Posts Tagged IOM
Grand poobahs, long robes, ivory palaces, exulted wise men — is it the Arabian Nights? — no, it’s graduate medical education in the US. Finally, a voice of reason — coming from the Institute of Medicine (IOM). The surprising report released 7/29/14 says doctor training is not meeting the needs of the country.
The problems: $18 billion per year going to academic medical centers without adequate accountability. Money lavished on the Northeast fails to trickle down to community training programs elsewhere. Self-serving training of an academic workforce but not main-street primary care.
The US has never had a coherent plan to train doctors — academic medical centers have been making decisions that should have been made by ordinary people, people who don’t like waiting lists. A huge manpower shortfall has been expected for a long time. The IOM expert committee is calling for big changes to the system. The hope of the country, West of Harvard, is that Congress will follow the recommendations — the report is not asking for more money (which would be a stake in the heart) just a rational use of funds to meet obvious needs.
A primary care doctor does not need to go to Harvard to be a very good doctor and the US does not need to support super specialty programs at the expense of towns lacking a doctor. The cost savings by diverting funds to community training programs could be huge, possibly training 2 or 3 physicians instead of one in Boston.
Funding of training needs to be tied to providing service where service is needed. What better way to train doctors for Iowa (or other areas needing doctors) — train young people in the communities where they live.
The above graph is from a recent publication of the Institute of Medicine entitled “U.S. Health in International Perspective: Shorter Lives, Poorer Health (2013)”. The graph depicts the causes of death for males less than 50 years old. Compared to other wealthy countries the U.S. life-expectancy ranks 17th for men and 16th for women According to the report “The tragedy is not that the U.S. is losing a contest with other countries, but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.” Several causes were cited including lack of insurance, lack of access to primary care, high poverty rate, poor diet, lack of exercise and use of firearms in acts of violence.
Although the report is blunt enough the bottom line is we have good doctors, good nurses, good medications, good equipment, good hospitals, and good clinics but we have poor management of our health care system. The equation is:
Good Providers + Bad Management = Bad Health Care
You may ask: what is health care management? In a word a “PLAN” or simply coordination of action — we truly do not have a health care system. We have a variety of types of insurance, government programs and fee for service (i.e. no money no service). Even the very wealthy get poor health care because of a lack of quality management. Some States do much better than others. If Minnesota was a country it would rank near the top. If Louisiana was a country it would be a third world country ranked near the bottom.
One of the big political concerns is cost. We pay more for health care than any other country. One third of our cost is attributed to waste (i.e. paperwork). When a system is poorly coordinated the cost is high. So, why would any country spend more money on such a system?
The above report is just another in a long series of bad reports on U.S. health care. Although the Affordable Care Act (Obama Care) is helpful it will never move life expectancy to the top of the list.
There are lots of solutions. But, they all require planning and system thinking. Trying to solve one problem at a time to evolve a better system will take about as long as human evolution. Perhaps in a million years we will have evolved beyond illness — yes, that’s the plan.
The IOM is a government organization that studies medical care and issues reports. The reports are scholarly and well regarded. Below is an excerpt from a recent 380 page report.
The full report is available online and worth reading.
What is the bottom line?
There are numerous areas where US health care wastes money and delivers poor care. The wasted money is estimated at over $750 billion dollars each year. The IOM opines an environment where everybody has the attitude of gladly improving health care so each problem could be addressed and by an evolutionary process the US would end up with a great health care system.
Frankly, it ignores working health care systems in other countries and fails to outline a structure for management of US health care. All great quality improvement ideas fail without a structure . From a political standpoint the question will be “what am I buying”? The answer “the cost will evolve” is just not adequate.
So, in the absence of structural suggestions here is a place to start:
This system replaces all existing government health care agencies with an insurance system covering “basic care benefits”. All private insurance would offer the basic care benefit with insurance add-on products as desired.
Top level: Administrator
Department: United States Health Care (USHC)
Funded by: Congress (has a budget each year)
- Office of budget compliance with regional offices (comptroller)
- State divisions of quality improvement
- National drug and equipment evaluation and approval (formulary)
- Office of hospital, specialist, device and prosthetic payments
- Office of primary care and drug payments
- National patient registry
- Office of basic care benefits
- Office of national health records (System wide EMR)
- Office of health research integration
- Office of manpower training (free training in exchange for service)
Now we are getting somewhere. An administrative structure and a payment structure. There is huge efficiency by consolidating current US agencies like Medicare, Medicaid, Veterans Health System, Indian Health Service and all others. Private insurance is encouraged for those items not covered by basic care benefits (e.g. heart transplants, cosmetic surgery, fertility services, extremely expensive chemotherapy etc).
You may say the forgoing is just not possible for the US. But, consider the idea as restructuring, a management technique used by large companies all the time. The IOM says change is needed but we need that change NOW — we need to think like a large company and get the job done.