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US health reform

The recession
is not hitting news headlines as much as last year. However, the question of how to reduce healthcare costs in a difficult economic climate still seems to be grabbing headlines across the world.

First came the news that Donald Berwick , founder of the Institute for Healthcare Improvement and pioneer of EBM, was appointed by President Obama as the Head of the Centers for Medicare & Medicaid Services (CMS), which delivers America’s piecemeal state healthcare system. Berwick has a proven track record in putting EBM into practice and improving the quality of patient care. He has long been an admirer of the UK’s NHS, saying that, “The decision is not whether or not we will ration care - the decision is whether we will ration with our eyes open.”. Unsurprisingly, his appointment has been criticised by Republicans, who fear that he might actually do something about America’s spiralling healthcare costs. His appointment will hopefully bring accountability and some transparency (and hopefully some EBM) to America’s industry- and private sector-dominated health systems.

Germany has a national health insurance system largely funded through employers’ contributions, but now spends more on health care as a proportion of GDP than any country apart from the USA and Switzerland. Health reforms were pushed through last week which resulted in capping of employer's contributions, but also allowed Germany's health insurance providers to demand unlimited top-up fees from individuals. In short, Germany has chosen reduced coverage of healthcare rather than evidence-based reductions in costs.

Recently, development aid for health has increased substantially, from $5.6bn in 1990 to $21.8bn in 2007. With increases in spending by the poorer countries themselves, a BMJ article calls for greater rationalization of health spending, based on local needs and demands, and not the demands of international stakeholders and NGOs. The authors give the example of Rwanda where earmarking of funds for HIV/AIDS and target-setting led to just $1m for the integrated management of childhood illnesses, compared to $47m for HIV/AIDS, grossly disproportionate in a country with a 3% infection rate." This meant that "physicians employed by NGOs to deliver HIV/AIDS services are paid almost 6 times as much as physicians paid by the state, making it impossible to keep well qualified health personnel in the public sector."

Disdain for externally-set targets is shared by the UK’s coalition government, which has been quick to criticize Labour’s targets as it sets out its health reform stall. The two main aspects seem to be more power to GPs to commission services that are more aligned with patient needs and and independent sector providers will be encouraged to compete for patients. The problem is that in order to cut costs and improve services, there is going to have to be some measurement. And so the Health Secretary, Andrew Lansley has given us some political waffle to get our teeth into, saying that he wants to move from national targets to a "set of national outcome goals". New metrics and standards of healthcare are currently being designed and the first set of new standards is due by April 2011. The plan is for the new NHS commissioning board to use them to hold GP groups to account. Good evaluation using good measurement tools (yet again, evidence-based healthcare) are essential for any such plans to work.

I spent this week in a conference centre the size of an airport for the Annual American Heart Association conference in Orlando, Florida. With over 25 000 delegates, it represents the world’s premier meeting for doctors and researchers interested in vascular disease. For 5 days, there were presentations, posters and seminars about every conceivable aspect of diseases that block up your arteries. There is far too much to mention individually, but some of the highlights for me were (1) research showing that coronary heart disease (CHD) and its underlying cause, atherosclerosis, are lifelong processes that start in childhood and might be programmed by the intrauterine environment; (2) evidence that multivitamins, particularly vitamin A, C and E do nothing to protect us from CHD; and (3) a trial of transcendental meditation showing its protective effect on CHD.

However, the most fascinating session I attended was about the so-called “Sunshine Act”, which is currently going through the United States legislature to completely overhaul the interactions between physicians and the pharmaceutical industry. In the 15 years that I have been visiting the US, I was always struck by the scale of the pharma industry and its lobbying power. However, in the massive exhibition hall at a conference that used to be brimming with drug companies and freebies, the restrictions were clearly visible. No free pens, no free food, and nowhere near as much hard-sell. The new bill will make it mandatory for any interactions, particularly financial, to be reported, leading to more openness from health professionals and industry, whether in relation to education, research or corporate hospitality. At the conference, both journal editors and scientists discussed what should represent “disclosures”and “conflicts of interest”. If this bill becomes law, America will be leading by example in an effort to rebuild trust in medical practice and to preserve the independence of clinicians.

The attendees of the session found out that the speakers were not the first-choice speakers for this debate. The conference organisers had asked the two US Senators who were in charge of the Sunshine Act and government advisors from Harvard to lead the session, but they had all declined because they would not be receiving an honarium from the American Heart Association. It is interesting that policymakers and other public servants expect doctors to be impartial and independent in their practise and yet they are happy to accept speaker fees and all manner of expenses in the name of their jobs. This is not an American problem as our hugely embarrassing MPs’ expenses scandal in the UK illustrates. We cannot have one rule for one sector, and one rule for another. Wherever taxpayers’ money is at stake and people are employed in a public service, there should be certain standards across the board.

As the US Senate prepares to vote on President Obama’s proposed health reform bill, which would greatly broaden access to healthcare, the previous Chief Executive of the NHS, Lord Crisp, suggested that the NHS and the Department of Health in the UK need to separate in order for greater accountability to the taxpayer, and greater independence of the NHS. There is clearly no one solution to better healthcare and better accountability, but any move that leads to greater transparency will surely be a good thing.

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