Health care reform in the USA: Recommendations from USA and non-USA radiologists

Abstract

AIM: To compare the opinions and recommendations of imaging specialists from United States (USA) and non-USA developed nations for USA health care reform.

METHODS: A survey was emailed out to 18 imaging specialists from 17 non-USA developed nation countries and 14 radiologists within the USA regarding health care reform. The questionnaire contained the following questions: what are the strengths of your health care system, what problems are present in your nation’s health care system, and what recommendations do you have for health care reform in the USA. USA and non-USA radiologists received the same questionnaire.

RESULTS: Strengths of the USA health care system include high quality care, autonomy, and access to timely care. Twelve of 14 (86%) USA radiologists identified medicolegal action as a major problem in their health care system and felt that medicolegal reform was a critical aspect of health care reform. None of the non-USA radiologists identified medicolegal aspects as a problem in their own country nor identified it as a subject for USA health care reform. Eleven of 14 (79%) USA radiologists and 16/18 (89%) non-USA radiologists identified universal health care coverage as an important recommendation for reform.

CONCLUSION: Without full universal coverage, meaningful health care reform will likely require medicolegal reform as an early and important aspect of improved and efficient health care.

Key Words: Health care reform, Health care policy

INTRODUCTION

Through the legislative process, a health care reform bill passed through the United States (USA) congress on March 23, 2010 marking an effort to improve the USA health care system. Although the bill does not cover 100% of USA citizens, it potentially represents a major advance in the American health care system[1]. Many challenges remain ahead, including refining major initiatives in the reform measures. Critical flaws in the USA health care system have been at least partly addressed in the bill, such as prohibiting denial of health care insurance for patients with pre-existing conditions and extending health care coverage for young adults on their parental insurance programs[2,3]. Since the changes have primarily focused on health insurance reform, many key aspects that may have an enormous impact on the health care system have not been adequately addressed, such as access to adequate health care and safety of delivered health care.

The intention of this current survey-based study is to perform a small scale preliminary study to allow radiologists who are both practicing in non-USA developed nations and in the USA to voice their concerns about their respective health care systems and to convey what they believe is essential to achieve meaningful health care reform in the USA.

MATERIALS AND METHODS

A survey on health care reform was emailed to 18 imaging specialists [17 radiologists, 1 cardiologist (Italy)] living in 17 developed nations, all with a universal health care system [Australia (2 radiologists), Austria, Belgium, Canada, Denmark, Germany, France, Ireland, Italy, Japan, Netherlands, Portugal, South Korea, Spain, Sweden, Switzerland, United Kingdom]. Findings from the survey administered to non-USA imaging specialists alone have been reported[4]. The identical survey was emailed to 14 USA radiologists located in the following states/districts (California, District of Columbia, Georgia, Florida, Illinois, Maryland, Nebraska, New York, North Carolina, Oregon, Pennsylvania). The survey asked: (1) what are the strengths of your health care system; (2) what problems are present in your nation’s health care system; and (3) what recommendations do you have for the USA as it embarks upon health care reform.

The respondents were all acquaintances of the senior author on the study. No specific communications were held with the respondents by authors on this study to guide their responses, so that the information they provided could be considered unbiased by the authors.

The answers from all respondents were tabulated by one of the investigators. Descriptive statistical analysis was performed.

RESULTS

Strengths

All of the USA radiologists included in this survey praised the USA health care system for the high quality of care that is provided to patients nationwide. Eleven of 14 respondents (79%) felt that the high degree of innovation, research, and state-of-the-art technology provided in the USA makes the USA health care system one of the best health care systems worldwide. However, 3 of 14 (21%) respondents stated that access to state-of-the-art health care is dependent on adequate health insurance. This high technology-based quality of care that leads to outstanding health care comes with a cost; 7 of 14 (50%) respondents felt that this was a primary factor in the rising health care costs. Of the non-USA radiologists, 14 of 18 (77%) felt that despite offering universal health care coverage their nation was able to provide state-of-the-art health care.

Five USA respondents (36%) described access to timely care as a strength of the USA health care system. These five felt that one advantage that the USA health care system has over those countries that offer universal health care is the fast access to care, including medical appointments, imaging, and surgical interventions.

Patient autonomy was named by 4 of 14 (29%) USA respondents as a great strength of our USA health care system. One USA respondent felt that this autonomy comes at a high cost; an educated patient may demand to see subspecialists as opposed to a generalist or demand further work-up with expensive exams. The respondent stated that, while this free market environment inspires innovation, he believed that the cost of health care rises as a result.

Weaknesses

USA respondents overwhelmingly cited two weaknesses in the USA healthcare system: the current medicolegal environment and lack of universal insurance coverage. Twelve of 14 (86%) USA radiologists identified the current medicolegal environment as a critical short-coming in the USA health care system and an important reason for continuously rising healthcare costs in the US. These respondents felt that medical liability is unpredictable, often arbitrary, and a strong player in the over-utilization of tests. These 12 respondents questioned why medicolegal reform has not already been addressed at a national level given the long-standing and escalating problems with medical liability. Nine USA radiologists felt this was due to the lack of physician input in health care policy decisions. These opinions are in contrast to the non-USA imaging specialists, of whom none cited medicolegal concerns in their health care system or included medicolegal reform as a potential component to USA healthcare reform.

The second commonly cited weakness by the USA physicians [11/14 (79%)] is the lack of universal insurance coverage for USA citizens. In discussing this weakness, these USA respondents are critical of the for-profit companies that currently provide health care insurance. Ten (71%) of the respondents blamed the growing number of uninsured citizens on the insurance industry for setting limitations on who qualifies for healthcare policies and denying coverage for pre-existing conditions.

Recommendations

The two commonly cited recommendations stemmed from the cited major weaknesses of the USA health care system. First, the need for medicolegal reform was emphasized by 12/14 (86%) USA radiologists. Potential solutions include capping financial penalties and capping the financial award to attorneys, including physician representation in all medicolegal policy reform, and establishing an alternative to the medicolegal system, such as expert medical panels.

Second, 11 of 14 (79%) USA radiologists recommended universal health care as a critical part of health care reform; one respondent stated “failure to provide basic health care insurance to all citizens is an inexcusable moral failure”. This mirrored recommendations by the non-USA radiologists; 16 of 18 (89%) non-USA respondents recommended that the USA move to a universal health care system. As part of the health care reform process, 8 of 14 (57%) USA respondents recognized the need to have more physician involvement in health care reform; 10 of 18 (56%) non-USA radiologists cited lack of physician representation as a limitation in their own systems.

DISCUSSION

Although there are many other health care providers who occupy important positions in the health care delivery system, physicians hold a key role: physicians are the primary managers in meeting patient health care needs. Acknowledging the importance of the role of physicians, governmental representatives have emphasized that new health care measures should not interfere with the physician-patient interaction. However, ironically, there is little representation by physicians in the health care reform discussion and legislation.

In this preliminary study, the imaging specialists praised the USA health care system for high quality and autonomy of care as well as access to timely care; nevertheless, the majority of respondents felt that lack of universal health care is a disservice to USA citizens. Additionally, respondents felt that our medicolegal practice in the USA is a costly short-coming that needs to be addressed during health care reform. This opinion is supported by a recent analysis by Price Waterhouse determined there was approximately $1 trillion in waste in the USA health care system with $200 billion attributable to defensive health care practice[5]. Similarly, Lubell reports, “Medical malpractice costs average about $55.6 billion annually, or 2.4% of annual health care spending”[6]. In reality, due to the pervasive nature of defensive health care practice, the real cost may be considerably larger.

There is a complex interplay between several factors that may account for the difference in perception between USA and non-USA radiologists in the need for medicolegal reform in their respective countries, including cultural differences amongst physicians, the public, physician-patient interaction, and differences in legal systems. However, it is notable that the great majority of USA radiologists in our study considered medicolegal reform an important goal, whereas none of the non-USA radiologists cited medicolegal issues as an important limitation in their own national health care systems. This raises the question of how did the USA system evolve so differently from other developed nations that medicolegal concerns should be perceived by radiologists to be an enormous impediment in the USA but not of any special concern in other developed countries

In a prior study which evaluated Standard of Care in medicolegal practice, the authors postulate that in a non-universal coverage system, if a patient loses health insurance and has continued (often expensive) health care needs, that patient has essentially no option but to litigate against some party in order to get funds to continue to pay for their health care[7]. The obvious parties to litigate against are those with the greatest financial resources, which are often the health care providers and the hospitals involved. Thus, financial need likely represents one of the main drivers of litigious activity, even if the injured party feels that the health care providers are not responsible. We propose that the absence of a comprehensive and universal healthcare plan in the USA is one of the key factors related to the disproportionate degree of healthcare litigation. The disconnect between medicolegal practice and quality of health care is best expressed by studies that show that the USA has the greatest affliction of medicolegal action (including this current study)[8-13], while at the same time possessing the best-trained, best-qualified physicians, and the latest health care innovations and hospital systems[14,15]. However, universal health care systems have their own drawbacks, such as long wait times[4].

A down-side of a system that relies on litigation settlements to compensate for shortcomings in healthcare coverage is that a relatively small percentage of those injured are able to win a medicolegal case[16]. In addition, a confrontational culture develops mistrust in the doctor-patient relationships. A manifestation of this phenomenon may account for the pattern of practice referred to as “defensive medicine”; physicians feel compelled to perform additional tests and procedures, some of which increases cost and/or risk to the patient (for example, the over-utilization of CT)[17-21].

The major limitation of our study is the relatively small number of respondents included in this survey. As such, this study should be considered a preliminary investigation. We attempted to compensate for the low number of respondents by selecting for wide geographic variation within both the non-USA group (17 different countries) and the USA group (representation from states widely distributed). Furthermore, our finding that 86% of our USA respondent radiologists considered the current medicolegal environment as a major limitation in the American system concurs with an earlier survey of 1231 physicians, in which 91% of the responders stated that they believed physicians in the USA order excess tests for medicolegal reasons and not for patient care reasons[22]. In addition, all respondents were acquaintances with one of authors (RS). It would be of interest to carry out a large-scale survey to hundreds or thousands of radiologists across the US; however, this would require access to central databases and likely incentives for responses in order to achieve adequate response rates.

Health care reform should address the core issues of excessive medicolegal actions, relative to other countries. Increasing the number of individuals covered by health care, reduction in denials and improved long-term care coverage may decrease the number of patients who seek legal action. Meaningful medicolegal reform should have as overarching goals the reduction of defensive medical practices. It is our opinion that meaningful cost reductions can only occur if physicians do not work under the constant threat of litigation.

In summary, our small-scale study has described results from a survey administered to non-USA and USA radiologists, which mirror larger scale national surveys. Both groups separately considered that universal health care was important for health care reform in the US. Non-USA radiologists did not identify medicolegal issues as a drawback in their health care system, whereas the majority of USA radiologists did, indicating that this is perceived by healthcare providers to be a fundamental issue of the USA health care system that needs to be addressed within the healthcare reform process.

COMMENTS

Background

To compare the opinions and recommendations of imaging specialists from United States (USA) and non-USA developed nations for USA health care reform with the attempts to determine important factors in refining the USA health care system.

Research frontiers

The future delivery of health care is an important issue world wide. How best to allocate resources for this purpose remains an extremely controversial subject and one that is in need for quality research studies.

Innovations and breakthroughs

Without full universal coverage, meaningful health care reform will likely require medicolegal reform as an early and important aspect of improved and efficient health care.

Applications

This is an opportunity for radiologists in the USA and in non-USA countries to have their opinions heard regarding the state of health care and their recommendations for the delivery of future health care.

Peer review

This is a small scale survey-based study to allow radiologists who are both practicing in non-USA developed nations and in the USA to voice their concerns of their respective health care systems and to convey what they believe is essential to achieve meaningful health care reform in the USA. The results are interesting, with a large percentage of physicians surveyed stressing the need for medico legal reform.