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 chemotherapy...you'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!

Related posts:

Friday, August 14, 2009

A Quick Way to Rein in Medical Costs

I've been participating in an excellent conversation on healthcare reform between healthcare providers, patients, and others, which has been taking place at this link. In this post I summarize the conversation and share my thoughts.

The original post, written by Dr. George Lundberg and titled "How to Rein in Medical Costs, RIGHT NOW," describes an immediate strategy for saving money by:

  • Eliminating six costly tests and procedures that research has shown (with differing degrees of certainty) to be unnecessary (excessive, inappropriate) for certain types of patients
  • Ceasing to "prolong dying" and providing a "dignified" death that is "free from pain and suffering as possible."

While no one rejected the basic premise of the post, our conversation has focused on examining the scientific, economic, and ethical challenges of implementing that strategy. The many comments readers made can be divided into 12 strategies for dealing with these challenges; they are:

  1. The need for more and better research related to the creation and use of evidence-based guidelines from which to base healthcare decisions
  2. The need for tort reform to counter the excessive cost of defensive medicine
  3. Dealing with overutilization due to fee-for-service incentives
  4. Dealing with overutilization of specialists and excessive number of surgeries
  5. Dealing with end-of-life care
  6. Empathy & compassion versus greed & dishonesty
  7. Determining who should run healthcare
  8. The need for government reform
  9. Reliance of "free market" forces
  10. The need to reduce administrative waste
  11. The need to put more people to work
  12. The issue of marijuana legalization.

I discuss each of these issues below. I've included snips of a sampling of comments that were made (the screen name of each commenter is included so you can go back to original posts and read them in full). I added some remarks in italics.

  1. Research and Evidence-Based Guidelines. Everyone seems to agree that care decisions should be evidence-based as much as possible. That means obtaining and using the results of valid and reliable scientific research on the comparative-effectiveness and cost-effectiveness of tests, procedures, meds, and preventive actions. This information should be disseminated to patients/consumers and clinicians in a way that supports decisions (e.g., through guideline, protocols, best practice recommendations, etc.). The guidelines should let everyone know what is most likely to help the individual, what is unlikely to help (or even harm) the person, what the alternatives there may be, how to implement them efficiently and effectively, and how much it all will cost. In this way, everyone is adequately informed and the consumer can make a valid decision based on value (bang-for-the buck).

    There are several issues concerning implementing this strategy. One has to do with determining the areas in which scientific (statistical) certainty exists. This includes the challenge of being able to identify outliers, i.e., people who would benefit from a test/procedure/medication, although the vast majority of others would not benefit. For example, Dr. Oberlander wrote: "My wife was diagnosed with high-grade breast cancer in an asymptomatic breast cancer screen via mammography. She was well less than fifty at the time…She successfully underwent chemotherapy, mastectomy with reconstruction…is my wife really such an outlier? Was it worth it' to go and pay for that 'asymptomatic' patient's mammogram?...There's the rub. I find outliers and exceptions each week in my practice. Is it worth it? Perhaps not in the global perspective vis-a-vis health care costs, but try explaining that to someone you love." Our country has to become prepared to deal with such painful ethical dilemmas.

    The ethical issues aside, an example of where scientific certainty exists is the kind of low-hanging fruit offered by Dr. Bestermann: "14 studies now showing that stents do nothing to prevent heart attack in patients with stable angina who receive optimal medical therapy. 85% of stents are done in stable angina patients." While having this knowledge is essential, to encourage its use in utilization decisions requires the kind of financial incentives and disincentives that would promote rational decisions based on cost-effectiveness.

    In many (most?) other areas, however, such scientific certainty is lacking. For example, maggiemahar wrote: "The scientific evidence from randomized trials on the impact of screening mammography in saving lives is conflicted, and the quality of the individual trials limited." Several other comments voiced similar uncertainty.

    The solution, I suggested, is to establish international collaborative networks of clinicians and researchers who focus (a) on defining the areas of outcomes research that's needed and then (b) on doing such research to determine the most cost-effective methods of delivering personalized care by answering these three questions:

    1. Who (or what) should decide if a test or procedure is unnecessary or inappropriate for a particular patient in a particular situation? Should it be the clinician, the patient, the insurance company, the government … Who?
    2. What guidelines (if any) should be followed by those making the utilization decisions? Should the guidelines be evidence-based? How will political influence of vested interests be prevented from pressuring the guideline developers, so that only sound (valid and reliable) science is used to justify the guidelines? What do we do if the necessary guidelines are not yet developed? And for those that exist, how do we assure that they continually evolve? How should the guidelines be disseminated?
    3. Should the use of clinical decision support software systems be used, or should be simply rely on the unaided human mind? If decision systems are used, should they implement patient-centered cognitive support (see this link)?

    Since obtaining valid results from such research (that includes taking genetics into account) can take many years, current decisions should be based on the best available evidence, if any. But since we know so little about so much, our healthcare system will have to continue to operate in a high-ignorance mode in the near future. This means cost savings and quality improvements will be low compared to operating in the kind of high-knowledge mode that will emerge and evolve over time. No quick fix/silver bullet here; but there are no rational alternatives!

  2. Tort Reform & Defensive Medicine. Numerous comments focused on the need to reform malpractice litigation in order to minimize defensive medicine. Suggestions included use of special health courts were recommended (see the Common Good website at http://commongood.org/society.html).

    For example, Barry Carol wrote: "…substantive tort reform is essential if we are ever going to convince physicians to give up some of their cherished autonomy and accept some accountability for the healthcare utilization…if we replace the current jury system for settling medical disputes with specialized health courts and we provide robust safe harbor protections against suits based on a failure to diagnose a disease or condition as long as evidence based protocols were followed, it should be easier to convince doctors to embrace reform, at least over a reasonable timeframe…it should be much easier to ask for and expect physician cooperation on the utilization issue." AndyS wrote: "We need to understand that the focus on malpractice originates in the legitimate frustration of doctors -- but it is fueled by those with political objectives and is absolutely irrelevant to the struggle to control healthcare costs." DocJ wrote: "I would gladly order fewer tests & provide fewer services when I feel they were unnecessary or inappropriate, if the necessary changes in our system could be implemented. This would take things like tort reform with economic damage caps, 'loser pays' rules, medical court reviews for merit of claims, and legal protection for providers to refuse unrealistic demands of patients/family members without fear of legal entanglements & costs. Until these things happen". Steve h wrote: "As a practicing ER physician, I know that MOST of the tests I order are not designed to find the correct diagnosis, of which about 80 percent is a good history and physical, but rather defensive in nature, to rule out the 1 in 100 or 1 in 1000 chance of the presentations being a atypical presentation of something nasty. I routinely order expensive tests for this reason, and the truth is, it is better to spend the patients money on testing than for them to sue you and get to spend your money. Most practicing physician, whether they admit it or not, practice the same way…the truth is, most physicians dont get paid any extra no matter what tests they order or how many they order." And even though maggiemahar doubts that fear of malpractice suits really explain such significant variations in Medicare expenditures, she agrees that "…we could handle malpractice differently."

    I'd add that a good deal of defensive medicine would be eliminated it we do a better job with the first item, developing and using evidence-based guidelines. The reason, if clinicians follow an approved guideline in making their decisions, and if they are given ample opportunity to explain why they chose not to follow it for a particular patient, then they will be better protected from the kind of malpractice suits that give rise to defensive medicine. For example, pcb wrote: "I would love to have the support, guideline, whatever you want to call it to stop routinely ordering them. I personally believe the evidence suggests more harm than good from routine PSA screening…So I order the test. Not because I make any money (quite the contrary) But for almost exclusively defensive medicine reasons…Until I legitimately feel protected from the lawyers on these topics, I have a disincentive to change. And it has nothing to do with fee for service. So I order the test. Not because I make any money (quite the contrary) But for almost exclusively defensive medicine reasons."

  3. Fee for Service. Dr. Lundberg wrote in the initial post that "fee-for-service incentives are a key reason why at least 30% of the $2.5 trillion expended annually for American health care is unnecessary [and] eliminating that waste could save $750 billion annually with no harm to patient outcomes." This was refuted by two comments. Dr. Reece wrote: "I don't see how you can end fee-for-service, herd doctors into multispecialty clinics nationwide, or put them all on salary." propensity wrote: "There are many academic medical centers at which doctors are salaried without fee for service, yet the over utilization is high." And Peter Nesbit wrote: "…in many cases fees have been driven sufficiently low that service suffers. In turn, the clearest result has been to drive over-utilization, perhaps to make up some of the differences in income. It's time to look at medical fees not as the problem but as the solution…[and] follow the medical science that most benefits patients and the public health at lowest cost."

    Thus, as with tort reform, fee-for-service would become much less of an issue if the decisions made by patients and clinicians were guided the sound scientific evidence based on cost-effectiveness research (as per strategy #1).

  4. Overutilization of Specialists and Excessive Surgeries. Denise Cleveland wrote: "Medicine is first and foremost a business. The proof is that as many as 99% of c-sections and 98% of hysterectomies can be avoided with conservative treatment options, or no treatment at all…What we need is emergency care for everyone and to stop making doctors and corporate executives rich with damaging, unwarranted surgeries." J Bean wrote: "The big, fat, low-hanging fruit of waste that I see from my perspective as a community primary care physician, is over-utilization of specialist care. We have so many specialists and so few primary care docs that many specialists wind up doing the primary care functions that correspond to their specialty…In reality, the care is fragmented, contradictory at times, and the total cost is 3 or 4 times what it should be. Note that the French are trying to control their costs by restricting access to specialists…British diabetics always refer to their doc as "my GP" while the US diabetics always refer to "my endo". Otherwise, they get the same care."

    This issue can also be addressed in part by use of valid, reliable evidence-based guidelines (#1) shared between primary care physicians and specialists, as well as establishing patient centered medical homes. These guidelines would advise PCPs when it is appropriate to refer a particular patient to a particular type of specialist, and the medical homes would help coordinate the care (see this link). And, as Rob MD wrote: It would be great if "Primary Care Doctors regain…comparable pay for effort and build Medical Homes."

  5. End-of-Life Care. This is certainly a thorny issue. fnp wrote: "…allowing someone to die with dignity is all good and well unless that patient is your child, you sister, your brother, your parents, etc…I have seen and watched families torn apart do to this terrible disease. And I have seen teenagers and children come back from what looked terminal." Dr. Ransom wrote: "I think knowing when to stop is a major problem in healthcare...however, this problem is NOT generated by MDs in most cases. It results from the American culture of denial of mortality. I see this in the ICU all the time." Ron wrote: "…how many physicians are going to rein in a family's desire to extend heroic measures to prolong life - especially when its highly profitable? Until and unless you change the fundamental incentives, you won't change the fundamental trends." Yana wrote: "It is ridiculous, cruel and transparent to suggest physical therapy/rehab for a patient who is obviously on his deathbed, but I have seen that happen. On the other hand, where there IS hope, everything should be done in favor of life." Maggiemahar wrote: "Doctors and nurses can make sure that the patient knows that the hospital has a palliative care team--and that the patient has a chance to talk to that team about treatment options, potential benefits and risks before deciding on further treatment. Palliative care specialists also are experts at keeping patients out of pain. Too often, doctors are reluctant to hand 'my patient' over to palliative care." Margalit Gur-Arie wrote: "…the end-of-life discussions and the rationing discussions are emotional for most people and everybody falls back on a personal experience…or the natural fear of mortality…The discourse needs to be based on logic and numbers and dollar figures, not the 'what if MY granny has a stroke' argument. Ethical questions do not belong in a public policy debate, and in this case, they are derailing the case for health care reform…I am suggesting is that in the interest of passing some sort of health care reform, we decouple the emotional debate from the factual one."

    I see this as an extremely emotionally-laden issue with religious belief overtones that tend to defy logic and reason. Yet the end-of-life care discussion must be a rational debate that balances the needs of the terminally ill with the needs of society. The only way that can happen, imo, is if our culture comes to terms with the question: What's the most humane way to treat a person who will soon be dead? (i.e., is death to be avoided at all costs, or is it more important to die with dignity as decently as possible; e.g., see this link). It ought not to be based on: What will make the family of the dying person feel less sorrowful or guilty? I therefore agree with Margalit that we should have an unemotional discussion about this issue, which is going to be very difficult to do.

  6. Empathy & Compassion versus Greed & Dishonesty. RD wrote: "It may be true that billions could be saved...but there are several underlying problems: Greed, Stupidity, Dishonesty, Irresponsibility…When is the US/World going to wake up and realize that when you look in the mirror, do you really like the person looking back at you?" Margalit Gur-Arie wrote: "We all know that we are being grossly overcharged for pharmaceutical products. We all know that insurance companies realize significant profits and spend many health care dollars on archaic administration." John Brooks wrote: "The corruption associated with inflated costs for medicare extends to such items as oxygen concentrators, which medicare pays up to 10x the free market price for. The corruption just seems too endemic [that it]…will lead to the collapse of the medical care system sooner than later." I written and debated about this issue at length at a series of posts starting at this link.
  7. Who Should Run Healthcare. Peter Nesbit wrote: "…it is abundantly clear that neither the government nor private insurers have been able to control the cost of health care. [Instead]…place the control of health care in the hands of the medical community. Who better to oversee how doctors are paid and whether they are providing appropriate care to their patients. Who can speak with more authority when individual doctors stray away from the course of appropriate care? Creating an independent, non governmental medical agency to manage and control medical care has the potential to both assure appropriate patient care and control medical costs. This agency could negotiate medical fees fairly, provide care guidelines, process medical bills, collect treatment data, and pay providers in a timely manner. This independent medical agency could work with doctors to help them follow appropriate treatment patterns thereby reducing over-utilization, the most important factor in lowering overall medical costs. It could bring substantial cost saving in medical losses to insurers, government and private." See strategy #8.
  8. Government Reform. Bill wrote: "Let's start with eliminating the incentive of Congress to waste our money on pork, jets, 'gold plated' healthcare, retirement benefits, etc. Paying for a massive new healthcare bureaucracy and expanding coverage will not lower healthcare costs and will continue to generational transfer of wealth to current seniors from our children and grandchildren." This seems to go hand-in-hand with the strategy #7 about who should run healthcare. The question is: Can government be reformed in such a way—e.g., through transparency and independent oversight—that it can do the job of running healthcare more efficiently and effectively than an independent, non governmental medical agency?
  9. Free Market Forces. Dr. Dubey wrote: "The best way to bring down the Healthcare cost is to have the consumer manage the healthcare dollars, i.e. bring free market forces to bring down the cost. Have the cost and quality data available to the consumer aka. the patient, and have then shop very similar to shopping for airline tickets." This actually reinforces the Research and Evidence-Based Guidelines strategy (#1) because it's based on assuring the availability of good information a about value to the consumer.
  10. Administrative Waste. Ravi wrote: "Too many Officers. The cost is not just in care but also in administrative waste, organizational efficient or there-lack-of, and so much more." If we're going to focusing on cutting clinical waste by increase efficiency, etc., why not do the same for administrative waste?
  11. Put People to Work. Dr. Kuthuru wrote: "We can have a flat 10% tax to have them pay for their care…Lets make everyone work who can. This will increase the amount of people paying into the system so taxes can go down." Can't argue with getting people decent jobs!
  12. Legalize Marijuana. Jason H. Monroe wrote: "If we could follow CA and legalize weed and the taxes from THAT along will absolutely pay for anyone's and everyone's health care!" A proposal worth discussing, imo.

Conclusion

The most important strategy, I contend, is #1: focusing long and hard on getting and using the scientific knowledge need to guide decisions based on cost-effective care and prevention. This is because such knowledge would help to deal with some of the top issues by helping to:

  • Diminish the number of malpractice suits and overutilization due to defensive medicine (#2)
  • Curb the overutilization tendency of fee-for-service (#3) and of specialists and surgeries (#4)
  • Enable whoever (or whatever) controls the healthcare system to make evidence-based decisions (#'s 7 & 8)
  • Bring down costs through "free market" forces (#9).

However, unless our country begins to evidence greater empathy & compassion, a "me-only" mentality by those how have decent insurance and don't care about those who are suffering will make healthcare reform more difficult, as well as making it even more problematic to deal with greed and dishonesty (#6).

Cutting administrative waste and getting people to work are certainly valid strategies. Finally, legalizing marijuana and using the tax money to help pay for healthcare reform is also worth consideration, although likely a hard sell (#s 10-12).

What should be done right now?

First, anyone with empathy and compassion could not tolerate the fact that many tens of millions of Americans lack health insurance or are underinsured. Sadly, unlike European, Canadian, and other societies, many in America have little concern for the wellbeing of less fortunate Americans because:

  • Have a vested interest in the status quo (i.e., they are greedy—they are making plenty of money and want to keep things the way they are, or they young & healthy or have a stable job with good benefits and can't stand the idea of paying more taxes to help others get good care)
  • Are afraid of change because they believe that if our country takes better care of the less fortunate (e.g., via a public plan options) it will somehow harm them (e.g., they believe in the "death panel" fabrication or that they will lose their Medicare)
  • Believe that private insurance is superior to a publically (government run) plan and don't want to risk losing it
  • They are self-centered, heartless, prejudiced and believe they are simply more worthy than others.

Such beliefs, attitudes and emotions are, in the long run, very self-defeating since our current healthcare system is simply unsustainable (i.e., doing nothing is bad for everyone), human nature is such that we are too easily driven by irrational fear, ignorance, self-deception, and ego (e.g., "me-ness"—greed & selfishness); these are just natural human fallibilities. And when conservative organizations hire clever lobbyist-run groups (such as Americans for Prosperity and FreedomWorks) to disrupt rational dialogue by manipulating human fallibilities and spurring irrational fears, meaningful reform becomes ever more difficult.

This means proponents have to present a healthcare reform plan that is easily understood by all and refutes people's irrational fears. The plan, I contend, should include a publically funded option, and can include private insurance options, so long as everyone is covered, regardless of their income, age, and health. The cost of such a plan, the coverage if provides, and the means of paying for it should be spelled out clearly, so that everyone knows what it means for them. This includes directly and convincingly dispelling all falsehoods propagandized by the opposition.

Equally important is for the plan to have a sharp focus on these two goals (as I discussed in a previous post):

  1. Enabling all clinicians to continually learn how to make (and keep) their patients healthiest and happiest for longest, using the most cost-effective methods of treatment and prevention, and encourage/reward them for doing so.
  2. Enabling all consumers/patients to continually learn how to make (and keep) themselves healthiest and happiest for longest, using the most cost-effective methods of self-care and self-maintenance, and encourage/reward them for doing so.

That requires doing whatever is necessary to work diligently toward answering these three questions about value to the consumer:

  1. What are the most cost-effective (high-value) ways to prevent, manage, and treat problems with people's physical health and psychological wellbeing?
  2. How can such high-value care (including prevention, self-maintenance, and sick-care treatment) be implemented safely, effectively, and reliably by all persons involved?
  3. How do we put into action an incentive program that makes it increasingly likely the high-value this will implemented successfully by everyone?

Enabling and rewarding clinicians and consumers/patients to do these things would save huge amounts of money, continually improve care quality, and vastly improve the health and wellbeing of all by:

  • Eliminating waste, over-treatment, and excessive expenses
  • Minimizing errors, omissions (under-treatment), and legal expenses
  • Fostering wise decisions and competent actions based on valid, ever-evolving, evidence-based knowledge
  • Making healthy living more feasible (e.g., making good foods more available and affordable than unhealthy foods).

Related posts:

Tuesday, August 11, 2009

Empathy, Taxes, Personal Responsibility, and Healthcare Reform – A Timely Debate (part 2)

In a prior post, I examined the how empathy (i.e., the ability to put oneself in the shoes of another), which is often lacking from the healthcare reform debate, ought to be an essential ingredient in the decisions our country makes. My discussion about the need for greater empathy triggered a contentious debate between a man working in the insurance industry and myself. The first part of this hot debate is at this link. Following is the second part. Please feel free to join in.

He wrote:

I own three TPAs…Both sides of my business entail helping employers offer insurance more efficiently. This is usually at the expense of insurance companies. We attack the fat. We have also been carving out a lot of drug plans because employers can self fund the risk cheaper then paying premium to a carrier.

And, in response to a discussion we've been having about Wendell Potter— insurance exec turned whistleblower, who spoke out against the underhanded tactics of the health insurance industry—he continued to discredit Mr. Potter by saying:

I do know the left is quick to point out he was an ex "insurance industry" executive but fails to mention he is now on the payroll of a pro-reform, anti insurance company advocacy group. On THCB [The Health Care Blog] previously I posted a very long and detailed explanation of what terms he doesn't appear to understand and where he was lying. When time permits I'll try to find it. I think there are all sorts of abuses that could turn someone off of insurance companies and even lead someone to campaign against them…Mr. Potter is by no means a whistle blower, he hasn't disclosed any abuse or actions that are not common knowledge. He's a paid shill at best.

I responded:

I would like to see your post. And I'm glad you are not defending the abuses of insurance companies, even though the ones Mr. Potter pointed may be common knowledge to certain people. What would be great is if you would share your knowledge of all the abuses and underhanded actions you've observed.

In response to my question—"Are you are insinuating that the right kind of capitalism is the pathologically mutated form of free market capitalism we've been living with for many years, with its weak gov regulations" – He responded:

You don't know what the term free market means. Nothing about our current system is free market or weakly regulated.

To which I replied:

As I understand it, many legislators have a free market ideology that focuses on weakening or eliminating certain governmental regulations that were originally created to protect the public. For example, Federal Reserve Board Chairman Ben Bernanke said we need to strengthen regulation of financial markets to stem excessive risk taking (see this link). And my reason for saying we have had a pathological mutation of capitalism comes from an interview of John Bogle, who has been named by FORTUNE magazine as one of the four giants of the 20th century in the investment industry, and by TIME magazine as one of the world's 100 most powerful and influential people (see this link). Anyway, call our current system whatever you want. The point is that those with free market cravings have been conspiring to kill regulations that were preventing our financial meltdown and, no doubt, important regulations in other areas have been on the chopping block.

In response to my statement—These sub-systems share various business models, operational processes, and metrics." – He replied:

I wouldn't call Medicare and private employer plans sub systems they are to distinct. And this whole point matters because the failures of Medicare and Medicaid are a terrible reason to destroy our successful private insurance system. None of the reform being discussed will improve the private systems, it will reallocate resources to the failed public plans so they can last a few years longer. Far from being semantics it is the underlying reason why all government reform fails to deliver what they promise the public it will.

To which I replied:

Still semantics. Sure, sub-systems can be distinct. For example, like the healthcare system, Nature is a complex system composed of interconnected parts (sub-systems) that as a whole exhibit one or more properties not obvious from the properties of the individual parts; that is, it is a system of distinct interacting sub-systems. Same goes for the human body; the digestive and respiratory systems are distinct interacting sub-system of the human biological system.

As far as Medicare and Medicaid being failed systems and private insurance being successful system, I guess we have to define what is meant by "success." There are those who say these programs are successful because, with Medicare for example:

  • Its universal coverage nature creates the ability to redistribute benefits to those who are neediest.
  • It pools risk in order to share the burdens of health care among the healthy and the sick.
  • Through Medicare, the government protects the rights of all beneficiaries to essential health care (Reference).
  • Medicare is more efficient because, in contrast to private insurers, Medicare doesn't have to spend millions on marketing, advertising, and Washington lobbyists. On top of that, private insurers must generate profits for their shareholders. (Reference)

And in an interesting interview, John Stewart summed up his conversation about healthcare reform with conservative pundit Bill Kristol (editor of Weekly Standard): "So what you are suggesting is that the government could run the best health care system for Americans, but it's a little too costly, so we should have the shitty insurance company health care" (See this link for the interview).

Nevertheless, others say the Medicare's efficiency is over-hyped (e.g., see this link).

In any case, private insurance has never been designed to cover everyone, unlike proposals such as "Medicare for All." While I'm not opposed to any coverage/payment strategy—be it single payer, public together with private insurance plus subsidies, or any other method—just as long that gives everyone access to good care.

In response to my statement—"Are you implying that we should eliminate Medicare because it has inefficiencies, or are you saying we should work to make it more efficient?" – He responded:

I'm saying we should eliminate Medicare because it is a complete failure. It never delivered what the public was promised when it was passed. It's poorly ran and destroying our entire healthcare system. Medicare is a cancer on American Society.

To which I replied:

Just as private insurance has very serious problems (including cold-hearted abusive tactics, which I hope you can elaborate upon), Medicare and Medicaid certainly have their share of problems. Radical reform is the only way to solve these problems. But failure to cover everyone is a deal-breaker as far as most Americans are concerned (e.g., see this link).

In response to my statement that we must focus on—"making our entire healthcare system (including all sub-systems) much more efficient by cutting out waste, fraud, abuse, and inefficient operational processes." – He replied:

This is not accomplished by expanding governments role. If you really wanted to accomplish any of this you would eliminate government from healthcare as it is the main driver of waste, fraud, and abuse.

To which I replied:

Few would argue that we need government reform, just as we need healthcare reform. But I'm hard pressed to conclude that there is less waste, fraud, and abuse by the private insurance industry compared to government. In fact, it seems to me that government and the private insurance industry have been in cahoots since, as reported recently in the Chicago Times: "Health insurers have lavished $41 million in campaign contributions on current members of Congress since 1989, with more than half going to lawmakers on the five House and Senate panels writing this year's health bills, according to the nonpartisan Center for Responsive Politics. Since the beginning of 2008 alone, they have spent $145 million on lobbying, led by Blue Cross-Blue Shield organizations and the AHIP trade group."

This tells me that no matter what is done, we must have independent oversight and strong regulations to minimize waste, fraud, and abuse, as well as the knowledge to know what constitutes cost-effect care.

In response to my question—"Do you want private insurance to become more efficient and affordable as well?" – He replied:

Yes I do and this is achieved by eliminating wasteful and inefficient regulation like COBRA, HIPAA, ADA, and the limiting of self funding. This is not accomplished by a public plan, 1000 page bills no one has read, or insurance exchanges.

To which I replied:

What's required is a rational plan that is well-read and understood (although I don't know how many pages it should have), which gives everyone access to good care, and equally important, the plan should:

  • Enable all clinicians to continually learn how to make (and keep) their patients healthiest and happiest for longest, using the most cost-effective methods of treatment and prevention, and encourage/reward them for doing so.
  • Enable all consumers/patients to continually learn how to make (and keep) themselves healthiest and happiest for longest, using the most cost-effective methods of self-care and self-maintenance, and encourage/reward them for doing so.

These two bullets, sadly, have not been adequately discussed since we're so consumed with how to pay for care that we aren't discussing how to make that care much more cost-effective. A sustainable solution MUST fully address both these issues.

He wrote:

I didn't ask how to measure value I said who? It is VERY easy to come up with legitimate methods to measure something. Depending who's hand you put that in though is what matters. In the absence of a fair, honest, and efficient god to do this judging it needs to reside with the consumer. Government and corporations have both been given this chance and failed completely, neither can be trusted to measure value.

How does some disinterested third party appointed to this job make those decisions better?

Self funded Employer plans deliver the highest percent of dollars to legitimate benefits. All employer plans have lower administrative cost, when you include loss due to fraud, then public plans.

And I replied:

Actually, the necessary measures and related research are FAR FROM EASY; anyone believing otherwise is likely unfamiliar with what's necessary. Anyway, asking who would do the judging is certainly a reasonable question.

I absolutely DISAGREE with your assertion that consumers should be the judge of whether they received the best possible (i.e., most cost-effective) care. That's because the typical consumer doesn't and can't have a clue as to what generally constitutes cost-effective care; in fact, rarely do clinicians, administrator, or anyone else! Why? Because that knowledge doesn't exist! Why? Because we've been overly focused on issues related to insurance/payment and not enough on (a) discovering what works best for each patient and how to provide that care efficiently and (b) how to incentivize the delivery of such cost-effective care.

In any case, what we need are three basic things:

  • Independent researchers and other healthcare experts focused on collaborating world-wide to establish ever-evolving, personalized, evidence-based guidelines.
  • A new generation of computerized decision support tools that help clinicians and patients select the most cost-effective guideline to follow for promoting competent self-care and efficient prevention and treatment.
  • A cost and payment system that rewards good self-maintenance and effective care that results in good clinical outcomes, as well as penalizing inefficiency and ineffectiveness.

That's where the debate stands now.

Let me add this: I'm thoroughly convinces that any sustainable healthcare reform strategy must focus on transforming our current low-value healthcare system into one that brings high-value to the consumer/patient. I discuss this in a post at this link.

Related links:

Monday, August 10, 2009

Healthcare Reform’s Most Important Issue: How to Make it a High-Value System


In his July 22nd press conference, President Obama said something that, I contend, is the single most important issue about reforming our healthcare system. He said: "…here's what I'm confident about. If doctors and patients have the best information about what works and what doesn't, then they're going to want to pay for what works. If there's a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half price for the thing that's going to make you well?"

I'd add a logical extension to the President's statement by including this sentence: "And if there's a white pill that works even better than the blue and red pills, while costing the same or less, then why not pay for the more cost-effective white pill."

By expanding the word "pill" to mean "any health-related treatment, approach, method, or procedure," I read the President's message (and the logical extension) to mean that curing the healthcare crisis in a sustainable way requires that we focus on knowing ever-more about answering these three questions:

  • What are the most cost-effective (high-value) ways to prevent, manage, and treat problems with people's physical health and psychological wellbeing?
  • How can such high-value care (including prevention, self-maintenance, and sick-care treatment) be implemented safely, effectively, and reliably by all persons involved?
  • How do we put into action an incentive program that makes it increasingly likely the high-value this will implemented successfully by everyone?
While it is certainly necessary to have a deep, rational debate about universal insurance versus single payer systems, it is equally (if not more) important to address the core issue, i.e., dramatically increasing cost-effectiveness (value to the consumer).

Why? Because the only sustainable strategy for giving everyone access to affordable quality care requires (a) knowing what constitutes high quality and (b) assuring such quality care is delivered efficiently.

Why? Because making informed healthcare decisions and taking competent/responsible action requires that we know the personalized methods of self-care and professional treatment most likely to get the best outcomes (results) for each particular person. These evidence-based outcomes include illness avoidance, symptom reduction, disease control or elimination, complication prevention, quality of life improvement, etc.

Lacking such crucial scientific knowledge means there will continue to be plenty of over-treatment (errors of commission), under-treatment (errors of omission), ineffective (unproductive) treatment, and inefficient (inappropriate, wasteful) treatment, which all result in overly costly, poor quality care. This, in turn, means healthcare expenditures will continue to rise for reasons such as these:
  • Instead of doing things right the first time, errors, ineffectiveness, and inefficiencies will prolong a "fix it and pay again when it breaks" process resulting in excessive care, which may then result in even worse outcomes and greater expenditures (e.g., due to increased risk of medication side-effects, drug-drug interactions, and complications).
  • Unless we know the most cost-effective approaches to care, there is a good chance that the more expensive/profitable methods of care will be chosen over the lower-cost alternatives.
  • If clinicians don't have the scientific evidence need to guide them in making informed, justifiable decisions, this lack of certainty can cause them to feel pressured into doing unnecessary tests and treatments because (a) they want to avoid malpractice suits and (b) there are economic pressures to use available resources when guidelines for determining their appropriate use are inadequate (such as use of medical scans).
  • Waste and fraud will not be adequately controlled unless we know when something is wasteful (excessive, unnecessary, inefficient) and fraudulent (e.g., purposely doing something for monetary gain that knowingly harms or disadvantages a person); such controls require valid, reliable, targeted guidelines and incentives for following those guidelines.
Replacing our ignorance about what works best for least cost requires doing two basic things:
  • We have to learn, through valid scientific research, how to answer questions about what health-related treatment, approach, method, or procedure has the best clinical outcomes for the best price for particular types of people with particular types of problems. These answers would identify the most cost-effective kinds of self-care and treatment that give consumers/patients the greatest value ("bang-for-the-buck").
  • Whenever such knowledge exists, any healthcare program that is government run or supported should only pay for the most cost-effective (high-value) approaches to care. Of course, special arrangements should be made for sound research studies and experimental treatments. In any case, people who want to waste their money by paying out of pocket for less cost-effective care should be informed about it, but not be prevented.
Implementing this rational forward thinking healthcare reform strategy presents daunting challenges and requires some radical changes to our current system. The challenges include the following:
  • It is well documented that the current fee-for-service model penalizes healthcare providers for rendering high-value care because doing more means greater income/revenue than doing better; they are thus punished for providing high quality services efficiently.
  • The healthcare industry knows very little about cost-effectiveness because there has been great resistance in doing the necessary research.
  • There are too many ways to "play the system" for personal financial gain that adversely impact one's health and wellbeing.
  • Doing the necessary research is costly, complex, time-consuming, and requires large-scale collaboration between clinicians, researchers, and consumers across the globe.
What are the options?
  • Doing little or nothing. Simply giving into the pressure and deceptive politics of special interest groups who currently gain financially from our current broken healthcare system means maintaining the status quo. This solution is supported by people who: (a) lack of empathy for those who currently suffer [see a series of posts starting at this link], (b) refuse to accept that the current system is so dysfunctional that it is unsustainable and threatens our entire society [see this link], and/or (c) fear they have too much to lose financially from significant changes to the current system.
  • Focus on payment strategies to provide some sort of insurance coverage for just about everyone (i.e., universal access), without adequate acknowledging and embracing the cost-effectiveness issue. This half-backed approach would lead to ever-increasing costs and poorer care quality since:

    • Inefficiency and ineffectiveness remains unconstrained because knowledge of what works best for least is lacking, which means there is pressure to do what pays the most, or to purchase what costs the least without knowing if its of lesser quality.
    • Simply paying healthcare providers less will result in worse care as clinicians cut back on the time they spend with each patient (which is often too brief already) in order to maintain their current standard of living by adding more patients to their already over-demanding case loads. This is already having a negative impact on care quality.
    • Even if there are pay-for-performance incentives, lacking adequate knowledge of what works best for least means that such rewards will be based on inadequate performance guidelines. In other words, clinicians will be paid more if they follow certain procedures, even though it is uncertain if those procedures will actually help, harm, or have no meaningful affect on a particular patient.

  • Implement strategies based on a Patient-Centered Life-Cycle (PCLC) Value Chain. As I discussed two years ago in a series of posts starting at this link, the PCLC Value Chain focuses on rapid and radical (profound) transformation, so that people are aware of cost-effective approaches to care and are rewarded for implementing such cost-effective care in a high-value, patient-centered healthcare system.
I welcome all comments.
Related links:

Monday, August 03, 2009

How to Reform Healthcare Sensibly: Focus on Two Clear Goals

The focus of the current healthcare reform debate is way out of balance:

  • Issues of money and insurance are by far the main focus
  • Issues of quality and knowledge are a minor focus
  • Issues of empathy and compassion are mostly out of focus.

Focusing on all these issues in a balanced way is absolutely essential for creating a sustainable, high value system in which everyone: (a) has access to excellent affordable healthcare, (b) gets the knowledge and guidance needed to make informed decisions and take responsible action, and (c) is incentivized to "do the right thing."

If, however, we continue to focus on financial matters without equal regard to quality, knowledge, empathy, and compassion will result in more of what we already have: A healthcare system (comprised of many disparate sub-systems) that delivers inferior quality care and poor access compared to other countries, while (a) costing much more than any country in the world and (b) knowing almost nothing about the most cost-effective ways to prevent and treat health problems (see this link).

In other words, the American healthcare system has the lowest level of value (cost-effectiveness) in the industrialized world with no end in sight! Our dire situation will only get worse UNLESS we begin to take a balanced approach that focuses on improving care quality and efficiency, providing everyone access to good care and information, and fostering healthy lifestyles.

The ONLY way to accomplish this, it seems to me, is to focus on these two goals:

  • Enabling all clinicians to continually learn how to make (and keep) their patients healthiest and happiest for longest, using the most cost-effective methods of treatment and prevention, and encourage/reward them for doing so.
  • Enabling all consumers/patients to continually learn how to make (and keep) themselves healthiest and happiest for longest, using the most cost-effective methods of self-care and self-maintenance, and encourage/reward them for doing so.

Enabling and rewarding clinicians and consumers/patients to do these things would save huge amounts of money, continually improve care quality, and vastly improve the health and wellbeing of all by:

  • Eliminating waste, over-treatment, and excessive expenses
  • Minimizing errors, omissions (under-treatment), and legal expenses
  • Fostering wise decisions and competent actions based on valid, ever-evolving, evidence-based knowledge
  • Making healthy living more feasible (e.g., making good foods more available and affordable than unhealthy foods).

Isn't it time we start figuring out how best to do this!?!

My next post expands this discussion and relates it to President Obama's healthcare reform objectives.

Related links: