Tuesday, July 28, 2009

Low-Cost, High-Quality Care In America: A Reply

An interesting article was just posted to the Health Affairs blog titled Low-Cost, High-Quality Care In America, which can be summarized by this quote:

As President Barack Obama and his allies press their case for health care reform, the president exhorts that his vision will slow the growth of medical expenditures, expand coverage to millions, and improve the quality of care. In the trenches, where millions of medical interventions occur daily, physicians and hospital managers who do the heavy lifting describe a far more grueling path "to bending the cost curve," one that takes dedicated years to navigate and often loses money because the inflationary fee-for-service payment system rewards providers for rendering more, not less, health care. At a conference last week, that was the clear message of doctors and managers who have tried to bend the cost curve while improving the quality of care in health care enterprises in communities across the United States.

My comments follow …

The perverse incentives of the fee-for-service model are certainly a problem area that needs to be addressed. But it seems to me that it is not the underlying cause of our healthcare crisis. The real problem, I contend, that the healthcare industry has failed to focus enough on answering this question: How can providers and patients make valid, reliable evidence-based decisions about the most cost-effective ways to prevent and treat each person's physical and mental health problems? Lacking answers to this question is a critical knowledge gap that cannot be filled by being overly focused on economic strategies.

Filling the knowledge gap by answering the cost-effectiveness question is a daunting challenge. It requires persistent widespread (country-wide, world-wide) collaboration among clinicians in all disciplines, researchers, patients, and informal caregivers. Such collaborative effort includes collecting, sharing, and analyzing comprehensive biopsychosocial (biomedical, psychological, social, and mind-body) health data and translating them into evolving personalized practice guidelines that are vastly superior to the generic guidelines currently in use. And it means developing next generation health IT for healthcare professionals and consumers that (a) implement patient-centered cognitive support using evolving computational models to increase understanding of people's risks, strengths, needs, preferences, and care options; (b) guide decisions for selecting the most cost-effective options for each particular person; (c) provide training, instruction, and other relevant educational materials tailored to each person's level of knowledge; and (d) continually track the clinical and financial results of treatments and self-care using outcome measures (not just process measures) and compile the results in research data warehouses.

We MUST FAIL UNLESS we balance (a) economic strategies that focus primarily on cost-control with (b) strategies aimed at filling the knowledge gap. As the article discussed, likely consequences of this failure include reduced care quality and productivity, as well as provider resistance. The only rational solution, therefore, is to focus on replacing ignorance with profound evidence-based knowledge and on providing health IT tools that expand the limits of the human mind, so we can answer the question: What are the most cost-effective (i.e., high-value) ways to prevent and treat a person's health problems? Once we can answer that question with confidence, we can then incentivize providers for following guidelines that prove to bring high-value to the consumer. This is an ABSOLUTELY ESSENTIAL part of solving our healthcare crisis, and it expands President Obama's healthcare reform strategy from not doing what doesn't work ... to ... doing what works AND is most cost-effective.

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