Healthcare reform is taking place thoughout the globe, but nowhere more than in the United States has it received more attention and nowhere have such wrenching changes been planned or taken place. The problems driving this are essentially twofold: the U.S. spends far more than any other developed nation on its healthcare and the resulting healthcare statistics are mediocre at best. Neither the current costs, rising faster than inflation, nor the poor results are sustainable. At the patient level, there are some 47 million Americans without healthcare insurance coverage and many more who are medically indigent. In the meantime, physicians and hospitals are attempting to comply with the many mandates that result from efforts from Medicare and other insurance carriers to curb the excessive costs and at the same time prepare for the burdensome changes that will result from the Affordable Care Act (“Obama Care”). Unfortunately these efforts have done little to attenuate the upward cost spiral or to improve outcomes and add to the already growing downward pressure on physicians and other providers.
A big gap in our knowledge is that no one seems to have looked at the fundamental reasons for the excessive costs and poor outcome. The focus on use of certain drugs for heart failure and myocardial infarction or reducing hospital readmissions and surgical infections is laudable but not likely to result in much change. Giving everyone healthcare insurance will then allow 47 million more individuals access to a poorly operating healthcare system. There is scant evidence that forcing the use of the currently available EMR systems will make healthcare better or cheaper. And aside from pediatric vaccinations, there is even less data showing the cost savings of prevention efforts despite the positive effects on patients. However there are systems of care that do seem to be successful at providing high value care efficiently. The Cleveland Clinic, the Mayo Clinic and Geisinger Health System, to name a few, have been highlighted by doing just this. Understanding the reason for large geographic disparities in the per capita cost of healthcare might also provide insight.
For solutions, the need for physician leaders to become involved is critical. Presently medical care decisions are being made by non-clinicians. Involvement can be at any number of levels, local community hospital boards, academic centers, medical regulatory bodies at local, state or national levels are all needed. This leadership can show the way to choose meaningful outcome targets and investigate the inner workings of apparently successful medical entities. We are armed with valuable data from ACC, and STS that can be used to demonstrate how excellent outcomes are achieved. Successful examples of physicians working collaboratively with hospital leaders to achieve quality outcomes and share in the financial rewards can be found at such places as the Vascular Institute at Baptist Hospital in south Florida. Interventional procedures have the potential to enhance the value equation not just by reducing cost, but through demonstration of improved outcomes, when performed in the appropriate patients. Also, interventionalists as a group must have the discipline to look at their own appropriate use of procedures.