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Guest column
Dr. Donald D. Trunkey, OHSU Professor of Surgery

Dr. Trunkey presented his ideas on health care reform at the City Club of Portland on June 9, 2006.

Access to US healthcare is a lottery, and what used to be a “not-for-
profit” system has become a “for-profit” system.

I would like to begin this dissertation with two relatively recent quotes. “We live in a great country that has got the best healthcare system in the world, and we need to keep it that way.” (George Bush, June 2003) “We do have the best healthcare system in the world.” (Bill Clinton February 2000)

Unfortunately, the evidence does not support the two presidents. One barometer of measuring effectiveness of a healthcare system is the average lifespan and the per capita cost. In the United States, we have an average lifespan of 77.8 years, at a cost per capita per year of $4887. In Spain, the lifespan is 79.6 years, at a cost of $1100. In Canada, the average lifespan is 80.2 years, at a cost of $2792, and in Japan, they live an average of four years longer than we do in the United States, at a cost of $2003 per year. Another measure of healthcare system effectiveness is the infant mortality. In the United States, it is 6.9 deaths per 1000 live births. In Denmark, it is 5.3, France 4.6, Sweden 3.4, and Japan 3.2. In fact, in the WHO Global Ranking of Healthcare, the United States is number 37, between Costa Rica and Slovenia, both developing countries.

What are the problems with our current system? Access is a major problem, with 44 million having no insurance and another 105 million underinsured. The costs are 50% greater than any other Western society, at $1.7 trillion, which is 16% of our Gross Domestic Product. Pharmaceutical costs are out of control. There’s been a 1250% increase in these costs in the last 25 years. That’s eight times more than defense and nine times more than VA services and benefits. Additionally, we have problems with malpractice costs. We are the only Western society that has a contingency fee, and we are also the only society that punitive damages go to the plaintiff or the attorneys, whereas in most instances, punitive damages are designed to fix the process or system that is at fault. We could summarize our current healthcare system as the best mediocre healthcare in the world. Access to US healthcare is a lottery, and what used to be a “not-for-profit” system has become a “for-profit” system.

In order to better understand the crisis in healthcare, we only have to go back a few years. When I was growing up, the hospitals in eastern Washington were Sacred Heart, Deaconess, Holy Family, Mercy, and St. Luke’s, to name a few. The first HMO was started just prior to World War II. Edgar J. Kaiser founded the system to take care of shipyard workers, and it was a relatively effective system. It is noteworthy that organized medicine, including administrators and physicians, shunned Kaiser and perceived it as a “socialized form of medicine.” The next advance in managed care is attributed to Alain Enthoven, a whiz kid who served under Robert McNamara during the early parts of Viet Nam. It was Enthoven who came up with the “body count” methodology for measuring the progress of the war and whether or not we were successful. To quote a three-star general, this concept was “the height of arrogance.” After Viet Nam, Enthoven went to Stanford, where he developed his Consumer Choice Health Plan alternative to combat the high cost of healthcare (10.5% of our GDP) at that time. This in turn led to the development of two fairly large HMOs, US Healthcare and Humana. These were both very unpopular with doctors because fees were negotiated or salaries were provided. In contrast, the CEOs of these firms did extremely well, and at least one made it into the Forbes 400 richest Americans. The concept of managed care also received an additional stimulus after Bill Clinton was elected president in 1990. He charged Hillary Clinton with coming up with some kind of strategy for a nationalized healthcare system. The Jackson Hole Conference was held in 1992, but failure to include the very providers that would have to give the healthcare with this plan, was not met with enthusiasm. It did lead, however, to increases in HMOs, both governmental and for-profit systems. For-profit systems soon outstripped governmental plans. Most of the government plans have been failures, including Tennessee and Oregon. According to an article in the Wall Street Journal in December of 2004, TennCare, which was a government-managed care system, cost the State of Tennessee one-third of its entire budget. It did cover 1.3 million of the state’s 5.8 million people, but the article characterized it as 10 years of mismanagement and law suites. The Oregon plan, championed by Dr. John Kitzhauber, who at the time was in the state senate, was very comprehensive, but the legislature removed the portion that would require small businesses to contribute to employee health insurance under the modified Medicaid system. It was also very innovative in that there was public input, particularly on prioritizing the various diagnostic treatment pairs; however, the legislature was not required to cover all diagnoses and/or treatment.

Private HMOs took off, and the largest of these is HCA, which now consist of approximately 200 hospitals. Under this for-profit paradigm, we have several tiers of fees for various disease processes. For example, at the Oklahoma Medical Center, a craniotomy for an uninsured patient is $85,400. This is essentially a “retail” price. The same procedure when billed to Blue Cross Blue Shield is $14,600, and the same procedure under Medicare is $13,900. In Orlando, Florida, the Seventh Day Adventist Hospital charges an uninsured patient $35,200 for an appendectomy, whereas under commercial insurance, it’s $7000, and for Medicare, $6200. From the patient’s perspective, it’s difficult to understand these various fees and how they are determined. An illustrative example is from Presbyterian/St. Luke’s Medical Center in Denver. AS gives birth to a baby girl that has defective bronchial tubes. This requires the baby to stay in the hospital for several weeks, after which time, the patient is discharged, and the father receives a bill for $213,802. This is six times the father’s salary. He writes back that he cannot pay this bill, and they respond by adjusting the bill downward by $85,520. This leaves a settlement amount of $128,281, on which they demand payment in 30 days. If he cannot pay it, he is offered a credit card. The entire amount is charged to the credit card, and he has 40 years to pay at 17% interest. The total amount paid would be $777,153, with annual payments of $21,833, which is two-thirds of the father’s annual salary. HCAs record is very blemished. In 2003, they made $21.8 billion in revenue. Tom Frist owned 17 million shares, and allegedly, his brother, who is a United States senator, also has the same amount, now in a blind trust. HCA defrauded Medicare, Medicaid and Tricare out of $63 million. They overcharged the uninsured in 2002, $2.1 billion. They have paid $840 million in criminal fines, civil restitution, and penalties of $250 million were paid to Medicare to settle over-billing. Altogether, they have paid over $1.72 billion for fraudulent practices.

The second largest HMO is Tenet, subsequent to buying National Medical Enterprises. Tenet doctors and administrators have over billed patients, insurers and Medicare. They have also charged for services and treatment never provided. They have signed false insurance claims. They’ve paid $40 million to doctors in kick-backs, and they have paid $379 million in criminal fines, civil damages and penalties. One of the most egregious examples is at Redding Medical Center, which consists of 238 beds. They hired Dr. Chae Hyun Moon (cardiologist) and Fidel Realyvasquez, Jr. (cardiac surgeon). The patients would see Dr. Moon, many of them with no symptoms whatsoever related to their heart, and he would refer them to Dr. Realyvasquez for surgery. They did over 1000 cardiac procedures, and in 2002, billed Medicare alone $2,403,000. One-hundred-sixty-seven patients died. They subsequently were fined $54 million for unnecessary heart procedures.

Managed care is not limited to hospitals. There are very large physician practice groups who have also set up organizations to provide outpatient care. One of the largest was MedPartners, a southern California practice group that allegedly made $6 billion per year, and in 1995, went public. PhyCor, the second largest practice management group, proposed a merger with MedPartners. When the books were examined, there was a mythical profit, and in fact, they had lost over $1.2 billion. MedPartners went into bankruptcy, and this was bought at a significant discount by KPC Medical Management. For the next few months, KPC offered insurance to multiple people, and it in turn went bankrupt, however, the owner, Dr. Kali P. Chaudhuri, did not suffer personal financial losses.

There are other scams that adversely affect our current healthcare system. One is the so-called call center. To better understand how some of these work, we will take a patient, a 74-year-old female in San Leandro, California. She’s been a Kaiser patient for 50 years. She awakens one morning with pain in her abdomen, but primarily in her back. She calls her physician’s office at 8:15 in the morning, and this call is forwarded to a call center. The person at the call center says that her physician cannot see her today because he is not in. The patient’s daughter comes over, and they make a second call, again trying to get access to the HMO. Subsequently, a third call and a fourth call are also made, each appealing to somehow be seen by a physician. After the fifth call, shortly after noon, an appointment is given to her at 4:30 to see her physician. He sees her and makes an immediate diagnosis of an abdominal aortic aneurysm and sends her to the hospital, whereupon, she ruptures the aorta and is rushed for emergency surgery and receives 20 units of blood. Postoperatively, she never regains consciousness and dies. There are even off-shore call centers that handle doctor’s appointments and even diagnostic capabilities, such as x-rays. Many of these go under the rubric of “Night Hawk” and may be located in Spain, Australia, and some are even located in the United States. These diagnostic radiology call centers primarily read x-rays during our nighttime hours. These x-rays are digitized, sent to these various centers, and a report comes back, usually within about 30 minutes. The following morning when the U.S. radiologists come back to the hospital, they do “over reads” of these x-rays and make a charge for these. In many instances, the surgeon or specialist surgeons will read their own x-rays at night or rely on the report from the “Night Hawk” radiologist. Thus, a therapeutic decision has been made, and yet the x-ray is read the following morning, and a charge is made. This is unethical.

With the development and expansion of HMOs, the medical bureaucracy has also soared. Examples include CPT codes or Current Procedure Terminology. There are over 7800 of these codes that allow physicians and hospitals to bill patients through their insurance companies. These CPT codes are developed by the American Medical Association, who has a 16-member editorial panel, including 11 physicians that apply 5-digit numbers to various diagnoses and procedures. These are used throughout the United States, and royalties are charged for these codes. This brings in approximately $70 million to the AMA. There are geographic differences in what these procedures are worth, and there is manipulation of the codes by applying modifiers dealing with complexity and time spent. This leads to “a reimbursement jungle.” There is an American Academy of Professional Coders, which consists of over 35,000 members. Their job is to maximize billing or, if they work for the government, is to make sure that the codes are legitimate. In one community – Seattle – there are over 755 health insurance products. It is no wonder that the patients cannot understand the concept of retail prices, insurance prices, and Medicare prices. Similarly, there are length of stay guidelines developed by Milliman, which are used in utilization review and reimbursement of hospitals by insurance companies. Some of these length of stay guidelines are arbitrary and essentially removes the physician or healthcare extender (NP, PA) from using judgment.

The cost of the medical bureaucracy is staggering. In the US, it’s $1059 per capita per year. In contrast, in Canada, it’s $307. In the US healthcare system, administrative workers constitute 27.3% of total healthcare costs. In Canada, it’s 3.1%. If we had a single payer system, this would save $375 billion a year in healthcare costs, according to an article in the New England Journal of Medicine in 2003. They estimated that there are one million workers (middle men) who are doing unneeded work. Physicians and pharmaceutical companies also contribute to these unneeded scams. A particularly poignant example is provided by TAP. This is a partnership of Abbott Laboratories in the United States and Takeda Laboratories in Japan. This partnership primarily sells Lupron, a medicine for prostate cancer that essentially does an endocrine orchiectomy. The other drug that is also marketed by this firm is Prevacid, a drug for acid reflux. Starting in the mid-1990s, TAP provided free samples of Lupron to urologists. It was heavily marketed, and 14,316 urologists prescribed Lupron in 1997; 482 of these urologists received 25% of Medicare payment ($126 million). Overall, TAP made $2.5 billion. In many instances, the free samples were sold by the physicians to the patients, and they also billed Medicare. TAP provided a 2% management fee to high-volume urology practices and a $25,000 unrestricted educational grant. For urologists who were particularly high users of Lupron, lavish entertainment and trips were provided by TAP. TAP is not the only pharmaceutical firm, however, that were involved in fraud cases. Pfizer was fined $49 million for its drug, Lipitor. Glaxo-Smith-Kline was fined $88 million for fraud in marketing Paxil, an antidepressant. Bayer paid $275 million for its drug Adolat, a drug for high blood pressure. Astra Zeneca was fined $555 million for misuse of Zoladex, a drug similar to Lupron.

There are numerous other problems adversely affecting healthcare delivery. In 2002, Cooper published an article on physician supply. He predicted that there would be a shortage of physicians that would not be made up for by physician extenders, including nurse practitioners and physicians’ assistants. A follow-up paper in 2004 stated that by 2020, the deficit will be as great as 200,000 physicians, primarily specialists, particularly in the surgical fields, but also gastroenterology and cardiology. This will have a profound negative effect in several areas, including rural surgery, care for the elderly, and it is already a major problem in trauma.

The shortage for trauma surgeons is now and will be exacerbated in 2010 when the Baby-Boomers hit age 65. The average age of a general surgeon in the United States is 59. There has been a recent decline of applicants to general surgery programs, and this is further influenced by gender. Rightly graduating medical students are at least 50% female, but very few apply to general surgery (7% or a little over 500 applicants). Part of this disinterest in general surgery is hours and part of it is lifestyle, part of it is a desire to combine a professional career with a traditional role as a mother, and it also reflects that the general surgery programs have not provided protected times so that they can do both. In addition, general surgery continues to become more fragmented and specialized, but the general surgery specialists have one commonality: they don’t want to take trauma call. In a study in 1990, Esposito, in the state of Washington, polled all surgeons and got a 50% response rate. The top four factors influencing the decision not to treat trauma patients was time commitment, compensation, dissimilar reimbursement and a perceived increased medical/legal risk. My own take on this is that surgeons do not want trauma in their hospital because it’s a nocturnal disease, it’s disruptive to the operating room schedule, it’s disruptive to their elective surgery, it’s disruptive to clinic, and it’s a high user of ICU beds, and many of these patients are Blue Cross negative. Specialty surgeons and general surgeons are increasingly asking for exorbitant on-call pay. This ranges anywhere from $1000 a night to over $7000 in some of the subspecialties, such as neurosurgery. A major problem by 2010 will be the 30% increase in the elderly population. It used to be that the peak in death rate was in the 16-24 age group. We are now seeing a bimodal distribution with an increased death rate in the elderly. They are more active, and unfortunately, the mortality rate for Injury Severity Score >15 is 3.5 times those of their younger counterparts. They spend more time in the ICU, and unfortunately, do not have a good return to independent living status or quality of life after their trauma episode. The lack of general surgeons also impacts negatively on the Department of Defense and their need for surgeons. Approximately 20% of DOD surgeons are active duty surgeons; 80% must come from the reserve. Unfortunately, young surgeons do not join the reserve. Studies after Desert Storm by the General Accounting Office showed that surgeons were not being trained properly for trauma, particularly the active duty surgeons; however, DOD has recently improved this over the last four years. Another negative impact on trauma care is that many trauma centers are closing or downgrading their level of care. Since 2003, “dumping” is becoming an increasing problem for Level I and II trauma centers. This phenomenon is characterized by community hospitals calling the trauma centers and speaking to an emergency physician or surgeon, telling them they have a trauma case that they cannot provide care for; either because of lack of personnel or that the patient is too complex. Many of these patients, once they reach the trauma center, are observed and then discharged the following morning.

Another major problem in trauma care is that rehabilitation beds are not available after a severe injury. The General Accounting Office did a study showing that only one in eight patients with traumatic brain injury receive appropriate rehabilitation following their acute care. Rehabilitation is particularly a problem in patients who have no insurance. I had a patient approximately eight months ago who was 36 years old, married and had four children – all boys. He started his own construction company, but unfortunately, he did not have enough money to buy health insurance, which would have cost $6000/year for a family of six. He fell while constructing a building and became paralyzed. As a result of the accident, his acute care was provided by my hospital free of charge, but we could not find a rehabilitation facility that would take him. We taught his wife the bare necessities of care for a paraplegic, but obviously he is high risk for complications, and home care with his wife doing most of the care, will not allow her to work and provide for the family. It is not surprising that the World Health Organization ranks US healthcare in the range of developing countries.

The solutions necessary for this dysfunctional healthcare system will require a major paradigm shift. I do not believe that tweaking the current system or maintaining the status quo will be acceptable. The current system is an admixture of employer/employee (patient) union-negotiated healthcare. There is government-provided healthcare, including the military, VA and public health. There is government contracted healthcare, which is made up of Medicare, Medicaid and Tricare. And finally, we have a number of patients who are not insured or underinsured. This is aggravated by a free enterprise pharmacy industry and a medical litigation system that neither fixes what’s wrong with healthcare and benefits primarily trial lawyers.

There is no question that the current system is undergoing some change and/or tweaking, based on the global economy. In Friedman’s book, “The World is Flat,” he points out that we are already outsourcing pharmaceuticals, and we even outsource some surgical procedures. We have been importing healthcare professionals for many years, primarily nurses, but more recently, physicians and surgeons. In order to fill general surgery slots, increasingly, these individuals are coming into the United States as foreign medical graduates. I’ve already previously mentioned how we outsource diagnostic radiology, and we could certainly expand on that. We also outsource medical bureaucracy, and medical call centers serving the United States are common in India. It is ironic that one of the top three reasons for U.S. manufacturers to outsource to Asia and Mexico is the high cost of U.S. healthcare.

Outsourcing surgical procedures is already a reality, and patients are going to India, Thailand, and Singapore for major surgical procedures. In the attached table, taken recently from a Time Magazine article, our costs based on US insurers’ cost and US retail cost are compared to the same costs in India, Thailand, and Singapore. It should be noted that the costs in India, Thailand and Singapore also include the airfare.

There are many disadvantages to a “world is flat” model. This includes the brain drain from these developing countries. There is also a major problem in assessing knowledge and professional competence. For example, India has 205 medical schools, of which 20 are private medical schools. Medical degrees in these private schools can sometimes be bought. A recent study in the British Medical Journal showed that the state-run medical schools in India have problems with infrastructure, such as inadequate faculty and facilities, in almost 50% of these state-run schools. Another problem exists in regards to importing surgeons from these countries. The only test they must pass is the USLME. This does not include knowledge or psycho-motor tests related directly to surgery. Knowledge tests could be developed similar to the ones that the American Board of Surgery administers, and with virtual simulators, psycho-motor skills could be tested. These virtual simulators, however, are quite costly. Probably the biggest disadvantage of “the world is flat” model is that it is a short term solution. It does not ensure a steady output of physicians and/or specialists in the U.S.

Some individuals, particularly economists, would argue that medicine should be a public good similar to military, fire and police. This could be government directed care vs. contracted care. The access problem would certainly be solved. The disadvantages of a public good model is it does not address who pays, costs may be excessive, and there would be a loss of incentives. Detractors of the public good model also point to the European experience as an example of “bad” care. In most public good systems, there is still a double standard, since some individuals will always pay more through insurance or through their own means to have “better” care, usually characterized by upscale private hospitals and clinics.

Others could argue that we should have a public utility model, where medicine is regulated either by local, state or federal government. This model could be unregulated and government would simply set standards. Costs could either be regulated or not. One of the advantages of a public utility model would be public input through commissions similar to public utility commissions. The disadvantages of a public utility model are that we already have gaming of these systems, the evidence is weak that it would work, and the double standard would certainly be maintained.

A recent book by Barlett & Steele called, “Critical Condition,” has 13 suggested solutions. They argue strongly for universal healthcare, which I would strongly support. They also argue for a single payer system. This may or may not be the best method. Countries such as Germany have a multiple payer system that seems to work quite well and may provide competition by insurers. They also argue for a commission that they arbitrarily named the US Council on Healthcare to oversee this change. They suggest that this be modeled after the Federal Reserve System and be a quasi-government council. My impression is that the Federal Reserve is a very ponderous bureaucracy and not one to emulate. Every patient in this new system would have a defined level of basic care; there would be flexible co-pays, and catastrophic care. All of these items I would certainly support. The patient would have freedom of choice, both for physicians and hospitals, and this is also easily supported. There would be a disease prevention component to the solutions, and this is sorely needed. Five hundred thousand Americans die every year from cigarette smoking; another 100,000 die from cirrhosis due to alcohol. Obesity is a major public health problem, which leads to hypertension, diabetes and cardiovascular disease. Japan has a very strong disease prevention emphasis, and most likely contributes to their increased longevity. Barlett and Steele also argue that there should be a curtailment of out of control drug costs. There should be patient education and oversight of insurers. The final two solutions would be to reverse over-diagnosis/over-treatment, and to arbitrate malpractice.

A simpler set of solutions has been proposed by the Progressive Policy Institute. They argue for universal healthcare equal to what the members of Congress have. They would also require a shared responsibility for the cost of coverage. They would pay doctors and hospitals according to their performance, and they would deploy information technology for better care and lower cost. They would create health courts for reliable justice in malpractice cases, and the last solution is to create a national care center to speed medical breakthroughs.

My solution on payment for the change in healthcare would be based on a V.A.T. or consumption tax. I believe this would be the fairest way for the business community, employers and patients to pay for it. It would probably be a very small VAT, but everybody, including the poor, would pay through this mechanism. If we had universal healthcare, it is projected that one-fourth of our current budget would be eliminated just simply by eliminating the bureaucracy of our current system. I would favor arbitration or medical courts to solve the malpractice issue. One of the more vexing issues is how to solve pharmaceutical costs. There are lots of problems with the current system, of which Congress contributes to. They have forbidden Medicare to be able to negotiate with pharmaceutical companies in order to get discounted drugs on a mass purchase basis. This is absurd. Another practice that has to be discouraged is the relationship of pharmaceutical companies to physicians. “Detail” men and women should not be able to give free drugs to physicians and/or free trips, or pay for educational expenses.

In summary, our current healthcare system is broken. It is a high-cost, mediocre system. Access is a major problem. Pharmaceutical costs are out of control. Malpractice costs are egregious, and there is no question that solutions will be difficult. In my opinion, leadership will not come from the Executive Branch of our government, and Congress is so partisan at the present time, they are simply impotent in dealing with not only healthcare, but other problems, such as Social Security. Unfortunately, organized medicine has not provided any solutions either. It is most likely that if we are to have a change, it will have to be based on a grass roots campaign and demand by the public.


US Insurers' cost US Retail India Thailand Singapore
Angioplasty 25,704 - 37,128 57,262 - 82,111 11,000 13,000 13,000
Gastric Bypass 27,717 - 40,035 7,988 - 69,316 11,000 15,000 15,000
Heart Bypass 54,741 - 79,071 122,424 - 176,835 10,000 12,000 20,000
Heart Valve 71,401 - 103,136 159,326 - 230,138 9,500 10,500 13,000
Hip Replacement 18,241 - 26,407 43,780 - 63,238 9,000 12,000 12,000
Knee Replacement 17,627 - 25,467 40,640 - 58,702 8,500 10,000 13,000
Hysterectomy 9,591 - 13,854 20,416  - 29,489 2,900 4,500 -----
Spinal Fusion 25,302 - 36,547 62,778 - 90,699 5,500 7,000 9,000

Author bio (courtesy of City Club of Portland)

Dr. Trunkey is regarded as an internationally renowned trauma surgeon and the father of modern trauma systems. He was one of the first surgeons to incorporate the concepts of preventable death methods and evidence-based practice in support of trauma systems. He shares his expertise and vast experience in research, education and trauma care with OHSU staff and patients by remaining active on the trauma call schedule. He remains an advocate for improved trauma care throughout Oregon and the United States.

Dr. Trunkey was born and raised in farm country in Eastern Washington: the Palouse Country. Early work included farm work, mining, hod carrying and carpentry, sheet rocking and building contracting. He attended Washington State University for his undergraduate degree and the University of Washington Medical School. Uncertain about medicine or surgery as a career, he chose to do a rotating internship with Dr. Bert Dunphy at the University of Oregon. After one month on the surgical service, there was no question of what career to pursue. Following his internship, he spent two years in the United States Army as a general medical officer in Germany.

Upon completion of his military duties, he rejoined Dr. Dunphy at the University of California, San Francisco, where his general surgery training was completed. He spent one year in the Organ Preservation Laboratory with Dr. Folkert Belzer. Following his general surgery training, he spent an additional year with Dr. Tom Shires at Southwestern Medical Center in Dallas, Texas, where he was involved in a National Institutes of Health special fellowship in trauma. Following completion of his fellowship, he returned to the University of California, San Francisco, where he became very involved in the care of trauma patients. He was Chief of the Burn Center at San Francisco General Hospital and also had an extensive interest in elective vascular surgery and non-cardiac thoracic surgery. He established a laboratory to study mechanisms of shock at the cellular level with a special interest in myocardial performance following shock, lung injury, and cellular immune mechanisms following injury.

Donald Trunkey served as Chief of Surgery at SFGH from 1978 until 1986 when he was appointed Chair of Surgery at the University of Oregon Health Sciences Center. Trunkey was a major force in pushing the Trauma agenda. He served as Chair of the American College of Surgeons (ACS) Committee on Trauma; and during his tenure, both the Advanced Trauma Life Support Course and Trauma Center Verification Program were adopted by the ACS. The use of the CT scan in the evaluation of blunt abdominal injury and early experience with non-operative management of selected liver injuries were important clinical advances initiated at SFGH during the Trunkey years.

In April 1986, he assumed the Chair at Oregon Health Sciences University Department of Surgery, a position he held until 2001. Dr. Trunkey is a founding member of both the Homeland Security Department and the National Foundation for Trauma Care. His own special interest remains trauma surgery.

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Join the dialogue here

Jul 11, 2006 4:37:49 PM
sweet lou says

This is an amazing post and a must read. I urge people to print it and share it with everyone they know. My only concern is that simply seeing the problem, and conceptualizing potential solutions, provides no practical methods for changing the system. "Solutions require a paradigm shift" doesn't help regular folks such as my self actually set about working on change.

I'm pretty sure that the point of this blog is to help empower people to make the necessary changes. What can we do? Come on people, let's start the dialog and make the changes.

Jul 14, 2006 3:21:43 PM
Margaret says

Accepting that we don't have the "best healthcare system in the world" is an important step.

Jul 17, 2006 10:48:30 PM
Stephen Gregg says

Lot's of content here. Can't disagree with much of anything. In my travels, most folks seem to agree "tweaking the existing system" is a waste of time, and worse, just complicates the mess we ultimately must fix.

The shortfalls of incrementalism are so obvious to so many, it should challenge the professional integrity of those who should offer the community more. Let's face it, most industry leadership has an assignment to maximize organizational and individual self interest, while maintain the easier pickings of status quo. Oregon's limited size and intimacy of the players should yield a far better behavior.

We do not know the vision or the force for the change.

Jul 21, 2006 9:12:05 AM
Bill Kramer says

Dr. Trunkey's column is very informative and thought-provoking. I do have some comments, however, about the broad-brush criticism of "managed care".

Dr. Trunkey pointed out the problems resulting from the entry of for-profit organizations in the health care system. I agree that many of the newer for-profit hospital systems, HMOs and physician practice plans have committed fraud, pursued short-term profit at the expense of patients, and mismanaged their way to bankruptcy. I'm a little concerned, however, by the implication that market competition and "managed care" were the source of the problems.

My observation is that the problem is that there is not enough "healthy competition" and too much "unhealthy competition". For example, many private health insurers "compete" by avoiding the sickest and poorest patients rather than improving administrative efficiency and customer service. This doesn't provide value to consumers. Likewise, many hospitals "compete" by building bigger buildings and buying high tech equipment to attract physicians an dpatients, rather than focusing on improved quality outcomes and operational efficiency. One of the root causes of this is the way the health care market is (mis-)structured: limited information about true prices and quality, limited price sensitivity, and limited choices for consumers. In other words, it is lacking the necessary attributes of a well-functioning market.

If the market were re-structured to encourage "healthy competition", we might be able to drive improvements in efficiency and quality. Initiatives such as transparency (publication of prices and quality outcomes data), appropriate consumer cost sharing (while protecting low income people), and consumer choice of health plans would move us in the right direction. This could be done by building on the current employer-based system, but only if the business community takes a constructive leadership role.

On a side note, I believe this was the intent of Alain Enthoven's original proposal, but it never was implemented on a broad scale. (Some elements of his concept do exist in well-managed employer benefit plans, e.g ., the Federal Employee Health Benefits program, Wells Fargo, CalPERS.) The Clintons' plan started with Enthoven's concept, but they added so much traditional regulatory oversight ( e.g., price controls) that he withdrew his support.

Of course, market forces -- even if used to encourage "healthy competition" -- won't fix the access problem. As Dr. Trunkey pointed out, health care is a public good, and we need public financing to provide access to care for all. The key to building a financially sustainable solution, however, is to make sure that we fix the cost and quality problems at the same time we fix the access problem.

Market forces are important, but they aren't everything. We also need to strengthen the ethics of everyone in the health care system -- physicians, hospitals, medical supply companies, drug manufacturers, insurers, etc. We also need to strengthen public health programs and encourage people to take more personal responsibility for their health. But market forces drive many real-world decisions, and we need to find a way to create the appropriate incentives to support "doing the right thing" and improve the value of what we're spending on health care.

Aug 17, 2006 10:49:37 AM
Donald Trunkey says

Solutions will require a paradigm shift. Unfortunately, I do not have much faith in our current executive branch, nor congress, to initiate a paradigm shift. It is noteworthy that Senator Frist, who most likely owns at least as many shares in HCA as his brother (17 million), is certainly not going to lead a charge to change the system. A grassroots development might be worthwhile. Such a movement has already been started in San Francisco under the leadership of Andrew McGuire. www.traumaf.org Paying for the paradigm shift is clearly problematic. By eliminating the medical bureaucracy, which is 29% of our healthcare costs, would free up $375 billion. Clearly, all of the bureaucracy could not be eliminated, but if we were to match Canada, it would only be about 3% instead of 29%. I believe a National Commission on Healthcare should be appointed by congress. Their first charge would be to determine who pays how much now. This would include government, such as VA, Tricare, Medicare, and Medicaid. It would also include commercial insurance that employers’ pay for, Workman’s Compensation, etc. The commission should then determine if the amount paid by the various payers is fair. If not, they should assign a percentage or per capita amount to the various groups. This would include large employers such as Boeing, General Motors, etc. I would propose that the remainder of the costs would be paid by a value-added tax on essentially all goods. This means that all potential users of the healthcare system, including the poor, would be responsible for a share of medical costs. I personally would also favor a multiple payer system as outlined above rather than a single payer system as advocated by Barlett & Steele in their book, “Critical Condition.” Bill Kramer has a number of thoughtful suggestions, many of which I could agree with. He rightly points out that many private health insurers compete by avoiding the sickest and poorest patients rather than improving administrative efficiency and customer service. I would also like to emphasize that many of the managed care organizations are not dissimilar from Enron, Global Crossing and Health South. Corrupt management should not be tolerated. Market forces should be encouraged, but there must be a watchdog organization with teeth that can deal with corrupt practices.

Sep 18, 2006 11:43:54 AM
Rick Ray says

For readers who want to get involved in crafting and implementing a paradigm shift in our approach to health care--one that is in line with this article--please visit www.archimedesmovement.org. This is the project begun in January 2006 by former Oregon governor John Kitzhaber, M.D.


Apr 5, 2009 1:48:09 PM
Jennyrivera says

O, well, thank`s for the article that you wrote! A lot of time I was trying to find some new material for me, and I guess I have it thanksto you. tnx once more. I will be waiting for exciting information that you write.

May 20, 2010 3:07:13 AM
diabetes says

Market forces are important, but they aren't everything. We also need to strengthen the ethics of everyone in the health care system.

Sam Nisbett

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