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Sept. 25, 2007

Prescriptions for U.S. Health Care

deansGiven the opportunity to prescribe fixes for America’s ‘crazy quilt’ health care system at a Bloomberg School forum, the three deans of Johns Hopkins’ health-related schools recommended more training in geriatric care, expanding public health insurance programs and shifting more autonomy to nurses and other health care providers.

Michael J. Klag, Martha N. Hill and Edward D. Miller, deans of the Schools of public health, nursing and medicine, respectively, shared their views at a September 11 Bloomberg Leadership Series discussion on how to improve health care in the United States, which outspends every other country yet posts consistently poor results when it comes to quality of care, access to care, efficiencies of the health care system and health outcomes.

“We don’t have a system, we have a crazy quilt,” Klag, MD, MPH ’87, Dean of the Bloomberg School, said of U.S. health care during his portion of the discussion, which focused on meeting the health care needs of 47 million uninsured Americans.

Klag, who chose a story to illustrate one facet of the problem, recalled one night a few years ago as he was driving home through East Baltimore. Another driver hit him from behind, crushing the rear of his car. The driver at fault emerged  from his old, battered vehicle, and promptly informed Klag that he had auto insurance.

“He had auto insurance because as a society we have decided that if you drive a car you need to have auto insurance,” Klag said. “We talk about health insurance and that’s not the case.”

“Most people in this room think it’s a right to have access to good quality health care,” he said, “but others think it’s a privilege and we haven’t resolved that as a society.”

Ideally, Klag said, a publicly financed single-payer health insurance model would be the most efficient way to provide universal coverage in the United States, quickly adding that  it’s not a politically viable solution. As an alternative, he supports expanding eligibility to Medicaid and Medicare to increase health care access for more families in the “working poor” category and to cover “pockets of people with specified conditions as we currently do for end-stage renal disease.”

Hill, PhD, RN, Dean of the School of Nursing, spoke about the role of evidence-based medicine and nursing in modifying the U.S. health care system.

She said that any assessment of an evidence-based approach requires an appraisal of people’s priorities with respect to health care. “If I could collect enough evidence to change the health care system, I would look at what really matters to people,” Hill said.   “And one thing that really matters is cost.”

The fact that some individuals who are able to afford health insurance choose not to buy it, as well as the growing popularity of “medical tourism” to buy cheaper health care abroad, suggest a disconnect in the system. “This is telling us we don’t have it quite right here in terms of aligning with the willingness or ability of the American people to invest in their own health care,” Hill said.

She recommended following through on a nursing retention study conducted at Johns Hopkins Hospital approximately 20 years ago. It found that when nurses were given the opportunity to design their own models of practice to deliver patient care, with control over budgets and schedules, outcomes improved in several areas.

The study, Hill said, “demonstrated that the nurses actually saved money, cut down on absenteeism and turnover, and some of the parameters for patient care improved.”

As the health care system braces for a doubling of the U.S. population aged 65 and older by 2030, the demand for technologically capable nurses will intensify—as case managers and caregivers, in home settings and across all health care facilities.

“What we see is an increasing need for skilled and competent nurses who can nurse the technology as well as the patient and family,” Hill said.

Miller, MD, Dean of the School of Medicine and CEO of Johns Hopkins Medicine, recounted a personal story to convey a sense of the complexities of caring for the elderly.

His father-in-law, who lived in a retirement community in Hilton Head, S.C., had been admitted to a nursing facility because of deteriorating health following a hip replacement. His condition worsened and Miller eventually learned that he was over-medicated.

After four weeks, Miller said that his father-in-law “was in a coma-like state and had lost 40 pounds. He was going to die.” Miller and his wife brought him to Baltimore and made arrangements for him to live in a local retirement community where he made a swift and dramatic recovery.

Miller said his father-in-law’s experience clearly illustrates the need for a greater understanding of the specialized health care needs of seniors.

“They have a whole different set of problems,” he said. “Frailty is a big issue. How do you keep them active mentally? What do you do about drugs and how they react?”

“If I were going to focus on one thing, I’d train a corps of people to start to figure out how to take care of the elderly,” he said. “Because that’s the biggest burden on health care costs we have in this country right now.”

Now in its second year, the Bloomberg Leadership Series is a slate of schoolwide talks from leaders in diverse fields. The aim of the program is to foster leadership development across the entire student body.–Jackie Powder