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Can U.S. Health Care Be Improved?

6DF89413F33043C086B85362A4D02562David Blumenthal, MD, MPP, did not mince words. “Fundamentally dysfunctional”: that was how he described U.S. health care today. On the financial side, unnecessary and wasteful spending still runs to billions of dollars. Comparing the costs of health care in other nations, Blumenthal said, with dry irony, “We win this race.” The United States spends 17 percent of its gross national product on health, substantially more than other countries do. And that was how Blumenthal began his recent presentation on the Penn Med campus, “U.S. Health Care: Where We Are, Where We Need to Be, and How to Get There.”

Despite gains in recent years, Blumenthal continued, the United States still does not have anywhere near the health coverage for its citizens that it should have, and large disparities still exist. He noted that the rate of increase in spending has levelled off – but that has happened before. “We shouldn’t get too excited,” said Blumenthal, unless the nation can maintain such positive trends and make substantial cuts. He also referred to an article published in 2003 in The New England Journal of Medicine, “The Quality of Health Care Delivered to Adults in the United States,” calling it “the most important document” in health policy. Based on their surveys, the researchers stated that only 54.9 percent of patients in the nation received the recommended care. What is troubling is that the health-care system has not done much to improve that percentage in the years since.

Blumenthal, who recently stepped down as a Penn Medicine trustee, was this year’s recipient of a visiting professorship endowed by Mitchell J. Blutt, MD ’82, MBA ’87. The professorship focuses on the fields of entrepreneurism and medicine. Blutt himself, founder and chief executive officer of Consonance Capital, a health care investment firm, introduced the event. He noted that the professorship seeks to spotlight physician leadership beyond the traditional academic roles and to examine the interface among the delivery, the business, and the policy-making of health care. It was no surprise, then, that in the audience were both J. Larry Jameson, MD, PhD, executive vice president of the University of Pennsylvania for the Health System and dean of the Perelman School of Medicine, and Ralph Muller, CEO of the Health System, as well as several other physicians and administrators – and physician-administrators.

Like several others attending his talk, Blumenthal has worn many hats. He is now president of the Commonwealth Fund, a private foundation. It seeks to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable groups. As a consequence, the Fund supports independent research on health care issues and makes grants to improve the practice and policy of health care. Blumenthal was formerly the Samuel O. Thier Professor of Medicine at Harvard Medical School and chief health information and innovation officer at Partners Healthcare in Boston. From 2009 to 2011, he served in the federal government as the national coordinator for health information technology. In introducing Blumenthal, Dean Jameson noted that Blumenthal was given “an enormous charge” to ensure interoperability of such a system and foster what is now called “meaningful use.”

Blumenthal has also been a practicing primary-care physician, a professor of medicine and health policy, and a member of the editorial boards of professional journals. He has many publications, and his most recent book is The Heart of Power: Health and Politics in the Oval Office. A member of the Institute of Medicine, Blumenthal was the founding chairman of AcademyHealth, the national organization of health services researchers. When Blumenthal speaks – or writes – people in the field of health care tend to listen!

Making Progress, Offering More Coverage

But it was not all bleak. Blumenthal noted that, although progress has been “agonizingly slow,” there have been small gains in safety and quality, and the number of Americans without health insurance has gone down. If you have insurance, he said, it does make a difference. “I never thought I would see this kind of change.” Because of the Affordable Care Act (ACA), people are more likely to have a regular source of care. He also pointed out that there have been important declines in deaths from certain conditions. When Jameson and he were attending physicians at Mass General, Blumenthal continued, they didn’t recognize that some of the conditions they were seeking to treat were preventable. Other encouraging signs in the last few years are fewer adverse drug events and fewer urinary tract infections associated with catheters.

How to push the improvements along? Blumenthal posited two parts of health care: microsystems and macrosystems. The former involve activities that interact directly with patients, that are delivered to “real people.” Macrosystems include government programs and regulations, health plans, hospitals, accreditation organizations, and so forth. Up to this point, Blumenthal said, it has been easier to study the microsystems and see where they have been more effective. For example, he noted reminder systems, many of which are now done with computers, and such simple advances as checking a patient’s feet for signs of diabetes. But according to Blumenthal, those models and potential solutions are not widely picked up, even when they have been described in medical journals. That, he said, is a failure of the macrosystems. The medical establishment has failed to create macrosystems that encourage and support the uses of such solutions. With a humorous nod to Muller, the Health System’s CEO, Blumenthal said, “We have to make it easy to do the right thing.”

One notable attempt to do so is the ACA, which, Blumenthal said, “has filled the toolbox to overflowing – so many things that should be done or could be done.” In a blog he posted at The Huffington Post this summer with David Squires, Blumenthal cited a recent study by the Centers for Disease Control and Prevention. The center projected that, thanks to the ACA, increased use of anti-hypertensive medication would lead to 110,000 fewer cases of coronary heart disease, 63,000 fewer strokes, and 95,000 fewer deaths by 2050. But as Blumenthal said in his talk at Penn, mentioning the ACA brings us “right back into the political firefight.” Blumenthal made his own point of view clear, calling it the most progressive attempt in his lifetime to improve the health care macrosystem.


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