By investigating variations in rates of surgery and total expenditures, TDI researchers have concluded that it is important to consider patients' preferences when determining whether or not to perform surgery, rather only than following predetermined guidelines, Fisher said.
Fisher illustrated this point with the example of bypass surgery, which reduces chest pain in most cases, but on average does not increase life expectancy. Between 10 and 20 percent of patients experience cognitive impairments as a result of the surgery, according to Fisher.
Rather than automatically operating on a patient who is experiencing chest pain, doctors should consider how much the patient values being able to remember his grandchildren's names, Fisher said. TDI is currently developing methods to help patients make better decisions about their health care, he said.
Fisher cited a large variation in total medical expenditures in the United States and explained that doctors are more likely to intervene in decision-making processes when patients' possible treatments are more costly.
"If you let the builder decide how big a house you want, you get a bigger house," he said.
In communities with higher spending, hospitals are more driven to make a profit and "health care is about money," Fisher said. In communities with lower spending, "hospitals know their books need to be balanced but also have some sense of shared responsibility," he said.
Fisher said these variations must be addressed in order to reform the health care system. New payment models should reward hospitals for providing better care at lower costs, and "accountable care organizations" should provide financial incentives for doctors to provide better care at lower costs, he said.
The medical community should formally define referral networks and hold those networks accountable for the care they provide, Fisher said. He also advocated for producing and analyzing better performance data to evaluate hospitals.
The U.S. health care system is a third-party payer system that consists of providers, such as physicians and hospitals; purchasers of care, such as employers; and insurers, such as for-profit private insurance and government-sponsored insurance, according to Anthony.
Anthony said that the presence of for-profit insurance companies is a unique aspect of the United States' "accidental system." Nearly every other country that has a universal health care system has established that system by law, she said.
Employer-sponsored insurance became prevalent during World War II, when the government implemented wage controls intended to prevent private employers from competing with the war effort, Anthony said. Benefits packages were not included in wage freezes, and employers attracted employees by offering them insurance benefits.
Before the war, 1.4 million people were enrolled in Blue Cross Blue Shield, the first insurance program which was initially nonprofit, according to Anthony. After the war, 60 million people were enrolled, she said. This created a new market for insurance and brought the rise of for-profit, private insurance. The private companies competed with Blue Cross Blue Shield by offering premiums to different people based on actuarial risk ratings caculated from their age and health, Anthony said.
In 1965, the Great Society programs introduced Medicare and Medicaid, Anthony said. Medicare, which is federally operated, is universal health insurance for people over 65.
"The fact that it is federally operated means it's exactly the same everywhere in the country," Anthony said.
Medicaid is insurance for the poor who meet other criteria, such as being under the age of 18, pregnant or a parent of a child less than six years old, Anthony said. Unlike Medicare, Medicaid is state-managed, so coverage and treatment varies from state to state.
Anthony compared the U.S. health care system to those in other countries, including Canada, Germany and the United Kingdom. Germany also has a third-party payer system, but unlike in the United States, private third-party funds are all non-profit. Canada has single payer health insurance and the United Kingdom's government provides health care directly to its citizens.
"We are one of the only countries in the industrialized world that does not have universal health coverage for our citizens," Anthony said.
Even so, the United States spends over 16 percent of its gross domestic product on health care, the highest spending by any nation, Anthony said.
"We are clearly an outlier," she said.
Despite high spending, America's health outcomes are not better than those in other countries, Anthony said.
"We are spending a lot more than everyone else, and yet the U.S. doesn't seem to be getting the most out of what we're spending our money on," Anthony said.
