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Achieving accountable care

April 21, 2008

World Health Care Congress
Marriott Wardman Park Hotel
Washington, DC

Cecil B. Wilson, MD
Immediate Past Chair
Board of Trustees
American Medical Association

The AMA believes strongly that physicians have to play a leadership role in improving the value that our nation gets for its health care dollars. So we definitely congratulate the World Health Care Congress for inviting three physicians to address this important topic.

My big challenge is that I'm the last speaker, in the last presentation, on a Monday. Whose idea was it to finish up today's discussions with somebody who has a slow, Southern drawl?

I've enjoyed listening to my colleagues, who are quick speakers with equally quick minds. In the jargon of this year's election politics, you'll notice that what I've just done is tried to lower expectations.

We all agree that geographic variation in healthcare spending is a problem. It's a complex problem. And we certainly appreciate the work that Dr. Fisher and his colleagues at Dartmouth have done to try to sort it out.

I also think most of us would agree with those words of wisdom from H.L. Mencken. He said, "For every complex problem, there is an answer that is clear, simple, and wrong." Let me be clear, I am not saying that Dartmouth is wrong by any means. What I am saying is that there isn't a clear and simple solution.

We at the AMA have gained a lot of insight from the Dartmouth Atlas, and are very grateful. More than anything, it demonstrates a real need to research comparative effectiveness. Physicians need to be able to look at hard data revealing how their own practice patterns compares to their peers. Then we need to make any necessary adjustments. Because it's helpful to understand what drives those differences.

And you'll find that when physicians have information, we respond well. So if we can analyze the groups who are doing the best, that benefits everyone.

The AMA also has no argument that the rate of growth in health care costs these days is too high. We definitely agree. And we believe these rising costs contribute to far too many Americans being uninsured. It puts premiums out of reach for many families.

At the same time, there needs to be a distinction between cost and value. Our discussion can not be simply about lowering costs.

All the efforts to explain geographic variations in spending, especially in Medicare, have shown that many factors play a role. It would be a lot simpler if there was just one, but there isn't.

A recent review by the Congressional Budget Office showed that in high-spending areas with costlier treatments, some treatment patterns didn't improve health outcomes at all. But some did. The CBO even wrote: "The evidence on the relationship between spending and quality … is not straightforward …" So it's not a simple problem.

It's our opinion that the risk adjusters used in the studies are probably not as sensitive to the factors that drive health care spending as they could be. For example, work by Professor Ken Thorpe at Emory University has shown that the increases in the number of obese people - and the dollars spent treating them - accounts for 27 percent of the rise in per capita spending. [Thorpe, "The Impact of Obesity on Rising Medical Spending," Health Trends, 20 October 2004, considering data 1987-2001.] That number has become so high, in part, because we think we're more successful if we start treating them earlier.

Which brings us to the importance of preventive medicine. We know that some of the studies of geographic variation have looked at the factors like obesity and smoking. We believe if the risk adjusters were more refined, they'd better capture the impacts of these factors.

Then, there's always going to be the patient component. That's where practicing physicians can provide some key input. How do individual patients respond, geographically and culturally? What do they demand of their physicians? How can we provide the right incentives to patients, so they'll be comfortable with more conservative treatment recommendations. The last thing we want is for them to go off looking for a doctor more willing to prescribe the drug or device they saw advertised on TV.

What are our patients willing to do when it comes to prevention? Could we even prescribe exercise? How do we deal with the patients who don't t respond to their physicians exactly the way we'd like them to? Will they be left out in the cold because they can't or won't follow a treatment plan that affects their doctor's ranking or payment? That goes against everything physicians believe in. But designing a system that protects these patients will be a challenge.

I mentioned value versus just cost alone. We like to think of value as the balance between the benefits and costs of health care. And that's always done in accordance with the needs of patients.

Almost a year ago, we adopted four broad strategies to fix rising health care costs. And we're talking about systemic problems where it's possible for physicians to actually have some influence:

The first is to reduce the burden of preventable disease. My friend Ron Davis coined a phrase a while back. He said too many patients have PDD: Preventive Deficit Disorder.

That seems like something that should be easy to get rid of. But it's definitely not. It requires patient cooperation, doctor persistence, and health care policies that support both of them. But working together, we can reduce risk factors for disease. Do you smoke? Do you eat too much fast food or fatty food? Do you abuse drugs or alcohol? Easier said than done, but they're all stoppable.

We can also prevent, or at least delay, the onset of chronic illness. We can improve patient compliance with medications and preventive recommendations. We can encourage physical activity. In public health, we can campaign to prevent injuries from accidents and violence.

Now, this is going to require putting more emphasis on prevention in the medical education phase. We also need some new positive steps in payment policies and codes, so counseling is covered. An ounce of prevention is too often uncompensated, even when it would be much cheaper than the pound of cure.

Our second strategy to address rising health care costs is to make health care delivery more efficient. That means improving the coordination of care, improving the management of chronic illness, reducing unnecessary use of services, and increasing services that will eventually have a positive return on investment when it comes to future diseases.

For example, medical liability reform would decrease "defensive" medicine. It's inefficient, and it's an obvious cause of geographic variations.

This second strategy also means increasing the availability of information where comparative-effectiveness can be judged. It means reducing medical errors. And it means shifting care to more cost-effective sites, like physicians' offices, instead of emergency rooms.

Our third strategy is to reduce the health system costs that aren't clinical and don't really contribute to patient care. These include excessive spending on administration, profits, and marketing. Physicians have plenty of examples of excessive and duplicative paperwork imposed on them by both the public an private payers. The small but growing number who no longer accept insurance have found that they can cut their costs and charges substantially.

And our last strategy is to promote what we call "value-based decision-making" at all levels. That means improving the processes by which physician and patient decisions are made. We'll need to continually develop health information technology. That should give us more relevant, reliable, timely and actionable information.

Steady improvements are the key. When it comes to change, physicians are sometimes accused of putting our feet on the brakes. Well, we don't want to slow things down. But we also don't think it's safe to always be on the accelerator, with "the pedal to the metal." That's how accidents happen.

We believe that the strong, evolutionary changes we're proposing are the best way to realistically bring costs down.

It's always tempting to think about revolutionary changes. But while radical plans may lower costs in the short run, they most likely lower benefits, and raise costs in the long run, too. So yes, we agree that there is a lot of room for improvement in our health system today, but the problem with a revolution is, there's enormous potential for making things far worse.

All right, that's the opinion of an internal medicine physician who's been at it in the Navy and in private practice for 30 years. I also consider it an honor to be here representing the quarter of a million members of the American Medical Association. Virtually all of us are - admittedly and proudly - more concerned with helping patients than anything else in the world.