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Our Health Care Apocalypse

The political dialogue and the media coverage focused on “reforming the U.S. health care system” misses the central point-the U.S. has no health care “system” to reform. What we have is a patchwork quilt of different responses to different health problems. And as the years have gone by, that quilt has frayed. We now face …

The political dialogue and the media coverage focused on “reforming the U.S. health care system” misses the central point-the U.S. has no health care “system” to reform. What we have is a patchwork quilt of different responses to different health problems. And as the years have gone by, that quilt has frayed. We now face the need to make changes at a system-wide level.

Unfortunately, most proposed reforms address just two questions: costs (how much we spend on health care) and coverage (the lack of coverage for major fractions of our population). But we won’t be able to control costs and coverage until we systematically address three other Cs. These are fundamental problems that have been largely ignored by the presidential candidates and the news media: consistency, complexity and chronic illness. And they are key to dealing with our health care crisis.

Consistency is sadly lacking in American health care. Every year thousands of wealthy patients travel from all corners of the globe to get access to American treatments for heart disease, cancer, neurological diseases, joint failures and so forth. Yet here is a dirty little secret: While the best of U.S. health care may be the world’s finest, on average, American health care as a system performs poorly. A RAND survey of 30 common medical conditions in a dozen American communities found that patients get appropriate treatment only about 55 percent of the time.

In other words, only slightly more than half of the people who fall sick tomorrow will get good and appropriate care, while slightly less than half won’t. And which half you experience doesn’t seem to be determined by whether you have health insurance or not. Only a system-wide focus on consistent use of best practices and measured outcomes can solve this problem.

Then there is the mind-boggling complexity of our health care system. At The Johns Hopkins Hospital, we bill more than 700 different payers and insurers. Each has its own rules regarding services covered, the level of reimbursement and the documentation and preapproval required.

Health care billing is the modern day Tower of Babel, in which no one speaks the same language. Nationally, this inefficiency costs patients billions of dollars. Administration represents (by conservative estimates) 20 percent of health care costs. Requiring all payers and providers to use a common billing format would remove much of this administrative burden- and patients might be able to understand their medical bills.

Finally, fully two-thirds of all Medicare spending is for beneficiaries who have five or more chronic conditions. About 80 percent of all health care costs involve patients with one or more chronic illnesses like hypertension, diabetes, obstructive pulmonary disease, arthritis, asthma or depression.

American medical research has revolutionized our ability to treat the sick. Formerly, diabetes, HIV and heart attacks were death sentences. Now they are merely conditions requiring daily medication and regular medical attention. But chronic conditions are both difficult and expensive to treat. Only when we begin to focus systematically on disease management will the big gains be made in better patient care and cost reduction.

Consistency, complexity and chronic disease: these are the three riders of our health care apocalypse. Addressing them systematically-at the national level-is the only way we hope to earn the best possible return on our health care dollars.


William R. Brody is president of The Johns Hopkins University. This text is adapted from a speech he made recently at the National Press Club in Washington.

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