2012

University of Portland

Ahmed Seliem

[SUGGESTIONS TO IMPROVE
US HEALTHCARE]
Introduction:
In the past 50 years there were dramatic changes in the biological, pharmaceutical,
technological and medical practices that create a status of hope to alleviating fatal conditions,
improving outcomes, maintaining equality of access within a reasonable degree of qualified care;
however the U.S healthcare system was practicing a fundamental paradox.
According to recent statistics, U.S is the largest country in spending on healthcare
services in relation to GDP (18%), more than $2.6 trillion, far higher than UK (9.5% GDP),
Germany (11.6 percent) or Japan (9.5 percent); however it comes lagging on many healthcare
indicators beyond these countries, and according to WHO reports It is ranked 37. This
discrepancy shows chances to decrease expenditure while enhancing care.
The American healthcare system is still in a stage of crisis despite the incremental efforts
to reform it with increasing in the number of uninsured, shooting of the costs and a big question
mark on the quality and safety of care. So the attention of the policy makers, healthcare
professionals and the public agencies and whole society should be directed towards radical
reforms of the current system.
The main concerns of reform focuses on the three major aspects, one is the coverage and
access to care especially after implementation of Obama care plan, the second concern will be
about the expenditure and costs which are rising in unexpected erratic jumps, creating a major
challenge to any reform. The third is about the quality and safety of healthcare services provided
to population and of course the current worse quality indicators.
These three concerns raise significant challenges, firstly they seem for the first look that
they are simple easy going but the they have deep roots of complications, the second thing that
the solutions will not be simple as any one expect as any solution will have many impacts on
other concerns, at last the conflicts which may arise from solutions as any attempt to decrease
cost may has an implication on quality
This paper provides a vision to health care reform in these three aspects. It stresses on the
three chief alarms just mentionedcoverage, cost and spending, and quality

Healthcare costs:
Drivers:
the healthcare costs of American system are in continuous case of shooting due to many
drivers, one of them is the payment process for services provided as fee for service which gives a
strong incentive to increase volume of tests and services regardless the quality expected , on the
other hand the fragmentation of healthcare services give providers little incentives to coordinate
with other providers the efficient delivery of care to patients
the complex system creates an increase in paper and administrative work which leads to
increase costs for payers and providers, moreover the increase in population needs for care with
continuous aging of population leading to increase in federal expenditures (Medicare) which
accompanied by the increase of susceptibility of chronic diseases and comorbidity which
increase utilization of high volumes of complex health care services
The advances in medical technology increase the health system efficiency and the overall
expenses and unnecessary utilization of new technology. The high clinical specialization and
shortage of healthcare forces increase the salaries of all healthcare providers leading to
overshooting of expenses especially with high medical malpractice insurance.

This figure shoe the increase of health expenditure as a share of GDP over time

Suggestions to improve US healthcare system costs
Us healthcare system is like the train which takes a wrong pathway and all the passengers
know well that they are in the wrong path but no one has the will to take the risk to stop the train
or change the path. I think that I have some idea that may get the train back to its right way, but
really I am confused if they are practical or just imaginary.
1- Healthcare providers
The great imbalance between generalists and specialists, shortage of physicians should be
amended by:
a) Increase benefits for primary healthcare physicians and increase investments
primary healthcare services.
b) Import physicians who have some reliable qualifications like MRCP and sign
with them long term contracts to work as primary care physicians
c) Create an integrated network of primary care physicians all over the state that the
patients should visit first before seeking specialist advice.
2- Change the payment mechanisms with giving incentives to health insurers which use
utilization management and cost control and predetermined fees of any care provided
3- Defragmentation of the system by beginning to unify the different public payers
(Medicare, Medicaid, Etc.) Into single payer managed by federal or state government
4- Supply side rationing to control new technology use and studying carefully cost
effectiveness of any new technology
5- Establishing guidelines for healthcare providers, evidence based, which when followed
waive the medical malpractice of healthcare providers,
6- Decrease premiums of malpractice insurance or increasing taxes on the insurers to
control these expenses and introducing new laws to consider medical malpractice in cases of
negligence of providing suitable care only not on the complication of any medical service
7- the federal government can establish holding insurance company which will pay for
providers for all enrollee supported by either federal or state government so this will give
negotiating power to government to cut costs of services and it can make contracts with large
employers to give them health insurance services
8- Extend coverage of public insurance to middle class who are not covered but they
should pay premiums based on incomes
9- Maximize taxes over products that disturb health e.g. cigarettes and these taxes support
public insurance.

Coverage and access
It was estimated in 2008 that 55 million people had no health insurance and after the
recession the number fired up and even after Obama care plan there will be about 15 to 20
million without coverage. It is clear that coverage is not the same like access you may have one
and do not have the other e.g. if you are insured (covered), you may not easily find a doctor like
patients of Medicaid who are covered but the payment for doctors are low in relation to private
employers so the doctors decide to see patients came from private insurance, on the other hand
you may not covered but you can access community health clinics or take service from doctors
providing pro bono work.
People with deductible insurance and losing their jobs will not afford the healthcare costs,
moreover the patients with comprehensive plans with low deductibles may have difficulty in
payments of ongoing costs of chronic diseases and serious illness
Uninsured patients will not have access to preventive and screening services which may
affect health status of the general society and the uninsured will increase utilization of
emergency services, decreased desirable outcomes.
On the other hands the medical underserved areas and shortage of healthcare providers
play a major role in decreasing access to medical service
Other issues has been raised like if it is a mandatory for individuals to have a coverage or
not, if there is a priority for certain groups like elderly and children to be covered first, if the
coverage will be important to certain group rather than others. Is health care a basic human right
for any individual? Yes it is so what are the suggested solution to provide this right to those
human beings?
1- The laws and policies should consider basic coverage for all people for basic
screening and preventive services as a social security issue
2- The government should coordinate efforts of philanthropy, charity directed to
healthcare like healthcare services provided by churches to reach underserved areas
and rural areas and afford healthcare services for some of uninsured like homeless
3- Launch new saving type called healthcare savings supported by banks like you can
save every year small amount of your money to healthcare emergency like major
illness , chronic disease and if you lose your insurance, these savings can be put in
one pool managed by government to leverage the benefits
4- Increase public and community health services and make a network providing very
basic services like ambulatory care, follow up , screenings, preventive medicine,
health education
5- Health care providers
The great imbalance between generalists and specialists, shortage of physicians should be
amended by:
a) Increase benefits for primary healthcare physicians and increase investments
primary healthcare services. Like increase salaries, and providing scholarships to medical
students who will work as primary care physicians
b) Import physicians who have some reliable qualifications like MRCP and sign
with them long term contracts to work as primary care physicians
c) Create an integrated network of primary care physicians all over the state that the
patients should visit first before seeking specialist advice.
d) Increase healthcare workers, physician assistants, nursing assistants who can provide
some clinical services to remote and underserved areas
6- Change focus of healthcare system from medical model to holistic model with more
focus on primary healthcare services
7- Use of technology like telephone triage, video conferences, mobile diagnostic and
therapeutic units to reach under covered areas
8- Ensure availability of services (Priority) to vulnerable group
9- Control of prices of healthcare services

Quality
In spite US spends higher dollars more than any industrialized country, the score of
American healthcare services regarding quality indicators came late, a recent CDC report ranked
US in 29
th
in the world in infant mortality rate, while it was ranked before 37
th
in all over health
indicators by WHO, so the Americans do not receive the best value in relation to their money
spent on healthcare
On the other hand large concerns had been raised especially after reports of Institute of
medicine 1999 To err is human mentioning that more than 44,000 deaths yearly due to medical
errors and unsafe medical care, another study also by Institute of medicine mentioned that about
1.5 millions are harmed due to medication errors yearly.
Other studies found that Americans receive recommended evidence-based care only
about 55% of the time. On the other hand there is a discrepancy in the level of care provided
based on sociodemographic subgroup, whites receive better care than other races
Suggested solutions
1- Continuous education of health care providers to ensure culturally competent care.
2- Provide funds to guarantee a culturally diverse group of health care providers.
3- Developing new efficient care delivery models in all practice levels that gurantee
quality of care.
4- Utilize the most cost-effective healthcare providers and beneficial therapeutic choices
in the most correct setting.
5- maintain sufficient staff and spaces to deliver timely care that run into the patients
desires
6- use evidence-based standards of care to deliver timely diagnostic intervention
7- Create funding for research addressing the outcomes associated with different health
care interventions.
8- Provide financial incentives to health care organizations dedicated to investing in an
integrated clinical information system that keep patient safety goals and decrease
risks
9- Establish guidelines that guarantee the health care environment is free of dangerous
products that impact the health of patients and health care providers
Conclusion
The complex and fragmented American healthcare system is the responsible for tha main
losses of money spent without value and there would be a long run vision and hard
decisions to change the culture, attitude of people first the complexity of the system to
more simpler form to provide high quality care.
The complex and fragmented American healthcare system is the responsible for tha main
losses of money spent without value and there would be a long run vision and hard
decisions to change the culture, attitude of people first the complexity of the system to
simpler form to provide high quality care.



References
1- The World health report 2000 : health systems : improving performance.
2- http://www.cdc.gov/nchs/data/databriefs/db09.htm.
3- Essentials of the U.S. Health Care System book 3
rd
edition
4- http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-
Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf