By Todd Sloane, Senior Writer, Press Ganey Associates

The snowstorms that hit Washington earlier this month were an all-too-easy metaphor for the fate of health care reform. Just as the storms shut down the government and caused traffic gridlock, a rising tide of partisanship and the inability of the Democratic majority to achieve consensus in its ranks brought reform to a standstill. The loss of the Democrats’ Senate supermajority after a Senate election in Massachusetts came after much of the damage had already been done.

There are a number of scenarios under which reform may be resurrected in 2010. It may be a pared-down bill that attracts a few Republican votes in the Senate. There may be concessions to Republican points of view on malpractice reform and the taxation of health benefits. Or the Senate bill could be passed by a party-line vote in the House and its more egregious problems “cleaned up” in a complex process called budget reconciliation. Each option is fraught with difficulty.

But here is the real story, glaringly obvious but somehow forgotten in the furor over the details of reform legislation: Doing nothing is really not an option. Either we fix the problems of health care now, or the problems will soon force the kinds of choices nobody wants to make—drastic budget cuts, rationing of care and providers seeing their business slip away.

Just as the obituaries on the current House and Senate reform bills were being written, a key report was published by actuaries at the Centers for Medicare and Medicaid Services that went all but unnoticed. CMS estimated that health care spending grew to nearly $2.5 trillion in 2009 and now stands at 17.3% of the U.S. gross domestic product. It was the largest one-year jump in health care as a share of GDP since the government started keeping such records half a century ago.

The long-term outlook is far gloomier. Total health care spending as a share of GDP will reach 22% in 2020, according to the Congressional Budget Office.

As baby boomers morph into seniors, private health coverage cost increases may subside, but public spending will leap into the stratosphere, gobbling up more and more of the federal budget. The public share of health spending will amount to 52% by 2019, CMS predicts. By 2080, projections show that absent reform, rationing of care or some unforeseen new technologies, the government would be spending about as much on Medicare and Medicaid as a share of GDP as it spends on everything today.

Costs have a more immediate effect on average folks. Between 1999 and 2008, employer family health insurance premiums rose by 119%, while the median family income rose by less than 30%. Some 75 million adults—42% of people aged 19 to 64—were either uninsured or underinsured in 2007, up from 35% in 2003, according to the Commonwealth Fund. More than half of all personal bankruptcies are attributable to medical debt, even among insured citizens, the fund reports.

Already, we are seeing significant budget cuts in state health programs. Absent reform, that is the near-term future at the federal level, as attention will soon shift to soaring budget deficits. And what has been a steady erosion of employer-sponsored coverage may soon become an earthquake.

Is health care delivering value equal to the dollars being spent? The short answer, unfortunately, is not really.

To be sure, some quality indicators are rising, the direct result of public reporting on established metrics. For example, hospitals participating in the CMS-Premier hospital value-based purchasing demonstration project raised their overall quality by an average of 17.2% over four years based on their delivery of more than 30 nationally established and recognized care measures to patients in five clinical areas. Patient satisfaction scores spiked upward following the onset of public reporting in March 2008, the largest increase since Press Ganey began tracking such data more than two decades ago.

A number of highly integrated health systems such as Geisinger in Pennsylvania, Cleveland Clinic and Intermountain Healthcare in Utah are proving that you can improve quality and reduce costs at the same time. These providers are managing chronic conditions and using some evidence-based medicine and electronic health records. And they avoid unnecessary care.

Unfortunately, the rest of the picture is not so uplifting:

• Infant mortality in the United States is 6.8 per 1,000 births, more than twice as high as in Japan, Norway and Sweden and worse than in Poland and Hungary.
• Care quality is highly variable. For years, the Dartmouth Atlas project has tracked Medicare spending and quality of care, and the findings consistently show that higher spending does not equal better care. More recently, the Congressional Budget Office has followed up with similar research findings.
• Depending on the study, anywhere from 20% to 45% of all medical interventions fail to meet standards of care.
• Well over 100,000 people die needlessly each year as a result of preventable medical errors. According to the Centers for Disease Control and Prevention, 1.7 million Americans acquire infections while in the hospital and nearly 100,000 of them die from them.
• Despite widespread evidence of the value of surgical checklists, most providers have failed to incorporate this low-tech, low-cost intervention.
• One out of five Medicare beneficiaries discharged from the hospital is readmitted within 30 days, and half of non-surgical patients are readmitted to the hospital without having seen an outpatient doctor in follow-up, according to study published last year in the New England Journal of Medicine. All told, unplanned re-hospitalizations cost Medicare more than $17 billion annually, the study found.

The question remains whether this round of health care reform will join its predecessors as classic examples of the failure of political will, or whether our nation’s leaders will awaken to the need to act now to solve health care’s many problems of access, cost and quality before they leave our nation with dwindling choices, none of them good.

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