Healthcare policy

We want to bring you up to speed on the Archimedes Movement, provide you with some background information and outline what we’re trying to get done throughout the rest of September.

There are two documents that provide the basic background: the text from John Kitzhaber’s presentation On the Road to Revolution; and a second document called Moving from Principles to a DRAFT Legislative Concept: Next Steps. This second document describes the process we are setting up and the ground rules for participation – such as the willingness to engage as citizens rather than as stakeholders, and the ability to envision what a new system would look like “if anything were possible” (which, by the way, is harder than it sounds).

As you will see from this second document, Archimedes is engaging different groups in a discussion of how to move from a draft set of principles to an actual legislative concept that could be considered in next year’s Legislative Session. You may be participating in one of those groups already, in a chapter discussion or here – online at the OHSU blog or on the Archimedes website.

This is an issue that many people are concerned about; they know the current system is unsustainable; they want to change it – but they don't know how to make it happen or how to engage – they feel disempowered. The Archimedes Movement has tapped into this enthusiasm and this frustration and given them a sense of hope. People seem genuinely excited about having the opportunity to help shape the Vision for a new health care system and to spark the kind of serious national debate we so desperately need.

Last October I lost my mother at the age of 88. Like most elderly people, both she and my father wanted to die at home - not in an acute care hospital bed. Indeed, throughout my political career senior advocates have supported legislation to create “durable powers of attorney” and “advance directives” for exactly this reason.

I remember a point in her gradual decline when we went to see her physician because she was having increased muscle pain. Lab work had been done to find the cause of this pain which was being treated with low dose steroids. One of the laboratory results that came back was a high erythrocyte sedimentation rate, a nonspecific indicator of inflammation. It was not just high, it was extremely high, and one of the possible reasons was an undetected cancer.

The workup to find out exactly what was going on would have been very invasive - including endoscopes, colonoscopies, and possibly a biopsy. My mother was not interested in any of these aggressive therapies because even if a tumor were discovered her question was “what were we going to do about it in a frail 88 year old woman?”

At this point my mother made a conscious distinction between “cure” and “care.” She was interested in being comfortable and enjoying whatever time she had left. She did not want to spend her remaining time in the hospital or recovering from various invasive diagnostic procedures.

by Dan Handel, M.D. and colleagues

An OHSU physician and reseracher, Dr. Handel has submitted an editorial from the Annals of Emergency Medicine for discussion.

It is the end of another busy afternoon in the emergency department (ED). As you finish up your dispositions, a 35-year-old patient with poorly controlled diabetes and hypertension comes in for a medication refill. Reviewing his medical records, you discover he presents often for medication refills. His demographics sheet is marked as “self-pay.”

“Sir, do you have a primary care physician?” you ask.

“No, I don’t have any insurance, and they all ask for the payment up front, which I can’t afford,” he replies.

You have heard this all before. You return to your desk to refill this patient’s prescriptions yet again, knowing that he will soon return to the ED when he runs out or, even worse, will present with an exacerbation of his medical conditions because of his inability to obtain medications.

Residency trains physicians to handle all medical emergencies that present to the ED’s door, but it does not necessarily train physicians to address the ED’s significant social issues. Physicians’ best acute clinical care may be undermined by the social factors that affect the way their patients receive follow-up care. Read the rest of the editorial (PDF).

By Peter Kohler, MD, OHSU president emeritus

When the Institute of Medicine released the now landmark reports on the state of health care in the nation in 2000 and 2001, a key finding was that patients and their families do not have the information they need to be full participants in their health care. Even physicians may only have a partial view of the performance of any individual hospital.

The authors basically saw a system that was not living up to its potential in terms of health care excellence. In response, some institutions have begun to take steps to create a more patient-centered model of health care. First among these is the effort to become more transparent.

A transparent health care system is usually defined as one in which patients, their families and health care providers have access to information that supports the full range of their health care decision making. Such information includes outcomes and performance measures, patient satisfaction data and charges.

Guest column
Jim Holman

Jim Holman lives in Gresham, worked as an analyst for OHSU for many years, and now works in the field of veterinary medicine.

Changing jobs or employment status often means having to change health insurance, which often means receiving care from a new primary physician.  If you're self-employed you might not be able to purchase health insurance because it's too expensive. If you work for a company that doesn't offer a health benefit then you're out of luck. Many people with existing health problems can't purchase private health insurance even if they can afford it.

Specific health insurance reform is difficult even to discuss. Many proposals for health insurance reform are met with a charge of "socialized medicine," an accusation that can be fatal to the proposal.

But "private" approaches to health insurance reform are often little more than new ways to distribute the current unfairness. The system I propose contains both socialized and private elements. It socializes the opportunity for health insurance while retaining private funding and private choice. It retains the link between employment and heath insurance even as it widens the opportunity for health insurance to those whose employment status does not now afford them the opportunity for health insurance.

Guest column
Andrew Gioia

Andrew Gioia is currently a senior at Cornell University majoring in government and political science.

Though there’s been great debate lately over various issues in health care, few have spoken at any length on a moral or ethical basis for reform. Health care decisions are inherently personal, yet within the current health care system individuals and families have little genuine choice when it comes to the terms and benefits of their health plan.

Furthermore, advances in biomedical research promise great improvements in care, yet at the same time many Americans would likely object to funding procedures or treatments through their health insurance premiums that they find morally offensive. Such decisions, however, are almost always made by employers, insurance executives, or government officials, leaving no room for Americans to control their own health care dollars and participate in plans that respect their values.

Recently, the Heritage Foundation published a paper outlining the merits of what they call a values-driven health plan. In it, the authors answer a number of important questions and call attention to several freedoms current health plans prohibit, all of which respect individual moral beliefs and give greater control over personal health plans. The paper identifies the legislative and policy changes that would be necessary for consumer- and values-driven health plans to exist and flourish.

Guest column
Angela Heider, M.D.

I recently retired from the practice of obstetrics and gynecology at the young age of 32 and after only two years in practice. My reasons are, of course, complex, but they boil down to the impossible logistical, financial, and familial implications of practicing medicine within the confines of the current system. Alarmingly, four of my young female partners have also elected to hang up their stethoscopes – a growing trend. If we are to reverse this trend, we need to reform our health care system.

Some health policy experts believe comprehensive reform is impossible in the absence of a national disaster. I believe we can make a difference but a really important first step is to make insured people understand the necessity of such an endeavor.

True enough, there are millions of uninsured and underinsured Americans who are clearly suffering under our current system. However, there are many more happily insured Americans who are completely unaware of the horrific state of a system they trust whole-heartedly. The fact is, even wealthy Americans are impacted by the looming health care crisis. They just don’t know it yet.

As a proportion of total U.S. health care expenditures, emergency department (ED) costs are small: 1.9% of all expenditures of which 88% are covered by insurance.[1]  If ED costs are so small, relative to the whole pie, what can trends in ED use tell us about the broader health care system?

I believe trends in ED use – patient type, insurance status, etc – are like the canary in the coal mine. They can tell us when there are serious systemic access problems in the health care system.

Across the nation, 62% of EDs are now overcrowded.[2]  As an emergency physician, I have noticed a specific category of patient that gives insight into the problems with our medical care system. Two anecdotes illustrate what I think is currently happening.

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.

In health care, the safety net exists to “catch” those who would otherwise fall through the cracks – primarily those without health insurance but also the underinsured, who may have at least some coverage but lack access to health care providers.

OHSU Hospital and other health systems provide significant amounts of uncompensated care for low-income individuals in Oregon each year, and the clinic-based community safety net provides crucial access to primary and preventive care. Comprised largely of Federally Qualified Health Centers, these clinics have traditionally served specific groups – the homeless, migrant workers, low income, temporarily unemployed, and so on.  Generally, safety net clinics use a sliding fee scale tied to income.

In Oregon, our safety net is badly frayed. Demand for free or low-cost services is growing too fast. About 1 in 6 people in Oregon are uninsured, and the numbers continue to rise. There are 210,000 uninsured people in the Portland tri-country area alone. The underinsured, who now include those with Medicaid/Oregon Health Plan coverage, increasingly need the safety net too. According to the Oregon Medical Association, almost 60 percent of our primary care physicians either limit or do not see Medicaid patients at all.