The Forgotten Half of Healthcare Reform

| Tue Oct. 13, 2009 6:03 AM EDT

With the Senate Finance Committee set to vote today on its long-awaited health-care bill, a number of medical experts have criticized the legislation, as well as other committees' bills, for failing to seriously address the country's health delivery system. As I recently wrote, the pitched debate over reforming healthcare has largely focused on the sexier issue of reforming insurance, i.e., creating a public option, co-ops, fine-tuning the system in place, etc. Meanwhile, our broken delivery system—in which costs soar higher, preventive care is marginalized, and doctors get paid on fee-for-service basis—continues to crumble.

Over the past couple days, doctors and policy experts have come out to urge lawmakers to tackle delivery problems before it's too late. "The discussion has gone from health care reform to insurance and payment reform," Toby Cosgrove, president and CEO of the Cleveland Clinic, recently told a reporter for The New York Times's "Prescriptions" blog. Cosgrove added, "We're not really reforming the system. We are reforming how we pay for it. It's certainly all about politics right now." In addition, four former US surgeons general released a statement on Saturday saying our "unsustainable" health-care system is in need of "reform that prioritizes prevention, preventive care and health literacy to encourage healthier lifestyles and we must also lower costs in order to make quality health care affordable for every single person who needs it."

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This latest wave of advocacy is necessary. While our insurance system surely needs overhauling if we're to expand care to the 46 million uninsured Americans, the delivery system in place will crumble under the influx of patients. Most experts, including those quoted in my piece, say we need to move away from a fee-for-service system, and start rewarding proactive care that catches chronic illnesses earlier. Our system needs more primary-care doctors—right now the ratio of primary-care docs to specialists is 30:70—and doctors' salaries need to go up in order to attract brighter, younger medical students. More primary care is proven to lower costs for patients and providers, improve outcomes, and lower mortality rates.

The various health-care bills currently circulating Capitol Hill each devote a modest amount of funding for improving the healthcare delivery system—but arguably not enough. After all, you can't solve one part of the puzzle and not the other; insurance and delivery go hand-in-hand. And when you don't address both sides, you end up in a predicament like Massachusetts, where costs for near-universal health care are spiraling out of control, waiting times to see a primary-care doctor are two months or longer: the whole system is flirting with collapse. In some ways, Massachusetts could be a preview of national reform if it doesn't simultaneously fix the delivery mess.

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