INTENSE DEBATE is under way as to what type of health care payment system is best.
Should it be a single payer/universal coverage system? Or an expanded employer-based system, with a Medicaid and Medicare safety net? Or another alternative?
In Maryland, health care accounts for 30 percent of the state budget, and employers are seeing huge premium increases. Is there a way to both save money and help people?
Once someone has suffered an injury or been diagnosed with a serious illness, medical options narrow to two: either treat the person with the best medical care available or deny him that care. The only real choices exist in preventing or lessening the injury or disease process before it occurs.
How can we do this? The best way to save money in health care is to aggressively invest in prevention and deal with the "Big 7" main drivers of the health care system. They are:
Care at the end of life. Fully 25 percent of health care dollars spent in the average American's life are spent in the last two weeks of life, when the likelihood of recovery is minimal or absent. This raises complex personal, ethical, spiritual and legal challenges. What can be done?
Expand the use of advanced directives so that people can make informed decisions about the kind of care they want. Remove barriers to adequate pain relief. Support medical providers who work with dying patients. Help our culture understand that "doing everything" may not always be the best thing to do.
Reduce legal addictions, specifically tobacco and alcohol abuse. Today, our insurance system will pay thousands of dollars for lung cancer care, but nothing for smoking cessation. Instead, we should help patients change their destructive behaviors and reward providers for helping patients do this.
Treat illegal addictions. Addictions cause an estimated 80 percent of crimes, 80 percent of uncompensated health care costs and 80 percent of major trauma care. Addiction treatment works. For each dollar spent, $7 is saved. Maryland has made great strides to increase funding for and efficiency of addiction treatment programs. This has yielded positive results, but there is still a long way to go.
Lifestyle and obesity. Fifty percent of Americans are overweight, a cause of diabetes, heart disease, kidney failure, degenerative joint disease. Our system does not pay for weight reduction programs and does not pay providers to help patients lose weight. Obesity leads to high prescription drug costs by paying for multiple medications instead of dealing with the underlying cause. One example: even a 10-pound weight loss can eliminate the need for blood pressure medication.
Simple injury prevention. Wearing seat belts and putting children in car seats have proven effective in reducing injuries. Let's expand this to other well-recognized accident scenarios. It costs much less to help safety-proof a senior's home than it does to care for avoidable injuries like hip fractures.
Mental health. This system is breaking down, with clinics closing at an alarming rate. When patients can't get mental health services, they deteriorate, stop working (and paying taxes) and end up in emergency rooms, state hospitals and the criminal justice system. Domestic violence and child abuse increase. Modest investment in mental health services -- especially out-patient care -- pays back with huge dividends.
Environmental impact. Maryland's cancer, asthma and allergy rates continue to climb. Common sense tells us that a cleaner environment is better for everyone, especially for the most vulnerable: children and seniors. New thinking in design, construction, manufacturing and technology will allow us to pursue job creation and economic development that contribute to ecological restoration and a vibrant economy.
These seven categories drive almost all health care expenses, and no system of insurance or payment will work unless they are addressed. Each can be targeted with specific strategies that improve health and reduce costs, and if each is addressed, the whole system benefits.
With a creative approach, sound management and a clear vision, we can build the model for a healthier America here in Maryland. The adage "An ounce of prevention is worth a pound of cure" is truer now than ever. Let's live up to it.
Dan K. Morhaim, an emergency medicine physician, represents Baltimore County as a Democrat in the House of Delegates.