Saturday, September 13, 2008

Healthcare Reform: Where to Focus?

A recent article in the Washington Post by Robert J. Samuelson presents healthcare statistics, which he interprets as meaning that:
  • Controlling cost is the central problem
  • Healthcare for the poor in our country is actually quite good
  • We cannot afford to view healthcare as a "'right' that demands universal insurance" for every American.
Following are some quotes and my comments.
The central health-care problem is not improving coverage. It's controlling costs…a quarter of the U.S. economy [will be] devoted to health care. Would we be better off? Probably not. Countless studies have shown that many tests, surgeries and medical devices are either ineffective or unneeded. Greater health-care spending forfeits any superior moral claim on our wealth by slowly crowding out other national needs…There's also a massive and undesirable income transfer from the young to the old, accomplished through taxes and the cross-subsidies of private insurance, because the old are the biggest users of medical care.
The central problem isn't cost or insurance, per se, it's increasing healthcare value to the patient/consumer. That means improving the poor quality and inefficiency of care, so that we all receive only the care we need, delivered in timely and effective manner, without waste and over-treatment, and with a focus on integrating "well-care" (prevention and self-management) with sick-care. High value implies lower cost since poor care cost more and delivering only the minimal necessary care typically results in better outcomes!

More appropriate care, delivered competently and cost-effectively (e.g., through cost-conscious, patient-centered "medical homes"), is the ONLY WAY to control costs long-term.

And there's no way to increase healthcare value without dealing with the knowledge gap. That is, our healthcare community is drowning in oceans of information, yet no one knows the best ways to prevent health problems and treat them cost-effectively, especially when you take individual differences into account. Better health information technologies are needed, as is a collaborated effort to develop, disseminate, and deliver cost-effective evidence-based care.
It is widely assumed that health care, like most aspects of American life, shamefully shortchanges the poor. This is less true than it seems…On average, annual health spending per person -- from all private and government sources -- is equal for the poorest and the richest Americans. In 2003, it was $4,477 for the poorest fifth and $4,451 for the richest.
There are many ways to interpret these numbers; for example:
  • It quite likely that the wealthy are far more healthy than the poor, e.g., due to access to better food, cleaner and safer living and working environments, better education, greater availability of the most competent doctors, access to gyms for working out, etc. That would mean the poor should be receiving much more in the way of healthcare treatments than the rich because they lack those things, but they don't according to the numbers.
  • It's likely that the poor don't go to the doctor as often because they can't afford it, it's unavailable, they don't realize they should, or they have psychological blocks (e.g., hopelessness, denial, etc.). That means they become sicker before they go, which means spending on the poor should probably be greater than on the wealthy, but it's not.
  • Since the poor receive less primary care, they tend to go to the emergency room, which is much more expensive than an office visit, thereby skewing the numbers.
  • I don't know how many working poor are in those numbers, who don't have any insurance (or have inadequate insurance), and who don't qualify for government programs (Medicare & Medicaid).
  • What about the quality of care and preventive services? It's quite likely that the wealthy receive better and more timely care, which is not reflected in the numbers.
…Government already insures more than a quarter of the population, including many poor…10 percent of patients account for two-thirds of spending. Regardless of income, people get thrust onto a conveyor belt of costly care: long hospital stays, many tests, therapies and surgeries.
I would suspect that those with good health insurance or personal wealth receive more costly care. Nevertheless, I agree spending is excessive due to inefficiencies and ineffectiveness, as well as broken economic models.
…the uninsured receive less care and, by some studies, suffer abnormally high death rates. But other studies suggest only minor disadvantages for the uninsured. One study compared the insured and uninsured after the onset of a chronic illness…20.4 percent of the insured and 20.9 percent of the uninsured judged themselves "better"; 32.2 percent of the insured and 35.2 percent of the uninsured rated themselves "worse." The rest saw no change.
Relying on patients to judge the value of care received—considering all the complexities, options, and nuances—is simply ludicrous. What we need is valid scientific outcomes research and clinical guidelines before accepting such claims!
The trouble with casting medical care as a "right" is that this ignores how open-ended the "right" should be and how fulfilling it might compromise other "rights" and needs. What makes people healthy or unhealthy are personal habits, good or bad (diet, exercise, alcohol and drug use); genetic makeup, lucky or unlucky; and age. Health care, no matter how lavishly provided, can only partly compensate for these individual differences.
So, what's being implied here? If you have bad genes; if you live in poverty—in a crime-ridden, drug-infested—and can't afford healthy food, a safe place to exercise, or become drug addicted; if you're old and have chronic conditions … then what? You don't deserve good healthcare? All prisoners do! See this link:
There is a basic dilemma that most Americans refuse to acknowledge. What we all want for ourselves and our families -- access to unlimited care paid for by someone else -- may be ruinous for us as a society. The crying need now is not to insure all the uninsured. This would be expensive…and would provide modest health gains at best. Two- fifths of the uninsured are young…and relatively healthy.
I don't think many people view universal healthcare as being unlimited care for which others pay. It should not be about getting something for nothing. Instead, it should be about assuring that everyone gets the quality care they need at an affordable price.

Private insurance companies don't focus on improving care quality; they're out to make profit for their shareholders by (a) minimizing payments to providers, pharmacies, and suppliers, and (b) by reducing the amount of care rendered in whatever way they can. They'd prefer to drop all members with serious (i.e., expensive to treat) illnesses because they are driven by the profit motive.

Concerning the young and healthy uninsured, it would be inexpensive to cover them via a government run single-payer system (e.g., HR 676 – "Medicare for All") since they would not require much care.
The McCain and Obama health-care proposals, either impractical or undesirable, largely ignore the existing challenge of Medicare. By some studies, 30 percent of its spending may go to unneeded services. Medicare is so large that by altering how it operates, government can reshape the entire health-care system. This would require changes to encourage more electronic record-keeping, better case management, fewer dubious tests and procedures, and a fairer sharing of costs between the young and the old.
While I interpret the numbers Mr. Samuelson presented in a different way, we actually agree, in part, about what has to be done. I offer a blueprint for comprehensive healthcare reform—the Wellness Plus Solution—available on our Wellness Wiki at
From a philosophical viewpoint, radical reform of our healthcare system in the ways I describes requires that we, the American people, take a good hard look in the mirror to examine our culture's priorities and values. Why? Well, consider the following Commonwealth Fund report:
The U.S. health system is the most expensive in the world, but comparative analyses consistently show the United States underperforms relative to other countries on most dimensions of performance...[It] fails to achieve better health outcomes than the other countries [and] is last on dimensions of access, patient safety, efficiency, and equity.
In other words, our healthcare system is broken; healthcare in America is gravely ill and we should be looking at ourselves--our cultural values, priorities, and economic/political/business models--to understand why things have gotten so bad!

To cure our healthcare system, and to begin fixing many of our other domestic and foreign problems, the American people ought to be willing and eager to look far beyond ourselves and family and focus on giving much to others in a way that makes our country and world a better world for all.

This sentiment was reflected in link above (about medical homes), which points out that the teams of doctors who hit "medical home runs" for the patients have an exceptionally compassionate nature that drives them to go that "extra mile" for their patients. I quote:
While the specific clinical innovations to prevent unplanned hospitalizations vary somewhat across the four practices, they converge in two ways. At least one primary care team member demonstrates saliently to each chronically ill patient that they care deeply and personally about them and protection of their health. This includes mobilizing family members, social services, and other resources required for successful patient self-management. In addition, as soon as a chronically ill patient senses impending health crisis, a member of the health care team familiar with their history is readily reachable and prepared "to go the extra mile" [italics added] to prevent hospitalization, including actively coordinating with ER physicians and hospitalists in exploring alternatives to hospitalization.
An attitude of "protection of your health matters to me personally" and "I'm prepared to invest special effort to spare you a health crisis" was memorably captured in Atul Gawande's 2004 New Yorker magazine portrait of Dr. Warren Warwick in The Bell Curve. It is the exception rather than the rule in American health care delivery. Because it reflects a personality characteristic of clinical team members rather than a readily teachable behavior or a structural enhancement of a primary care practice, assuring this expression of patient-centeredness requires new selection criteria for medical home team members serving the chronically ill. Given the prolonged time frames required to correct failure to integrate robust patient-centeredness into medical student selection and into graduate and postgraduate physician training, near-term improvement implies selecting for this attitude among nonphysician team members. Other organizations, such as the retail giant Nordstrom, have shown that selecting employees for high natural service orientation is feasible."

This observation is consistent with last week's post: We Ought To be willingness and eagerness to give (sacrifice) much in ways that makes this a better world for all. Unfortunately, this runs counter to the ideals of the "Me Generation" and the American consumerist way of life, which are destroying our society by rewarding and encouraging short-term self-centered hedonism (my pleasure now!), ego-based materialism (e.g., judging human worth in terms of one's bank account), and Machiavelli's "the end justifies the means" philosophy to business ("buyer beware!").

The good news is that compassionate people with awareness and understanding are bucking this tendency! THEY are the ones who Ought To be gaining financially by, for example, paying primary care physicians for taking the time to know their patients deeply and for going the extra mile to prevent illness and deliver high-value care, as well as investing in more and better clinical outcomes research.

While this is the only sane way to proceed, there are many tough challenges to enabling and rewarding healthcare providers who go the extra mile and offer high-value services. See, for example, a recent post by Josh Siedman titled Perils of Pay for Performance (P4P) at this link, which discusses the difficulty establishing fair and valid performance measures, and the consequential perverse incentives of today's P4P programs. One commentor added that we don't have the detailed information needed to understand the unique needs of each patient and thus cannot know if an individual is getting the right personalized care, even if it's right for other patients with the same diagnosis. Also see this link to our Wellness Wiki.

Sunday, September 07, 2008

Aligning the Ought-To’s with the Can-Do’s

If our country is serious about healthcare reform, it behooves us to ask:
  • What OUGHT TO BE done to guarantee everyone has access to affordable, high-quality healthcare?
  • What CAN BE done, realistically, to make that happen?
Wherever there is a misalignment between these Ought To's and the Can Be's (i.e., when we can't do what we ought to be doing), it is wise to ask: WHAT'S PREVENTING US and HOW CAN WE overcome those obstacles?

Unfortunately, when it comes to healthcare, other domestic issues, and even foreign policy, answering these questions isn't easy because it requires that we stop deceiving ourselves, and start critically and objectively evaluating the values, priorities, goals, and underlying beliefs of our culture.
For example, let's say we agree that we ought to have access to high-quality healthcare we all can afford. And let's assume that high quality, highly efficiency universal healthcare isn't possible because of government budget deficiencies. Since this scenario would mean a continuation of our healthcare system's poor quality, high cost, and access inequity, we should be asking questions such as:
  • Why isn't the necessary money available?
  • Is it being spent elsewhere?
  • Are there policies that promote waste and abuse?
  • Would there enough tax dollars if the government's current funds were to be redistributed?
  • Must taxes be increased to raise additional money?
  • Who would be for it and who against redistribution and tax increases?
  • Why would certain people be opposed if it would help so many?
  • How are the winners and losers in the current system, and why?
  • What does it say about the priorities/values of those opposed, and how do they compare with those in favor?
  • What is it about our culture and economic system that promotes belief in such priorities/values?
  • Is the American capitalist model broken; is it pathologically mutated?
  • Would it be wise to make "compassionate capitalism" the norm?
  • How would we deal with the negative aspects of human nature, such as ego, greed, fear, and denial?
  • How can people's minds be enlightened to balance between selflessness and selfishness?
  • Is part of the problem a broken healthcare system driven by a perverse economic model, pervasive ignorance, resistance to (fear of) change, etc.?
While the knowledge we would gain from answering these questions would direct us in developing solutions to the healthcare crisis, many (most?) people would react to all this by saying: "Be realistic! You can't change these things; it's just too difficult. We can't do what we ought to do because there are too many obstacles, so don't waste your time trying!

I disagree! We simply cannot afford such a defeatist view. We can gain a great deal by "looking at ourselves in the mirror." We'd be wise to ask the tough questions and not shy away from the radical transformation of our healthcare system and national priorities. It would be wise to do this with other domestic and international problems, as well.

Consider, for example, the recent interview of Andrew J. Bacevich on the Bill Moyer's Journal. Mr. Bacevich is an author, professor of international relations and history at Boston University, and retired Army colonel. He focused on the relationship between failed U.S. foreign policies and American consumerism. He concluded that our country's biggest problems are internal and the solution requires looking at ourselves in the mirror and asking the tough questions. Here are some quotes:
The pursuit of freedom, as defined in an age of consumerism, has induced a condition of dependence on imported goods, on imported oil, and on credit. The chief desire of the American people…is that nothing should disrupt their access to these goods, that oil, and that credit. The chief aim of the U.S. government is to satisfy that desire…what we want, by and large is, we want this continuing flow of very cheap consumer goods…And we want to be able to do these things without having to think about whether or not the book's balanced at the end of the month, or the end of the fiscal year. And therefore, we want this unending line of credit…[We should] look ourselves in the mirror, to see the direction in which we are headed. And from my point of view, it's a direction towards ever greater debt and dependency.
…[There is a] yawning disparity between what Americans expect, and what they're willing to pay… we don't live within our means. I mean, the nation doesn't, and increasingly, individual Americans don't. Our saving - the individual savings rate in this country is below zero. The personal debt, national debt, however you want to measure it, as individuals and as a government, and as a nation we assume an endless line of credit…[This assumption] is going to be shown to be false. And when that day occurs it's going to be a black day, indeed…[We've moved from] 'an empire of production'…[to] 'an empire of consumption.'… This continuing tendency to borrow and to assume that the bills are never going to come due. I testified before a House committee six weeks ago now, on the future of U.S grand strategy.
…How are we gonna pay the bills? How are we gonna pay for the commitment of entitlements that is going to increase year by year for the next couple of decades, especially as baby boomers retire?" Nobody has answers to those questions…[we] have opted for a false model of freedom. A freedom of materialism, a freedom of self-indulgence, a freedom of collective recklessness
…The big problem, it seems to me, with the current crisis in American foreign policy, is that unless we do change our ways, the likelihood that our children, our grandchildren, the next generation is going to enjoy the opportunities that we've had, is very slight, because we're squandering our power. We are squandering our wealth. In many respects, to the extent that we persist in our imperial delusions, we're also going to squander our freedom because imperial policies, which end up enhancing the authority of the imperial president, also end up providing imperial presidents with an opportunity to compromise freedom even here at home. And we've seen that since 9/11.
…We have created an imperial presidency. The congress no longer is able to articulate a vision of what is the common good. The Congress exists primarily to ensure the reelection of members of Congress…[Our political] system is broken.
…One of the great lies about American politics is that Democrats genuinely subscribe to a set of core convictions that make Democrats different from Republicans. And the same thing, of course, applies to the other party. It's not true. I happen to define myself as a conservative… Parsing every word, every phrase, that either Senator Obama or Senator McCain utters, as if what they say is going to reveal some profound and important change that was going to come about if they happened to be elected. It's not going to happen… because the elements of continuity outweigh the elements of change. And it's not going to happen because, ultimately, we the American people, refuse to look in that mirror. And to see the extent to which the problems that we face really lie within.
…We refuse to live within our means. We continue to think that the problems that beset the country are out there beyond our borders. And that if we deploy sufficient amount of American power we can fix those problems, and therefore things back here will continue as they have for decades.
…How did we come to be a nation in which we really thought that we could transform the greater Middle East with our army? What have been the costs that have been imposed on this country? Hundreds of billions of dollars. Some projections, two to three trillion dollars. Where is that money coming from? How else could it have been spent? For what? Who bears the burden?...It was a fundamental mistake...And that might be the moment when we look ourselves in the mirror. And we see what we have become. And perhaps undertake an effort to make those changes in the American way of life that will enable us to preserve for future generations that which we value most about the American way of life.
So, the U.S. is an empire of consumption relying on credit and military might to feed our materialistic addiction, as we indulge ourselves recklessly and squander our wealth and power with little regard for the common good. Instead of examining ourselves in the mirror and asking the tough questions about what we've become, we foolishly focus beyond our borders to fix the problems that are actually caused by our internal attitudes and systems.
This brings up a few final questions:
  • If we were a wise and virtuous country, what would we say we OUGHT to be doing about healthcare and other domestic and foreign policies?
  • If we were a brave and compassionate country with the will to make fundamental changes for the common good, what would we say we CAN do after peering bravely into the mirror and asking the tough questions about ourselves, our assumptions, and our way of life?
  • If we were such a country, would we then be able realigning our misaligned Ought-To's and Can-Be's by changing values, priorities, goals, and underlying beliefs of our culture?
  • Or are we so deeply enmeshed in our maladaptive ways, and so controlled by our broken/pathological systems and policies, that all we can do is watch hopelessly and helplessly as we "go down the drain" and hand over to future generations a weak and pathetic country in which the American Dream has become the American Nightmare?
The following is an update added on 9/9/08:

Conversations I've been having subsequent to the original post--with with Phil Wray and John Milligan--have offered several useful ideas.

One is to think of aligning the Ought-To’s with the Can-Do’s as a dynamic process, as opposed to a static process, especially when there’s a potential “show stopper” obstacle (i.e., there is no way to achieve our Ought-To goals). This means that when we are prevented from doing everything we Ought-To be doing, the odds are that we can still do some of the things we Ought-To do. Those actions, and the knowledge we gain the process, can, in turn, “open new doors” that enable us to achieve more of the Ought-To’s by, for example, trying different tactics than originally considered, and/or by refining our definition of the original Ought-To’s within reason. In other words, by evolving our vision (goals & objectives) and methods (strategies and tactics) in light of the current realities, but without abandoning our initial intent, we can move ever closer to achieving our mission even when confronted with powerful obstacles.

Another idea is to think of what we should be doing in two levels: Ought-To’s and the Must-Be’s. That is, it is important to clearly rank our goals and objectives in terms of their priorities (primary, secondary, tertiary, etc.). We would have to debate to decide what are our moderate priority Ought-To’s (which need not be essential) and our high priority Must-Do’s (which are absolutely essential). In this way, failure to do what we Ought-To is regarded as undesirable, while failure to do what we MUST is considered totally unacceptable. In either case, the dynamic process above is a way to foster progress even in the face of possible show-stoppers.

So, when faced with major obstacles that prevent us from doing all we should be doing, it is wise to (a) evolve our vision and methods in order to make forward progress and (b) get our priorities straight, so we know what to focus on first. Doing these things, it seems to me, would best be accomplished via a “bottom-up” process in which we look straight “into the mirror” and examine our cultural value and beliefs, while having serious and in-depth debate about who we are as a people, who we want to become, and how to make that societal transformation. This process would work for all the big issues our country now faces, which includes not only healthcare, but entitlements, grand foreign policy strategy, transparency & accountability in government, etc.

Monday, September 01, 2008

Care Quality and Cost: Why Poor Quality can Cost More

Two recent posts by Niko Karvounis (see this link and this link) discuss critical issues concerning healthcare quality (care effectiveness/results) as it relates to healthcare costs. I, too, have written extensively (e.g., see this link, this link, and this link) about the challenge of measuring and improving quality and controlling costs, and will now share some thoughts in the context of her interesting posts.

Her first post is about the history of managed care. It discusses the managed care model's original vision, early stages of growth, the trouble it had managing quality, the shift from non-profit to organizations driven by the profit-motive, the focus on managing costs alone, the fallout, and its decline. The second post, which focuses on the challenge of healthcare quality assessment and improvement, overlaps the first in that failure to deal effectively with quality-related issues was a key factor in managed care's demise. It goes on to discuss how low care quality is contributing significantly to the high cost of American healthcare and poor health of its citizens, but is not getting the attention it deserves for some very interesting reasons, including patients' inability to determine what constitutes high-quality care.

These posts reinforce what I've been saying for the past two decades: Unless we make healthcare quality a priority, cost will continue to spiral out of control and the U.S. continues to deliver inferior care compared to many other industrialized countries. After all, low quality means excessive errors and omissions, as well as less effective preventive care and treatment of existing conditions. According to the Business Dictionary, the cost of poor quality is the cost of 'not doing it right the first time,'" which translates to fix then fix it again when it breaks. In healthcare, this waste, redundancy, and ineffectiveness means increased cost to the patient (and society), not to mention increased risk of harm from multiple unnecessary procedures, adverse affects of medication changes, infections from longer hospital stays, progression of diseases caused by delay in receiving the right care, and so on.
High quality, on the other hand, means keeping people healthy through good well-care (including prevention and effective self-management of chronic conditions), as well as the timely and efficient treatment of health problems with effective sick-care leading to more rapid recovery and lass chance of relapse.

Improving care quality starts with doing an effective job measuring quality, as well as promoting decisions and actions that continually improve quality.
There are several ways to measure the quality of care.
  • Comparative-effectiveness research, which focuses on comparing the effectiveness of different preventive and treatment approaches, does not take cost into consideration.
  • Taking both cost and quality into account, means focusing on care value, which is what cost-effectiveness research does. One way to deploy this is the strategy is to do what Great Britain's National Institute of Health (NIH) does through use of the Quality Adjusted Life Years (QALY) method. The QALY method is used to determine if a healthcare treatment is worth the cost. Another method is to determine the treatment procedures and medications that produce similar outcomes, and then select the ones that cost the least, but generate results as good as the more expensive ones.
Once we evidence about the quality and cost of competing methods, we've got to determine how to analyze, package, and disseminate such data as useful and understandable information that guides decisions and actions in ways that control costs and lead to better outcomes. For more, see this link about improving care quality with evidence-based practice guidelines and this link about using evidence-based decision systems, both on our Wellness Wiki.