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State of the Nation's Health Care 2011 - J. Fred Ralston Jr. Remarks

Health Care Coverage, Capacity and Cost: What Does the Future Hold?
A Report from America's Internists on the State of America's Health Care

Oral Remarks
J. Fred Ralston Jr., MD, FACP
American College of Physicians

Thank you for joining us for this report from America's internists on the State of the Nation's Health Care.

I have had the privilege of serving as president of the American College of Physicians for the past year. One of the greatest parts of my presidency is how it has allowed me to be active in advocacy on health-care issues. I've combined my political science background with the real-world perspective of a physician in full-time clinical practice.

Since 1983, I have been in the practice of general internal medicine in Fayetteville, Tennessee. My group -- Fayetteville Medical Associates -- includes internists, family physicians, pediatricians and a nurse practitioner. The group traces its roots to 1909 and serves a rural county of 30,000 near Huntsville, Alabama.

Clearly, a highly-partisan and polarized debate over health care reform legislation regrettably has taken the country's "eye off the ball"-from the continued urgency of implementing reforms to making health insurance coverage more affordable, available and secure; to ensuring a sufficient supply of primary care physicians and other specialties facing shortages; and to reforming payment and delivery systems to achieve better value.

Today, I have some good news and bad news to report about the state of the nation's health care.

The bad news is that the United States is facing an unprecedented crisis in affordable health insurance coverage. We have more uninsured people than ever before. We still are facing a crisis in access to primary care. Health care costs are increasing at rate that the country-and individual families-can't afford.

The good news is that the Affordable Care Act has essential policies to begin to address these challenges, but only if Congress allows them to take root and grow.

Today's report:

  • Describes the challenges the U.S. faces in providing affordable health insurance coverage for all, ensuring that the system has the capacity to meet the growing demand for health care, and controlling costs;

  • Discusses how the ACA begins to address these challenges and the necessity of preserving, building upon, and improving its essential policies to expand coverage, increase health care capacity, and address rising costs;

  • Recommends improvements in the ACA, including changes that have the potential of attracting bipartisan support; and

  • Presents the recommendations of the American College of Physicians (ACP) for building upon the ACA's reforms to create a better health care system for all Americans, including release today of a new ACP position paper on conserving and allocating limited health care resources in accord with distinctly American values.

I see patients every day struggling to manage health care.

  • I have a patient with a limited education who struggles to make ends meet Like so many others during the Great Recession, he lost his job in the auto manufacturing support industry for a year. I treated him for free during that time, as I knew his health would deteriorate without proper medical attention. I was pleased when he was rehired but was distressed to receive a letter asking if I had treated him for similar conditions over the past year - clearly an attempt to exclude or limit coverage due to pre-existing conditions. This is an example of how our health care "system" doesn't work for many hard working Americans trying to make ends meet.

  • He is one of the more than 129 million Americans with pre-existing conditions who will benefit from the ACA's prohibition on insurance companies excluding or rescinding coverage or charging excessive rates to people with pre-existing conditions.

  • And starting in 2014, if my patient should be unfortunate enough to lose his job again because of another economic downturn, at least he'll know that he'll be able to get affordable coverage because of the ACA.

Every physician can cite stories of individuals who live sicker or die younger due to lack of health insurance. I continue to be haunted by the story of one hard-working patient without health insurance who did not deal with gradually advancing digestive symptoms until he could no longer bear the pain. He came to me with advanced colon cancer, which was not treatable. He said he would have come in earlier if he had not feared being bankrupted by medical costs.

ACP views necessary health reform not from a partisan or ideological perspective, but from the standpoint of what the evidence tells us will be the most effective course of action. Lack of health insurance can be a matter of life and death. Studies show that being without health insurance leads to tens of thousands of premature deaths annually and unnecessary suffering.

Instead of turning away from the ACA's promise of ensuring access to affordable health insurance to nearly all Americans, ACP believes that Congress should seek bipartisan common ground on making improvements to it, including giving states more freedom earlier to implement the coverage expansions in a way that best meets their own needs.

Ensuring that all Americans have affordable health insurance coverage is essential, but insurance coverage alone does not guarantee access to care in the absence of well-trained physicians and other clinicians to provide the care that they need.

  • The United States is facing a growing shortage of physicians in key specialties, most notably in general internal medicine and family medicine-the specialties that provide primary care to most adult and adolescent patients.

  • A recent study projects that there will be a shortage of up to 44,000 primary care physicians for adults, even before the increased demand for health care services that will result from near universal coverage is taken into account.

A new report details the potential impact of many of the ACA's policies to begin to address the crisis in primary care. Yet even with such policies, the U.S. will likely continue to face a shortage of primary care physicians for adults, as well as shortages in other critical physician specialties, but this shortage will be much more severe if the ACA's policies to ensure adequate workforce capacity are under-funded or repealed.

Finally, I want to talk about the biggest challenge facing our health care system: costs that are rising faster than we can afford. The ACA has important programs to begin to bend the cost curve, including funding for comparative effectiveness research and new payment and delivery models to align incentives to clinicians with value. These need to be supported and sustained by Congress.

But the medical profession must also do its part. Several months ago, ACP launched the High-Value, Cost-Conscious Care Initiative, a broad program that connects two important priorities for ACP: helping our physicians to provide the best possible care to their patients, and simultaneously reducing unnecessary costs to the health care system.

This initiative will provide physicians and patients with evidence-based recommendations for specific interventions for a variety of clinical problems. The Initiative will assess benefits, harms, and costs of diagnostic tests and treatments for various diseases to determine whether they provide good value - medical benefits that are commensurate with their costs and outweigh any harm. The February 1, 2011 issue of the Annals of Internal Medicine, ACP's peer-reviewed, flagship journal, will publish two important papers related to the High-Value, Cost-Conscious Care Initiative.

But if the polarized health care debate has shown us one thing, it is that the public itself needs to be engaged in decisions on how best to conserve limited health care resources. We physicians can't do it alone, and the public won't accept cost controls that are imposed upon them by government, insurance companies, or employers. Instead, all of us-physicians, our patients, government, insurers, employers, and other stakeholders-need to have a frank discussion on how to conserve and distribute limited health care resources, effectively and efficiently, and in a way that is in accord with distinctly American values.

Therefore… today, ACP releases a new position paper, How Can Our Nation Conserve and Distribute Health Care Resources Effectively and Efficiently?

The paper offers more than a dozen principles for engaging the public in a process that we hope will lead to consensus on conserving and allocating resources, based on the best evidence of value. To ACP's knowledge, this is the first time that a major physician membership society has called for a national consensus on conserving and allocating health care resources and proposed a framework on how to make such decisions.

To be clear, ACP is not proposing that care be rationed. Rationing is a term that is poorly understood, emotionally-driven, and not conducive to reaching consensus. It conjures up images of shortages, delays in obtaining treatment, long waiting lines, and government bureaucrats coming between patients and their physicians.

But there is a difference between medical rationing, in which decisions are made about the allocation of scarce medical resources and who receives them, and rational medical decision-making, by which judicious choices are made among clinically effective alternatives.

I look at rational use of resources on a personal level as obtaining and using the proper information on diagnostic and treatment options that I would want used on my family. If a test or treatment is shown to be superior to other options on the basis of safety, outcomes, and/or cost it is what I would want my mother, my wife or my sons to receive. We need unbiased research to make sure that physicians and patients have access to the best treatment options.

Every country makes decisions on how to allocate available health care resources, but their approaches vary widely, reflecting the different political and cultural conditions in each country. The United States limits access to services based on access to affordable health insurance coverage and insurance company decisions on covered benefits and cost-sharing. Socio-economic and racial and ethnic characteristics of the population being served, the availability of physicians and health care facilities, and other factors clearly impact the access to care in the U.S.

Yet the U.S. has largely failed to address the reality that health care spending is increasing at a rate the country can't afford. This is a societal issue that transcends medical care itself-how much should we as a society spend using public funds on health care versus education, the environment, or the defense of our country?

Democratically elected countries have a responsibility to develop ways to determine the allocation of public resources that have broad public support; such decisions in the U.S. cannot and must not be "imposed" on the population without the consent of the people. This means that:

  • At the patient encounter level, physicians-in consultation with patients-- have a responsibility to use health care resources wisely, based on evidence of safety and effectiveness, the particular needs and circumstances of the patient, and with consideration of cost.

  • At the societal level, allocation decisions should be informed by evidence on the value of different interventions, be in accord with societal values, and reflect moral, ethical, cultural, and professional standards, and developed with broad public input.

ACP's paper proposes specific principles for achieving such a consensus on conserving and distributing health care at both the patient encounter and societal levels.

We believe that engaging the public in such a consensus can help eliminate much of the $700 billion of health care spending per year, 5 percent of the nation's GDP, which studies suggest are wasted on tests and procedures that do not improve health outcomes. We also believe that eliminating wasteful spending may be the only way that the United States can avoid the explicit medical rationing that exists in other countries.

We know it won't be easy. We know we don't have all of the answers on how to initiate such a discussion. We offer our paper, though, in the fervent hope that it will lead to a non-partisan dialogue on how best to ensure that spending on health care is sustainable and doesn't bankrupt our country.

Now, I am pleased to introduce Bob Doherty, the senior vice president of ACP's division of government affairs and public policy. He will describe the current political environment and provide more information on ACP's policy recommendations for finding common ground on building and improving upon the essential policies in the Affordable Care Act.