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Fix This Mess

Fix This Mess

Fix this Mess (continued)

By Mary Beth Regan

Equity

The Problem: The U.S. ranks the lowest on measures of equity, or fairness, in the Commonwealth study, in part because of the lack of universal health coverage. The hardest hit are the poor. "Low-income Americans were much more likely...to report not visiting a physician when sick, not filling a prescription, or not seeing a dentist when needed because of costs," the report concludes.

How We Got Where We Are Today ...1970s
Most public and private insurers began negotiating discounted hospital charges.

Thomas A. LaVeist, the William C. and Nancy F. Richardson Professor in Health Policy and director of the Hopkins Center for Health Disparities Solutions, sees this every day: "In this country, some people get very good care. Some people get very poor care. It depends on your race, ethnicity, social and economic status, as well as where you live," he notes.

The disparities problem is complex. Among the Medicare population of adults over 65, for example, African-American diabetics are eight times more likely to require amputation of a limb because of poor management of the chronic condition. "Yet they have the same insurance coverage," says LaVeist, PhD.

The causes are multifaceted, he says. African Americans may live in areas without adequate primary care; they may be receiving sub-optimal care or health education; or they may not be engaging in behaviors to properly manage their disease.

How We Got Where We Are Today ...1980s
Managed care plans began to negotiate with hospitals. They wanted discounted charges in return for placing hospitals in their network. The Medicare program had moved away from paying costs in 1983 with the implementation of the Prospective Payment System.

Another area of growing concern is the number of uninsured Americans, particularly Hispanics, who also face language barriers to obtaining proper care. One-third of Hispanics have no health insurance coverage—the largest percentage of any ethnic group.

The Fix: LaVeist says the United States has to move toward evidence-based medicine—with more tightly regimented treatment protocols to level the playing field. "The one place we don't find racial or ethnic disparities in health care is in the active-duty military," he says. "In the military you don't have black culture or white culture, you have 'green' culture," he says.

How We Got Where We Are Today ...1990s
Nearly all private insurers and managed care plans stopped using full charges as the basis of payment. Each segment of the market found its own way to pay hospitals—the Medicare program began limiting the amount it would spend; managed care programs used market power to negotiate discounted charges; and commercial insurers asked for similar discounts.

"When the lifestyles, health care access, and practice are similar, the outcomes are similar," he says. To LaVeist, U.S. experience shows that health care does not flourish when left to a free market. "There are public goods and services that are not optimally distributed by the free market—for example, police services, emergency services and national defense," he says. "Health care may also be one of them."

Medical Error

The Problem: A well-functioning health care system should ensure that people lead healthy lives, the Commonwealth report says. To that end, the report looks at deaths that could have been prevented. The United States, compared to other nations, ranks last on measures of healthy life expectancy at age 60, infant mortality and mortality amenable to health care.

Albert Wu, an HPM professor, believes one way Americans can lead healthier lives is to cut down on medication errors by being more aware of the medicines they are using. He estimates that at least 1.5 million Americans are injured every year by medication errors.

The Fix: "We are a medication-taking society," says Wu, MD, MPH. He estimates that four out of five Americans take at least one medication every week. That means 4 billion prescriptions are filled every year. "It's not surprising there are so many things that go wrong," he says.

How We Got Where We Are Today ...2000s
Hospital charges began increasing much faster than hospital costs. Today hospital charges today are roughly 2 to 4 times more than the actual cost of the service. Most insurers—including Medicaid, Medicare and private insurers—don't pay hospital charges. They pay a negotiated percentage of hospital cost. The result: It's only the uninsured or self-pay patients who end up paying the full charge, up to 4 times as much as people with health insurance pay.

TIMELINE SOURCE: Gerard F. Anderson, Congressional Testimony, 2004, and Health Affairs, 2007.

Patients need to have and maintain complete records of medications they are taking as well as information about allergies or other health problems. For their part, physicians can rely more heavily on electronic information resources and electronic decision-making aids to help prescribe medicines more safely. "Rather than scratching a prescription onto a piece of paper, physicians could type the medication, dosage and instructions they want to prescribe into a computer," Wu says. "The program—with information about the patient and his or her medication history—could pop up a warning about any potential drug interactions."

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