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A way to deliver health care that's better, safer and cheaper

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By Henry F.C. Weil and Philip R. Lee
Saturday, December 19, 2009

The health-care debate in the Senate has, thankfully, returned to the paramount issue of cost. Unfortunately, the most obvious, time-tested and feasible approach to providing high-quality care at reasonable cost remains excluded from consideration.

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The irony is that President Obama and a number of legislators have lauded the work of approximately 30 health-care organizations, caring for about 6 percent of the population, that for decades have provided care reliably better than average at lower cost. These are the "group employed models," or GEMs, such as Geisinger Health System, the Marshfield Clinic, Kaiser Permanente, the Mayo Clinic and the Cleveland Clinic. Two of these GEMs -- the Cleveland Clinic and the Mayo Clinic -- have been ranked among U.S. News and World Report's top five hospitals in the country. And shouldn't all Americans have access to such better and cheaper care?

Most health-care organizations are run on a "fee-for-service" model. GEM organizations are different in that their physicians are employed, they are physician-led, and they work closely together and share information. Their track record makes sense: Unlike in most clinic or hospital settings, the physician at a GEM has no reason to give more or less treatment and simply seeks to provide the right treatment for patients. Wouldn't one assume that to be the goal every member of Congress would target for Americans?

GEMs compete in the same market as other health-care organizations and in every demographic niche. Data from Dartmouth University and from numerous quality surveys by government and nongovernmental agencies, have indicated the superiority of this model. It follows that better care could be delivered and the country could save billions of dollars each year if the model were given incentives by Congress and more doctors were prompted to consider merging into integrated systems. Just think: All uninsured Americans could be covered, quality would go up and costs would fall.

If health care could be delivered better, safer and cheaper, why would Congress not make this model the centerpiece of reform? The answer is that cutting the annual expenditures on health care, now about $2.5 trillion, would mean lower profits for the health-care industry. Today, health-care expenditures are more than three times as much as even the defense budget. If it were a country, U.S. health-care spending would be the world's seventh-largest national economy. It's no surprise that the industry has spawned powerful lobbies and has made sizable corporate contributions to the reelection campaigns of members of Congress. If all Americans are to get better treatment (and possibly hundreds of billions of dollars in tax relief), these powerful interests would ultimately take in a lot less money, something they're not likely to be happy about. That creates a heavy lift for lawmakers who need to get reelected.

Members of Congress are aware of the data supporting the efficiency of GEMs. Some have pointed to elements of GEM approaches in the bills they have has considered this year. But these elements are pilot projects or topics to be studied by task forces, rather than serious, substantive changes to the health-care delivery system.

The cost differential between pushing an aggressive effort toward integrated, employed physician care vs. continuation of the status quo would be at least $4 trillion to $5 trillion over 10 years. A difference of this magnitude has implications for America's future well beyond health care. Consider the effects just on the millions of Americans who are unemployed or underemployed, as some of those funds could be invested in productive enterprises or tax cuts targeted to stimulate job growth.

The threat posed to our democracy by legislators being co-opted by powerful interests was warned of as far back as the Founding Fathers. As Alexander Hamilton wrote in Federalist No. 1, "Happy will it be if our choice should be directed by a judicious estimate of our true interests, unperplexed and unbiased by considerations not connected with the public good. But this is a thing more ardently to be wished than seriously to be expected."

Health-reform negotiations have reached the eleventh hour, but people must get aggressively involved if they want the public good -- better health care and an economically better future for the country. Otherwise, Congress will stumble forward like the alcoholic who knows what needs to be done and intends to quit drinking next week.

Henry F.C. Weil is assistant dean for education at Columbia University's College of Physicians and Surgeons and practices medicine with Bassett Healthcare Network. Philip R. Lee, a former chancellor of the University of California at San Francisco who has been on the faculty of its medical school since 1969, was assistant secretary for health and scientific affairs in the Johnson administration and assistant secretary for health in the Clinton administration.



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