We are facing some very tough times and health care will not be immune from changes dictated by economic necessity. Drastic macroeconomic revisions need to be made in our health care system soaring in cost (nearly 20 % of the GDP-gross domestic product so far) and coupled to a rapidly growing ageing population that will require increasing increments of care on the one hand and some *49 million uninsured and underinsured , in effect, without access to care.

*This number is going to increase dramatically as our economy continues into an even stormier economy while businesses fail- leaving employees with no medical coverage. The number underinsured will skyrocket as those companies that survive the financial crisis struggle with plummeting revenues and are saddled with rising benefit costs that they can no longer sustain. Insurance companies will (as they have been doing) engineer new plans that attempt (unsuccessfully may I add) to control unbridled medical costs. Managed care will show its ugly head again, deductibles and co pays will continue to increase and the percent of coverage as well as what is covered will decrease. All of this will add up to worse health care in the U.S.

How medicine will and should be financed aside, I am quite concerned about how effective any of the changes that might come down the road will be if we do not commit to more than a economic restructure of medicine (i.e. single payor, tax credit based, etc.), but a paradigm shift in how medicine is practiced in the U.S. I am not suggesting that we should throw out the baby with the bathwater. There are some things that are simply outstanding about U.S. medicine:

1. U.S. diagnostic technology (lab testing, radiology, etc.) is the world leader.

2. U.S. trained specialists and primary care providers are beyond reproach, and,

3. U.S. medical standards and health facilities are the best in the world.

However:

1. U.S. medicine is the most expensive in the world (even when adjusted for currencies). Yet, we have some of the worst health care statistics- shamefully comparable to the health in a third world country.

2. In countries that spend a fraction on health care, you would live longer and arguably enjoy a much better quality of life.

3. We have been adversely affected by a legal system that encourages “defensive medicine” whereby physicians in order to avoid often frivolous lawsuits and awards that are excessively high for medical negligence; over utilize testing, specialty consultations and therapies. The resultant misuse of resources plus the outrageous cost of medical malpractice for health care providers as a consequence has contributed to elevated medical care costs.

4. Pharmaceutical, medical device and diagnostic testing equipment companies have unduly influenced medical training, research institutions, faculty members and their students creating a cadre of professionals virtually brainwashed in the over use of unproven and unnecessary technology that itself is one of the key causes of morbidity and mortality and escalating health care costs in the U.S.

5. These same, powerful companies have successfully driven a disinformation and marketing campaign that has reached almost every segment of our society- selling Americans on often unneeded tests, medications, tests, etc.

6. The major source of drug addiction in the U.S. is not from Latin American “cartels” but, in fact, from prescriptions written by doctors.
7. Resource allocation in preventive services is relatively limited because treatments and testing is much more profitable (if not as practical and cost effective as prevention).

8. Very little has been done to address clear environmental dangers that impact directly on the health of American families and their children.

9. Regulatory agencies such as the FDA (Food and Drug Administration) and the EPA (Environmental Protection Agency) have dangerously conflicted relations with the very industries that they are charged to oversee- receiving funds from private industry, often exchanging employees and allowing industry and lobbying representatives to write and/or influence public policy.

10. Federal government officials enjoy excellent health insurance, available to them for life- even if they are no longer a government employee so they are immune to issues of affordable health insurance and insurability- problems for most Americans.

11. Specialists spend most of the dollars in health care on testing, treatments, procedures and drugs and yet the more specialists in a community, the HIGHER the mortality because more technology bears NO relationship to better health. Yet, specialists are the heroes of medicine- paid the most and the most influential politically within the medical profession.

12. Specialists, as a rule, earn much more than primary care providers (family physicians, general internists, pediatricians) and yet communities that enjoy a greater number of primary care doctors have LESS mortality and less expensive care. Modern medicine in the U.S. does not reward cognition (thought and reasoning) as much as it prizes procedures, testing and medications. Why? Thinking might cause health care to be more rational, more cost effective and therefore- LESS PROFITABLE!!! Primary care doctors who think utilize fewer resources and contribute positively to the length of life as well as its quality. (There are few who perceive of medical care today as contributing substantively to quality of life. There are few who see their physicians as even interested in the quality of their lives.)

The answer clearly requires creative and clever financing that can drive a paradigm change that favors optimal health for Americans first- not maximizing profits for health care related industries as the first priority. But, much more is needed when we talk of real change:

1. First, income of specialists should be substantially reduced while the incomes of primary care providers should be proportionately increased so that more young physicians will be encouraged to enter primary care careers which support cognition, caring and commitment to patient care. This would allow primary care providers to afford to spend time with patients, listen to patient needs and devote more efforts to empowering patients and decreasing their dependence on drugs and tests.

2. Immediately, all physicians and their staffs should be freed from the overwhelming burden of having to fill out different forms for different insurance companies on a daily basis. The amount of paperwork is overwhelming and absurd- adding to practice overhead which is passed on to the health care consumer and taking precious time away from patient care.

3. All administrative physicians working in federal, state and private for and not for profit companies such as insurance companies should be required to return to the practice of medicine full time in their specialty periodically so that :

a. They help out with a national physician shortage and

b. They become more sensitive to the actual needs of patients and health care providers. (Perhaps managed care medical directors would not be as insensitive were they reminded periodically of their responsibilities in actual patient care.)

This is entirely justifiable and not a form of forced servitude (Docs can and should be paid for their services) because all physicians have willfully been trained in programs funded by federal and state dollars (all public funds). Their personal loans that in some cases paid for part of their medical school education covered only a fraction of the actual cost of their education. In essence they owe the taxpayer! Both their employers and the communities they serve as part of their rotation should reimburse them while engaged in clinical care.

4. All members of the federal and state governments should NOT be guaranteed health insurance that is any different that that available to the American public while employed or after employment. A Congressman, for example, should be no more privileged with regard to health care benefits than anyone else. This would light a fire under bureaucrats to truly address our health care crisis since then they and their families might actually be affected by coverage issues.

5. The FDA should not be able to accept any funding from the very same private industry that it regulates and its employees should be required to have longer periods of time once they leave government employment to work within the pharmaceutical and medical device industry or related political action groups designed to lobby in behalf of these industries.

6. EPA operations should be restructured so that it is a regulatory agency governed by science and much better insulated from politicians and lobbying groups such as the chemical industry.

7. Americans should have a choice with regard to the kinds of practitioners they choose and the kinds of medical care they seek. Funding whether single payor or private insurance based should not discriminate against some forms of complementary and alternative medicine (CAM) and qualified medical doctors(M.D.), osteopaths (D.O), naturopaths (N.D.), chiropractors (D.C) and licensed acupuncturists (L.Ac.) as bona fide providers giving reimbursable care. Although called “unproven medicine” many CAM therapies (such as acupuncture, nutritional medicine, etc.) can be supported by a credible body of literature and have never been demonstrated to be anywhere near as harmful as conventional medicine ( Remember Vioxx?) and yet enjoys more outpatient visits annually and more out of pocket patient expenditures. The American public has expressed its desire for more CAM, but, conventional medicine politics has kept it in abeyance. This is not acceptable any longer. However, national and/or state standards credentialing alternative providers must be put in place and strictly enforced and the scope of practice of each class of provider should be clearly defined.

8. More safeguards should be placed on claims made by pharmaceutical and natural remedy producers and the quality of production should be improved by funding regulatory agencies to adequately enforce codes already on the books.

9. The U.S. Department of Agriculture (USDA) in collaboration with the FDA, EPA and U.S. Customs should be adequately funded, better organized and better insulated from the politics of beef growers or dairyman (for example) so that our food supply can be better protected and that children and pregnant women are not subject to the dangers becoming increasingly prevalent in domestic, but especially imported foods.

10. Much better collaboration between agencies is required to especially monitor products arriving from countries such as China, Mexico, India, etc. which have consistently and adversely affected the health of Americans (e.g lead laden toys, melamine contaminated candies, lollipops with lead, unsanitary and mislabeled pharmaceuticals such as heparin etc.)

11. A national commission should be convened to explore the extraordinary implications for our nation of what many believe to be the excessive use of behavioral pharmaceuticals- which I believe has established a level of drug dependence (anti anxiety, sleeping and anti depressant pills that could affect national productivity, political and military decisions. Recently, it has come to our attention that many of the national leaders who have promoted these drugs have received large financial rewards from the very companies that produce the drugs and yet have not disclosed their conflicts of interest to the public or other health care professionals. This, at the very least, makes one wonder about the credibility of their research which has influenced physicians and nurse practitioners across the nation. In the military alone it has been suggested that nearly 20% of our armed forces engaged in active duty in Iraq and Afghanistan are using such drugs. College students seeking help at student health centers are routinely prescribed these drugs because of convenience and the decreased intensity of resources required when compared to group and/or psychotherapy. The effectiveness of these drugs when compared to placebo, exercise, dietary changes, some nutritional supplements, psychotherapy and group intervention is questionable at best. Health insurers have found it expedient to pay for drugs rather than psychotherapy which is more costly. Yet, both in the U.S. and around the world warnings related to increase suicide risk with these drugs and possibly an increased rate of cancers with prescribed methamphetamines, for example, has been described. We need objective clarification- free of pharmaceutical company interests before an entire generation end up using possibly unproven mind altering drugs without a clear long term track record.

12. The cost of drugs must be addressed. Americans should be allowed to purchase prescription and over the counter drugs from other countries- especially Canada where the quality of production is as good (if not better than) ours. Vehicles must be established to allow for inspection of pharmaceutical manufacturing facilities in other countries so that we can open up yet further the doors of free trade and competition for these products. The notion that by so doing we will discourage R&D (research and development) for new drugs is ludicrous. Most research supported by drug companies is to replicate the product of another company already under patent and so to compete they must develop a similar family of product but different enough so that there will be no patent infringement. This is called a “me too” drug research program and does not necessarily add incrementally more to public health- just to drug expense. Yet other research is to find another use for an already existing drug so that it will have new indications. This allows the pharmaceutical company to milk more money from an already existent product. Since the majority of new drugs annually approved by the FDA fall into these categories, one could hardly argue that the exorbitant cost that we pay for drugs as a result of this research is justifiable. Truly new drug development that can benefit society will not be inhibited by competition.

13. The ethics of advertising of pharmaceutical and natural product manufacturers as well as corresponding service providers needs to be explored. National and regional standards should be developed to protect the consumer and they should be enforced. The public needs to be protected against false claims and misrepresentations in advertising. The health care consumer needs more, objective and understandable information in order to make wise choices that effects the health of themselves and their families and more often than not this is just not the case right now. Consumers need to know a lot more about risk/benefit, cost and side effects.

14. State professional licensing agencies should become more insulated from local and regional political influences and the undue influence of attorneys representing professionals who slow down the process of protecting the public. Alternative and conventional medicine licensing boards should be streamlined, possibly merged and at the very least have close coordination to ensure public safety. Continuing education requirements must become more stringent and the number of hours increased. More public funds should be made available for this purpose.

15. Hospitals need to be better regulated. Regional planning must once again be instituted to avoid replication of expensive services such as heart surgery, gamma knives, etc. Hospitals should receive financial incentives for providing services that are needed in their communities – rather than choosing clinical services needed by their doctors to increase income which leads to duplication. In other words every cardiologist (heart doctor) in Phoenix might want to do heart catheterizations in the hospital- rather than travel to a regional center of excellence. The hospital wants to fill its beds and keep the doctor (who admits patients) happy and increase revenues and so a new catheterization center is born. In fact, it would be more cost effective and efficient to have but a few centers of excellence regionally for heart caths. They become more efficient and have better quality because of well trained teams, handling higher volumes of patients and practice does make perfect generally speaking.

16. Doctors and hospitals should be subject to competitive government and consumer scrutiny. Healthgrades.com is a good first attempt at ranking doctors and hospitals by both consumers and in this case CMS (Medicare) rankings of hospitals for certain procedures and diseases. This concept of transparency needs to be enlarged and made more available to the public.

Money and effort expended in the “right” directions can contribute to the kind of changes in health care that we all seek. Just changing how we finance health care alone will not achieve our goals. The upcoming months after the elections (whomever is elected and whatever their political philosophy) will bring health care yet further in our sights. You should be thinking about health care because it affects you and your family and just getting “covered” is simply not enough!