• Q & A With Sen. David Durenberger

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    (Photo by David Ellis)

    A flawed health care system will take more than mandates to recover; it will take consumer engagement

    What are the primary differences between the health care reform movement now versus that of the Clinton administration?

    The costs and problems of poor health faced by individuals and by health care providers are much worse. At the same time, the number of Americans without the assurance of affordable financial coverage has doubled. Care providers are getting desperate or they are turning entrepreneurial to improve access and affordability with retail solutions. Information technology has finally reached the health care business, and social media has rocked the doctor-patient relationship.

    Public policy solutions to the cost, coverage and quality problems have turned 100 percent partisan for the first time in our history, and distrust of partisan policymakers to make the right decision is at an all-time high. And finally, the collapse of the post-World War II debt/inflation economy has forced policymakers to act on costs and coverage, as President Obama did.

    What, in your opinion, is the fundamental flaw in the current American system of health care?

    American employers carry the burden of both the poor health of their workers and their families, and the high cost of insuring access to health care for them and for all other Americans, many of whom are uninsured through payroll and income taxes, and in sharing a substantial cost of private health insurance.

    In every other country, the government – liberal, conservative or autocratic – distributes the burden of financial security and health care cost containment across all businesses and individuals. The burdens of poor health, aging employees, unusual health care costs or inefficient health care are never a competitive disadvantage.

    The American “edge” is our potential to turn inefficient, unproductive, questionable quality health care systems into high-value production systems using the knowledge developed from public and private insurance data on what works and what doesn’t to improve and to reward performance.

    And how do we go about eradicating this flaw?

    By improving the ability of Americans to become responsible health care consumers and by rewarding that behavior. Everyone knows that staying healthy reduces health care costs. But nothing in our payment system has rewarded healthy people and those who provide them with the sources of a healthy lifestyle, the way they reward poor health and its consequences.

    Some argue that financial “skin in the game” will do it. We can’t afford the money it will ultimately cost to start there. We have to start by changing the doctor-patient relationship. Each of us should have a health care “home” that is readily accessible and in which a health professional has the burden to inform the patient/consumer, who then assumes responsibility for making informed decisions. We call it “shared decision-making.”

    What specific information do consumers need to take part in this shared endeavor – and how do they access it?

    America prides itself on providing the best health care in the world. If that’s true, then consumers are entitled to know, in every community, which is the best care, who does it best and what it costs – consistently. American business abandoned the cottage industry approach to product and service design and delivery long ago – everywhere but in health care, where primary care is still undervalued and specialty care over-compensated for its comparative value. A variety of professionals are linked in an integrated health system where patient care can be coordinated with the patient/consumer determining what is “quality” and “value.”

    Consumers are entitled to know that American hospitals, doctors and health systems never will guarantee the results of what they promise to deliver. No other business could survive on the error rate present in American health systems, including the brand-name best systems. Nor could they compete if all consumers knew in advance the number of lives lost unnecessarily, the excessive use of diagnostics, the average number of return trips required after surgery or the number of failed or unnecessary lower back surgeries or other therapies.

    Health professionals, hospitals and medical technology producers long have resisted consumer comparison on the basis of effectiveness or cost or quality, such as exists in electronic technology. Our ingenuity has brought the world into the living rooms of even the lowest-paid American worker and his four-year old daughter. In the second decade of the 21st century, I can communicate with almost anyone around the globe in seconds, but I cannot make an appointment online with my doctor.

    Much of your prescription for a more effective health care system relies upon consumer engagement. What, if anything, does the profession itself need to do to contribute to any improvements?

    The American health professions education industry is inefficient. It costs twice as much as adequate professional training anywhere else in the world. The cost of health professions education has grown much faster than care costs, and graduate debt burden is skewing professional choices.

    America’s health care education enterprise is hopelessly dependent on medical industry-driven research grants and a battle for the “best” researchers who can convert discovery into highly profitable new device or drug businesses. Scope-of-practice laws designed by and for the income protection of hundreds of medical, ancillary and allied professions discourage consumers from using lower-cost alternatives. “Competition” leads to overbuilding of costly facilities to house overly expensive diagnostic and therapeutic technology, and prices are passed on to businesses trying to compete across the world.

    You wrote recently in your commentary that “a national economy that commits twice as much to paying for worker and retiree health care as all of its competitors, without a value return, cannot compete in tomorrow’s global marketplace.” What is the “value return” that would make the United States more competitive?

    In what other industry – in what other country – would product prices vary by as much as medical diagnostics, services and surgeries vary in this town, in this region or in this country? What other industry requires you to buy insurance in order to be able to buy its products and services? If health care systems in this country could self-insure and thus reap the financial benefits of healthy members and efficient service provision, how much value would we add? If we honored choices at the beginning of marriage about family and its health, and honored choices at the end of life about support systems for disabilities and for terminal illness, how much value would we add to an American health system?

    The good news is that you can learn all this and meet physicians and health professions leaders who are trying to raise the value of life in their communities by changing the value question in their design and delivery of health and health care services.

    There has been much debate about instituting a national health care system similar to those currently in place in the United Kingdom or Canada. All efforts to date, however, have been met with opposition by large segments of the population, whether in politics or not. What are the pros and cons of such a system in the United States?

    In other developed countries, everyone has health services from birth and access to the benefits of continuous improvement in medical technology at costs which are affordable to individuals and to the community and to the national economy. The result is healthier people at a lower overall cost. On the other hand, Americans are convinced that they get better care because they see and hear about new medical discoveries which they presume will be available to them over the counter or in an emergency whenever they need them, so they are leery of changing the system or taking more responsibility themselves, even when the costs of not doing it, as patients or as taxpayers, exceeds what they can afford.

    Experience has taught some of us that a U.S. health system that plays to our strengths as a nation can provide more and better health for less money. We have seen the evidence in several communities – ours among them. We need simply to make the value of health and appropriate health care more visible and the financial rewards for it more consistent. Implementation of the new national health reform law at the state and local level has great potential for creating this uniquely American system … one community at a time.

    Sen. David Durenberger is a Senior Health Policy Fellow at the University of St. Thomas, and chairs the National Institute of Health Policy. He was elected to replace Hubert and Muriel Humphrey to serve as the senior U.S. Senator from Minnesota from 1978 to 1995, becoming the only Republican U.S. Senator from Minnesota to be elected to three terms. During his time in the Senate, Sen. Durenberger served as chairman of the Select Committee on Intelligence and chairman of the Health Subcommittee of the Senate Finance Committee, and was catapulted into a leadership role in national health reform.

    Durenberger was Senate sponsor of the Medicare Catastrophic Act, AHCPR (now AHRQ) voting rights for handicapped, Americans with Disabilities Act, President H.W. Bush’s 1000 Points of Light and President Clinton’s National and Community Service Act, National Service Learning, Consumer Choice Education Act (charter schools authority), Safe Drinking Water Act, higher education Direct Lending Act and Women’s Economic Equity Act.

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