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New York College of Osteopathic Medicine, of New York Institute of Technology, Old Westbury, Stony Brook (NY) University School of Medicine, Winthrop Pediatrics Associates, Mineola, NY

To the Editor: As a resident of the New York City–metropolitan area, I occasionally find myself in situations in which I inadvertently meet power brokers.

At a friend's retirement party last year, I happened to have a conversation with an author and filmmaker who was working with some Democratic Party politicians on "getting their word out." At that particular time, the word to get out was that the newly elected governor of New York State, Eliot Spitzer, wanted to make major cuts in state funding to hospitals.

As I listened to the comments of my new acquaintance, I realized that he had a rather superficial grasp of the complex intricacies of public healthcare. At one point, he turned to me and asked, "So what would you do to fix our broken healthcare system?" I replied that this was a rather deep question, which required more reflection on my part than could be accommodated at a cocktail party.

The following ideas are based on a letter that I sent him a week after our conversation. That letter contained my personal reflections on how government might address the current healthcare morass. Although I wrote these ideas with New York State in mind, they could also be applicable to the United States as a whole.

Before instituting revisions to our healthcare system, it is important that the government have a firm foundation of appropriate underlying assumptions about public healthcare. These assumptions should include the following four points:

• All people deserve access to primary preventive care in a medical home model (ie, direct access to one physician who is responsible for a patient's care and who practices in a system organized to support better healthcare).¹ All people also deserve access to catastrophic healthcare, including mental health parity.²
  
• Public money spent on disease and injury prevention provides a better return on investment than does money spent on disease and injury management or "high-tech" interventions used at the end of a patient's life.³
  
• The difficult decisions regarding distribution of limited healthcare dollars must be confronted. Resources expended on end-of-life care must be thoughtfully balanced with resources needed for preventive and public health measures.
  
• Medical interventions are only a small part of the total health experience for an individual or population. The influence of the combination of an individual's genetic makeup, environmental factors, and health-related behaviors far surpasses that of medical care in determining one's health experience.⁴
  

With these underlying assumptions in mind, I offer the following 13 guidelines for improving our healthcare system:

1. Simplify and decrease the bureaucracy that is associated with providing medical care, thereby enabling physicians to spend more time serving patients. Physician time currently spent filling out insurance forms and making referrals would be better spent caring for patients.
   
2. Recognize that highly structured, impersonal industrial and corporate models of organization (ie, the "medical-industrial complex") do not work well in the human-service activities of healthcare.
   
3. Develop healthcare policies that value and strengthen physician-patient relationships—rather than undermine them.
   
4. Develop creative methods for measuring the quality of healthcare delivery. When these measures are shown to be meaningful, implement incentive structures for physicians, such as pay based on proven performance.
   
5. Differentiate and pay physicians based on their levels of professional training—not according to their acumen in the use of Current Procedural Terminology codes.
   
6. Develop mechanisms to create incentives for physicians to practice in underserved areas. Consider implementing compulsory postgraduate service in such areas.
   
7. Limit market-based reimbursement to insurance company administrators and shareholders. Moreover, explore ways to completely remove for-profit companies from the healthcare business.
   
8. Create incentives for patients to learn to adopt good health practices regarding the leading health indicators (eg, physical activity, overweight and obesity, tobacco use, substance abuse, immunization).⁵
   
9. Outlaw direct-to-consumer advertising of prescription pharmaceutical products. In addition, consider regulating advertising by insurance companies.
   
10. After a vaccine is approved by the US Food and Drug Administration and endorsed by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, ensure that physicians are reimbursed for the entire cost of the product—plus 20% overhead.
    
11. Ensure that all healthcare providers who work diligently, ethically, and faithfully are reimbursed in a manner consistent with their educational investment and role in society—at least compared with the reimbursement of teachers and union plumbers.
    
12. After closely examining workforce issues and public needs, create mechanisms to direct physician training into the areas of greatest need.
    
13. Absolutely include physicians who have current clinical experience, especially in pediatrics and geriatrics, into the ongoing conversation regarding improvements in the healthcare system.
    

I hope that these thoughts are of use to my acquaintance from the cocktail party, as well as to the readers of JAOA—The Journal of the American Osteopathic Association, and the leaders of our nation's political establishment as they ponder our healthcare conundrum.

I invite readers' reactions.

Footnotes
Editor's Note: Dr Marino serves as a member of the Editorial Advisory Board for JAOA—The Journal of the American Osteopathic Association.

References
1. Doherty RB. Can the `medical home' model solve health care's woes? ACP Observer. November 2005. Available at: http://www.acponline.org/journals/news/nov05/washington.htm. Accessed December 12, 2007.

2. Sperling A. Details and background on the Mental Health Parity Act of 2007 [National Alliance on Mental Health Web site]. February 13, 2007. Available at: http://www.nami.org/Content/ContentGroups/ENews/20073/February10/Details_and_Background_on_the _Mental_Health_Parity_Act_of_2007.htm. Accessed December 12, 2007.

3. Swenarski L. Return on investment in disease prevention outlined in CDC report [press release]. Atlanta, Ga: Centers for Disease Control and Prevention; March 17, 1999. Available at: http://www.cdc.gov/od/oc/Media/pressrel/r990317.htm. Accessed December 12, 2007.

4. US National Institutes of Health. Genes, Behavior, the Environment, and Health. Bethesda, Md: US National Institutes of Health; January 17, 2007. Available at: http://www.nih.gov/about/researchresultsforthepublic/GenesandBehavior.pdf. Accessed December 12, 2007.

5. Leading health indicators; 2000. Healthy People 2010 Web site. Available at: http://www.healthypeople.gov/Document/HTML/uih/uih_4.htm. Accessed December 12, 2007.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Google Scholar Articles by Marino, R. V. PubMed Articles by Marino, R. V.