faces serious challenges in health care: cost, access, quality, and a projected shortage of caregivers. Rather than acknowledge these issues, some leaders hope tinkering with the structure of medical education will reinvigorate primary care medicine and help fix a failing health care system.
      • Whitcomb M.E.
      • Cohen J.J.
      The future of primary care medicine.
      A recent editorial mused, “Instead of being discouraged by some of the realities of primary care practice, particularly lower incomes and greater demands on their time, more students might find in this specialty precisely what they were seeking when they chose to pursue a career in medicine.”
      • Whitcomb M.E.
      • Cohen J.J.
      The future of primary care medicine.
      This optimism is misguided and does not address the real problems. Five paradoxes describe the current crisis, and a sixth may help solve it.

      Paradox 1

      As the United States spends more on health care, the number of uninsured grows.
      The United States spends more on health care than any other country.
      • Anderson G.F.
      • Reinhardt U.E.
      • Hussey P.S.
      • Petrosyan V.
      It’s the prices, stupid why the United States is so different from other countries.
      During the next decade, the proportion of the gross domestic product spent on health care will reach approximately 20%.
      • Heffler S.
      • Smith S.
      • Keehan S.
      • Clemens M.K.
      • Zezza M.
      • Truffer C.
      Health spending projections through 2013.
      The cost of health insurance has jumped 60% since 2001, while the insured shoulder greater deductibles and copayments.

      Henry J. Kaiser Family Foundation. Employer health benefits 2004 annual survey. Available at: http://www.kaiserfamilyfoundation.org/insurance/7148/index.cfm. Accessed March 22, 2005.

      Medicare beneficiaries will pay 17% more in monthly premiums this year than in 2004, the highest increase in the history of the program.

      Department of Health and Human Services. HHS announces Medicare premium, deductible for 2005. Available at: http://www.omhrc.gov/omhrc/pressreleases/2004press0903a.htm. Accessed November 22, 2004.

      Multiple forces underlie these increases.
      • Heffler S.
      • Smith S.
      • Keehan S.
      • Clemens M.K.
      • Zezza M.
      • Truffer C.
      Health spending projections through 2013.

      Regence Blue Shield of Idaho. Why does health care cost so much? Available at: www.id.regence.com. Accessed March 22, 2005.

      Most often, the consumer does not pay directly for care. Americans are older, sicker, and more obese; expect the newest and best treatments; and overuse the system. The cost of prescription drugs jumped 20% in 1 year alone. The government has enacted more than 1500 mandates, such as the Health Insurance Portability and Accountability Act. Malpractice premiums encourage defensive—and more expensive—medicine. By one estimate, 3% of total health care spending is a result of fraud.

      Regence Blue Shield of Idaho. Why does health care cost so much? Available at: www.id.regence.com. Accessed March 22, 2005.

      Despite this spending, the number of uninsured people continues to climb, increasing by 1.4 million in 2002 alone.
      • DeNavas-Walt C.
      • Proctor B.D.
      • Mills R.J.
      One in 6 people lack insurance, and 80% of these individuals come from working families.
      • DeNavas-Walt C.
      • Proctor B.D.
      • Mills R.J.
      Families USA.
      Those fortunate enough to be insured cannot depend on their coverage. At some time between January 1996 and December 1999, 85 million people were living without health insurance.
      Families USA.
      As Schroeder
      • Schroeder S.A.
      The medically uninsured—will they always be with us?.
      observed nearly 10 years ago, “the link between employment and health insurance has eroded,” and this trend is likely to accelerate.

      Paradox 2

      Increased costs and external oversight fail to improve the quality of health care.
      Government, insurers, providers, health care organizations, and professional societies have not met the Institute of Medicine’s minimum goal of reducing medical errors by one half.
      • Kohn L.T.
      • Corrigan J.M.
      • Donaldson M.S.
      • Altman D.E.
      • Clancy C.
      • Blendon R.J.
      Improving patient safety—five years after the IOM report.
      Care remains fragmented. Most third-party purchasers provide little incentive to improve safety and quality. Although the medical profession is highly monitored, controlled, and regulated, these efforts are poorly coordinated. The culture in health care relies on individuals rather than systems. The structure of medical liability impedes systemic efforts to uncover and learn from errors.
      Quality varies by ethnicity, economic status, and community. With the possible exception of care in the Veterans Health Administration, African Americans receive lower-quality health care than whites.
      • Jha A.K.
      • Shlipak M.G.
      • Hosmer W.
      • Frances C.D.
      • Browner W.S.
      Racial differences in mortality among men hospitalized in the veterans affairs health care system.
      • Bach P.B.
      • Pham H.H.
      • Schrag D.
      • Tate R.C.
      • Hargraves J.L.
      Primary care physicians who treat blacks and whites.
      The “failure to deliver standard care” to African Americans cost 886 000 lives between 1991 and 2000.
      • Woolf S.H.
      • Johnson R.E.
      • Fryer G.E.
      • Rust G.
      • Satcher D.
      The health impact of resolving racial disparities an analysis of US mortality data.
      People with better education and higher paying jobs receive better care, and the quality gap widens between the haves and the have nots.
      • Isaacs S.L.
      • Schroeder S.A.
      Class—the ignored determinant of the nation’s health.

      Paradox 3

      As the need for primary care increases, interest in such careers declines.
      Despite growing concern about physician shortages, fewer US medical school graduates choose primary care careers.
      Council on Graduate Medical Education
      Medical students have more choices, struggle with greater debt, and seek controllable lifestyles; they recognize that primary care physicians earn less, have lower job satisfaction, and provide care the current system does not value.
      • Ibrahim T.
      The case for invigorating internal medicine.
      In the 2005 National Resident Matching Program, US graduates filled 15 669 residency positions.
      National Resident Matching Program.
      Only 3929 students (25%) matched into family practice, internal medicine (excluding preliminary programs), pediatrics, or medicine-pediatrics.
      National Resident Matching Program.
      Moreover, two thirds of internal medicine residents currently pursue subspecialty training.

      American Board of Internal Medicine. Summary of workforce trends in internal medicine training—academic years 1994/1995 through 2003/2004. Available at: http://www.abim.org/resources/trainover.shtm. Accessed March 22, 2005.

      Paradox 4

      Although society needs well-trained physicians and groundbreaking research, medical schools and teaching hospitals pursue clinical dollars.
      Each year, US medical schools depend more heavily on patient care revenues.
      Association of American Medical Colleges
      The schools create centers and institutes and cultivate a product-line mentality to generate income, irrespective of the educational consequences.
      • Ibrahim T.
      • O’Connell J.B.
      • LaRusso N.F.
      • Meyers F.J.
      • Crist T.B.
      Centers, institutes, and the futue of clinical departments part I.
      • Smith L.G.
      Medical school applications have declined dramatically, from 46 965 in 1996 to 35 735 in 2004.
      Association of American Medical Colleges

      Association of American Medical Colleges. FACTS—Applicants, matriculants, and graduates: applicants by state of legal residence, 1993-2004. Available at: http://www.aamc.org/data/facts/2004/2004slr.htm. Accessed March 22, 2005.

      The educational mission is further stressed by an imbalance between the number of medical students and residents. The number of graduates has remained constant for 2 decades, but the number of residents has increased sharply, largely to provide clinical service. This discrepancy has increased dependence on international medical graduates, a quarter of whom are now US citizens.
      National Resident Matching Program.
      • Hallock J.A.
      Finally, medical schools and teaching hospitals have not adequately addressed the shortage of physician-scientists.
      • Nathan D.G.
      Clinical research perceptions, reality, and proposed solutions. National Institutes of Health Director’s Panel on Clinical Research.

      Paradox 5

      In the nation’s capital, political capital is worth more than operating capital.
      Health care is the public’s third-highest priority after the war in Iraq and the economy.

      Henry J. Kaiser Family Foundation. Health care agenda for the new Congress. Available at: http://www.kff.org/kaiserpolls/pomr011105pkg.cfm. Accessed March 22, 2005.

      The public understands the need to increase the number of insured, improve quality, control costs, and establish the viability of Medicare and Medicaid. However, current budget priorities make it difficult to tackle these challenges. The budget deficit is more than $400 billion. Medicare is expected to go bankrupt in 15 years.
      Centers for Medicare and Medicaid Services
      Last year, for the first time ever, states spent more on Medicaid than on education.

      Leavitt MO. A review of the administration’s FY 2006 health care priorities. Testimony to the House Energy and Commerce Committee. February 17, 2005. Available at: http://www.hhs.gov/asl/testify/t050217a.html. Accessed March 22, 2005.

      Meanwhile, the Bush administration has recommended spending “below inflation” for discretionary programs, such as the National Institutes of Health.

      Department of Health and Human Services. Budget in brief for FY 2006. Available at: http://www.hhs.gov/budget/06budget/FY2006BudgetinBrief.pdf. Accessed March 22, 2005.

      Providers, particularly physicians, remain virtually powerless. Of the top 114 organizations with the greatest influence in Congress, the White House, and the federal agencies, only 2 represent physicians (the American Medical Association and the American College of Physicians).

      Fortune. The power 25. Available at: http://www.fortune.com/lists/power25. Accessed September 17, 2002.

      The more influential groups—such as the Association of Trial Lawyers of America (ranked fifth)—promote agendas that conflict with physician interests. Between 2002 and 2004, congressional advocacy for teaching hospitals has waned, despite the economic and social benefits they bring to communities across the country.
      Association of American Medical Colleges

      The Stockdale Paradox

      As the highest-ranking US military officer in the “Hanoi Hilton” prisoner-of-war camp during the Vietnam War, Admiral James Stockdale endured repeated torture for 8 years. When asked how he managed to survive and eventually lead his fellow prisoners, Stockdale advised: “You must never confuse faith that you will prevail in the end—which you can never afford to lose—with the discipline to confront the most brutal facts of your current reality, whatever they might be.”
      • Collins J.
      According to Stockdale, the optimists, those who failed to confront the brutal facts, perished.
      The Stockdale Paradox is applicable to health care in the United States today. Medical, political, and societal leaders must have an honest, open discussion about the current reality. The health care system must become more transparent and less fragmented. Reimbursement for physicians must reward high-quality primary and preventive care for the growing elderly and chronically ill populations. Medical schools and teaching hospitals must produce an adequate number of doctors and better translate medical research into patient care. Leaders must work together if there is to be improved health care for all Americans, regardless of ethnicity, economic status, or community.
      To overcome the current crisis, the leadership of American medicine must first confront the brutal facts. Only then can genuine health care reform begin.

      Acknowledgment

      Dr. Henderson receives grant support from the US Department of Health and Human Services Health Resources and Services Administration, Rockville, Md. This editorial represents the opinions of the authors and not necessarily those of their employers.

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