From the Dean: The changing face of health coverage
As I mentioned in last week’s column, we held the White Coat ceremony last Friday for our incoming first-year medical students. We had a terrific turnout of the students’ families and friends, with over 530 people in attendance. During the event, each new student was given a white coat kindly provided by the North Dakota Medical Association, and several talks were presented regarding the significance of the coat. In my comments, I mentioned how the coat symbolizes the unique and precious relationship between doctor and patient, and how the white color reflects the purity of that relationship. I also emphasized the high expectations that patients and society have of their physicians.
And I touched on some of the challenges in healthcare delivery today, including issues of cost, access, outcomes, and patient satisfaction. For example, even though the U.S. spends much more on healthcare than any other country – some $4.7 trillion estimated for 2023! – we don’t always have the best health outcomes. Somewhat serendipitously, it was in the aftermath of the ceremony that I read three related and provocative articles – two in highly acclaimed medical journals and one, an op-ed piece, in the New York Times. All three were directly related to the issues of the current healthcare delivery model, here and elsewhere.
The first article was an opinion piece in the Times (“We’re Already Paying for Universal Health Care. Why Don’t We Have It?” from July 18, 2023), which advocated for universal health insurance for all Americans, noting that upwards of a quarter of our fellow citizens will have no insurance or inadequate insurance at some point over a two-year period. It is well-established that the lack of adequate insurance leads to less healthcare and worse outcomes. Even those of us with health insurance tend to find the coverage to be less-than-adequate, often leading to our need to pay a lot of money for many services and medications. But universal health insurance has been a contentious and debated issue for some time, with one big issue being its cost and who would pay for it.
With that debate in mind, the next article that I read put the universal coverage argument into some perspective. The piece – titled “At the Breaking Point or Already Broken? The National Health Service in the United Kingdom” (July 13, 2023 in the New England Journal of Medicine; 389:100-103 DOI: 10.1056/NEJMp2301257) – looked at one of the previously most admired healthcare systems in the world and one based on universal coverage, namely, the National Health Service (NHS) in the U.K. As you might surmise from the article’s title, the piece chronicled the many problems and failures of the NHS, including long wait times for clinical care, outmoded and aging facilities, and demoralized healthcare workers. One example cited is that currently more than 7 million patients in the U.K. are waiting for a consultation with a specialist – in a country of 66 million people! That’s over 10 percent of the population! So regardless of the putative advantages of universal health coverage, it obviously is not the sole answer to the ailments extant in the healthcare enterprise.
The last article (https://doi.org/10.1377/hlthaff.2022.00844) looked at efforts to control a related factor in healthcare (especially in the U.S.): the cost of care that now consumes 17.6 percent of our gross domestic product. The payment for a lot of healthcare in the U.S. continues to be for episodes of care, called fee for service. Alternate payment models focusing on the outcomes of care rather than the service delivered are gaining traction. One highly touted effort is called value-based payment where healthcare providers are paid based on the achievement of quality outcomes, using a system of rewards and penalties. This article looked at the penalty outcomes of one value-based program run by the Centers for Medicare and Medicaid Services (CMS) in the U.S. The authors found that penalties often were unfairly assessed to healthcare providers for societal and environmental factors – like a patient living alone without family support – that really were not under the control or province of the healthcare provider. That’s a real no-no in any incentive-based system; the system should only give rewards (or penalties) for actions and outcomes that are under the control of the responsible party.
My conclusion after thinking about all three articles is not that universal health coverage or value-based payment systems are necessarily good or bad; rather, it is that as we think about creative approaches to make our healthcare delivery system even better, we must continually assess whether we actually are achieving the expected outcomes. And if the evidence suggests otherwise (like with the value-based payment system mentioned above), we need to adjust our approaches accordingly. Only by doing this can we improve clinical outcomes and patient satisfaction, facilitate access to care, and better control cost increases in the future.
Joshua Wynne, MD, MBA, MPH
Vice President for Health Affairs, UND
Dean, UND School of Medicine & Health Sciences
