A Health Care Plan for 2010

Dr. Arthur Garson, Jr., is senior vice president and dean for academic operations at Baylor College of Medicine. He served as president of the American College of Cardiology this past year, and on March 13 delivered his Presidential Plenary address, "The U.S. Healthcare System 2010: Problems, Principles and Potential Solutions." The entire text can be accessed at http://www.bcm.tmc.edu/pa/headline.htm. Dr. Garson recently sat with the TMC News to discuss his thoughts about the future of American health care. Excerpts from his lecture accompany his interview.

Q: There have been thoughts about a health care delivery system in the near future with teams where the physician is the leader and with social workers, nurse practitioners and other members dedicated to the patients. Do you see this as viable.

A: Yes, I sure do. I think we need to get away from arbitrary numbers of how many specialists, primary care physicians, and nurses there need to be. The concept will evolve where the right person is taking care of the patient. We don't have a model yet for the future. Just imagine: there will be virtual home visits with the Internet and television cameras; patients won't have to go to the doctor's office for routine visits and follow-ups. With these improvements in technology, our roles are likely to change.

But there will continue to be the need for the patient and doctor to interact. In fact, I believe that 10 years from now, the doctor-patient relationship will be more important than ever.

Q: And we're looking at an increasingly older population.

A: Yes. A recent estimate predicts that there will be twice as much heart disease in the next 25 years as there is now - the Baby Boomers are ageing and we will get better at keeping people with chronic disease alive longer. We're going to need all the help we can get-from all varieties of practitioners.

Q: We hear so much about quality outcomes measurements.

A: Quality is the right thing done at the right time by the right person, for the greatest benefit... I believe the quality will improve in the next ten years; outcomes will become more similar for similar types of patients. In the past, outcomes were determined from paper records, but with electronic medical records, the data will be there instantly to determine what might be the best thing to do. Our understanding of quality (and the patient's understanding of quality) will also improve. As outcomes become more similar, physicians will be judged by their ability to innovate with patients (not only in treating the sickest-but also in keeping patients well)-and we will be judged by our patients on how we relate to them as people.

Q: How would payment, quality and peer review work?

A: Physicians would be paid fee-for-service-no pre-approval. But there could be guidelines embedded in the Electronic Medical Record. Most of us get concerned about the notion of guidelines. They may be wrong, out of date or they just don't fit a particular patient. But if you could tell a physician what is the prevailing practice in his health plan, "For your information, 85 percent of doctors do this, or do this..." So I can see a very interactive process. If a physician disagrees with the guidelines after a certain number of cases, these could be automatically referred to peer review by Email; the physician could get feedback, and/or the guidelines could be amended. In a fee-for-service environment-some sort of oversight-as unobtrusive as possible-will be necessary.

Q: Your idea for a new health care system includes everyone, even the uninsured, and physicians working with private insurance plans?

A: In this plan, everyone can apply for a federal tax subsidy, dependent on the income, to cover all of part of the cost of the individual's part of the premium. There are two alternatives to employer-based insurance. In both, employers with more than 10 employees would be required to pay for health insurance on behalf of their employees-you know, right now, 80% of businesses with more than 10 employees already do. The first is one where the employer can still provide insurance, or would be required to pay a portion of the premium. In the fully developed system, the employer doesn't provide health insurance at all but pays a regional agency - much like the Federal Employees Health Benefits Plan. Then the regional agency would pay each health plan a severity adjusted premium for each member of the health plan.

I think most everyone is a winner with this plan. Patients would have choice, guaranteed coverage and be freed from "job lock." Employers could get out of the healthcare business. Insurers will benefit from the technology. Doctors will get to spend more time with their patients-the reason we all went into medicine.

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©2006 Texas Medical Center

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