Saturday, August 29, 2009

A Principled and Pragmatic Approach to Healthcare Reform

On 8/13/09, Paul Begala's Washington Post article titled Progress Over Perfection made the case that our country needs the "right blend of principle and pragmatism" and we ought not to prefer "glorious defeat to an incremental victory." The primary issue, imo, is how to take an approach I discussed in the past, i.e., (1) define what we have to (ought to, should, must) do in order for our healthcare reform strategy be judged as principled and, at the same time, (2) define what we can do in order for it to be judged as pragmatic. Following is how I see it.

To be principled, we ought to ensure that our strategy be guided by empathy ("putting yourself in others' shoes" to understand what they are going through) and compassion (caring what others are going through and doing what we reasonably can do to help those in distress). Failure to do so makes the strategy inhumane, fosters civil unrest, and causes cognitive dissonance that is often resolved by heartless, selfish, ignorant rationalizations (e.g., blaming the victim or believing that you are somehow more worthy than those less fortunate). As I have written in my blog, many humans are short on empathy and compassion, and our pathologically mutated form of capitalism breeds this disgusting tendency. When it comes to healthcare reform, a humanely principled strategy, therefore, means giving all Americans ready access to affordable top quality (high value, cost effective) care. Hence, we must have some sort of universal coverage and the means to continually improve the quality and lower the cost of treating persons with biomedical and psychological problems, as well as enabling people to take good care of themselves to prevent and effectively manage those problems.

To be pragmatic, we ought to find fair and effective ways to pay for the tactics aimed at realizing the two main objectives of a principled strategy: (1) providing universal coverage and (2) continually improving care effectiveness and efficiency leading to ever-better and more affordable approaches to care. The methods for financing these tactics must be sustainable over the long term, and there must be ample reliable oversight and transparency to assure no one is gaming the system for their own unprincipled selfish gains at other expense. These requirements are not easy to satisfy, especially since our society tends to focus on short-sighted, quick-fix solutions that are short on empathy and compassion for the public good, and also fail to promote self discipline and personal responsibility & accountability. This points to the need for substantial governmental reform aimed at minimizing lobbyists' influence, quid pro quo favors to party benefactors, operational inefficiencies, etc.

Some of the major healthcare reform tactics being discussed include the public option vs. co-ops, tort reform, and price gouging by pharmaceutical companies. These tactics are all important considerations for a healthcare reform strategy, but they do not explicitly address how they will help achieve the two main objectives of a principled strategy, i.e., prevent healthcare costs from continuously rising and promote ever-greater care quality. That is, these tactics fail to explain how they will to bring ever-increasing value (cost-effectiveness) to the consumer. As a result, it doesn't matter if the government (public option) or private insurers (co-ops) provides insurance coverage, malpractice insurance expenditures drops, and costs medication prices drop because expenditures will continue to climb and quality will not show much improvement unless we can answer these two unaddressed questions:

  1. What is the most cost-effective ways to prevent, diagnose, treat and manage health problems for each person?
  2. How can healthcare providers and consumers be enabled and encouraged to make decisions and take actions that implement those cost-effective ways of avoiding, understanding, and treating/managing health problems?

Answering these two questions requires that we focus extensively on (a) implementing coordinated international scientific research, (b) disseminating ever-evolving evidence-based guidelines emerging from that research, and (c) incentivizing everyone to act accordingly. Any strategy that fails to include the methods and means for achieving these tactics cannot possibly answer to the two questions above, which means it is an inferior unsustainable solution that is neither principled nor pragmatic because:

  • Consumers will never know how to take care of themselves in the most effective and least costly manner. This ignorance leaves all sorts of opportunities for the promulgation of ineffective and overly expensive self-management approaches.
  • Healthcare clinicians/providers will never know how to take care of their patients effectively for the least cost. This leaves all sorts of opportunities for ineffective and overly expensive testing/diagnostic and treatment procedures to promulgate due to widespread ignorance. The result is continuing escalation of costs due to over-treatment and over-testing; prescriptions for new and costly procedures, medications and medical devices that offer insignificant gains compared lower cost alternatives; gaming the system through fraudulent and unethical practices aimed at personal financial gains; etc.
  • The best way to curb malpractice expenditures has less to do with tort reform and more to do with (a) giving everyone the information they need to know the most cost-effective way to diagnose and treat each particular patient and (b) promoting clinicians' competence and willingness to deliver such cost effective care.
  • The best way to curb prices charged by pharmaceutical companies and medical device manufacturers, and for consumers not to overpay, is for widespread cost-effectiveness and comparative-effectiveness research to be done, including post-market surveillance.

As far as the public option versus co-ops is concerned, I suggest that if co-ops can provide high-value care via affordable coverage for everyone in a way that cost the taxpayer less than a comparable public option plan, then we don't need the public option. I reject arguments by the insurance industry that they are better able to manage universal coverage because they have more experience and patient data by which to make decisions since the data they have are "claims/administrative" data, which is grossly inadequate for answering the two questions above; what's needed are comprehensive clinical outcomes data (see this link). Nevertheless, the problem is that it is impossible to validly determine if co-ops are superior unless the public plan is also implemented, so we can compare the two.

Here's an idea: Since it will take some time to establish and initiate a public plan, how about starting by instituting a nation-wide co-op system immediately and having it run for a year while the public plan is being created. The cost, quality, and access data depicting the co-op's performance would be analyzed at the end of the year, the results would be made transparent o the public, and this information would serve as a baseline by which to rate the performance of the public plan and subsequent versions of the co-op system. I suppose we can start by estimating the cost of the public option by extrapolating expansion of the current Medicare system, and then compare it to the co-op option supported by government subsidies. Anyway, both options must include the price of implementing the necessary cost-effectiveness research and incentives, as well as providing a justifiable game plan about how it will all be done in a sustainable way. In addition, there must be transparency of cost and quality for both options, so consumers can make an informed decision. No matter the method used, there must be a valid way to clearly compare the two options.

Lots of details to be worked out, of which cost of coverage is only one factor. Other factors required for continuous increase in the value (cost-effectiveness) of care to the consumer--in addition to the need for universal coverage, knowledge of cost-effectiveness, incentives for delivering high-value care, tort reform, and cost controls on pharmaceuticals—include the need for (a) care coordination (e.g., through patient-centered medical homes, which includes giving primary care physicians more equitable income compared to specialists), (b) well-care/sick-care integration, (c) serious consideration of complementary and alternative (CAM) approaches to care in addition to conventional Western allopathic approaches, (d) serious consideration of the mind-body connection, (e) supporting shared decision-making between informed patients and their providers, and (f) development and use of next-generation health information technology that provides clinical decision support through implementation of patient-centered cognitive support methods.

Being overly focused on the immediate cost and management of universal coverage, without a balanced focus on the urgent need to continuously increase care value to the consumer, will never result in a better healthcare system and, most likely, will cause further deterioration of care quality and substantial rise of costs over time! Need further evidence? See this link about money-driven medicine. It explains how :

...a profit-hungry medical-industrial complex has turned health care
into a system that squanders millions of dollars on unnecessary tests, unproven
and sometimes unwanted procedures and overpriced prescription drugs...Right now
the incentives [for healthcare providers] in America are if you want
profit, do more. You make money by doing stuff and there's no limit. So we do
and do and do and we get this oversupply, this excess activity because that's
how people, hospitals, doctors make money...we spend more than any other country
and we spend a higher percentage of our gross domestic product and our gross
domestic product is larger than most other countries'...But interestingly,
disturbingly, frighteningly, pick your own word, we spend more money and we are
not healthier. We don't live longer. We don't seem to be getting as much value
for money
[italics added].

...[It is widely believed that] American health care is the best in the world. It's not. There's a much more complicated story there. For...rescue care...[such as] very complex cardiac surgery or very advanced're pretty lucky to be in America...But most health care isn't that. Most health care is getting people with diabetes through their illness over years or controlling the pain of someone with arthritis or just answering a question for someone who is worried or preventing them from getting into trouble in the first place. And on those scores: Chronic disease care, community-based care, primary care, preventive care. No no, we're no where near the best. And it's reflected in our [poorer] outcomes.

...What's truly staggering is how much waste there is in our health
care system. Up to one out of every three of the more than two trillion dollars
that we spend is wasted on ineffective, often unproven procedures, overpriced
drugs and devices that are no better than the drugs and devices that they're
replacing. Unnecessary hospitalizations, unnecessary tests. Now this may seem
like an overstatement. I mean, how can it be that 1/3 of the money is
wasted?...[Similar patients in some parts of the coutnry are] getting more
aggressive, intensive, and expensive care [than in other parts]. And here's the
stunner: The outcomes are no better. Often they are worse on average in states
like New Jersey or New York or California than they are in low treating states
like Iowa or North Dakota

...The thing [many doctors] miss most is being able to sit in a room and talk to a patient for an hour. But [they are] so compressed with [their] time and the amount of patients [they] have to see [that]15 minutes is a long time these days...[because it's an] assembly line...We're now treating medicine as if it were an industrial product. Through put. How many units of care can you deliver? The idea that you are going to see a patient on average for between 12 and 15 minutes, no matter what their condition or how many kinds of problems they have or how complicated their diagnoses or how much reassurance they might need is an idea that you can treat medicine like a production line product and you can turn out patients in the same way like we produce widgets. That's a commercialization and an industrialization of the relationship. So this is a system which is fundamentally broken in terms of the kind of conflicts it raises in the minds of physicians and, also, in the minds of the patients.

...We have really good data that show when you take patients and you really inform them about their choices, patients make more frugal choices. They pick more efficient choices than the health care system does...when patients actually got to participate in the decision, surgery rates fell by almost 25 percent. And satisfaction in outcomes improved. So an activated patient really engaged...[results in] better outcomes, lower cost, higher satisfaction.

This all supports what I've been saying about how our broken healthcare system spends way too much money to deliver mediocre quality care, which translates to low value for the consumer. Focusing only on providing insurance coverage for everyone will fail to raise the quality of care and control costs!!! Focusing on providing insurance coverage for everyone AND on continually improving care cost-effectiveness through the emergence, dissemination, and use of evidence-based knowledge is the only sensible, sustainable way to reform our healthcare system!

I conclude, therefore, that we certainly do need a principled and pragmatic approach to healthcare reform. Unfortunately, the current debate in our country is grossly imbalanced as we focus on ways to pay for and administer universal coverage, without due consideration for how we will pay for and administer ways to continually increase value to the consumer in ways that reduce healthcare expenditures and improve care quality over the long haul. The bottom line: I contend that the ONLY principled and pragmatic way to minimize cost while maximizing care quality (i.e., optimizing cost-effectiveness/value) is by assuring everyone get all the personalized care they need—and only the care they need—which is delivered in the most efficient and effect way possible. We are literally in the dark ages, however, when it comes having such evidence-based knowledge! This means that we much commit the resources necessary to (a) obtain and evolve such knowledge through international collaboration focused on ongoing clinical outcomes research, and (b) use such knowledge to support the decisions and actions taken by clinicians and consumers. This should be a top priority equal in importance to universal coverage!

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