Wednesday, September 2, 2009

In “The Tragedy of the Commons,” Garrett Hardin wrote, “Each man is locked into a system that compels him to increase his herd without limit — in a world that is limited. Ruin is the destination toward which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in a commons brings ruin to all.”

In the health reform rhetoric, many are quick to cast stones of singular blame at the insurance industry. And, as Hardin aptly commented, “to avoid hard decisions many of us are tempted to propagandize for conscience … .” We need to change this debate, as none can rightfully claim residency in health care’s elusive glass house.

So who, then, are the real villains in health care?

Are they the world’s best-trained physicians and health care professionals who care for our loved ones? Perhaps our hospitals, which bring both employment and cutting-edge medical technologies to our communities? Our pharmaceutical, biotechnology and device companies, whose researchers give hope to those afflicted with diseases once thought incurable? Or our insurance companies, which provide access to these vital health services and whose nurses help coordinate care for patients? The answer is all of these groups standing together. The villain is our collective overgrazing on the commons of the U.S. health care system.

Physicians provide too many services, at least 30 percent of which do not improve health. Twenty percent of hospital patients are readmitted within 30 days of discharge, and pharmaceutical companies challenge generic medications that perform equally well at a fraction of the price. Health plans don’t provide clear information on the quality and cost of physicians and hospitals. Our Medicare and Medicaid programs lack the political will to adopt the best approaches to improving quality while lowering costs. And our federal, state and local governments have failed to address costly new public health epidemics such as childhood obesity and diabetes.

As citizens, we too have overconsumed: gasoline, fast food, tobacco, television and health care. We spend nearly twice that of our international peers but rank a dismal 37th in overall health. We hold the innovative keys to the future of medicine but leave nearly 50 million Americans without access. Our health care costs are sapping our nation’s economic vitality, making us less competitive in international markets.

As a country, we have overgrazed our health care commons down to nearly barren soil. Over time, our health care financing, whether by government or private payers, will become unsustainable. So it is our responsibility, the responsibility of the collective health care villains, to recultivate a higher-performing, lower-cost health care system accessible to all Americans. As health care grazers with a $2.4 trillion stake in the future of our commons, we all can help change the debate.

Help change the debate to include new reimbursement models that reward physician quality over quantity and hospital value over volume. Help change the debate to focus on new delivery models such as patient-centered medical homes that coordinate care and help prevent the extinction of primary care physicians.

Help change the debate to invest in technology that connects patients, doctors, hospitals and insurers and guides better-informed decision-making. Help change the debate to eliminate racial, financial and geographic health inequities, to improve the health and productivity of our work force and to enable a future that embraces clinical discovery and innovation.

Help change the debate so all Americans have the greatest potential for fulfilling and healthy lives. Health insurance reform is certainly vital to this end, but it is not, in itself, health care reform.

Dr. Sam Nussbaum is chief medical officer and executive vice president for clinical health policy at WellPoint Inc.

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