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Fix This Mess

Fix This Mess

Fix this Mess

The United States, with its state-of-the-art medical institutions, groundbreaking research and cutting-edge technology, is the home of medical haves and have-nots. Today, 47 million Americans are without health insurance, up from 45 million in 2005. Worse, recent gains in coverage to children have been eliminated, leaving 8.6 million youngsters under the age of 18 uninsured.

By Mary Beth Regan

As the national outcry for health care reform grows louder, every presidential candidate has scrambled to assemble a health care platform. They don't have a choice: U.S. voters—fed up with rising health insurance premiums and studies showing U.S. health care lagging behind that of other nations—are pushing reform as a top domestic priority.

"Every person who aspires to be president knows the nation wants vigorous debate and reform on this issue," says Laura Morlock, PhD '73, a professor of Health Policy and Management (HPM).

To detail the complexity of the nation's health care woes would fill volumes. Simply put: "It's a mess," says Jonathan Weiner, an expert in health care organization and financing, and an HPM professor.

How We Got Where We Are Today ...1900s
Most hospital care was free or very inexpensive. Hospitals, set up as philanthropic organizations, housed the poor and insane who were sick. Hospitals provided little clinical benefit for most illnesses.

How bad is it? A May 2007 Commonwealth Fund study, which has compared the U.S. to five other industrialized countries since 2004, ranks the U.S. system last on its scorecard. The United States spends more than other nations, yet scores lowest on measurable parameters—quality of care, access to care, efficiencies of the global health care system, equity of care and health outcomes.

"There is no one approach that is going to fix the problem," says Ellen MacKenzie, the Fred and Julie Soper Professor and Chair of Health Policy and Management. "We have sociologists, economists, gerontologists, lawyers, business experts... And it is going to take this collective expertise to move forward."

Bit by bit, piece by piece, Bloomberg School health care policy experts are examining varied aspects of the country's ailing health care delivery system—and offering up their Rx's to the nation's policymakers. Ideas range from the straightforward to the downright revolutionary. Expand the existing Medicare program to cover everyone. Push the nation toward electronic personal health records. Create a super regulatory body, like the U.S. Federal Reserve Board, to oversee health care pricing.

How We Got Where We Are Today ...1920s
The ability of hospitals to improve the health status of patients increased dramatically. The upshot: Americans sought out hospitals when they became ill.

Baylor Hospital in Dallas, Texas, began the first program to sell health insurance, to school teachers in Dallas County. This became the prototype Blue Cross Plan.

The following pages offer both a brief inventory of America's health care problems and a sampling of solutions.

But first, a story that illustrates the schizophrenic nature of the American health care system.

Weiner, DrPH '81, remembers walking near Johns Hopkins Hospital with a German colleague. The visiting doctor was perplexed, and somewhat shocked, when a large tractor-trailer rolled up with a very expensive MRI scanning machine—certainly not the hospital's first.

The doctor turned to his American colleague: "He asked me how we could afford another MRI when people two blocks away don't even have health care," Weiner remembers. "I told him, I don't know."


The Problem: When it comes to coordinating care between specialists or empowering patients to manage their health, the United States falls short, according to the Commonwealth study. "Our system is focused on acute care," says Ellen MacKenzie, PhD '79, MSc '75. "With the prevalence of chronic conditions, and our aging population, we need to develop a system that emphasizes continuity and coordination of services. This will require an integrated strategy that empowers patients and families to become active participants in their care."

The Fix: Chad Boult, MD, MPH, MBA, and his team have developed just that type of interdisciplinary model, called Guided Care, for the elderly.

"Guided Care is like having a nurse in the family," says Boult, director of the Lipitz Center for Integrated Health Care and the Eugene and Mildred Lipitz Professor in Health Care Policy.

The Hopkins team is halfway through a multi-site randomized trial to evaluate the approach with 48 physicians and 933 older patients and 319 family members in the Baltimore-Washington area. With Guided Care, chronically ill patients work closely with a specially prepared registered nurse who coordinates the efforts of all the patients' health care providers; coaches the patients in self-management; smooths the transition between sites of care; and educates and supports the patients and their family members.

MacKenzie and her team have applied similar strategies to help people who have lost a limb to injury or chronic disease like diabetes. Their program, called "Promoting Amputee Life Skills," uses an eight-week course to teach patients the skills they need to manage pain and their daily lives. In a randomized, controlled trial involving 500 amputees, they found the program to be successful in building self-confidence and improving functioning. The program is now being translated to an online format, so more people can benefit—especially those in remote areas or with limited mobility.

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