Practices for Comprehensive Health IT Systems

Following are practices for developing comprehensive health IT systems.

Something I realized early on is that such systems should be flexible enough to continually adapt to new healthcare knowledge and concepts; data models; value sets; data format, terminology and transport standards; use cases; workflows; and diverse user needs.

It should be able to accommodate the needs of PCPs and all clinical specialties, approaches and user roles, as well as patients, with highly useful and useable tools.

It should be able to work in centralized, distributed, point-to-point, and tightly- and loosely-coupled networks using client-server and standalone (desktop) tools.

It should be able to leverage cloud-based storage and computing (all flavors), as well as the local resources of untethered devices that may connect to the internet occasionally.

It should be able to work with third-party tools that provide additional relevant capabilities.

And if it provides decision support, it should focus on enabling knowledge-feedback loops among diverse groups of collaborators who build, share and refine models aimed at continually increasing the value of care patients receive through systematic process and outcomes research that cross organizational and geopolitical boundaries. These models should include ones that focus on the whole person (biomedical and psychosocial), social determinants of health (SDH), precision medicine, clinical workflows, population health, finances, and prevention (wellness care) as well as treatment and self-maintenance of chronic conditions.

Small Independent Practices - Big Transformative Potential

A post by Dr. John Brady titled My oasis of care is being threatened examined the dilemma small practices (the "little guys") are now facing. Should they become extinct, being consumed by large organizations (the "big guys")? Or does the little guy have an important place in the healthcare? How can the little guys autonomy have the power to transform our healthcare system in very positive ways, especially when centralized control by the big guys is so prevalent these days? Here's what I wrote ...

As a clinician and health IT software architect working in several Federal (ONC) workgroups over the past three years, I can confirm that government focus has been on the “big guys,” i.e., large provider organizations and EHR vendors participating in health information exchanges (HIEs). I’ve been fighting to have the focus extended to supporting the needs of small practices and EHR vendors (the “little guys”).

Having had a solo practice in NY for twenty years (as a clinical psychologist), I empathize with Dr. Brady’s sentiments about the importance of autonomy and independent practices in terms of clinicians’ quality of life and the well-being of their patients. This extends to primary care practices and specialists of all disciplines.

While I contend that care coordination and next-generation decision support are important to increasing healthcare value to patient, it is unwise to ignore or destroy the little guys in the process.

A case can be made for the government’s centralized, top-down, tightly-coupled network (TCN) model that it benefits larger organizations. Primary benefits of the TCN are control and consistency because this model limits participation to people within the same discipline, department, region, organization, etc.; who have access to the same information sources, share similar experiences; who do things in similar ways; and who are under the control of central authority.

An equally valid though opposite model can be made for decentralized bottom-up loosely-coupled network (LCN) of independent collaborators that benefit small practices and organizations. In addition to the professional autonomy benefit, the LCN’s other benefits include creativity, innovation, and attention to differing needs and circumstances of different parties. This is because collaboration among people with wide diversities of knowledge, ideas and points of view provides a larger collection of resource intellectual pools, and offers access to a greater variety of non-redundant information and more content on which to base decisions. As such, the LCNs provide the greatest opportunities for stimulating multifaceted discussions, out-of-the box thinking, and creative clinical and economic solutions.

An example of an LCN is the communities of referral that form patient centered medical homes/neighborhoods in which a primary care physician and specific specialists and facilities collaborate in the care of a specific patient. These LCNs can interconnect with each other on a nation-wide and even world-wide basis, as well as connect with TCNs. Given the political will and adequate business incentives, this global interconnectivity can be achieved rather quickly, easily and inexpensively. It can be done using a software architecture in which pub/sub nodes exchange information via simple encrypted e-mail (such as the ONC Direct Project).

Realization of this vision would enable independent-minded individuals to maintain their autonomy, while at the same time enabling them to collaborate in regional and international LCNs for the purpose of improving clinical decision support to increase value to healthcare consumers and reward providers who do so.

Dealing with EHR Dissatisfaction (Part 5)

This post is a continuation; Part 1 is at this link. In this post, I describe a examine the question: When it comes to EHRs, whose satisfaction is important?

Someone commented that EHR “satisfaction is in the eye of who? The physician? patient? government? business?... I only hope it is the patient that wins out.” This comment is intimately tied to the question: Who should gain the most VALUE/BENEFITS from EHR/health IT use?

I contend that if they improve clinical outcomes and quality-of-life (through prevention and treatment), while they contain or lower costs to providers/clinicians and prices to consumers/patients (i.e., increasing value/benefits to the providers and receivers of care), then our society (and species) wins in the long haul. A business model that focuses on short-term gains for “me & mine,” rather than on realizing a longer-term vision that focuses on the common good, inevitably harms consumers and those who care for them.

Beneficiaries of this dysfunctional business model are manufacturers, politicians, lobbyists, providers, consumers and others who line their pockets by “gaming the system” through all sorts of unscrupulous (and at times illegal) tactics. Some might conclude that this is just “the American way,” but based on the huge waste of money and resources in the in the UK's health IT system (NHS IT system one of 'worst fiascos ever'), I believe it’s a consequence of capitalism that has lost its way, along with its sense of virtue.

I contend that the underlying cause of our broken healthcare system is our pathologically mutated form of capitalism —a term coined by John Bogle, named by FORTUNE magazine as one of the four giants of the 20th century and by TIME magazine as one of the world's 100 most powerful and influential people—which he said is a “fundamentally a blight on our society…It says something very bad about American society…ultimately, the job of capitalism is to serve the consumer. Serve the citizenry. You're allowed to make a profit for that. But, you've got to provide good products and services at fair prices…What we've done is have…a pathological mutation of capitalism” (see this link).

The rational way forward with regards to EHRs, I contend, is for clinicians to demand health IT tools that enable them to increase value to the consumer and demand fair compensation for doing so (Pay for Value). These tools should be low cost, flexible, ever-evolving, interoperable, and highly useable & useful for the clinician, patient, and researcher/informaticists. It should combine the best (and simplest) methods for data entry, analytics, decision support, and presentation (display), as well as secure transport and storage. They should also be efficient and accommodate workflows (including referral point-of-care, and mandatory reporting processes), and they should include the capabilities that include clinical concept parsing & processing (i.e., tools that improve the use of clinical notes and aid in inductive and deductive reasoning). In addition, they should provide ongoing risk-adjusted information to clinicians about their individual patients and population (cohort) outcomes.

The use of innovative EHR add-ons (companion applications) is a sensible way forward, even though EHR vendors may resist for business reasons that run contrary to the goal of increasing value for patient and provider, which is not surprising as per Bogle’s criticism and the need for "real capitalism, not crony capitalism that we have now in many industries, especially healthcare.” And while EHRs should be able to incorporate information directly from patients, it should also be able to associate and substantiate it with clinical technicalities.

These capabilities are simply way too much for any EHR today, but they can be achieved over time through collaboration that expresses our views and needs, embraces creative destruction, and suppresses regulatory capture that increases complexity, cost, and inefficiency.

Should "Value" Be the New Mantra in Health Care?

On  the Commonwealth Fund blog at this link is a new post titled: "Should "Value" Be the New Mantra in Health Care?"

 

This is good to see! I began blogging about the need to focus on Value to the Consumer back in 2007, starting with a post at http://curinghealthcare.blogspot.com/2007/10/path-to-profound-healthcare.html.

 Value is a complex issue that brings into light the notion of cost-effectiveness and how to compensate providers who demonstrate a commitment to high-value care via Pay for Value (P4V) models.

 I contend that a firm focus on value is the ONLY way to solve the daunting problems plaguing healthcare delivery. If we don't, costs will continue to rise without corresponding quality improvements, and cost reductions will likely result in worse care outcomes.

Healthcare Reform "Value Promotion & Reward" Strategy

I've been writing about the need for high value healthcare for over four years. In the past year or so, more and more people have begun discussing the notion of value with regards to healthcare reform.

I've recently participated in one such discussion at KevinMD in a post about the tension between physicians and health policy experts (at this link) and another about how physician consolidation places health reformers in an ironic dilemma (at this link).

My comments focused on making the case that success healthcare reform models must be built on strategies focusing on (a) delivering high value care to every patient (client/consumer) by (b) enabling and rewarding the efficient delivery of high quality (safe & effective) “sick-care” (treating illness and dysfunction) and “well-care” (prevention and self-maintenance) within (c) a trust-worthy learning environment that promotes continuous, demonstrable improvement in care value.

Such strategies measure value as quality divided by cost, which is a measure of cost-effectiveness.

Key tactics of this value promotion & reward strategy are:

• “Value-pricing,” which means paying more for healthcare services and products proven to be more cost-effective (and vice versa)
• Patient-centered cognitive support, which consists of advanced health IT systems that help practitioners/clinicians/providers avoid information overload as they: (a) gain deep knowledge patients’ problems and risks, along with sharp awareness of the most cost-effective diagnostic, treatment and prevention options and (b) use that knowledge and awareness to make valid decisions, take competent actions and achieve good outcomes 
• Shared decision-making, during which health practitioners educate patients about their treatment options in understandable language that takes into account patients’ individualized needs, circumstances and preferences
• Practice-research collaboration (knowledge networks) that generate and disseminate ever-evolving evidence-based preferred practice guidelines and self-help recommendations
• Healthcare delivery models assuring access and availability of high-value care to everyone.

Related posts:

The Need for a Value-Pricing Model in Healthcare
Enabling EHRs to Improve Care
Healthcare Reform Models Focusing on Value to Consumers - Part 1
Healthcare Reform Models Focusing on Value to Consumers – Part 2
Healthcare Reform Models Focusing on Value to Consumers – Part 3
Four Interlocking Issues about Fixing American Healthcare
Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Pay for Value

Enabling EHRs to Improve Care

In last month’s Archives of Internal Medicine, researchers at Stanford University released results of a three-year study that found EHRs in the ambulatory setting did not improve the quality of care [Reference]. There are, however, a number of limitations to the study, including the use of process measures (what was done) instead of outcome measures (the results of care) to measure care quality, the use of data that was collected around five years ago, and the fact that the doctors’ ability to use the EHRs properly were not assessed. Nevertheless, the study’s results do raise serious concerns.

To me, these findings are no surprise. I wonder why anyone would assume that today’s minimalistic and immature EHRs (in which I include EMRs)—along with a healthcare system largely based on pay-for-procedure/fee-for-service economic models—would boost care quality or efficiency. I’m not saying EHRs can’t help improve care dramatically; instead, I’m asserting that EHRs must be greatly enhanced—in both their usefulness and usability—before significant benefits can be realized.

The core issues, as I see them, are (a) EHRs’ failure to provide patient centered cognitive support and (b) our economic model in which financial incentives, such as pay-for-performance, fail to promote better quality [Reference].

One thing that’s needed is much better clinical decision support (CDS) from next-generation EHRs. The EHRs should provide CDS based on ever-evolving, individualized, evidence-based guidelines and pathways that focus on increasing value to the patient. In addition, the EHRs should deliver to researchers comprehensive (de-identified) data collected from everyday clinical practice. The researchers would use these data, along with controlled clinical trials, to develop and continually improve personalized CDS guidelines/pathways supporting diagnostic and treatment decisions for physical and psychological sick-care and well-care (prevention).
The other thing needed is to incentivize providers who deliver high value (cost-effective) care to the patient. Data from the EHRs would be used to calculate such incentives.

Healthcare Reform Models Focusing on Value to Consumers – Part 3

My two previous posts (starting at this link) and this one discuss on how to bring high value to the healthcare consumer. I examined the two important models of healthcare delivery--the Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs)--and explored meaningful financial incentives models. In this post, I discuss issues concerning health information technology (HIT).

I defined high-value healthcare as cost-effective products and services that keep people well and improve the health & wellbeing of people who are ill. Providers (clinicians and healthcare organizations) who want to deliver such high-value healthcare require more than a desire to give their patients top quality affordable care. They also need a wealth of knowledge about the best way to prevent, diagnose and treat a wide range of health problems. This not only means continually learning, but also having access to latest evidence-based research and the guidance needed to use one’s knowledge in a way that fosters the best diagnostic and treatment decisions.

The only way to achieve high-value healthcare is to reform our current healthcare system, so it focuses 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.

Such a high-value healthcare system presents daunting challenges, however. One is being overload with overwhelming amounts of new information appearing daily. Another is the limited capacity of the unaided human brain to acquire, retain, recall and apply complex information about the human body and mind. See, for example, this link about the knowledge gap. Add to this the fact that we have a broken healthcare system full of perverse incentives (e.g., pay for procedure/volume rather than for delivering value), and there’s little wonder why healthcare in America is lower quality and much more expensive than in many other countries.

One crucial element of a high-value healthcare system it the sensible use of advanced HIT. That’s because HIT has the potential to bridge the knowledge gap and foster providers’ ability to deliver higher value care. The HIT industry, however, is having difficulty understanding what has to do; it has largely failed to develop the tools providers and patients need to increase healthcare’s value.

Consider this: The cornerstone of HIT—the electronic health record (EHR)/electronic medical record (EMR)—has been around for about 30 years. One would think, therefore, that today’s EHR/EMRs are successful. Well, knowledgeable experts have been having a great discussion at the HIMSS Linked-In group about this topic, with well over a thousand comments posted thus far. While some of the commenters believe that EHR/EMRs have been successful, most do not. The group gave many reasons for their failure, which focused primarily on technology, people and money.

From an HIT perspective, I indicated that before we can discuss EHR/EMR success or failure, we should first describe its primary goals. We could then determine whether the tools are achieving those goals. I therefore created a chart that defines three levels of EHR/EMR capabilities (weak, moderate and strong), the requirements for achieving success at each level, and the degree of usefulness of each level.

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Healthcare Reform Models Focusing on Value to Consumers – Part 2

This post follows up on my previous one about Patient Centered Medical Homes (PCMHs), Accountable Care Organizations (ACOs), and Meaningful financial incentives models. In this post I focus on the issue of how to incentivize healthcare providers in PMCH-ACOs who render high value care to their patients.

According to a recent article by the New England Journal of Medicine:

The challenges to implementation of the PCMH model include two issues that lie beyond the direct control of the primary care practice. First, although the model calls for primary care practices to take responsibility for providing, coordinating, and integrating care across the health care continuum, it provides no direct incentives to other providers to work collaboratively with primary care providers in achieving these goals and optimizing health outcomes. Second, although evidence suggests that increased investment in primary care can result in savings from several types of reductions…most primary care practices do not…share in these savings…and under the…fee-for-service payment system it is unlikely that other providers will respond to reductions in the number of referrals or admissions by allowing their incomes to fall [Reference 1] .

These issues can be resolved if the PCMH model were implemented in the context of an ACO, which is:

…a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population. Multiple forms of ACOs are possible, including large integrated delivery systems, physician–hospital organizations, multispecialty practice groups with or without hospital ownership, independent practice associations, and virtual interdependent networks of physician practices.

Regardless of the organizational structure, an ACO will not succeed without a strong foundation of high-performance primary care…investment in the PCMH model could accelerate the development of high-performing ACOs…Performance measurement for determining the amount of shared savings or other financial incentives for ACOs must weight primary care measures heavily rather than focus narrowly on metrics related to hospital care…[And] the payment mechanisms used must align the incentives of the two models to increase accountability for total costs across the continuum of care while ensuring that a sufficient investment is made in primary care capacity. [Reference 1]

Payment models to support such PCMH-ACOs could include:

…fee-for-service payment and share in any cost savings achieved relative to a risk-adjusted projected spending target for their patient population; alternatively, payment could be partially or fully capitated, with risks and gains both being shared by all providers. Performance measurement to evaluate the quality of care and to prevent potential overuse (in fee-for-service organizations) and underuse (in capitated ones) is a cornerstone of the model. [Reference 1]

[For a PCMH]…a primary care fee for all primary care or a blended payment of part fee-for-service and part monthly medical home fees, is beginning to take hold…But the most complex case is when a single global fee (or risk-adjusted capitation payment) is made for all of the care a patient needs—including preventive care, basic primary care, specialty care, emergency care, hospitalization, and post-acute care that is provided by numerous independent providers over a period of time. In that case, where should the payment go? If savings across the entire continuum of care are to be shared with providers, how should those savings be distributed?

[If the PCMH were also an ACO (PCMH-ACO), then]…physicians and other providers…agree to be accountable for the total care of patients, their outcomes, and the resources used in providing it. This solves the basic question of "to whom should I write the check" and leaves it up to the organization to decide how best to compensate providers for their contribution. [Reference 2]

In other words, providers collaborating in a PCHM-ACO work together to prevent and treat patients' health problems by focusing on delivering higher quality and lower cost care through use of cost-effective evidence-based guidelines, along with more efficient and coordinated workflow processes. Instead of paying each provider a separate fee for tests and services rendered, the PCHM-ACO team approach can adopt a combination of the following payments models:

• The primary care physician (PCP) could receive fee-for-service payments plus additional fees for running the PCMH.
• The PCP and specialists treating the patient could receive a flat fee for each patient to cover the entire episode of care, with the amount based on the severity of the patient's health problems; if they deliver high quality care at a cost lower than projected for similar patients, they would share the savings as well.

And as with any performance-based accountability system, it is important to determine the best ways to measure important aspects of care quality, minimize the cost of delivering such care, and reward those who accomplish these objectives, including:

• Mak[ing] the performance rewards large enough to matter, but not larger than the actual benefit of the improved performance.
• Creat[ing] measures that people can influence. Do not hold people accountable for problems outside of their control. [Reference 3]

Note that various types of performance measures have been endorsed by different organizations, including Physicians Quality Reporting Initiative (PQRI) process guidelines [Reference 5] and ones that:

…can be calculated using longitudinal administrative data…but it should be possible to get even richer data more widely available…One 'gaping hole' where more experimentation is needed…risk adjustment…We don't know how to case-mix adjust for episodes of care. We can't even agree on the definition of episode of care. [Reference 6]

The "richer data" mentioned above should include comprehensive clinical biopsychosocial data … [wellness wiki Reference 6].

And finally, a PCMH-ACO ought to have these four characteristics, which shared by all ACOs:

1. …an evidence-based approach to medical care; using the body of medical evidence
   
2. …heavy investments in information technology to organize data so that caregivers have the most accurate information available
   
3. …quality and cost reporting—the ability to actually report on costs and how quality is affected
   
4. …To be successful…the purchasers of healthcare [must] distinguish between the highest value of all the ACOs in that market and direct their people to those organizations…Price…or premium controls…[should be] based on quality and cost reductions…demonstr[able] through data on a defined population. [Reference 7]

In my next post, I'll discuss the health IT requirements for a sustainable PCHM-ACO.

References

[1] Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform http://healthcarereform.nejm.org/?p=2205

[2] Coherent and Transparent Health Care Payment: Sending the Right Signals in the Marketplacehttp://www.commonwealthfund.org/Content/Blog/Aug/Coherent-and-Transparent-Health-Care-Payment.aspx

[3] Financial Incentives Can Improve Public Sector Performance http://www.rand.org/news/press/2010/08/09/index1.html

[4] Building A Path To Integrated-Care Payment Systems http://healthaffairs.org/blog/2010/02/12/building-a-path-to-integrated-care-payment-systems/

[5] Physician Quality Reporting Initiative (PQRI) http://www.cms.gov/PQRI/

[6] Wellness Wiki http://wellness.wikispaces.com/Using+Claims+Data and http://wellness.wikispaces.com/Tactic+-+Deliver+Biopsychosocial+Healthcare

[7] Making Healthcare Accountable http://texasceomagazine.com/?p=418

Healthcare Reform Models Focusing on Value to Consumers - Part 1

Many important things have been happening in the healthcare industry. What I found most exciting is the recent focus on establishing and supporting:

1. Patient Centered Medical Homes (PCMHs)
2. Accountable Care Organizations (ACOs)
3. Meaningful financial incentives models for clinicians and organizations demonstrating care quality improvement and cost control (i.e., cost-effective healthcare delivery bringing value to patients/consumers).

PCHM

I've written about the PCMH model several times over the past four years (see this link). A PCMH is, in essence, a physician practice headed by a primary care physician, which provides coordinated care through collaborating interdisciplinary teams. These groups of sick-care and well-care practitioners focused on delivering high-quality preventive care and effective chronic disease management focused on demonstrating positive patient outcomes.

ACO

An ACO, which goes hand-in-hand with the PCMH, is a related model that focuses on "…the alignment of incentives and accountability for providers across the continuum of care" [Reference]. Together, the PCMH and ACO "…are helping organizations to create systems where care delivery is performed by a team of professionals led by the primary care physician and are held accountable for the care they provide…[T]he patient and the family are the major focus of the program. Engaging them into the process is key to the success. The programs that have been successful have [been] identifying patients at risk and developing a coordinated plan with the help of a multidisciplinary team" [Reference].

Financial Incentives: Pay for Value

Financial incentives used in performance-based accountability systems (such as the PCMH/ACOs) have been found to help improve performance, resulting in better outcomes (more effective and efficient care). "…But creating an effective performance-based accountability system requires careful attention to choosing the right design for the system, which must be monitored, evaluated and adjusted as needed to meet performance goals" [Reference]. And, I'd add, the incentives must be great enough to matter.

For example, "pay for performance" (P4P) programs that give small financial incentives result in only modest care quality improvements since the potential financial reward represents only a small percentage of the overall physician pay and thus do not serve as a strong incentive. This doesn't surprise me. As I wrote three years ago at this link, we ought to be focusing on transforming from P4P to a "pay for value" (P4V) approach that rewards providers who deliver high-value care to patients/consumers that promotes the cost-effective prevention and treatment of illness, dysfunction and distress. Dealing with such a complex and controversial issue is certainly a challenge.

In any case, the three inter-related transformational models discussed above hold great promise! They provide useful approaches for improving our dysfunctional healthcare system. These strategies and processes are consistent with the Patient Centered Value Chain I wrote about three years ago at this link.

A key question remaining is: How should P4V be implemented so it fosters and supports PCMH/ACOs through adequate incentives and meaningful use of health IT?

Affordable Care Act

The Federal government's Affordable Care Act offers answers to this question, although finding a solution is made more difficult--as stated eloquently by Karen Davis of the Commonwealth Fund--because the healthcare industry:

…is not like markets for other goods and services. Information on prices is not typically available, decisions…are often made in an emergency, and patients lack knowledge about the value of diagnostic and treatment services…or where to go for the best care with the best prospects for full recovery, functioning, and quality of life.

Nevertheless, the Affordable Care Act offers a solution by presenting:

...important provisions to increase access to information on the quality of physician and hospital care and establish multi-payer databases that will provide a more comprehensive picture of patterns of care across providers. It also begins to address the imbalance between primary and specialty care by increasing primary care payment rates under Medicare and Medicaid. [It seeks]…new ways of paying for and delivering health care, including 'bundled' methods of payment to encourage providers to work together across health care settings…[and] rewarding those who offer appropriate, high-quality, and efficient care.

These initiatives represent a move away from the current fee-for-service system…[and] can help improve transitions in care from one provider to another and one care setting to another. Many errors occur during these hand-offs and patients often experience frustrations due to inadequate communication among providers involved in their care. These initiatives are one important step in the evolution of a new payment system that will provide incentives to achieve the best results…and in doing so achieve savings from the elimination of wasteful, duplicative, or avoidable treatment.

[In addition to changing payment methods]…new health care organizations that are accountable for both patient outcomes and the resources devoted to care will need to be formed …[and supported with] better information, tools, and technical assistance to ensure that essential services are provided efficiently while quality, innovation, productivity, and prevention are enhanced. Safeguards will also be needed against potential under-provision of care or exercise of undue market power [Reference].

In my next post (part 2), I examine various financing models for paying for the kind of coordinated, high quality, affordable care PCMH/ACOs can deliver.

American Values and Healthcare Reform

Chris Fleming of Health Affairs recently posted and article about American values and health reform at this link. In it he writes:

During the current health reform debate, both Democrats and Republicans have often made their case in terms of values such as liberty, justice, and equality…philosopher Paul Menzel…argues that this apparent conflict between justice and liberty can be addressed by considering liberty "in its fullest context, bound up with responsibility – where both are connected to fairness and justice."…[And Thomas Murray, Hastings Center president] argues that"…simplistic understandings of values are deceptive and harmful to private insight and public discourse. Liberty, properly understood, is not the opposite of equality; justice, not the opposite of liberty; and responsibility, both personal and social, is crucial to the full realization of liberty and justice. Efficiency, an instrumental value rather than an end in itself, is intimately related to quality, solidarity, stewardship, and justice. Core American values, rather than existing in ineluctable tension with one another, form a sturdy, mutually reinforcing foundation for health reform."

I agree that personal and social responsibility, liberty and justice, efficiency and quality are (or at least should be) core American values that guide the healthcare reform debate. They fit in perfectly with the four criteria and eight objectives for judging how likely any government policy will create a sustainable healthcare system, which I wrote about last week at this link. And they are consistent with an article I posted last month at this link about a principled and pragmatic approach to healthcare reform that emphasized empathy and compassion.
Related posts:

• Personal Responsibility: A Thorny Issue in Healthcare Transformation
• Low-Cost, High-Quality Care In America: A Reply
• How to Reform Healthcare Sensibly: Focus on Two Clear Goals
• Healthcare Reform’s Most Important Issue: How to Make it a High-Value System
• Empathy, Taxes, Personal Responsibility, and Healthcare Reform Empathy, Taxes, Personal Responsibility, and Healthcare Reform – A Timely Debate (part 1)
• Empathy, Taxes, Personal Responsibility, and Healthcare Reform – A Timely Debate (part 2)
• Healthcare Reform: Where to Focus?

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:

• American Values and Healthcare Reform
• Personal Responsibility: A Thorny Issue in Healthcare Transformation
• Criteria for a Sustainable Health System
• Low-Cost, High-Quality Care In America: A Reply
• How to Reform Healthcare Sensibly: Focus on Two Clear Goals
• Healthcare Reform’s Most Important Issue: How to Make it a High-Value System
• Empathy, Taxes, Personal Responsibility, and Healthcare Reform Empathy, Taxes, Personal Responsibility, and Healthcare Reform – A Timely Debate (part 1)
• Empathy, Taxes, Personal Responsibility, and Healthcare Reform – A Timely Debate (part 2)
• Healthcare Reform: Where to Focus?

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:

• A Principled and Pragmatic Approach to Healthcare Reform
• Low-Cost, High-Quality Care In America: A Reply
• How to Reform Healthcare Sensibly: Focus on Two Clear Goals
• Healthcare Reform’s Most Important Issue: How to Make it a High-Value System
• Empathy, Taxes, Personal Responsibility, and Healthcare Reform
  Empathy, Taxes, Personal Responsibility, and Healthcare Reform – A Timely Debate (part 1)
• Empathy, Taxes, Personal Responsibility, and Healthcare Reform – A Timely Debate (part 2)
• Healthcare Reform: Where to Focus?

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.

Related links:

• How to Reform Healthcare Sensibly: Focus on Two Clear Goals
• Healthcare Reform’s Most Important Issue: How to Make it a High-Value System
• Empathy, Taxes, Personal Responsibility, and Healthcare Reform
• Empathy, Taxes, Personal Responsibility, and Healthcare Reform – A Timely Debate (part 1)
• Empathy, Taxes, Personal Responsibility, and Healthcare Reform – A Timely Debate (part 2)
• Healthcare Reform: Where to Focus?

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: http://curinghealthcare.blogspot.com/2007/09/worthiness-socialized-medicine-and.html

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 http://wellness.wikispaces.com/The+Wellness+Plus+Solution
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.