Of course, in 2010 the news cycle is 24/7, with more television channels to choose among than time to watch all of the material available. Add to that the enormous amount of material (both written and video) available on the Internet and through telephone access, let alone on license plate holders, and one could argue that since we now have access to a lot of information, we are less likely to be influenced by a few voices. On the other hand, it seems clear that sometimes there is just too much information for normal humans to process. And, of course, to whom should we pay attention? Who is believable? The information that is provided to us often is still “spun” in ways designed to help us reach conclusions that someone wants us to reach. I am sure that you, too, have seen ads that show an unflattering picture of given candidate’s opponent, often with unpleasant background music in a minor key, accompanied by selected quotes (sometimes taken out of context) designed to show why they are “not on our side”. Have you had trouble figuring out who was behind such ads? Have you wondered why the candidates could not just stick to presenting their thoughts and goals and plans, instead of spending most of their time impugning the opposition?

While the pre-election rhetoric has covered a large range of topics, and while it seems that the top 3 concerns to voters are the economy, the economy, and the economy, one area of particular interest to me is health care. I suspect that many readers of this Journal share that interest. It is widely reported that in the United States, we spend too much on health care, and get too little in return. A recent summary from the Commonwealth Fund Commission on a High Performance Health System, “Results From a National Scorecard on U.S. Health System Performance, 2008”, lists a series of indicators that could be used to describe health system “quality”, compares measures of U.S. performance against “benchmarks”, and concludes that we could certainly do better. Expressed as a ratio of U.S. performance to benchmark targets, overall average score was 0.65. Among a number of interesting points, the authors note a high infant mortality rate; inadequate control of chronic conditions such as hypertension and diabetes, leading to “avoidable” health care costs and preventable morbidity and mortality; a strikingly high rate of adults who are un-insured or under-insured; high rates of hospital re-admission within 30 days following discharge, suggesting that adequate care had not been achieved; high costs of care for common conditions, with large regional variations that are not easily explained; a surprisingly low rate of implementation of electronic medical records; and high administrative costs compared with those in other countries.

Recently, I had an experience that brought home in very concrete terms the difficulty of providing quality care. For the purposes of HIPAA compliance and patient confidentiality, I will take a few liberties with the facts, and be suitably vague. I was scheduled to see, in my weekly clinic, a middle aged patient who I have followed for many years. His problems are ones that many of us see every day—he has coronary heart disease and all the “fixins”: hypertension, dyslipidemia, glucose intolerance, a sedentary lifestyle, and so on. He had bypass surgery a number of years ago, and his caregivers now have focused—appropriately—on controlling modifiable risk factors in order to increase the likelihood that he will continue to lead a productive and enjoyable life, help his children grow up to become good citizens, and avoid future trips back to the cath lab and operating room! Published data surely provide clear guidelines about the kinds of medications that are beneficial to patients with similar conditions, and appropriate treatment targets.

Unfortunately, my patient never showed up for his clinic appointment. In investigating, I learned that he had stopped taking most of his cardiac medications because his insurance coverage did not cover their costs. For the same reason, he had not been seeing his primary caregivers very often, and I suspect that his failure to come to my clinic was primarily for financial reasons. I am not privy to his finances, and would find it inappropriate to pry into these details, but it seems likely to me that he had to choose, in essence, whether to spend his limited resources on medications and the costs of clinic visits (facility fees and doctor bills), or to buy food for his wife and children. A difficult situation, to be sure, but I suspect that many of us with families, if faced with the same dilemma, might be tempted to follow the same path.

While resolving this situation for my patient is of high interest to me personally, in the bigger picture, it re-emphasizes one of a number of large problems with our health care system. How ever can we expect aggregate measures of morbidity and mortality to “measure up” to benchmark values when we must count the costs of care for the large number of patients who do not have enough coverage to get the care that might otherwise be available? How many prescriptions for statins and beta blockers, and how many outpatient clinic visits and blood tests, does it take to equal the costs of a percutaneous coronary intervention or a coronary bypass operation (including related hospital costs)? If large numbers of patients (we are talking in the millions here, so “large numbers” is probably not hyperbole) do not have the ability to go to the doctor, take their medications as prescribed, or benefit from appropriate care for their chronic conditions, how can we possibly be surprised that “preventable” hospital admission rates are too high, lifespan is too short, and overall costs of care are higher than in countries where all citizens have access to basic health care? I have heard it said that there are long waiting lists for elective procedures in countries with what is sometimes termed, disparagingly, “socialized medicine”, and I am not arguing that national health care plans are an ideal solution. However, my patient reminds me that when one measures system costs, no matter how good the care provided to patients who are “in” the system, the results cannot look too good when we must also include the costs of care for those who are not able to participate, but whose health care costs ultimately will be paid by the rest of us.

I do believe that finding a solution to the problem of the “uninsured” and “underinsured” is an important priority. In that spirit, one could argue that the “Patient Protection and Affordable Care Act (PPACA)”, passed into law earlier in 2010, is a first step. I understand that many Americans do not favor this law, and I do realize that how (or even if) various portions of this complicated Act ultimately will be implemented remains to be seen. I certainly hope that health care professionals will have important input into many of the decisions that remain to be made, and refinements that will need to be implemented. However, regardless of whether we are Democrats or Republicans or Independents, or members of the Tea Party or the Green Party or the Libertarian Party or any other political group, or just concerned citizens, it seems hard to argue from the perspective of a health care provider that it is a good thing for patients to need medical care but not be able to afford it.

While providing access to health care to all citizens would in my view represent an important step forward, I certainly acknowledge that exactly what is provided, how much it costs, and who is going to pay for it are tough issues the need careful deliberation. As is so often true, the “devil is in the details”. It seems to me that other changes also are needed. I believe that the threat of legal action does create an incentive for some caregivers to practice “defensively” so as to protect themselves from allegations of having provided substandard care. Whether we can afford to order tests that are of unclear medical value, in order to protect ourselves from claims that by failing to do so we were acting in a negligent manner, is an important question. Administrative costs represent another area in which improvement might be. Over my career, I have watched administrative complexity grow, and have seen doctors turn into “providers” and patients into “clients”. I realize that disorganization is inefficient, but I cannot help but wonder whether patients would be better off if we could redirect some of the dollars currently used for administrative costs toward the care of patients themselves.

An additional topic for discussion is whether the old “fee for service” model is in need of major overhaul. In this case, I do believe that “change is needed”. The growth in diagnostic imaging utilization has been of interest to me for many years, and while much of this growth is testimony to the diagnostic power of imaging methods such as echocardiography, I believe that we need to re-visit the paradigm “the more services I provide, the more I earn”. The reasons for ordering diagnostic tests can be complicated and must be individualized, since a “one size fits all” approach works poorly for individual patients. It is my belief that most caregivers order tests because they think that doing so will benefit their patients. Nonetheless, it serves neither patients nor caregivers if some observers believe that health care providers sometimes order tests in order to keep up their income stream. Whether we like it or not, there seems to be a move toward reimbursement systems that reward caregivers for providing efficient and high quality services, and not just for providing a lot of services. We will, as I have written in other Editor’s Pages, need to adapt.

As we say goodbye to political attack ads (at least for a few months) and move on toward a new year, I believe that those of us who are lucky enough to work in the field of health care ought to continue to be guided by what is right for the patient. We can contribute on a daily basis by sharpening our skills, continuing to learn, and doing our best even if that takes a little more effort. In that manner, each of us has a chance to improve health care, one patient at a time. Those who are interested in contributing on a larger scale also should take advantage of opportunities to help shape policy decisions that will influence the way in which the practice of medicine evolves. In my view, plenty of improvements are still needed. And, as I have heard said, rather than worrying about the future, it is better to create it.

However you choose to celebrate them, happy holidays to all members of the JASE family—readers, authors, reviewers, and staff. As always, if you have comments or suggestions, I can be reached at jaseeditor@asecho.org .