A Proposal for Universal Coverage
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Four thoughtful pieces in the March 24 issue1,2,3,4 call attention to the need for universal health insurance and to the financial problems that must be resolved. The two Sounding Board articles, by Emanuel and Fuchs1 and Mongan and Lee,2 state that more federal taxes would be required, but neither suggests a unified insurance plan to replace the present costly mix of government entitlements and multiple for-profit plans and neither considers the possibility of changing the organization of practice or the system for compensating physicians in order to reduce costs and improve the quality of care. Such major reforms may not be politically feasible right now, but what will happen if the whole system begins to implode is anybody's guess. Mongan and Lee are therefore correct in urging physicians to become involved with these issues now, before the financial crisis gets much worse.
Arnold S. Relman, M.D.
Harvard Medical School
Boston, MA 02115
References
Emanuel EJ, Fuchs VR. Health care vouchers -- a proposal for universal coverage. N Engl J Med 2005;352:1255-1260.
Mongan JJ, Lee TH. Do we really want broad access to health care? N Engl J Med 2005;352:1260-1263.
Weissman JS. The trouble with uncompensated hospital care. N Engl J Med 2005;352:1171-1173.
Kronick R. Financing health care -- finding the money is hard and spending it well is even harder. N Engl J Med 2005;352:1252-1254.
To the Editor: The health care voucher plan presented by Emanuel and Fuchs is an inventive alternative to our current method of health care financing, but one might argue that it falls into the authors' self-identified trap of "incremental reform," rather than "major surgery." Vouchers would shift insurance costs from employers to consumers without curbing the excessive administrative costs created by our private insurance system. The establishment of the proposed Federal Health Board, Institute for Technology and Outcomes Assessment, and bodies to undertake risk adjustment and administration of a valued-added tax (VAT) would add further expense. Administrative costs for private insurance systems are more than twice those of public programs1; drastically reducing these costs through regulation of the insurance industry would slow the upward pressure on health care costs overall. Reining in administrative spending would free up finances for patient care and development of system infrastructure, allowing us to move toward universal coverage. We should rightly concentrate on cost control as the first step of reform. Otherwise, we could open ourselves up to even more explosive growth in health care spending.
Jennifer M. Hinkel, M.Sc.
932 Rye Valley Dr.
Meadowbrook, PA 19046
jennifer.hinkel@globalsurvivorship.org
References
Davis K, Cooper BS. American health care: why so costly? Testimony before the Senate Appropriations Subcommittee, June 11, 2003. (Accessed June 16, 2005, at http://www.cmwf.org/usr_doc/davis_senatecommitteetestimony_654.pdf.)
Drs. Emanuel and Fuchs reply: We agree with Dr. Relman about the need to reform the health care delivery system. The universal voucher system we propose would do precisely that, not by regulation or exhortation but by changing the incentives for physicians and hospitals. The experience of the past 40 years has shown that finance reform is a necessary prerequisite for widespread changes in the organization and delivery of care. Incentives need to be made more coherent, and they need to provide a financial as well as professional rationale for the implementation of electronic medical records, practice guidelines, physician extenders (e.g., nurse practitioners and physician assistants), drug formularies, and other mechanisms to improve quality and reduce costs. This is why we believe reform of financing must precede reform of the delivery system.
We agree with Ms. Hinkel that administrative costs should be reduced. The voucher system would do that by eliminating billions of dollars devoted to administering Medicaid and other means-tested insurance, especially by eliminating costly eligibility determinations. Additional billions would be saved by eliminating employer-based insurance. The voucher system would usher in the consolidation of the more than 1000 health insurance companies seeking business from millions of employers with costly annual negotiations of contracts — another savings of administrative costs.
However, not all administrative costs are wasteful. Systematic technology and outcomes assessment involve administrative costs that are essential for a well-functioning system that delivers cost-effective, high-quality care. One of the big defects of the current health care system is that we do not monitor the quality of the care actually delivered to most patients. Administrative costs are what we must pay for the information necessary to determine what works and what interventions are worth the money. Risk adjustment also entails administrative costs, but it furthers the important goal of preventing "cherry picking and lemon dropping." Such expenditures are worthwhile, as are administrative ones that reduce the hidden costs of fraud and abuse.
The voucher proposal is not a panacea, but it furthers the widely agreed-on goals of universal coverage, improvements in the organization and delivery of care, and reduced administrative costs in a manner congruent with basic American values.
Ezekiel J. Emanuel, M.D., Ph.D.
Posterity Project
Chicago, IL 60645
Victor R. Fuchs, Ph.D.
Stanford University
Stanford, CA 94305
Arnold S. Relman, M.D.
Harvard Medical School
Boston, MA 02115
References
Emanuel EJ, Fuchs VR. Health care vouchers -- a proposal for universal coverage. N Engl J Med 2005;352:1255-1260.
Mongan JJ, Lee TH. Do we really want broad access to health care? N Engl J Med 2005;352:1260-1263.
Weissman JS. The trouble with uncompensated hospital care. N Engl J Med 2005;352:1171-1173.
Kronick R. Financing health care -- finding the money is hard and spending it well is even harder. N Engl J Med 2005;352:1252-1254.
To the Editor: The health care voucher plan presented by Emanuel and Fuchs is an inventive alternative to our current method of health care financing, but one might argue that it falls into the authors' self-identified trap of "incremental reform," rather than "major surgery." Vouchers would shift insurance costs from employers to consumers without curbing the excessive administrative costs created by our private insurance system. The establishment of the proposed Federal Health Board, Institute for Technology and Outcomes Assessment, and bodies to undertake risk adjustment and administration of a valued-added tax (VAT) would add further expense. Administrative costs for private insurance systems are more than twice those of public programs1; drastically reducing these costs through regulation of the insurance industry would slow the upward pressure on health care costs overall. Reining in administrative spending would free up finances for patient care and development of system infrastructure, allowing us to move toward universal coverage. We should rightly concentrate on cost control as the first step of reform. Otherwise, we could open ourselves up to even more explosive growth in health care spending.
Jennifer M. Hinkel, M.Sc.
932 Rye Valley Dr.
Meadowbrook, PA 19046
jennifer.hinkel@globalsurvivorship.org
References
Davis K, Cooper BS. American health care: why so costly? Testimony before the Senate Appropriations Subcommittee, June 11, 2003. (Accessed June 16, 2005, at http://www.cmwf.org/usr_doc/davis_senatecommitteetestimony_654.pdf.)
Drs. Emanuel and Fuchs reply: We agree with Dr. Relman about the need to reform the health care delivery system. The universal voucher system we propose would do precisely that, not by regulation or exhortation but by changing the incentives for physicians and hospitals. The experience of the past 40 years has shown that finance reform is a necessary prerequisite for widespread changes in the organization and delivery of care. Incentives need to be made more coherent, and they need to provide a financial as well as professional rationale for the implementation of electronic medical records, practice guidelines, physician extenders (e.g., nurse practitioners and physician assistants), drug formularies, and other mechanisms to improve quality and reduce costs. This is why we believe reform of financing must precede reform of the delivery system.
We agree with Ms. Hinkel that administrative costs should be reduced. The voucher system would do that by eliminating billions of dollars devoted to administering Medicaid and other means-tested insurance, especially by eliminating costly eligibility determinations. Additional billions would be saved by eliminating employer-based insurance. The voucher system would usher in the consolidation of the more than 1000 health insurance companies seeking business from millions of employers with costly annual negotiations of contracts — another savings of administrative costs.
However, not all administrative costs are wasteful. Systematic technology and outcomes assessment involve administrative costs that are essential for a well-functioning system that delivers cost-effective, high-quality care. One of the big defects of the current health care system is that we do not monitor the quality of the care actually delivered to most patients. Administrative costs are what we must pay for the information necessary to determine what works and what interventions are worth the money. Risk adjustment also entails administrative costs, but it furthers the important goal of preventing "cherry picking and lemon dropping." Such expenditures are worthwhile, as are administrative ones that reduce the hidden costs of fraud and abuse.
The voucher proposal is not a panacea, but it furthers the widely agreed-on goals of universal coverage, improvements in the organization and delivery of care, and reduced administrative costs in a manner congruent with basic American values.
Ezekiel J. Emanuel, M.D., Ph.D.
Posterity Project
Chicago, IL 60645
Victor R. Fuchs, Ph.D.
Stanford University
Stanford, CA 94305