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By Arthur M. Feldman
Sunday, September 6, 2009 

As a cardiologist and the administrator of a large practice that includes general internists and specialists, I spend much of my time trying to figure out how to provide care for a growing number of uninsured or underinsured patients. I also have to battle billion-dollar private insurance companies that don't adequately cover patients with preexisting illnesses and often deny coverage for necessary treatments. 

On a basic level, I'm with the president: Our health-care system needs to be changed so that all of my patients, and all citizens, have access to the care they need. But I don't agree with how he wants to fix things. Most of my colleagues and I strongly oppose the health-care reform bills that Congress will take up again this week. The proposals leave enormous gaps unfilled. 

Before President Obama addresses a joint session of Congress on Wednesday, I hope he will consider these 10 major reasons why I -- and doctors like me -- worry that the legislation on the table will leave us worse off. 

1. Private insurance companies escape real regulation. 

This is what makes my colleagues and me so cynical about the reform proposals. Every physician has insurance company horror stories: patients who went untreated because their carriers wouldn't pay, endless hours on the phone to get administrators' approval for necessary tests and mountains of paperwork to collect reimbursements. It will be hard for doctors to buy into health-care reform if insurance companies get a free pass. 

2. We urgently need tort reform, but it's nowhere to be seen. 

Malpractice costs rise each year, as do the number of frivolous lawsuits. Our practice has seen a 10 percent increase in malpractice expenses this year. Sure, doctors make mistakes, and patients deserve fair compensation for their injuries and lost wages, but in this area of the law, physicians and hospitals are too often at the mercy of capricious juries. 

When the president brought up the "fear of lawsuits" in his address to the American Medical Association in June, he got a huge response from the crowd. That's because practically every doctor has a story about a jury that awarded huge damages to a plaintiff despite the absence of wrongdoing by the physician. The best from our practice group is the physician who was sued -- even though he was out of town during the patient's entire hospitalization. Without fixing these spiraling insurance costs and the legal environment that allows large payments in unjust suits, physicians will continue to practice expensive "defensive" medicine or simply leave states that do not enact tort reform. 

3. "Prevention" won't magically make costs go down. 

Obama has called for disease prevention on a national scale, but that won't be a cure-all. Louise Russell,, a researcher at Rutgers University, analyzed hundreds of studies on prevention and medical costs and found that, in general, prevention adds to costs instead of reducing them. That's because it often means medication for hypertension and elevated cholesterol, and screening and early treatment for cancer. Unless Congress outlaws McDonald's, cigarettes, alcohol and idleness and cleans up the environment, no amount of "prevention" will put a dent in the cost of keeping Americans healthy. 

4. Reform efforts don't address our critical shortage of health-care workers. 

Many people believe that the fix for our physician deficit is simple: expand class sizes at existing medical schools and create new ones. Sorry, it's not that easy. There is a cap on the number of federally funded training positions for newly minted M.D.s. It hasn't changed since 1996. If the number of graduates of U.S. medical schools increases but the number of post-graduate training positions remains the same, we won't have fixed the problem -- we'll have created a different one. Training programs will simply take more U.S. graduates and fewer foreign ones, and the total number of physicians trained each year will remain the same -- too low. And foreign medical school graduates tend to practice in rural and underserved urban areas, the very places that need the most help. 

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10 Things I Hate About Health-Care Reform

5. We need more primary-care physicians -- but we also need specialists. 

Everyone is worried about the dwindling ranks of primary-care physicians. But we need more specialists, too. There are impending shortages in fields such as oncology, cardiology, general surgery and gastroenterology. An article in the American Heart Association's journal Circulation noted that by 2020 there won't be enough cardiothoracic surgeons to treat the growing number of American seniors. Surgery, the journal of the Society of University Surgeons, reported an expected shortage of 1,300 general surgeons in the United States by 2010. Few Americans will tolerate not having access to a specialist in an emergency or having care rationed because of a limited number of skilled physicians. 

6. We have to streamline drug development and shake up the Food and Drug Administration. 

Creating and producing new drug therapies in the United States is a nightmare. Regulatory hurdles, disorganization and a lack of leadership at the FDA, as well as burdensome conflict-of-interest policies, have made the drug-approval process grindingly slow. At the same time, development costs are close to $1 billion per drug. Federal regulations are so convoluted that most clinical trials are now performed outside the country -- taking billions of dollars out of the U.S. economy and making it harder for American patients to be first in line for new treatments. 

7. We can't fund health-care reform by cutting payments to doctors. 

This isn't about one doctor looking out for his bottom line. It's about physicians being able to provide the accessibility and quality of care that their patients want. The Centers for Medicare and Medicaid Services has proposed increasing payments to primary-care physicians by approximately 6 percent while lowering payments for many specialists, including cardiologists and oncologists, by as much as 20 to 40 percent. These drastic recommendations were based on a questionable American Medical Association physician survey showing that expenses for cardiology and oncology practices dropped precipitously over the past five years -- a finding that defies logic. If these cuts are approved, the American College of Cardiology estimates that 40 percent of the cardiology practices in Florida will go bankrupt. We need to pay for performance, not automatically reduce fees for procedures that patients have come to expect. 

8. We can't forget about research. 

Every modern treatment for human disease is related in some way to research at U.S. academic medical centers -- much of it supported by the National Institutes of Health. These include new treatments for cancer, devices to prevent sudden cardiac death and medications that save the lives of patients having heart attacks. 

However, decreased federal funding for research over the past six years has threatened to decimate a generation of young scientists and the cures they could discover. While the stimulus package provided $10 billion for NIH-supported research, the allocation was for only two years. The health-care reform legislation provides no information about the level of research funding after 2011. 

9. Cutting reimbursements could shut some hospitals down. 

Proponents of the current reform legislation know that no one wants their local hospital to close. So the White House's initial call to pay for health-care reform through cuts of more than $200 billion in hospital reimbursements over the next decade was scary. Obama sought to reassure people in June, explaining that "if more Americans are insured, we can cut payments that help hospitals treat patients without health insurance." But there is no data to support this promise. It is unlikely that the homeless, the mentally ill, the substance abusers or the illegal immigrants who now receive their care in "safety net" hospitals will carry any form of health insurance. Grady Memorial Hospital, one of the premier public hospitals in the United States, which has cared for the underserved residents of Atlanta for more than a century, would probably have closed its doors had it not been for a $200 million gift from a local benefactor. 

10. We need to improve the quality of care. 

Obama has said that "if doctors have incentives to provide the best care instead of more care, we can help Americans avoid the unnecessary hospital stays, treatments and tests that drive up costs." This is an overly simplistic view of what is needed. Poor care clearly costs more money. However, as the Institute of Medicine has pointed out, poor quality of care can be divided into three types: underuse of care, misuse of care and overuse of care. While eliminating misuse and overuse will decrease the cost of care, correcting problems from underuse will actually increase costs. 

I have a close view of the limitations of our current health-care system. Not just with my patients, who are often unable to afford the care they need, but also in the plight of a young colleague. He was diagnosed with an aggressive form of lung cancer and sought treatment at a nationally renowned Boston cancer center. Most people with lung cancer undergo expensive chemotherapy and radiation therapy, but even those aggressive measures have a limited effect on long-term survival. His physicians discovered that he had a type of cancer that might respond to a new drug in clinical testing, provided free by the pharmaceutical company sponsoring the research. Although the cost of his care is far less than that of traditional chemotherapy, his insurance company refused to pay for it because it is "experimental." 

But he has been lucky. His friends and colleagues have helped support his treatment, and wherever possible his doctors have provided free care. His cancer has responded dramatically to the drug, he has suffered no side effects, and he is back at work full-time. 

However, I don't want my patients to rely on luck. I want them to have insurance that will pay for their care, and I want to be able to offer new medications and the most sophisticated treatment. I want to be able to give preventive care as well as to monitor patients effectively if they develop diseases. I want to be able care for my patients in their homes, and I want to offer palliative care if it becomes necessary. I want them to be able to afford all this. In short, I want to see major reforms in health care -- I just don't want what is on the table. 

Arthur.Feldman@jefferson.edu 

Arthur M. Feldman is a cardiologist and chair of the department of medicine at Jefferson Medical College. He is the author of "Pursuing Excellence in Healthcare: Preserving America's Academic Medical Centers." He will be online to chat with readers Tuesday at 2 p.m. Submit your questions and comments before or during the discussion. 

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Health Care in Japan: Low-Cost, for Now; Aging Population Could Strain System 
The Washington Post - Washington, D.C.  
Author: Blaine Harden 
Date: Sep 7, 2009 
Start Page: A.1 
Section: A SECTION 
Text Word Count: 1921 
 
Half a world away from the U.S. health-care debate, Japan has a system that costs half as much and often achieves better medical outcomes than its American counterpart. It does so by banning insurance company profits, limiting doctor fees and accepting shortcomings in care that many well-insured Americans would find intolerable.

The Japanese visit a doctor nearly 14 times a year, more than four times as often as Americans. They can choose any primary care physician or specialist they want, and surveys show they are almost always seen on the day they want. All that medical care helps keep the Japanese alive longer than any other people on Earth while fostering one of the world's lowest infant mortality rates.

Health care in Japan -- a hybrid system funded by job-based insurance premiums and taxes -- is universal and mandatory, and consumes about 8 percent of the nation's gross domestic product, half as much as in the United States. Unlike in the U.S. system, no one is denied coverage because of a preexisting condition or goes bankrupt because a family member gets sick.

But many health-care economists say Japan's low-cost system is probably not sustainable without significant change. Japan already has the world's oldest population; by 2050, 40 percent will be 65 or older. The disease mix is becoming more expensive to treat, as rates of cancer, stroke and Alzheimer's disease steadily increase. Demand for medical care will triple in the next 25 years, according to a recent analysis by McKinsey & Co., a consulting firm.

Japan has a stagnant economy, with a shortage of young people that hobbles prospects for growth and strangles the capacity of the debt-strapped government to increase health-care spending. Without reform, costs are projected to double, reaching current U.S. levels in a decade, according to the Organization for Economic Cooperation and Development (OECD).

For generations, Japan has achieved its successes by maintaining a vise-like grip on costs. After hard bargaining with medical providers every two years, the government sets a price for treatment and drugs -- and tolerates no fudging.

As a result, most Japanese doctors make far less money than their U.S. counterparts. Administrative costs are four times lower than they are in the United States, in part because insurance companies do not set rates for treatment or deny claims. By law, they cannot make profits or advertise to attract low-risk, high-profit clients.

To keep costs down, Japan has made tradeoffs in other areas -- sometimes to the detriment of patients. Some are merely irritating, such as routine hour-long waits before doctor appointments. But others involve worrisome questions about quality control and gaps in treatment for urgent care.

Japanese hospitals experience a "crowding out" effect, with space for emergency care and serious medical conditions sometimes overwhelmed by a flood of patients seeking routine treatment, said Naohiro Yashiro, a professor of economics and health-care expert at International Christian University in Tokyo.

"Patients are treated too equally," he said. "Beds are occupied by less-urgent cases, and there are no penalties for those who over-use the system."

The government has largely been unable to reduce the length of hospital stays, which are four times as long in Japan as in the United States. Hospital doctors are often overworked and cannot hone specialized life-saving skills, according to recent reports by McKinsey. Statistics show that the Japanese are much less likely to have heart attacks than people in the United States, but that when they do, their chance of dying is twice as high.

There are shortages of obstetricians, anesthesiologists and emergency room specialists because of relatively low pay, long hours and high stress at many hospitals, doctors and health-care analysts said. Emergency room service is often spotty, as ER beds in many hospitals are limited and diagnostic expertise is sometimes lacking. In a highly publicized but not unprecedented incident, a pregnant woman complaining of a severe headache was refused admission last year to seven Tokyo hospitals. She died of an undiagnosed brain hemorrhage after giving birth.

"We are in a hospital desert at night," said Yashiro, citing insufficient pay incentives for the robust 24-hour staffing common at large U.S. hospitals.

Skilled doctors tend to leave Japanese hospitals for the higher pay and predictable hours of private clinics. There, they become primary-care doctors, making up for low treatment fees with astonishingly high volume, seeing patients in an assembly-line process that leaves little time for questions.

Toshihiko Oba had spent most of his medical career in hospitals. As an ear, nose and throat specialist, he worked 80-hour weeks for 13 years, with an annual salary of $100,000. The average salary for a hospital-based doctor in Japan is about $150,000, according to the Ministry of Health.

"The money was not so good and you have lots of responsibility and pressure," said Oba, 47.

Five years ago, he made a career change common for Japanese doctors at the pinnacle of their careers. He left the hospital and opened a private clinic, and now treats mainly colds and allergies.

In his office in Tokyo's upscale Ginza district, Oba works from 9:30 a.m. to 7 p.m., five days a week. He said he works fast, typically treating 150 patients a day, usually for about three minutes each.

Volume has allowed him to increase his income severalfold, Oba said, although he declined to be specific. Most doctors in Japan who jump from hospitals to private clinics double their income, according to the Ministry of Health. Medical malpractice insurance in Japan is not a major expense for many doctors, in part because there are relatively few lawyers. Oba pays only about $1,000 a year.

One of the great strengths of Japan's health-care system -- the ability to see the doctor of one's choice and be seen quickly -- has become one of the greatest curses for controlling health-care quality and costs, experts here agree.

There is no gatekeeper for medical care or for hospital stays.

"The government has been trying for more than 20 years to put up gates," said Naoki Ikegami, professor of health policy and management at the Keio University School of Medicine in Tokyo. "But we don't train general practitioners to be gatekeepers."

Japan also has about three times as many hospitals per capita as the United States does. The government has tried to limit hospital beds, but with little success because of institutional inertia and a cultural preference for in-patient treatment. New mothers in Japan often stay in a hospital five days after a routine delivery; in the United States, they rarely stay for more than one or two.

Japan's health-care system mixes socialism with individual responsibility and market forces. The government pays one-quarter of the total health-care bill, and employers and workers pay the rest through mandatory insurance.

"More than one-third of the workers' premiums are used to transfer wealth from the young, healthy and rich to the old, unhealthy and poor," Ikegami said.

Workers at major corporations pay about 4 percent of their salary to a company-based insurance provider. These premiums are limited to $6,000 a year, but the average salary worker pays $1,931, the government says. Job-based insurance in the United States costs the typical employee $3,354 a year, according to the U.S.-based National Coalition on Health Care.

In Japan, employers pay premiums that match each employee's contribution. In the United States, where health insurance is far more expensive, employers pay private insurers three or four times the amount contributed by each employee.

The self-employed and the unemployed in Japan must pay about $1,600 a year for insurance coverage. In addition, working-age patients are required to make a 30-percent co-payment for treatment and drugs -- the highest such fee in the world. But those payments tend to be relatively low because of the tight lid on costs. If the co-payment exceeds $863 in any month, it drops to 1 percent of additional medical bills.

Hana Mukai, a fashion merchandiser in Tokyo, said she cannot think of anything wrong with health care in Japan.

She takes her son Yugo, 4, to an ear, nose and throat specialist nearly every week during the cold and flu season. They go about 12 times a year, often when her son has a runny nose. She does not need to make an appointment, but has to wait about 75 minutes to see the doctor.

The doctor checks his ears, irrigates his nose and prescribes medicine. The visit usually lasts a few minutes, and it is free. There is supposed to be a co-payment, but Mukai's local ward government covers all medical costs for children, which is common in much of Japan. Mukai says she never buys over-the-counter drugs for Yugo, because prescribed drugs for children are also free.

As for her own health-care costs, she says they are either invisible or negligible. She has never checked to see how much she pays through payroll deductions for health-care premiums. The co-payment for doctor visits is insignificant, she says, since the total bill for most visits comes to less than $30, including drugs.

"I know my medical fee is going to be cheap, so I have never, ever thought about how much it will cost me to go to the doctor," said Mukai, 39.

The health of Mukai, her husband and her son -- and of nearly everyone in Japan -- also benefits from free annual checkups. Japan requires companies to pay for annual physicals for employees.

Local and national governments also push preventive care. Since Mukai is nearly 40, her local ward government has notified her that she can sign up for a comprehensive, and free, battery of tests. Doctors will examine her eyes and teeth, and they will test for colon, stomach and cervical cancer. She will also receive a free gynecological workup.

For her son, an internal medicine specialist and a dentist visit his public day-care center twice a year to conduct free examinations. Once a year at day care, he is examined at no cost by two other doctors for potential eye, nose and ear problems.

The health-care system, though, does not deserve all the credit for the relatively robust health of the Japanese. Diet and lifestyle are generally healthier than they are in the United States. There is less violent crime, fewer car accidents and much less obesity. Only about 3 percent of Japanese are obese, compared with more than 30 percent of Americans, according to the OECD.

Still, Western food has encroached on the diet, and there are increasing numbers of sedentary, overweight Japanese. As part of the preventive focus of health care, the government is pushing back against obesity-related health problems -- known here as "metabolic syndrome" -- in ways that probably would astonish Americans.

There is compulsory obesity screening for 70 percent of the population. If people are found to be too fat around the waist, they are required to receive counseling on exercise and diet.

The law was passed three years ago, so it is too soon to know whether screening and counseling are effective. But health-care experts agree that the government has succeeded in making nearly everyone worry about fat, while thinking more about what they eat and how often they exercise.

It puzzles Mukai that the United States does not imitate the best parts of her country's health-care system, particularly preventive care, universal coverage and free treatment for children.

"If the Japanese can do it, why can't the Americans?" she said.

Special correspondent Akiko Yamamoto contributed to this report.

Credit: Blaine Harden - Washington Post Foreign Service

Reproduced with permission of the copyright owner. Further reproduction or distribution is prohibited without permission.  
  
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