University Times

“It’s been said that an pessimist is just a well-informed optimist,” said Harvey V. Fineberg, “but I prefer to say, ‘I’m pessimistic about the past, because we cannot change it, but I’m optimistic about the future because we can.”

Fineberg, who is president of the Institute of Medicine, part of the National Academy of Sciences, spoke to a packed house in the Graduate School of Public Health (GSPH) auditorium Dec. 1 on “Changing Health Care in America.”

The lecture marked the 25th anniversary of the Health Policy Institute, which is a component of GSPH’s Department of Health Policy and Management.

“Changing health care in America is really the topic that has emanated from this institute from its inception,” Fineberg said. “And it’s an ongoing dilemma. Although in this country we have a record of which we can be proud and impressed, we also have a number of failings that need to be addressed.”

Reflecting on the past, Fineberg cited much good news, including America’s emergence as the worldwide leader in biomedical research and education, the 50 percent reduction in deaths from cardiovascular events since 1900, the 75 percent decline in infant mortality rates during the 20th century, and the staggering rise in life expectancy from 40-something in 1900 to the upper 70s now.

“You can date the rapid rise in life expectancy back to about the mid-19th century, with improved water sanitation and other public health measures, but not before that. It’s a modern times phenomenon,” Fineberg said.

The steady rise in life expectancy was interrupted by the global flu pandemic, responsible for at least 20 million deaths, that reached its peak in 1918.

(“It was the flu and not because it was the last time the Red Sox won the World Series,” jested Fineberg, who spent 13 years as head of Harvard’s public health school before becoming that university’s provost. “It will be interesting to see if we’ll have a decline in population from all the people who vowed not to ‘kick the bucket’ until the Red Sox won again,” he quipped.)

But despite the good news, Fineberg said the U.S. health care system has a number of failings, including the fact that 43.6 million Americans are uninsured; costs are skyrocketing, with $1 out of every $7 – $1.6 trillion a year – spent on health care; the health care system is loaded with deficiencies in quality and safety; disease prevention is severely under funded with less than 5 cents on the dollar directed to prevention, and there are widespread disparities in access and outcomes.

“Even with all the successes we’ve had, we’re not in the top 20 countries in infant mortality rates, and we’re not in the top 5 in life expectancy,” he pointed out. Health illiteracy is rampant, he said, with too many patients who are unable to follow medical instructions but are too embarrassed to ask for help. Some three-quarters of patients are not getting the recommended care. As an example, he said that half of the victims of heart attack are not getting beta-blockers, which are known to work. “My own theory is that they’re too cheap, so there’s no incentive to promote them,” Fineberg said.

There also is a shortage of nurses in this country and physician specialists are abandoning their practices because of malpractice insurance costs. Furthermore, there is a systemic mismatch of health care providers and managed care operations.

There are no established standards for hospital care. “Tens of thousands are dying in hospitals. If you count human error as a cause of death it would make the top 10,” Fineberg said. “We need to see that as a system problem, not a problem of individuals.”

What needs to be accomplished?

“I have six criteria for health care: It should be safe, effective, patient-centered, timely, efficient and equitable,” he said.

The doctor then prescribed his 12-step program for American health care recovery.

“I’m not saying these are the only 12 steps, or that these are necessarily the best 12 steps, but each would contribute to remedy these fundamental predicaments,” Fineberg said. “It’s also a way of keeping our arms around the totality of the problem. If we don’t do that, it’s like a big cushion: When you squeeze down at one place, it expands at another.”

* Find a middle ground politically. The right wing has recognize the need for universal health care, while the left wing has to acknowledge that health choices are individual and needs to accept a system of income-based payments. “Both sides need to break down the problem of the uninsured into its components. For example, with near-poor children we’ve seen a 10-15 percent decline in coverage. Let’s address that, and go on to other segments.”

* Invest in health protection and preventive services. “We need to strengthen the public health infrastructure. The current flu vaccine shortage tells us we have the larger problem with the system of distribution,” Fineberg said.

“If UPMC tomorrow decided to promote diabetes management in the community, unless the people they promote it to are all signed up for UPMC’s pre-paid program, it’s not a good investment for UPMC,” he said. “There is a disparity between what makes sense for the community for disease prevention versus the payment system.”

* Put people first. A patient-centered philosophy of medical delivery would go a long way toward ending unequal treatment, according to Fineberg.

* Fund information technology. A system of electronic health records could reduce medication errors by two-thirds or more, Fineberg said. Having such a system was endorsed by both presidential candidates in the recent election, but it is still a long time away from being implemented, he added.

* Educate for quality and team work. In particular, chronic diseases, which afflict more than 100 million Americans, are managed better by a team of health care professionals, Fineberg maintained. “This means also building relationships based on trust, and again, educating for patient-centered care.”

* Rely on evidence as the foundation for guidelines of care. “Find out what works and make it the standard. Translate evidence into practice,” Fineberg recommended. “For example, a pilot has a checklist. It’s the same every time; the same list, done in the same order, with the same result.” But orthopedic surgeons organize their instruments in the operating room individually. “Mindless variation is the enemy of quality and the source of many errors,” Fineberg said.

* Use resources intelligently. “You gain efficiencies by reducing variation, by better scheduling administration and by simplification,” he said.

* Insist on transparency. “And I believe that includes making hospital data available to public access,” Fineberg said. “Privacy and ownership are different. For example, what if you decided to build on property without following building codes, but no one was allowed to know about it?”

* Experiment with care models, especially for chronic diseases. * Pay for performance. Financial incentives enable a competition-based system to thrive, leading to the best care, Fineberg said.

* Reform malpractice. “Malpractice is not as huge a contributor to the cost problems as many people believe,” he said. “But the malpractice system doesn’t work at any level, except maybe for lawyers. We need to get money to those victims who really deserve it, and we need real sanctions for [physicians’ errors]. Perhaps a workers’ compensation model [would improve the system].”

* Invest to ensure future progress. “We need to fund science discovery – large-scale science like the human genome – and clinical and health system research,” Fineberg said. “The average age of a first-time NIH grant [awardee] is 39. We need to do more to encourage young scientists especially.

“This is only a beginning, but if we take steps, here’s the vision: Prevention and public health will be integrated and applied to everybody,” Fineberg said. “The health care system will be affordable and not unequal, oriented around the needs of the individual. We will celebrate innovation driven by quality and value. I believe high performance is doable and can be comprehensive.”

He concluded his lecture with a humorous reference to “that noted popular social critic, Jerry Garcia, who said: ‘Something has to be done and it is simply pathetic that we are the ones who have to do it.'”

-Peter Hart