Standard of care or community standards are very important because they determine whether a health insurer will pay for a service or not. In an ideal world, standards of care would correlate closely with evidence based medicine that leads to favorable clinical outcomes. However, this is not always the case. Sometimes standards of care do not produce the best results with the least side effects and sometimes practices and procedures that produce favorable outcomes are not considered standard of care. This speaks to the fact the medicine is a mixture of art and science. Apparently, health insurers pay for science not art, regardless of the outcomes.
Pay for performance, or P4P as it is sometimes known, in the non-health care world refers to results, regardless of the process to achieve those results. In health care, there is a strong focus on the process and less on the actual results. The theory is that tried and true process brings about good results that would not otherwise be achieved by other methods outside the standard of care. This is not always the case.
Case in point, recent studies suggest that the popular antidepressants are no more effective than a placebo and in fact may be worse, given the side effects that come along with the drugs. The popularity of antidepressants is based on a seminal study in 1998 that demonstrated that they were safe and effective. However, when two researchers, Irving Kirsch and Guy Sapirstein of the University of Connecticut compared the improvement in patients taking the drugs to those taking a placebo in double-blind studies, they discovered, based on drug companies own study data, that patients on a placebo improved 75% as much as those on the drugs. So if a patient were given the drug, whether they improved or not, it would be paid for. However, if a patient were given a placebo and improved, it would not be paid for. In other words, clinicians are paid for what they do, not what they accomplish.
I am not suggesting that clinicians only get paid if a patient improves due to the clinical intervention, but I am suggesting that this is a complicated dilemma and we need to better understand the art of medicine. Recently, a primary care physician told me that a patient that she had been treating for many years was not following through on her advice and continued to complain about the same issue at every visit. Finally, she took the patients hands in hers and asked the patient what she could do to help her. The patient with a tear in her eye said "tell me you love me and that I am a worthwhile person". Having done so, the patient’s quality of life improved immeasurably. How does that factor into the standard of care verses the pay for performance debate?
Tuesday, February 9, 2010
Monday, February 8, 2010
Disease Management – Does it Work? Yes and No!
A recent article in Business Week reported that "Washington wants to pump big money into disease management, even though there’s scant evidence that it works". So what is disease management anyway? Essentially, it is a process where people with certain chronic diseases are flagged and contacted by disease management professional to assist them in doing the things necessary to control their condition. Typically, this disease management professional works for a company that provides this service over the phone. The disease management professional is armed with good ideas but is not someone who is known (or always trusted) by the patient.
Disease management sounds great. Who could argue with managing your disease better? This great idea created yet another layer of healthcare bureaucracy between patients and their doctors adding more costs to the healthcare system under the guise of saving money. GE, who was a leader in this movement, poured a lot of money into their program over a ten year period only to find out that it didn’t really work. According to Bob Galvin, GE’s chief medical officer, GE didn’t see any compelling evidence that it saved money or substantially improved workers health.
Why didn’t it work? Conceptually, it makes so much sense that disease management interventions that have strong evidence of improving patients health and wellbeing has to be a winner. In a typical analysis, if the concept is sound, one looks to the execution as the cause which leads me to believe that the message about health and wellness is coming from the wrong messenger, i.e., anonymous hired agents by health insurance companies. Instead, if the message came from a person or organization that the patient knows and trusts, it would seem logical that the results would be far better. So who do patients know and trust? Why their doctors’ of course.
What if doctors were given incentives (payments that would otherwise go to disease management companies) to establish a disease management program and the word came from the doctor’s office not from an unknown voice over the phone. I believe that patients would take this advice more seriously and it would eliminate conflicts between what the doctors recommend and what a disease manager from an unrelated company recommends. So if this makes sense, why isn’t done? I believe that answer is that there is a lack of collaboration between providers and payers (the doctors and the health insurance companies). For us to make any progress in this area of health care, there needs to be a why to bring the payer and provider forces together.
Disease management sounds great. Who could argue with managing your disease better? This great idea created yet another layer of healthcare bureaucracy between patients and their doctors adding more costs to the healthcare system under the guise of saving money. GE, who was a leader in this movement, poured a lot of money into their program over a ten year period only to find out that it didn’t really work. According to Bob Galvin, GE’s chief medical officer, GE didn’t see any compelling evidence that it saved money or substantially improved workers health.
Why didn’t it work? Conceptually, it makes so much sense that disease management interventions that have strong evidence of improving patients health and wellbeing has to be a winner. In a typical analysis, if the concept is sound, one looks to the execution as the cause which leads me to believe that the message about health and wellness is coming from the wrong messenger, i.e., anonymous hired agents by health insurance companies. Instead, if the message came from a person or organization that the patient knows and trusts, it would seem logical that the results would be far better. So who do patients know and trust? Why their doctors’ of course.
What if doctors were given incentives (payments that would otherwise go to disease management companies) to establish a disease management program and the word came from the doctor’s office not from an unknown voice over the phone. I believe that patients would take this advice more seriously and it would eliminate conflicts between what the doctors recommend and what a disease manager from an unrelated company recommends. So if this makes sense, why isn’t done? I believe that answer is that there is a lack of collaboration between providers and payers (the doctors and the health insurance companies). For us to make any progress in this area of health care, there needs to be a why to bring the payer and provider forces together.
Tuesday, January 26, 2010
Market Driven Health Care Reform
Health care reform that addresses cost, quality, and access will not happen from the top down given the results of the Massachusetts election, the Supreme Court ruling that allows unlimited spending on political campaigns, and the broad based distrust in government as pointed out by David Brooks in the NY Times. I foresee that we will continue on the path of more out-of-pocket spending by those who can afford to pay, federally funded community health centers, charitable organizations, and emergency room backup for those who cannot afford to pay and major growth in medical travel. We are backing into a consumer driven system that will rely on competition among providers, both domestic and foreign, to control costs.
We will continue to tolerate the physical and financial suffering of a minority of the American population to support the success of the health care industry as long as the minority remains at the 15 to 20 percent level.
Bottom line, it is highly unlikely that any direction and leadership will come from Washington. We probably have a better shot for patch work reform on a state by state basis.
We will continue to tolerate the physical and financial suffering of a minority of the American population to support the success of the health care industry as long as the minority remains at the 15 to 20 percent level.
Bottom line, it is highly unlikely that any direction and leadership will come from Washington. We probably have a better shot for patch work reform on a state by state basis.
Friday, December 18, 2009
Health Care Reform - No Progress
For those who oppose health care reform of any kind, you should reade the New Yorker article by Atul Gawande, one of the emeging great thinkers on the heathcare scene. He opens his article with the following:
Health-care costs are strangling our country. Medical care now absorbs eighteen per cent of every dollar we earn. Between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900. The costs of our dysfunctional health-care system have already helped sink our auto industry, are draining state and federal coffers, and could ultimately imperil our ability to sustain universal coverage.
You may read the whole artice by clicking the link below:
Read more: http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?printable=true#ixzz0a4Ii9xTu
In other words the status quo will lead us to a diseaster unless the market intervenes in some positive way. Think about it!
Health-care costs are strangling our country. Medical care now absorbs eighteen per cent of every dollar we earn. Between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900. The costs of our dysfunctional health-care system have already helped sink our auto industry, are draining state and federal coffers, and could ultimately imperil our ability to sustain universal coverage.
You may read the whole artice by clicking the link below:
Read more: http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?printable=true#ixzz0a4Ii9xTu
In other words the status quo will lead us to a diseaster unless the market intervenes in some positive way. Think about it!
Wednesday, October 7, 2009
Staying Resilient During Tough Times
From time to time, we will include a blog posting from a Marino Center clinician on a topic of interest. The first issue is on the topic of resiliency in tough times authored by Deb Morrill MPH, RNCS, APN. Deb is a long time Marino Center clinician who focuses on women’s health.
As a seasoned health care provider, I have witnessed loss and crisis in many patients and most recently have experienced a tragic and sudden loss in my own family. Many individuals seem to show strength and resiliency during the most heartbreaking losses. A common armament of character, belief and coping strategies seem to be common among this group.
Resiliency is the ability or process by which people adapt successfully to life’s difficulties and challenges. It is the capacity to bounce back from a traumatic event or to thrive under seriously stressful situations
Three characteristics seem to be common among resilient people: a staunch acceptance of reality, a deep belief often buttressed by deeply held values, (that life is meaningful) and an uncanny ability to improvise.
This is often accompanied by a strong sense of community. The majority of individuals look to support from a formal or informal community. This is often a spiritual/faith community but may also be a bereavement group, AA meeting, work group, or chat room. I found myself reaching out to my co-workers and friends to organize a prayer wheel during my nephew’s catastrophic illness. I found much support and solace in the prayer, support, and community via email communication.
Spirituality and religious traditions may play a key role in providing solace and comfort. This outlet may offer shared belief systems, ritual and spiritual practices, community gatherings, support, care, and outreach. Communities seem to be a strong factor in resiliency. Altruistic behavior also may be beneficial for emotional health by releasing the hormone oxytocin which has sustained anti-stress effects. This means that providing service or doing good is actually good for you. You no longer need hesitate to ask a friend to pray or provide a favor, as the health effects will come back to that person. You can return the favor.
A regular meditation program can also strengthen resiliency. Herbert Benson’s studies show an association between relaxation response and positive neurochemical changes in the brain.
We will all need to test our resilience many times over in life.
Perhaps this is the time to reexamine our life beliefs, spirituality, and community involvement. It is not too late to develop a resilient self.
Special Note:
This article was written by Deb in memory of her nephew Eric J. Gaffney who died September 6, 2009 and his resilient, loving parents.
As a seasoned health care provider, I have witnessed loss and crisis in many patients and most recently have experienced a tragic and sudden loss in my own family. Many individuals seem to show strength and resiliency during the most heartbreaking losses. A common armament of character, belief and coping strategies seem to be common among this group.
Resiliency is the ability or process by which people adapt successfully to life’s difficulties and challenges. It is the capacity to bounce back from a traumatic event or to thrive under seriously stressful situations
Three characteristics seem to be common among resilient people: a staunch acceptance of reality, a deep belief often buttressed by deeply held values, (that life is meaningful) and an uncanny ability to improvise.
This is often accompanied by a strong sense of community. The majority of individuals look to support from a formal or informal community. This is often a spiritual/faith community but may also be a bereavement group, AA meeting, work group, or chat room. I found myself reaching out to my co-workers and friends to organize a prayer wheel during my nephew’s catastrophic illness. I found much support and solace in the prayer, support, and community via email communication.
Spirituality and religious traditions may play a key role in providing solace and comfort. This outlet may offer shared belief systems, ritual and spiritual practices, community gatherings, support, care, and outreach. Communities seem to be a strong factor in resiliency. Altruistic behavior also may be beneficial for emotional health by releasing the hormone oxytocin which has sustained anti-stress effects. This means that providing service or doing good is actually good for you. You no longer need hesitate to ask a friend to pray or provide a favor, as the health effects will come back to that person. You can return the favor.
A regular meditation program can also strengthen resiliency. Herbert Benson’s studies show an association between relaxation response and positive neurochemical changes in the brain.
We will all need to test our resilience many times over in life.
Perhaps this is the time to reexamine our life beliefs, spirituality, and community involvement. It is not too late to develop a resilient self.
Special Note:
This article was written by Deb in memory of her nephew Eric J. Gaffney who died September 6, 2009 and his resilient, loving parents.
Tuesday, September 29, 2009
NIH GRANT AWARDED to MARINO CENTER
Studies in Patient-based Informatics for Comparative Effectiveness Research (SPICER)
The Marino Center, along with the University of Arizona, has been awarded a grant to study the comparative effectiveness of Integrative Medicine. The entire project award is just under 1 million dollars, with about half allocated to the Marino Center.
With the help of this grant money, we will examine the immense amount of clinical data, created daily at the Marino Center, to generate knowledge on the comparative effectiveness of treatment modalities. We will compare alternative and complementary therapies among themselves, and with conventional medicine. Traditionally medical research has relied on randomized controlled trials (RCTs) with specific focus. While RCTS's remain the gold standard for testing narrowly-focused questions, it has become increasingly clear that not all important questions about the delivery of health care can be answered by RCTs. Looking at real-world clinical encounters is a new way of conducting and thinking about research.
Ours is an observational study using event-stream analysis to provide patient-centered results. We will start by looking at four common conditions: back pain, fibromyalgia, irritable bowel syndrome, and peri-menopause. It is anticipated that further studies will also be done. While we intend to produce important disease-specific results from this project, we consider it a first step toward a much larger enterprise for changing how clinical research articulates with clinical practice. The long-range goal of this project is to create a sustainable model for collaboration of multiple clinical centers for conducting focused observational comparative effectiveness studies within and across multi-modality clinics, including more complex health care delivery systems and a very broad range of modalities.
Potential impact
1. Determine useful clinical treatments by providing patient-centered, evidence based medical information extracted from trajectories of care.
2. Improve research in IM by opening opportunities to mine clinical databases while maintaining scientific rigor.
3. Organize the collective experience and wisdom of medical practitioners in a way that spans medical systems, and bring the best treatment to each individual patient.
4. Create methodology that can develop neglected aspects of health and healing, such as patient choice and patient-practioner interactions.
Steering Committee:
Marino Center
Anne McCaffrey, MD, MPH
Robert DeNoble, MBA
Jennifer Cao, LicAc
Dan Himick
University of Arizona
Mikel Aickin, PhD
Ken Pelletier, MD
The Marino Center, along with the University of Arizona, has been awarded a grant to study the comparative effectiveness of Integrative Medicine. The entire project award is just under 1 million dollars, with about half allocated to the Marino Center.
With the help of this grant money, we will examine the immense amount of clinical data, created daily at the Marino Center, to generate knowledge on the comparative effectiveness of treatment modalities. We will compare alternative and complementary therapies among themselves, and with conventional medicine. Traditionally medical research has relied on randomized controlled trials (RCTs) with specific focus. While RCTS's remain the gold standard for testing narrowly-focused questions, it has become increasingly clear that not all important questions about the delivery of health care can be answered by RCTs. Looking at real-world clinical encounters is a new way of conducting and thinking about research.
Ours is an observational study using event-stream analysis to provide patient-centered results. We will start by looking at four common conditions: back pain, fibromyalgia, irritable bowel syndrome, and peri-menopause. It is anticipated that further studies will also be done. While we intend to produce important disease-specific results from this project, we consider it a first step toward a much larger enterprise for changing how clinical research articulates with clinical practice. The long-range goal of this project is to create a sustainable model for collaboration of multiple clinical centers for conducting focused observational comparative effectiveness studies within and across multi-modality clinics, including more complex health care delivery systems and a very broad range of modalities.
Potential impact
1. Determine useful clinical treatments by providing patient-centered, evidence based medical information extracted from trajectories of care.
2. Improve research in IM by opening opportunities to mine clinical databases while maintaining scientific rigor.
3. Organize the collective experience and wisdom of medical practitioners in a way that spans medical systems, and bring the best treatment to each individual patient.
4. Create methodology that can develop neglected aspects of health and healing, such as patient choice and patient-practioner interactions.
Steering Committee:
Marino Center
Anne McCaffrey, MD, MPH
Robert DeNoble, MBA
Jennifer Cao, LicAc
Dan Himick
University of Arizona
Mikel Aickin, PhD
Ken Pelletier, MD
Wednesday, September 9, 2009
What’s Wrong/Right with the U.S. Health Care System
Recently, a young person applying to medical school asked me for assistance in getting information about our health care system so she could complete a section on the application that asked her to comment on what’s wrong with the health care system. Naturally, I was able to provide a lot of articles, papers, as well as my own analysis of the issues. After giving her the information necessary to do a decent job of responding to the question on her application, I began to think about how I would respond to such a question. I thought of two alternative responses; one that articulated the problems and deficiencies of the system and the other that concluded that there is really nothing fundamentally wrong with the system. Below is how I might have responded in each of these parallel universes, addressing the underpinnings of any health care system Access, Quality, and Cost.
The U.S. Health Care System is a Disaster and Needs Drastic Reform Now
Many recent books, articles, and presentations that I have read start with a variant of the statement "The U. S. Health Care System is a Disaster". Depending on the authors view point, the primary emphasis will be on one of the three underpinnings, Access, Quality, and Cost. Sometimes all three are woven together. The issues of access, or lack thereof, is usually made with the argument that 15% of the population at any one time is uninsured, and lack of insurance creates a barrier for people to seek and get health care services. For those lacking health insurance and become truly ill (as opposed to ailments that are relatively minor and self healing) the choice is often between suffering and/or dying or getting care and suffering the financial burden that in extreme cases can lead to bankruptcy and/or impoverishment . To place a significant portion of American citizens in this position is unconscionable.
Moving to quality, statistics that focus on medical errors leads the way. It is often said that errors occur from the overuse, underuse, and/or misuse of treatment interventions. Obviously, human error plays a part as well, even when there is no evidence of over-, under-, or mis- use of services. This is a topic for another day. It is tough to legislate quality, however incentives and/or penalties may be built into payment systems that reward or penalize a provider for behaving in a certain manner that is deemed to result in better outcomes or to reward or penalize on the basis of the outcomes themselves.
Cost is the really "boogey" man in the equation. The cost of providing health care to American Citizens puts a financial burden on employers, the government at all levels (federal, state, local), and on individuals and families. Cost may be controlled in two fundamental ways at the extremes, by (1) controlling supply and price at the payer level (i.e., restrict payments for services and reduce the price paid to providers for services) or (2) going to a totally consumer driven model where price is controlled by consumer choice and demand. Moving to either extreme would be a significant change and in many respects defines the two philosophical camps in the health care debate (government central control vs. a free market solution). However, unless costs are controlled, U.S. companies may be unable to compete in a global economy and governmental units will either have to curtail other services (education, defense, infrastructure) or raise taxes. Neither solution is very popular.
The U.S Health Care System is Fundamentally Sound and Does Not Need Significant Government Directed Reform
The health care industry is a significant driver of economic growth in the U.S. currently accounting for about 16% of the gross domestic product, and rising. The industry provides employment for numerous U.S. citizens from the highest level professionals to blue collar workers. Given the importance of health care to the U.S. economy any changes should consider the impact on the wider economic picture.
A key concern expressed about the current system is that it limits access to a portion of the population (the uninsured and underinsured). The percentage in this population segment is said to be about 15% or 45 million people. The reciprocal of these numbers are 85% and 255 million (the number of people who are insured). These numbers have remained relatively constant over the past several years. Obviously, the vast majority of Americans have good to very good access to health care services, at least from a financial standpoint. As for the minority who are un- or under insured, they have access to health care services, albeit limited, through government funded community health centers and hospital emergency rooms that are prohibited by law from turning people away. So maybe access is not such a big issue afterall.
The quality of care, as judged by the cutting edge innovation and treatment of serious diseases, in the U.S. is second to none. This innovation is fostered by the free enterprise system that provides big rewards for creative entrepreneurs. To take away the big reward incentives would severely reduce the advancement of medical care and hurt quality care going forward. So for the sake of continued advancement, do not inhibit the incentives to be creative.
So now we return to the "boogey" man, cost. The supporters or health care reform claim that if we do nothing, the rising health care costs will strangle government and make U.S. companies non-competitive in the global economy. Recent analyses of the Medicare spending have shown that there is a wide disparity in spending per capita for health care services in different parts of the country without much difference in mortality and morbidity outcomes. This begs for better standards of care that can lead to a more efficient system. The government, through the Medicare program, can take a leadership role, along with U.S. medical schools, to create "best practice" models. This will begin to push the cost curve for government expenditures downward over time. As for the private sector, the market will respond accordingly. Employers have already begun to shift the cost of health care to individuals employees through premium sharing, co-payments and deductibles. As this trend continues, we will move incrementally toward a consumer driven model. As more people with financial capability need to seek health care insurance on their own, the market will respond. Health insurers will develop products to meet the market need. It is likely the health insurance will move to a more catastrophic model, covering high cost interventions and procedures, while leaving individuals to pay for less expensive services out-of-pocket. When people need to pay directly for a service, they are more likely to become discriminating consumers. This will lead to people seeking better value for the dollars they spend, just like when purchasing automobiles or appliances.
What Direction Now??
Is the U.S. Health Care system so hopelessly broken that it needs significant government directed change or if we leave well enough alone, will the fundamentals of our free enterprise system take care of the problem?
In all likelihood, neither extreme position will prevail. We will see elements of both philosophical camps in a creative U.S. solution. Let’s hope that open minds and thoughtfulness on the part of our leaders prevails.
The U.S. Health Care System is a Disaster and Needs Drastic Reform Now
Many recent books, articles, and presentations that I have read start with a variant of the statement "The U. S. Health Care System is a Disaster". Depending on the authors view point, the primary emphasis will be on one of the three underpinnings, Access, Quality, and Cost. Sometimes all three are woven together. The issues of access, or lack thereof, is usually made with the argument that 15% of the population at any one time is uninsured, and lack of insurance creates a barrier for people to seek and get health care services. For those lacking health insurance and become truly ill (as opposed to ailments that are relatively minor and self healing) the choice is often between suffering and/or dying or getting care and suffering the financial burden that in extreme cases can lead to bankruptcy and/or impoverishment . To place a significant portion of American citizens in this position is unconscionable.
Moving to quality, statistics that focus on medical errors leads the way. It is often said that errors occur from the overuse, underuse, and/or misuse of treatment interventions. Obviously, human error plays a part as well, even when there is no evidence of over-, under-, or mis- use of services. This is a topic for another day. It is tough to legislate quality, however incentives and/or penalties may be built into payment systems that reward or penalize a provider for behaving in a certain manner that is deemed to result in better outcomes or to reward or penalize on the basis of the outcomes themselves.
Cost is the really "boogey" man in the equation. The cost of providing health care to American Citizens puts a financial burden on employers, the government at all levels (federal, state, local), and on individuals and families. Cost may be controlled in two fundamental ways at the extremes, by (1) controlling supply and price at the payer level (i.e., restrict payments for services and reduce the price paid to providers for services) or (2) going to a totally consumer driven model where price is controlled by consumer choice and demand. Moving to either extreme would be a significant change and in many respects defines the two philosophical camps in the health care debate (government central control vs. a free market solution). However, unless costs are controlled, U.S. companies may be unable to compete in a global economy and governmental units will either have to curtail other services (education, defense, infrastructure) or raise taxes. Neither solution is very popular.
The U.S Health Care System is Fundamentally Sound and Does Not Need Significant Government Directed Reform
The health care industry is a significant driver of economic growth in the U.S. currently accounting for about 16% of the gross domestic product, and rising. The industry provides employment for numerous U.S. citizens from the highest level professionals to blue collar workers. Given the importance of health care to the U.S. economy any changes should consider the impact on the wider economic picture.
A key concern expressed about the current system is that it limits access to a portion of the population (the uninsured and underinsured). The percentage in this population segment is said to be about 15% or 45 million people. The reciprocal of these numbers are 85% and 255 million (the number of people who are insured). These numbers have remained relatively constant over the past several years. Obviously, the vast majority of Americans have good to very good access to health care services, at least from a financial standpoint. As for the minority who are un- or under insured, they have access to health care services, albeit limited, through government funded community health centers and hospital emergency rooms that are prohibited by law from turning people away. So maybe access is not such a big issue afterall.
The quality of care, as judged by the cutting edge innovation and treatment of serious diseases, in the U.S. is second to none. This innovation is fostered by the free enterprise system that provides big rewards for creative entrepreneurs. To take away the big reward incentives would severely reduce the advancement of medical care and hurt quality care going forward. So for the sake of continued advancement, do not inhibit the incentives to be creative.
So now we return to the "boogey" man, cost. The supporters or health care reform claim that if we do nothing, the rising health care costs will strangle government and make U.S. companies non-competitive in the global economy. Recent analyses of the Medicare spending have shown that there is a wide disparity in spending per capita for health care services in different parts of the country without much difference in mortality and morbidity outcomes. This begs for better standards of care that can lead to a more efficient system. The government, through the Medicare program, can take a leadership role, along with U.S. medical schools, to create "best practice" models. This will begin to push the cost curve for government expenditures downward over time. As for the private sector, the market will respond accordingly. Employers have already begun to shift the cost of health care to individuals employees through premium sharing, co-payments and deductibles. As this trend continues, we will move incrementally toward a consumer driven model. As more people with financial capability need to seek health care insurance on their own, the market will respond. Health insurers will develop products to meet the market need. It is likely the health insurance will move to a more catastrophic model, covering high cost interventions and procedures, while leaving individuals to pay for less expensive services out-of-pocket. When people need to pay directly for a service, they are more likely to become discriminating consumers. This will lead to people seeking better value for the dollars they spend, just like when purchasing automobiles or appliances.
What Direction Now??
Is the U.S. Health Care system so hopelessly broken that it needs significant government directed change or if we leave well enough alone, will the fundamentals of our free enterprise system take care of the problem?
In all likelihood, neither extreme position will prevail. We will see elements of both philosophical camps in a creative U.S. solution. Let’s hope that open minds and thoughtfulness on the part of our leaders prevails.
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