Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Pay for Value

Continuing the series on the PCLC Value Chain strategy [click here for the first post in the series], this post focuses on a third process in need of reform: The transformation from "pay for performance" to a "pay for value" model that rewards providers who deliver high-value to patients/consumers. Being a complex and controversial issue, this post is lengthy, but hopefully insightful.

Defining Pay for Performance

Today's Pay-for-Performance (P4P) model uses "quality" measures (metrics)--devised by insurers, government and big healthcare institutions--to judge the performance of providers (hospitals and clinicians) and pay them based on their performance. In the P4P process, monetary rewards are given to providers who follow specific evidence-based guidelines for particular types of patients and, for some conditions, who achieve certain results in patient health and well-being. And recently, the Centers for Medicare and Medicaid Services (CMS) decided to add a "stick" to the P4P "carrot," by announcing that they will cease paying for care made necessary by "preventable complications;" that is, they won't pay for certain conditions caused by medical errors or improper care--conditions that could have reasonably been avoided.

Thus, reforming healthcare via P4P "…rests on the following three principles: payers [insurers and CMS] should pay more for the treatment of conditions that require more resources and that the provider could not reasonably have prevented; they should pay more when evidence-based or consensus-based best practices are followed; and they should pay less or not at all for low-quality care. Naturally, the last will be the most controversial."[1]

While such an incentive model may affect clinician behavior [2][3], and although the number of P4P programs is growing, critics say that they increase providers' administrative burden while giving no clear evidence money will be saved or quality will be improved.[3a] Furthermore, using compliance to evidence-based guidelines as the measure of performance can be problematic for numerous reasons.[4][5]
These issues and others pose significant challenges to any P4P program.

P4P Challenges

P4P programs must deal with the following challenges:

• A provider's practice may be too small to permit valid analysis of the performance data.
• Patient population differences--in terms of health status, insurance coverage, etc.--may mean that a specific practice guideline may work well for certain patients in certain situations, but not work for others.
• Even though providers may adhere to practice guidelines tied to P4P, they may not comply with guidelines for which there is no performance assessment and financial incentive.
• Many specialties lack evidence-based guidelines, and the guidelines that exist may not be valid.
• Performance metrics must be adequately "risk-adjusted" for patients with difficult to treat problems. These risk-adjustments alter the criteria for determining "successful" care by accounting for differences in the severity of patients' conditions treated by different providers, thereby enabling fair comparisons. It can be very difficult, however, to establish valid are risk-adjustment equations.
• When a guideline is not clinically appropriate for a particular patient, a provider should not be penalized for deviating from it with minimal, but appropriate, documentation.
• P4P programs may end up costing the system more in the long run.
• If providers chase different P4P criteria developed by different payers, it can lead to duplication of services and unnecessary testing.
• Different insurer-based P4P programs often measure performance differently, which results in unnecessary administrative burdens, as well as failing to adjust for differences in patients' conditions, economics and demographics.[5a]
• Since quality metrics are largely arbitrary, different healthcare plans tend to have different performance indicators for the same disease, which convolutes the process.
• P4P could simply redirect money toward wealthier areas where patients are more likely to follow doctors' orders.
• Patient satisfaction surveys can be unreliable.
• When a patient is treated by multiple clinicians, it can be unclear who is responsible if a recommended guideline isn't followed.
• A patient's ability and willingness to adhere to self-maintenance instructions often affect outcomes, thus impacts provider performance measures.

One way P4P programs attempt to deal with such challenges is by establishing useful performance measurement standards.

Performance Measurement Standards

At least three standards are related to measuring clinician and hospital performance:

1. Process compliance standards
2. Care outcome standards
3. Care value standards.

Process Compliance Standards

Process compliance standards measure the "quality" of providers' performance based on whether they follow recommended guidelines reflecting preferred care processes. For example, typical P4P programs reward providers who perform certain predefined procedures (processes), such as doing a Hemoglobin A1c test a certain number of times each year for patients with diabetes. These standards measure the degree of compliance to such established procedures.

Some of the problems with P4P are exemplified by research showing that following recommended procedural guidelines for hospitalized patients with heart attacks--e.g., give patients aspirin and beta blockers at admission and discharge--doesn't mean better outcomes as measured by 30-day mortality rates.[6] So, after 30 days of an attack, the research shows that the health status of a patient with actuate myocardial infarction is influenced only slightly by whether or not his/her provider followed the guidelines. This is because outcomes research is still an infant science, which makes P4P premature, at best. In this case, and in many others, measures of performance are too crude (i.e., limited whether the patient died within 30 days, but ignores what happens after that time) and too narrow (i.e., aspirin, beta blockers and a few or recommended interventions are inadequate to address all of a patient's needs and problems). So, it appears that care quality is not necessarily related to guideline compliance.

Let's examine this issue a bit more deeply. Adhering to existing process guidelines are, no doubt, helpful for many patients. But numerous other things not appearing in a process guideline, and thus not used to measure the quality of care, may be as important (and possibly more important) to improving a patient's health and well-being.

For example, important processes lacking in today's P4P guidelines, and not being considered as quality metrics, include:

• Educating a patient suffering from congestive heart failure about the pros and cons of a heart operation
• Counseling and coaching the patient to make critical lifestyle changes (e.g., good eating and exercise) and to manage stress more effectively
• Implementing cost-effective complementary and alternative interventions
• Using computerized diagnostic aids, clinical pathways, continuity of care records, and electronic medical/health records.

Other important processes affecting care quality that P4P programs fail to measure include:

• How well a patient's plan of care maps to his/her primary diagnosis and comorbidities (the presence of one or more disorders/diseases that co-exist with a patient's primary disorder/disease)
• Whether a plan of care is based on a general guideline, or whether it is personalized, i.e., tailored to each patient's unique situation by taking into account patient-specific biomedical, psychological, genetic, cultural, and historical factors, as well as one's personal preferences
• How well care is coordinated among a patient's providers after discharge from the hospital
• The quality of care delivered in both inpatient and outpatient settings (e.g., whether there were errors, omissions, infections, etc.)
• The patient's ability and willingness to comply with self-management care plans to prevent complications or worsening a condition
• The appropriateness of the self-management care plans, as well as patient education and compliance counseling/coaching.

Care Outcomes Standards

Unlike process compliance standards, care outcomes standards do not focus on whether specific procedures were followed. Instead, they measure the effectiveness of whatever treatments were delivered, and whether clinical goals are achieved for patients with particular conditions. For example, a care outcome standard for diabetics is blood glucose control defined as a Hemoglobin A1c test target goal of less than 7.0%. This means care outcomes data should measure more than mortality rates (patient deaths); they should also measure a patient's physical and psychological signs and symptoms--including patient complaints, clinician observations, vital signs, lab test results, imaging studies, and quality of life (such as mental health, mobility, social functioning, role limitations, vitality, etc.).

Interpreting care outcomes data ought to take into account factors that may influence the care results, such as:

• Comorbidities and their effect on the patient
• Allergies and other things that can cause adverse reactions/side-effects
• Environment conditions (at home, in the workplace, etc.)
• Treatment history
• Family history
• Genetic markers
• Patient's attitudes and preferences
• Patient's emotional state
• Patient's psychosocial situation (e.g., degree of family support).

Understanding how to use care outcomes to measure quality, therefore, is a complex process that requires a wealth of diverse health data. Unfortunately, existing P4P programs do not use comprehensive care outcomes to assess the quality of care. Instead of obtaining and analyzing detailed lots of clinical data (signs and symptoms), they typically rely on insurance claims (administrative) data.

Claims data provide some useful measures of quality, including mortality rates, complications; and claims data provide useful information about cost. These data, however, provide grossly inadequate metrics for improving care quality and efficiency. This is because claims data do not include information necessary to determine, for example, how much a patient's signs and symptoms improved after treatment, if errors were made, if lower cost treatments of equal or greater effectiveness could have been used, if the patient was educated adequately in self-care and complied with the prescribed plan of care, and if coexisting conditions affected results. Without such care outcomes data, it isn't possible to evaluate a provider's performance accurately nor gain the knowledge needed to improve healthcare effectiveness and efficiency. So, instead of using claims data alone to measure care outcomes, they should be augmented with detailed clinical data.
Measuring process compliance, and balancing clinical and claims outcomes data are essential to assessing care quality, but rewarding cost-effectiveness require care value standards.

Care Value Standards

In contrast to care process and outcomes standards, care value standards combine process and outcome quality metrics with economic metrics to measure cost-effectiveness, which defines the value of care.

If our healthcare system was rational and guided by wisdom, a top priority of healthcare professionals and patients/consumers would be to maximize care quality and efficiency (i.e., value) by:

• Gaining valid knowledge about healthy living, the causes and diagnosis of physical and mental health problems, and the treatments delivering the best results most cost-effectively to each patient.
• Understanding how to use this knowledge to maximize value to the patient/consumer by increasing care effectiveness and efficiency, as well as improving prevention and self-maintenance of chronic diseases.
• Continuously evolving this knowledge and using it to improve care quality and lower costs continually.

For significant improvement in healthcare delivery, useful and reliable care value standards must be established for every health risk factor, illness/condition, and healthcare discipline/field; and these standards must be used to measure and reward high-value performance. Unfortunately, today's P4P programs fail to do this since, in part, measuring care quality is so difficult.

Pitfalls of Care Quality Measurement

Following are potential pitfalls of care quality measurement:

• Today's diagnostic systems often fail to point to the highest quality treatment options, which means we often don't know the what care interventions are likely to produce the best results.[7]
• Few guideline standards are specific enough to account for individual differences in patient with the same diagnosis. For example, a recent study found that a moderately high total cholesterol level is associated with higher survival in certain patients with heart failure.[8] Such specificity is needed for high quality personalized care.
• Constantly evaluating and revising evidence-based guidelines based on new knowledge is very difficult. But if they do not continually evolve, the guidelines do not promote quality since they are just "a record of the past, and little more-they should have an expiration date."[9]
• According to HHS Secretary Mike Leavitt, "Medical associations and others have begun the work of developing quality standards and cost measurement, but we have many years of work ahead of us to achieve the wide-ranging and meaningful quality standards we need."[10]
• No mater what quality measures are used, there are complex issues to be resolved, such as:
• At what point is there sufficient confidence in an evidence-based guideline that there is no longer any need to spend time or money on the continuous evaluation of its reliable and validity?
• When is a definition of quality too narrow, e.g., by focusing on cost or symptom reduction, but not considering prevention, recurrence, coordination and continuity of care, or the patient-physician relationship?
• How do you measure quality when resources are scarce and optimal care for the community may require less than "the best" care for its individual members (e.g., delegating office nurses to perform certain activities that physicians used to do)?
• What is the best way to measure quality if outcomes are more strongly affected by patient compliance than by physician orders? This may occur, for example, if certain providers have personalities that trigger greater patient compliance, and visa versa.
• Is it poor quality care if a provider follows the recommended practice guideline, but the patient is atypical and responds poorly? [11]
• Use of claims (administrative) data to measure care quality is grossly inadequate for many reasons.[12]
• As discussed earlier, assessing care quality using process data may not be valid since they do not necessarily reflect care outcomes.[13]
• One thorny issue is how to avoid political and ideological biases when determining what evidence to use as the basis for establishing the guidelines, since quality care is unlikely to be achieved unless treatments are based on objective science.[14]
• Many areas of healthcare lack care process standards and/or quality measures. That is, different healthcare disciplines and specialties require different types of data to evaluate quality. For example, it's foolish to measure the quality of mental healthcare services with data appropriate for evaluating cardiologists' performance; and the same is true for a podiatrist, dentist, chiropractor, etc.-each need different measures for determining quality, but they are often lacking.[15]

We must deal with these challenges and pitfalls before P4P incentives will lead to substantial care quality improvements. But even if P4P results in more effective diagnostic and treatment procedures, this increased higher quality care fails to address the problem of high costs due to inefficiency, which includes wasteful over-testing, over-treating, and delivery of more expensive care when less costly alternatives are just a effective, as well as inadequate focus on wellness/preventive care. Only the transformation to "Pay for Value" (P4V)--in which the most cost-effective (high-value) care is rewarded--will make healthcare more affordable and available.

Transformation to Pay for Value

Unlike P4P, P4V focuses on the relationship between diagnosis, treatment, clinical outcomes and cost to increase care value through incentives for improving care quality and efficiency, i.e., cost-effectiveness. The transformation to P4V requires that we:

• Revamp our diagnostic system to classify each patient more precisely
• Tailor treatment guidelines to patient's individualized needs and preferences by identifying and recommending the most cost-effective care for each patient, including attention to the mind-body connection and appropriate alternative and complementary interventions
• Maximizing efficiency by minimizing waste and paying strong attention to wellness & prevention
• Track patient's data across their entire lifetimes using comprehensive clinical outcomes and cost data.

If we did this, we would have patient-specific evidence-based guidelines defining the most cost-effective care tailored to each patient's particular needs. We could then reward providers for rendering such high-value care. This is the essence of P4V.

Unfortunately, our country has not been moving in the P4V direction because we fail to:

• Focus on supporting the kinds of research and information systems necessary for generating and using the kind of evidence-based guidelines providers and patients need to improve outcomes and control costs through greater quality and efficiencies
• Reduce waste and expense by selecting and implementing the most cost-effective care options and prevention strategies.

This means that today's P4P programs are built on flimsy knowledge. In essence, we are pretending that we know (a) what each patient needs to remain well through prevention; (b) when ill, what each patient needs to get well with least risk and complications; and (c) how to deliver such care with the greatest efficiently and least cost.

Let's Stop Deceiving Ourselves

Pretending we know what high-value (cost-effective) care is and how to deliver it--as we flounder in a knowledge gap dominated by ignorance and uncertainty and inadequate health information technologies--is a dangerous form of self-deception. We are deceiving ourselves into believing that rewarding providers via P4P for following current day best practice guidelines is going to increase the quality and reduce the cost of care when (a) research shows that today's guidelines are neither personalized nor focused on cost-effectiveness and (b) following the guidelines do not necessarily result in better outcomes, as discussed earlier.

So, instead of pretending, we should be obtaining and using the knowledge we need about care value by investing more in clinical research (in both lab and field) and advanced information systems that provide next-generation decision-support, collaboration, and continuity of care capabilities. This means we should be focusing on transforming our current healthcare system to a value-based system that:

• Pays for the research, collaboration and information systems needed to establish, evolve, disseminate and use high-value, evidence-based guidelines that are tailored to each patient's particular needs.
• Offers financial incentives to the providers who engage in this knowledge-building and utilization process to deliver high-value care, rather than simply rewarding those who follow today's inadequate guidelines.

Once we've established valid and reliable patient-specific best practice guidelines--which take into account both quality and cost--then we are ready to make the transformation to pay for value (P4V). In the mean time, we ought not postpone P4P initiatives, as long as:

• Clinicians who chose not to follow standardized guidelines for particular patients will also receive the reward if they have a good reason for doing things differently
• Ample clinical and financial outcomes data are collected to determine the effect of following general guidelines with particular patient types, so we are able to make them more personalized over time
• Built into the P4P methodology is an increased focus on rewarding clinicians who get good results at a good price, and decreased focus on simply following general processes
• Money spent in these early P4P initiatives do not restrict spending on research aimed at developing personalized guidelines and better decision tools
• There is an explicit strategy to move toward giving P4V rewards to multidisciplinary teams of clinicians who are involved in treating the same patient, as opposed to each individual clinician, in order to promote better continuity of care.

In other words, the transformation from today's P4P initiatives to P4V should be based on a clear strategy to:

• Improve/evolve current evidence-based guidelines to be ever more personalized
• Make financial rewards increasingly based on clinical outcomes data reflecting high-value care delivery
• Enhance collaborative efforts within teams of clinicians promoting better continuity of care.

In addition, P4V should include "shared decision making" augmented by patient decision aids for achieving informed patient choice. This strategy would promote "a new standard of practice for defining medical necessity for many discretionary treatments based on informed patient choice … [which is beneficial since] informed patients appear to demand less surgery than the amount now being performed … and the risk for serious medical error occasioned by providing an unwanted therapy is greatly diminished."[16]

Failure to do these things can do more harm than good by making us complacent in the belief that we are doing enough, whereas in reality, these early P4P models do relatively little when you realize what ought to be done in the long term to increase care value!

Bridges to Excellence

There are potentially useful P4P models being offered, which can foster the transformation to P4V. One such model, named Prometheus, is being proposed by the Bridges to Excellence organization, a non-profit group of employers, physicians, health plans and patients working to create significant leaps in the quality of healthcare. It focuses on a payment system that uses (a) "evidence-based case rates" that determine how much to pay providers based on the cost of the resources required to deliver care according to evidence-based practice guideline, and (b) a comprehensive scorecard of quality to pay more money to providers who consistently follow certain practice guideline processes, demonstrate good clinical outcomes, receive high patient satisfaction ratings, and operate cost-efficiently.[17]

In my next post in this series, I discuss the Whole-Person Integrated-Care solution.

References:

[1] Rosenthal, M.B. (2007). Nonpayment for Performance? Medicare's New Reimbursement Rule. New England Journal of Medicine; 357(16):1573-5.
[2] Ibid.
[3] Rosenthal, M.B., et al. (October 2005) Early Experience with Pay-for-Performance: From Concept to Practice. Journal of the American Medical Association, 294 (14):1788-93.
[3a] Modern Physician Online (Sep 17, 2007). P4P programs' value questioned despite growth.
[4] Garber, A.M. (2005). Evidence-Based Guidelines As a Foundation For Performance Incentives. Health Affairs, 24, (1): 174-179 Available at http://content.healthaffairs.org/cgi/content/abstract/24/1/174
[5] Cannon, M.F. (2006). Pay-for-Performance: Is Medicare a Good Candidate? Cato Institute Working Paper. Available at http://www.cato.org/pubs/wtpapers/cannon_whitepaper_2006.pdf
[5a] Minneapolis/St. Paul Business Journal (Nov 19, 2007).
[6] Bradley, E.H., et al. (2006). Hospital Quality for Acute Myocardial Infarction: Correlation Among Process Measures and Relationship With Short-term Mortality JAMA;296:72-78. Available at http://jama.ama-assn.org/cgi/content/abstract/296/1/72.
[7] Current Diagnostic Codes are Inadequate - WellnessWiki
[8] Reuters (Sep 20, 2006). Elevated cholesterol may benefit failing hearts.
[9] Gawande, A (2004). The Bell Curve. The New Yorker.
[10] Bush's Value-Driven Health Care Plan Gains Steam as More Employers Step Up (May 10, 2007)
[11] Donabedian, A. (2005). Evaluating the Quality of Medical Care. The Milbank Quarterly 83, 691-729.
[12] Use of claims data is inadequate - WellnessWiki
[13] HealthDay (July 5, 2006). Hospital Ratings Don't Fully Reflect Patient Outcomes.
[14] Healy, B. (Sep. 2006).Who Says What's Best? U.S. News and World Report.
[15] Need for specialy measures - WellnessWiki
[16] Wennberg, J.E., et al. (2007). Extending the P4P Agenda, Part 1: How Medicare Can Improve Patient Decision Making and Reduce Unnecessary Care. Health Affairs; 26(6):1564-74.
[17] Bridges To Excellence (2006). Prometheus White Paper - Paying for Excellence. Available at http://www.bridgestoexcellence.org/bte/wp_prometheus.htm

Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Value-Based Competition

Continuing the series on the PCLC Value Chain strategy [click here for the first post in the series], this post focuses on a second clinical process in need of reform, that is, the transformation to "value-based competition."

Current Competition Models are Misdirected

Healthcare market forces in America over the past decade have transitioned from managed care and capitation to integrated delivery (integration of health insurance with provider systems) to a vision in which providers compete to improve care quality and control costs, and consumers choose the best providers.[1]

There is now debate on whether competition should be redirected by:

• Eliminating provider networks and encouraging informed, financially responsible consumers to choose the best provider for each condition
• Encouraging integrated delivery systems with incentives for teams of professionals to provide coordinated, efficient, evidence-based care, supported by state-of-the-art information technology
• Basing selection of particular healthcare services on local population needs and core competencies of the providers.

Why redirect competition? Because there's ample evidence that competition in our healthcare system today is misdirected, for example:

• Instead of competing on the ability to prevent, diagnose and treatment healthcare problems … competition today is among health plans, hospitals, and networks
• Instead of competing to improve healthcare value - the level of care quality per dollar spent over time … competition today focuses on cost reduction by transferring costs to someone else without reducing total costs
• Instead of competing to create value at the level of health problems by developing expertise, reducing errors, increasing efficiency, and improving outcomes … competition today focuses on signing up healthy consumers, discounting prices to large payers and groups, consolidating for increased bargaining power, and cost shifting
• Instead of competing at the regional and national level … competition today is local
• Instead of competing based on distinctiveness by offering services and products creating unique value … competition today focuses on building full-line services, forming closed networks, reducing rivalry by consolidating with others, and matching competitors
• Instead of focusing on obtaining and sharing information about providers and treatment alternatives for specific conditions … most information shared today is about health plans and consumer satisfaction surveys
• Instead of helping consumers find the best care value for specific conditions, simplifying billing and administrative processes, paying bills promptly … payers today attempt to attract healthy subscribers, raise rate for people with health problems, restrict treatments and out-of-network services, and shift costs to providers and patients
• Instead of focusing on developing areas of excellence and expertise by engaging in quality improvement programs and use evidence-based practice guidelines to enhance care effectiveness and efficiency, and to eradicate mistakes … providers today tend to offer every service, often below prevailing medical standards, refer patients with their own network if at all, spend less time with patients and discharge them quickly, and practice defensive medicine.[2]

Redirecting Competition

Redirecting competition in this way focuses on delivering better outcomes and reducing costs. Methods offered as ingredients for changing the current system of competition include:

• Eliminate restrictions to competition and choice. Remove preapprovals for treatment or referrals, as well as network restrictions; enforce antitrust rules against collusion, excessive concentration, and unfair practices; and make co-payments and medical savings accounts more meaningful by applying high deductibles to give consumers incentives to seek high-value care, or else make people cost-conscious of their insurance premium and have clearly defined standardized benefit packages based on a community rated risk pool basis that allows unambiguous comparisons between different health plans.
• Make useful information more accessible. Collect and widely disseminate appropriate information about treatments and alternatives; make immediately available information about providers' experience in treating particular health problems; develop, continually enhance risk-adjusted outcomes data; standardize some information to enable national comparisons.
• Transparent pricing. Each provider sets a single price for each treatment/procedure, while different providers set different prices; price estimates are made available in advance to enable comparisons.
• Simplified billing. Use one bill per hospitalization or period of chronic care; payers have legal responsibility for medical bills of paid-up subscribers.
• Nondiscriminatory insurance. Eliminate re-underwriting; use assigned risk pools for those needing them; require health plan coverage that would create equity and value throughout the system.
• Better treatment coverage. Use a national list of minimum required coverage; additional coverage results from competition, not litigation.
• Fewer lawsuits. Provide more information that disclose risks and inform consumers of their choices; limit lawsuits to obsolete treatments and carelessness.[3]

New Care Delivery Models

There several care delivery models care, which focus on the establishment of collaborative, multidisciplinary teams of providers who deliver more coordinated care to their patients. These models include:

• Integrated care. "Integrated delivery systems" (IDSs) are built on the core of a large, multispecialty medical group practice, often with links to hospitals, labs, pharmacies, and other facilities, and often with sizable revenue based on per capita prepayment (as opposed to fee for service). Examples of IDSs include Kaiser Permanente, HealthPartners, Group Health Cooperative, Cleveland Clinic, Mayo Clinic, and Geisinger Health System). These systems execute processes to ensure the provision of appropriate, evidence-based care; offer the full spectrum of care coordination; use of comprehensive, shared patient records; and are able to improve efficiency on a large scale. Unlike a recommendation above, IDSs by their very nature restrict access to networks of providers.[4]
• Integrated care versus selective diversification. Unlike "integrated care," the strategy of "selective diversification" focuses on selecting the particular healthcare services to offer based on local population needs and core competencies of the providers. Whereas integrated care can work well for organizations with mechanisms for governance that balances the authority of the system with the autonomy of key service units, selective diversification is more appropriate for organizations in which facility-specific local boards retain ultimate fiduciary authority. Under the selective diversification model, hospitals compete not for the entire clinical continuum, but for each service separately, which takes advantage of their local expertise, market potential and financial resources.[5]

Value-Based Competition

The cornerstone of value-based competition is for providers who demonstrate better results to gain competitive advantage for higher profits/income. That is, clinicians whose patients remain healthier longer, recover more quickly, and avoid complications--and who achieve these positive outcomes at a least cost--would receive more referrals, a higher payment rate, and/or other financial rewards.

Let me first define what I mean by "value." Value is measured by dividing the quality of care delivered by its cost, i.e., V = Q / C:

• Q (Quality) is defined as the degree to which care is delivered safely, effectively and equitably. The care may include conventional and alternative interventions for treating illness, as well as wellness intervention for prevention and health optimization. Quality can be measured based process compliance standards, clinical outcomes standards, or both.
• C (Cost) is defined as the degree to which the care is delivered efficiently and economically.
• V (Value), therefore, can be defined as cost-effectiveness ("bang for the buck").

So, in this sense, providers delivering the most cost-effective care are producing the greatest value for the consumer, and that value ought to be recognized and rewarded.

There is already some movement in this direction. For example:

"Seeing low fees for family doctors as a weak link in the nation's health care system, some big employers and health insurers are seeking new ways to pay doctors to reward high-quality medical care. An influential medical standards group plans to present a new model today [11/7/07] for helping employers and insurers to identify the best primary care doctors and to steer patients their way. Those doctors, in turn, would be paid for more services than are currently reimbursed under typical health plan payments for office visits.

The idea is to encourage doctors to meet with patients for more than a few minutes during an office visit and to also compensate them, or nurse coordinators, for communicating with patients by phone and e-mail outside office hours. Doctors would also be compensated for helping patients manage chronic conditions - like reminding diabetic people to take their insulin-- and would be encouraged to transmit prescriptions electronically.

The group proposing this model, the National Committee for Quality Assurance, a nonprofit organization focused on health care, plans to present its plan today in Washington at a big meeting of doctors, insurers and employers that provide health benefits."[6]

A related model promoting value-based competition on results involves having providers form "integrated practice units" (IPUs) that pull together the talent and facilities required to deliver coordinated care over the entire care cycle (i.e., each episode of care) for each patient. These IPUs would include all providers treating a patient and all services delivered by these teams, from diagnosis to treatment to rehabilitation and long term management, and even prevention. The IPUs focus on particular health condition for which they have expertise enabling them to demonstrate superb clinical results and efficiencies. Both risk-adjusted outcomes and costs would be measured over the full cycle of care; not for discrete interventions or procedures. Teams who have better outcomes at lower costs, i.e., deliver greater value, have a competitive advantage and receive more referrals, as well as financial incentives. These comparisons would be made at regional, national, and even world level, not only locally within their own healthcare system; patients would be given incentives to travel to the best providers. Successful IPUs would, therefore, gain ever greater experience treating particular conditions and would develop ever greater expertise and efficiencies, thereby continually improving the quality and lowering the cost of care delivered.

While coordinating care within multidisciplinary teams and rewarding cost-effective care are critical to improving our healthcare system, the IPU model has several shortcomings, including:

• It is very difficult to categorize each patient's problems neatly into a finite set of standard medical conditions since they often have multiple (comorbid) conditions simultaneously requiring different treatments (e.g., Medicare patients are reported to suffer from five different chronic diseases at once). Thus, there is often need to deliver care across multiple conditions, which means such a complex patient cannot rely on a single IPU specializing on only one of his/her conditions. And it is unrealistic to expect complex patients to spend lots of time traveling to different IPUs, especially in rural areas where they may be few and far between.
• It is very difficult to define and capture valid and reliable health outcomes data for rewarding good results, especially since (a) it could take many years for certain conditions to be resolved, which makes value-based payment a problem; (b) the actions or inactions of the patients themselves influence the outcomes, which means that both prevention of illness and compliance to treatment plans are both important factors to consider; and (c) there is insufficient use of health information technologies, along with the fact that most current systems do not handle comprehensive clinical outcomes data.
• Specialists who are reputed to be "the best" in their field already have more patients than they can handle. This means referring more patients to them is hardly a reward since the have to turn them away.

For reasons such as these, I suggest that large, multi-specialty group practices (i.e., the integrated delivery and selective diversification systems described above) are better able than IPUs to provide high-value coordinated care to the average patients with multiple problems. And they should include patient-centered medical homes, which I discussed in my previous post.

Furthermore, we must focus on defining better measures of care value, which should go well beyond the quality metrics used today that are predominantly "process measures," not measures of clinical outcome (the results of care). For more about this issue, see this post.

In my next post, I examine how to transform current "pay for performance" into "pay for value" models that reward providers and insurers who offer high-value to patients/consumers.
----
[1] Ginsburg, P. (2005). Competition In Health Care: Its Evolution Over The Past Decade, Health Affairs, 24, no. 6 (2005): 1512-1522. Available at http://content.healthaffairs.org/cgi/content/abstract/24/6/1512
[2] Porter, M. E. and Teisberg, E. O. (Jun 1, 2004). Redefining Competition in Health Care. Harvard Business Online. Available at http://harvardbusinessonline.hbsp.harvard.edu/b01/en/common/item_detail.jhtml?id=R0406D
[3] Ibid
[4] Enthoven, A.C. & Tollen, L.A. (2005). Competition In Health Care: It Takes Systems to Pursue Quality and Efficiency. Health Affairs. Available at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.420v11
[5] Robinson, J.C. & Dratler, S. (2006). Corporate Structure and Capital Strategy at Catholic HealthcareWest: Balancing mission and margin in the capital-intensive hospital industry. Health Affairs; 25(1), 134-147. Available at http://content.healthaffairs.org/cgi/content/abstract/25/1/134
[6] Freudenheim, M. (Nov. 7, 2007). A Model for Health Care That Pays for Quality. New York Times.Available at http://www.nytimes.com/2007/11/07/business/07care.html?_r=1&oref=slogin
[7] Porter, M.E. & Tiesberg, E.O. (2006). Redefining Health Care: Creating Value-Based Competition on Results. Harvard Business School Press.

Patient-Centered Life-Cycle (PCLC) Value Chain--Process Reform: Patient-Centered Care

In my previous posts, I've discussed the benefit of integrating the three macro processes of the PCLC Value Chain strategy: emergency-care, sick-care & well-care. In my next series of posts, I'm going to focus on our healthcare system's problematic clinical and financial processes. I'll be examining ways to reform these processes so they enable the PCLC Value Chain strategy to succeed in increasing increase healthcare effectiveness, efficiency and access. I begin with the transformation to "patient-centered" care.

Patient-Centered Care

To define patient-centered care, let's start by contrasting it with the kind of non-patient-centered care we have today. We currently have a fragmented healthcare system in which:

• Plans of care are typically one-size-fits-all, which means clinical guidelines are rarely tailored to a patient's particular needs an preferences
  
• The vast majority of practitioners use paper-based patient records or electronic records that are not interoperable, which means sharing patient data between providers is inefficient at best and non-existent at worst, resulting in poor coordination of care when multiple clinicians treat the same patient
  
• Collaboration between providers, and between providers and researchers, is weak, which hampers knowledge growth and exchange
  
• Patient education tends to be insufficient and compliance to plans of care is low
  
• Transparency of cost and quality is grossly inadequate
  
• Profit is tied to quantity, not to efficiency and effectiveness.

In contrast, the patient-centered healthcare model I'm proposing focuses on prevention, delivery of cost-effective treatments that take into account patient preferences and unique needs, care coordination, and enhanced self-management of chronic conditions.

The following six core elements are identified most frequently in the literature as essential for patient-centered care:

• Education and shared knowledge
  
• Involvement of family and friends
  
• Collaboration and team management
  
• Sensitivity to nonmedical and spiritual dimensions of care
  
• Respect for patient needs and preferences
  
• Free flow and accessibility of information
  

…Seven key factors contribute to achieving patient-centered care at the organizational level are:

• Leadership, at the level of the CEO and board of directors, sufficiently committed and engaged to unify and sustain the organization in a common mission.
  
• A strategic vision clearly and constantly communicated to every member of the organization.
  
• Involvement of patients and families at multiple levels, not only in the care process but as full participants in key committees throughout the organization.
  
• Care for the caregivers through a supportive work environment that engages employees in all aspects of process design and treats them with the same dignity and respect that they are expected to show patients and families.
  
• Systematic measurement and feedback to continuously monitor the impact of specific interventions and change strategies.
  
• Quality of the built environment that provides a supportive and nurturing physical space and design for patients, families, and employees alike.
  
• Supportive technology that engages patients and families directly in the process of care by facilitating information access and communication with their caregivers.
  

…Key strategies identified as necessary to overcome barriers and to help leverage widespread implementation of patient-centered care can be divided into the following two groups:

• Organization Level. Strategies designed primarily to strengthen the capacity to achieve patient-centered care at the organization level include:


• Leadership development and training
  
• Internal rewards and incentives
  
• Training in quality improvement
  
• Practical tools derived from an expanded evidence base
  


• System Level. Strategies aimed at changing external incentives in the health care system as a whole, to positively influence and reward organizations striving to achieve high levels of patient-centered care, include:


• Public education and patient engagement
  
• Public reporting of standardized patient-centered measures
  
• Accreditation and certification requirements.[1]
  

Patient-Centered Medical Home

One implementation of patient-centered healthcare is the "advanced medical home"[2]--also called a "patient-centered medical home"--which is:

...a model of care that puts the needs of the patient first. The medical home is the base from which health care services are coordinated to provide the most effective and efficient care to the patient. This includes the use of health information technology, the coordination of specialty and inpatient care, providing preventive services through health promotion, disease management and prevention, health maintenance, behavioral health services, patient education, and diagnosis and treatment of acute and chronic illnesses...Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care. The medical home is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. The personal physician leads a team of individuals who collectively take responsibility for the ongoing care of patients...Quality and safety are the hallmarks of the medical home. Evidence based medicine, health information technology, and clinical decision support tools guide decision making to support patient care, performance measurement, patient education, and enhanced communication. Ensuring the coordination and comprehensive approach of the medical home model over time will improve the efficiency and effectiveness of the health care system and ultimately improve health outcomes.[3]

The above definition describes the kind of highly functional patient-centered medical home that is most closely aligned with the PCLC Value Chain and of greatest benefit to patients. Unfortunately, few exist today. But if we "water down" the definition to mean little more than a regular doctor or source of primary care who (a) has information about patients' medical history, (b) can be contacted by phone during office hours, and (c) coordinates care--then more exist, though not nearly enough. While the benefits to patients are not as great with this less functional type medical home, it can still help improve outcomes and value to the patient; consider the following:

Cross-national and U.S.-specific studies find an association between access to comprehensive primary care and both better health outcomes and lower medical costs. In light of such evidence, a movement has emerged to transform primary care practices into "medical homes" that provide an array of patient services in an efficient manner…[but] only about half of adults in all seven countries have medical homes. In each country, patients with medical homes reported more positive care experiences than those who did not, including more time spent with their doctors and greater involvement in care decisions.

In the U.S., the uninsured were at high risk of missing such a connection to the health system: just 26 percent of uninsured adults under age 65 had a medical home, versus 53 percent of the insured.

Those with a medical home were also much less likely to report medical errors, receive conflicting information from different doctors, or encounter coordination problems.

"Achieving better care coordination will likely require designs that include a mix of formally integrated organizations, co-locating or sharing services, and connecting through information systems," the authors conclude. "Developing medical home approaches offers the potential to move toward higher performance."[4]

The delivery of patient-centered care, including the extensive use highly functional medical homes, is therefore one systemic reform process that would bring value to the patient. In my next post, I discuss another: Value-Based Competition.

----

[1] Shaller, D. (October 2007) Patient-Centered Care: What Does It Take?, The Commonwealth Fund, Volume 74. Available at http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=559715&#doc559715
[2] Available at http://wellness.wikispaces.com/Tactic+-+Implement+the+Advanced+Medical+Home+Model
[3] Available at http://www.patientcenteredprimarycare.org/medicalhome.htm
[4] C. Schoen, R. Osborn, M. M. Doty, M. Bishop, J. Peugh, and N. Murukutia, Toward Higher-Performance Health Systems: Adults' Health Care Experiences in Seven Countries, 2007, Health Affairs Web Exclusive October 31, 2007 26(6):w717–w734. Available at http://www.cmwf.org/usr_doc/Gauthier_highperformance_909.pdf

Patient-Centered Life-Cycle Value Chain: the Well Care link

In my previous post, I discussed the second link in the Patient-Centered Life-Cycle (PCLC) Value Chain, which is sick-care. In this post, I discuss the third link, which involves well-care, as well as the integration of emergency-care, sick-care and well-care.

Well-Care (Prevention & Self-Management)

The third link in the PCLC Value Chain involves well-care, which includes prevention & self-management. Three well-care delivery models are the:

• Preventative Maintenance model, which focuses on (a) delivery of primary prevention -- such as physical activity, nutrition, stress relief, vaccinations, etc. -- that help people avoid health problems, as well as promoting peek performance, and (b) secondary prevention for at-risk persons to prevent recurrences of health problems, such as avoiding recurrent coronary artery disease events in a person with a history the illness.
• Recovery/Rehabilitation model, which focuses on adherence (compliance) to doctors’ orders to foster recovery, rehabilitation, and complication avoidance for patients having chronic or catastrophic health problems.
• Compassionate Home Care model, which focuses on making people near end of life as comfortable as possible in a supportive environment where they have dignity and family support.

Well-care is delivered by wellness coaches/practitioners, such as specially trained physician assistants, nurse practitioners, home health aids, personal trainers, and others:

• Recovery/Rehabilitation and Preventative Maintenance well-care may be delivered face-to-face, over the internet, and via phone sessions. They include processes for: (a) ongoing risk and health status assessments; (b) ongoing generation of personal health plans identifying any risk factors people may have, as well as primary and secondary prevention plans of action (i.e., health directives); (c) health education presenting concrete, understandable action steps and psychological counseling for dealing with physical problems and psychological stressors; (d) compliance motivation involving motivating and reminding people to do the things that will help them improve their own health; (e) accessing health coaches for health information and advice; (f) outcome studies used in continuous quality improvement feedback loops; (g) care coordination for patients with catastrophic health problems, so multidisciplinary teams can work together effectively; (h) promotion of environmental and workplace safety; and (i) encouraging lifestyle and attitudinal changes for peek performance.
• Delivering Compassionate Home Care well-care includes processes for helping individual obtain home care nursing and homemaking assistance; arranging for transportation to and from doctor appointments; and addressing the psychological, social and spiritual well-being of patients and families.

Integrating Emergency-Care, Sick-Care & Well-Care in the PCLC Value Chain

Instead of viewing emergency-care, sick-care and well-care as separate and distinct, the PCLC Value Chain solution integrating all three. This process involves a new kind of coordination and collaboration between:

• First responders focused on safe passage to and from disaster sites, victim rescue and triage, and trauma center response
• Medical and related sick-care practitioners focused on the diagnosis and treatment of health problems
• Well-care practitioners focused on prevention, recovery, and self-maintenance.

This integrated care strategy promises to bring the greatest value to patient/consumers over their life times by helping assure adequate resources are available and the right care is delivered cost-effectively in all possible situations. It provides a sensible way to keep people healthier longer, recover from illness and dysfunction more quickly, avoid complications of chronic disease, and enable first responders to rescue victims effectively in emergencies. This shifts our current healthcare system from being overly focused on episodic acute care to embrace prevention and chronic condition management, as well responding in emerging environments.

In subsequent posts [starting here], I discuss what’s needed to implement this integrated care strategy successfully, including:

• Specific clinical and financial processes of our current healthcare system that must be transformed
• Specific infrastructural needs, in terms of health information technology use.

Patient-Centered Life-Cycle Value Chain: the Sick Care link

In my previous post, I discussed the first link in the Patient-Centered Life-Cycle (PCLC) Value Chain, which is emergency care through emergency management. In this post, I discuss the second link, which involves sick-care, also known as the “clinical encounter” between a patient and one or more healthcare providers.

Sick-care consists of the following six categories of physical and psychological problems (including diseases, illnesses, dysfunctions, and traumas):

1. Acute health problems characterized by sudden onset and short duration, which progresses rapidly and require urgent care. An acute myocardial infarction (heart attack) and serious accident victim are examples.
2. Subacute health problem distinguished by abrupt onset, but it has longer duration or changes less rapidly than acute problems. Examples include post-operative care, complex wound management, and rehabilitation for stroke.
3. Chronic health problem of indefinite duration, which may persists with virtually no change over time, or which may lead to complications. Diabetes, depression, congestive heart failure, hepatitis and asthma are examples. Note that once stabilized, enabling patients to adhere to plans of care for avoid complications and premature death is part of well-care.
4. Physiological health problems consist of illnesses and dysfunctions in any part of the body.
5. Psychological health problems consist of emotional, mental, or behavioral disturbances and disorders.
6. Mind-Body (Biopsychosocial) health problems are related to the interaction between physiological and psychological factors.

Sick-care has five sick-care delivery models for delivering tests and procedures (treatments):

1. Inpatient Care model focuses on treating patients in hospitals, nursing homes, and other inpatient facilities.
2. Outpatient Care model focuses on treating patients in the offices of primary care physicians and specialists, clinics, and other outpatient facilities.
3. Medical/Bodily Care model focuses on delivery of (a) emergency medical care (e.g., accident victims, infections, poisoning, etc.) and (b) non-emergency medical and non-medical bodily care (e.g., elective surgery, chiropractic, dental, vision, etc.).
4. Psychological Care model focuses on delivery of medical/psychiatric and non-medical/psychological care for mental, emotional, cognitive, and behavioral problems.
5. Biopsychosocial/Integrative Care model focuses on delivery of integrative (mind-body) care for problems having physiological and psychological causes or consequences.

Sick-care delivery processes focus on diagnosing and treating health problems in inpatient and outpatient sick-care settings:

1. Inpatient care processes for physical and psychological health problems including (a) emergency room/trauma center care; (b) obstetrics; (c) tests and examinations; (d) elective surgery; and (e) psychiatric care for severely disturbed patients.
2. Outpatient care processes physical and psychological health problems including (a) tests and treatments for physical and psychological problems during primary care during office visits to primary care physicians and specialists, as well as to ambulatory clinics and other such facilities, and (b) coordinating care for patients requiring multidisciplinary teams can work together effectively.

A core problem with sick-care today is that we rarely know what constitutes cost-effective (high-value) sick-care that is tailored to a patient's particular needs and characteristics. That is, we lack patient-specific evidence-based guidelines about how to treat each patient so they get well rapidly and with least risk and complications. This is because our country hasn't focused on supporting the kinds of research and information systems necessary for generating and using the knowledge (best practices) providers and patients need for improving treatment outcomes/results and controlling costs.

On top of that, high-value sick-care is less profitable than wasteful, inefficient, redundant, excessively costly and error-prone care. This is because our crazy payment system rewards high volume and costly procedures through higher profits, while it discourages the efficient delivery of cost-effective care through lower profits.

In the PCLC Value Chain, therefore, sick-care focuses on:

• Using and evolving evidence-based practice guidelines defining how to deliver cost-effective care
• Assessing and improving clinical outcomes continuously
• Empowering healthcare consumers to make knowledgeable decisions about their own care by being active participants in shared decision-making
• Treating the “whole person,” both physically and psychologically
• Tailoring care to each person’s specific needs and preferences
• Coordinating care and facilitating cooperative communications across all providers treating a patient for better continuity of care
• Fostering collaboration between practitioners and researchers
• Maximizing safety and efficiency
• Utilizing advanced information systems for supporting diagnostic and treatment decisions
• Assuring greater financial gains to providers dedicated to delivering high-value care.

In my next post, I examine the third link in the PCLC Value Chain: Well-Care.

Patient-Centered Life-Cycle Value Chain: the Emergency Care link

In my last post, A Path to Profound Healthcare Transformation, I discussed how our low-value healthcare system is built upon our country’s pathologically mutated form of capitalism. I then described a new direction for transforming the current broken system into a high-value patient-centered system that delivers top quality care and does it efficiently and at a good price (i.e., cost-effectively) over a person’s entire lifetime.

This past week I came across two more articles that support my call for value to the patient.

The first one, Healthcare 2015: Win-win or lose-lose?, reported that:

Healthcare is in crisis…[and] will become unsustainable by 2015…

Value is in the eye of the purchaser, but today value in healthcare is difficult to see. Data regarding the healthcare price is tightly held and difficult, if not impossible, to access or comprehend; quality data is scarcer still and mostly anecdotal or incomprehensible. To complicate matters, the purchasers and benefactors of healthcare – consumers, payers, and society – all have different opinions as to what constitutes good value. Balancing and resolving these conflicting perspectives is one of the major challenges in the successful transformation of healthcare systems.

Today, consumers often have little direct responsibility for bearing the costs of healthcare and their ability to predict healthcare quality is equivalent to a roll of the dice. Payers – public or private health plans, employers, and governments – shoulder the burden of healthcare costs, but often incentivize poor quality care in pursuit of reduced episodic costs. Societies tend to pay little attention to healthcare costs or quality until service levels for healthcare or other societal ‘rights’ are threatened.

I contend that the only way to deal with our healthcare crisis is by defining value from the consumer/patient point of view, as well as enabling us all to obtain cost-effective care and be rewarded for doing so. In addition, providers and insurers who deliver the greatest value to the patient/consumer should enjoy competitive advantage and reap greater profits.

The second article, titled Survival Plan--which is written by a fine author, Maggie Mahar--reports how the Medicare Payment Advisory Commission (MedPac) warned that:

…unless Congress makes some hard decisions about how to contain health-care spending, Medicare won't be able to sustain its current program -- let alone expand coverage to the entire nation…if Medicare continues spending at the current rate, it will hit a wall in twelve short years: At that point, the trust will be able to cover only 79 percent of Medicare's costs. …Billings from physicians [have been] spiraling, largely because the volume and intensity of the services they provided were rising. This was in part because …Medicare pays physicians fee-for-service. The more they do, the more they are paid. In other words, the financial incentives of the fee-for-service system reward quantity, not quality.

Many physicians argue that in recent years they have been forced to "do more" just to maintain their income stream. While the cost of real estate, supplies, and malpractice insurance climbs, their fees have not kept up. They must make up the difference, they say, "on volume." Few consciously over-treat patients, but many see more patients more often-- which means that those patients receive more tests and treatments, and Medicare receives more bills…from 2000 to 2006, Medicare spending for physicians' services rose by more than 9 percent annually.

… In some parts of the country, Medicare spends twice as much per beneficiary as in other parts… In high-spending regions, patients undergo more tests, spend more days in the hospital, and are far more likely to see ten or more specialist during the final six months of life -- for reasons that have little to do with either medical necessity or patients' druthers… And here is the shocker: Patients who receive the most aggressive care fare no better than those who receive more conservative care. In fact, often, outcomes are worse.

…[One suggested solution by MedPac to Congress was to] abandon "fee-for-service," and pay physicians for quality and efficiency. Those who achieve the best outcomes -- while using fewer resources -- would earn more. …Long-term, this could lay the foundation for high-quality, affordable care.

So, the need to bring patient-centered value to our healthcare system is critical! Our Patient-Centered Life-Cycle (PCLC) Value Chain is a sensible path for our country to follow.

I previously said that integrating emergency care, sick-care and well-care is the cornerstone of the PCLC Value Chain. This is because high-value to the patient means receiving the care you need when you need it, including:

• Emergency care through emergency management if you are in an accident or if you are by a disaster site
• Sick-care if you are ill and need to see a doctor
• Well-care if you want to avoid becoming ill through prevention, and to keep chronic conditions (like diabetes or heart disease) from causing complications or premature death.

In this post, I will discuss emergency care from a PCLC Value Chain perspective. My subsequent posts will focus on sick-care, well-care and the integration of all three. After that, I will focus on describing the clinical and financial processes the need to be reformed, followed by the infrastructural needs surrounding health information technology use.

Emergency Care Through Emergency Management

The first link in the PCLC Value Chain involves emergency management. In an emergency, especially in a widespread disaster, saving lives and property depends on the timely exchange of information between command & control units, 1st responders (fire fighters, police, EMTs, trauma center staff, etc.). Our current system has failed in many areas, as witnessed by the Katrina and 9/11 disasters. We are vulnerable; the threat is real. Systemic changes needed to handle disasters include establishing Emergency Information Exchange networks that enable the following:

• Identification of the safest routes to and from a disaster site. We have to assist 1st responders in finding the safest routes to the site of a disaster, as well as the best routes for transporting rescued victims from the triage point to a trauma center. This requires obtaining environmental data (including roads and air) from the DOT, NOAA, FEMA, CDC, etc. to help identify the best routes for emergency vehicles to take to and from the disaster site.
• 1st responder and victim location, tracking and least-risk extraction: We have to improve the assistance given to 1st responders as they attempt to find and extract victims from the disaster area, including rescues from destroyed buildings. This requirement involves helping them locate victims, identify safe routes to and from the victims, as well as tracking the location of the 1st responders themselves in case there is a “man down” situation.
• Victim triage, transport and tracking: We have to do a better job assisting EMTs (emergency medical teams) in evaluating victims’ conditions and initiating emergency care at the triage point. In addition, they must have help determining appropriate transport locations, as well as tracking victims as they travel from triage to trauma center.
• Durable and reliable communications between 1st responders, trauma centers, and all other emergency personnel: We have to enable real time connectivity and clear communications between emergency personnel in real time using systems that work well even when broadband is down and the Internet is unstable. Sometimes only “spread spectrum” radio communication will do, but even that can be blocked by the structures of a high-rise building. In addition, conversations between multiple parties using the same communication frequency (i.e., “chatter”) make it impossible to understand what’s being said. So, we need a system that connects individuals in close proximity to one another and in a way that blocks out unwanted chatter.
• Integration of disparate data in real time and the ability to share the data in user-specific composite reports: The information that emergency personnel need must be obtained, in real time, from disparate data located in many different repositories. These data must then be integrated to generate composite reports, which are tailored to each person’s particular needs.
• Monitoring and managing resource use with instruction, reminders and alerts: We need a better way to monitor and manage trauma center (and other hospital) resources through delivery of instructions, reminders and alerts. This includes using efficient and effective means to:
• Establish plans of care (PoC) using evidenced-based practice guidelines and track their implementation
• Alert authorized staff when PoC orders are due to be implemented, as well as when the failure to implement the orders in a timely manner are likely to cause problems in the care of other patients
• Evaluate required against available resources to determine if there are adequate staff, beds, medications, equipment, supplies, etc. to care for patients’ entire length of stay, and notify authorized personnel when resource shortages currently exist or are projected
• Enable resources to be increased or PoCs to be adjusted in order to account for resource shortages
• Generate reports showing healthcare delivery performance and giving insight into ways to improve the performance.

• Transition from paper records to electronic health records: Paper-based health records, that haven’t already been destroyed, are of little use in a disaster. This is why we must speed the transition to electronic health records.

In my next post, I examine the second link in the PCLC Value Chain: Sick-care.

Think Small and Don't Rock the Boat

This post refers to two related articles. One is “RHIO experts talk about problems, future of movement” and the other, which is a response to the first, is “Key to RHIO success: Stop thinking big.” Following are my thoughts on all this. Let’s begin with some definitions. RHIOs (Regional Health Information Organizations) are “consumer-centric” governing entities focused on improving care value (i.e., care quality, safety and affordability) by enabling healthcare providers (hospitals and clinicians) to share patient information securely. This information sharing is done through Health Information Exchanges (HIEs), which tie together providers—via centrally controlled or decentralized networks—using different computer technologies. And, although it is rarely discussed, a RHIO may also include Emergency Information Exchange (EIE) networks, which help first responders rescue, triage and transport victims to trauma centers when disaster strikes. In the first article, several people involved in disbanded RHIOs were interviewed about the problems they faced and the insights they could offer. I was struck by some of the comments made. One gentleman said:

"One problem with RHIOs…is that they provide the bulk of their benefits to patients and health plans, people and entities that, according to our current healthcare payment structure, either don't pay at all for RHIO startup and operational costs, or pay a disproportionately small share … It does not make sense for a RHIO to have a consumer-centric model because, even though it’s a noble idea to put the patient first, … the technology [they need] will be funded by ... the federal government and the providers themselves … This model fails for two reasons. First, each entity is already managing an incredible list of internal priorities. Second, each entity currently operates at a different level of technological readiness. Through collaboration, without the restraints of a formal structure, [a] RHIO initiative is free to build partnerships through pilot projects among ready and interested entities...

So, according to the interviewee, many healthcare providers do not consider improving patient care a priority because it requires the use of technology to exchange patient information, which eats into their profits. This, in a nutshell, is why providers are out to destroy consumer-centric RHIOs. While I don’t know how many providers agree with his conclusion, I know one thing for sure: It’s disgusting that our healthcare system puts patients and their providers in such a rotten position! Making providers choose between profit and quality is reprehensible!!! Shouldn’t our healthcare system encourage and reward providers for improving the quality and efficiency of care their patients receive?!? With this question in mind, let’s turn to the second article, which is a response to the one I just discussed. In it, a person from the well-respected Markle Foundation is interviewed about his thoughts on RHIOs. His main point is that RHIOs ought not focus on putting in the technical infrastructure required for exchanging data

“...[until the] stakeholders can begin using it [otherwise it will lead to] debates over funding, business models, data ownership and any number of other issues that have prevented or significantly slowed the development of RHIOS.”

Instead, he suggests that RHIOs

“...start small and create a sort of ‘value chain’ between payers [insurers] and providers that builds on incremental success. Eventually, RHIOs, as originally envisioned, will logically emerge.”

He goes on to say that the way to start is by having payers share their patient data with providers for free. Then, once the providers using the data

“…grow to appreciate and depend on it … chances are providers will be more eager to share their data...[and eventually]…all entities on a patient's care team [will be willing to] share richer data… including real-time best practice and clinical decision support [information]. In effect, this would serve as the foundation for the larger, system-wide health information exchange necessary for reforming healthcare.”

OK, let’s see if I have this straight. Payers collect claims (administrative) data, which are used primarily for payment purposes; they don’t offer much useful clinical information for improving care quality and efficiently. Sure, it’s important for a practitioner to have certain claims data, such as what diagnoses, procedures, medications, and immunizations a patient has received in the past, if they don’t already know it. But, unlike claims data, rich clinical information—which no payer collects—is much more useful to providers. Such information includes: • Changes in a patient’s lab test results over time in response to different treatments and conditions • Symptoms a patient has reported and is reporting • History of vital signs • Treatment guidelines best suited for the patient • Plans of care being implemented by different providers • Outcomes of prior care • Imaging studies (e.g., x-rays). • Functional status • Risk factors • Drug interaction warnings • Etc. THIS is the kind of information that helps improve care quality and avoids costly errors by supporting clinical decision, but it is not what payers are able to share with practitioners (even if they wanted to). The article concludes with this:

“So, ironically, the key to RHIO success is to stop thinking big. Instead, we should focus on smaller initiatives that generate some legitimate return on investment. Once everyone involved begins to see the results, interest and enthusiasm will build until we have ourselves a legitimate trend. And some functioning RHIOs.”

WOW!!!! Ironic indeed!!! The conclusion after all this: STOP THINKING BIG …Do as little as possible, as slowly as possible...And whatever you do, don't try too hard to change the healthcare system and improve patient care!!! So, this is the “wisdom” of the day: We ought not to try to solve the big problems with patient right yet. We shouldn’t be wasting our time looking for innovative, low-cost ways for exchanging rich clinical information for better care outcomes. We should avoid shaking things up because it might annoy certain providers. After all, providers have other priorities—which focus on maximizing profits—and a consumer-centric approach to increasing value would actually decrease profits in our backward healthcare payment system. Conspicuously absent from this “wisdom,” however, is any mention of changing the system itself to bring greater value to healthcare consumers! How wise is this wisdom? I have to tell you, I’m just sick of this!!! Why do I even bother?!? I’ve been banging my head against an immovable wall for the past 25 years promoting innovative ways to deal with these problems cost-effectively. The response: I’ve been ignored and dismissed, attacked and ridiculed, and accused of self-promotion. I’ve been told repeatedly: “Wait …take it slow …think small …don’t try to change much.” Let’s face it, the healthcare payment system simply isn’t designed to promote care value. Providers who strive to deliver high value care are punished financially. Inefficiency (waste and redundancy) and ineffectiveness (fix it, then fix it again when it breaks) are rewarded, while efficiency and effectiveness are punished. This is why providers are justified in fearing they will go broke if they:

• Keep their patients healthy through good well-care (including prevention and effective self-management of chronic conditions)
• Help their patients recover quickly and cost-effectively when they are ill by using clinical decision tools, exchanging patient health information electronically, collaborating and coordinating care in multidisciplinary teams, etc.
• Spend more time with patients to make sure they understand what their patients need, how they feel, what they prefer, and what they must know.

WHAT’S WRONG WITH THIS PICTURE!!! WHERE’S THE SANITY? WHY THE HELL SHOULD WE FEAR ROCKING THE BOAT!!! OUR HEALTHCARE SYSTEM IS SO BROKEN IT’S SCARY!!! IT NEEDS RADICAL CHANGE AND IT NEEDS IT NOW!!! 

How to determine the best healthcare reform plan

There’s great debate about which candidate is presenting the best healthcare reform plan. A key issue is whether insurance companies (the private sector) or our government would do a better job managing universal healthcare. Both have been criticized for serious problems of inefficiency, bureaucracy and waste (as well as questionable practices and fraud).

 

It seems to me that the only way to determine who presents the best strategy is to compare the different plans head-to-head. The comparisons must consider costs to the public and patients in terms of taxes, premiums, deductible, co-pays, and coverage for people in different locales, who are in different economic and age groups, and who have different types of health problems and risk factors. This is a very complex issue, which cannot be understood with generalities and sound-bites. So, access to a detailed comparison grid that enables in-depth analysis is critical.

 

But even such an analysis, I contend, would fail to deal with the most important factor: The need for radical reduction of inefficiency, waste and fraud; errors and omissions; over-testing, under-testing, over-treatment, under-treatment; inappropriate care, problems with safety, quality and accessibility; inadequate wellness/preventive services; poor coordination of care; etc.

 

In other words, I assert that if all patients received cost-effective (high value) sick-care and well-care services—delivered safely, efficiently and competently—people would stay healthy longer, recover more quickly from illness, utilize fewer expensive services, medications and medical devices, and have a better quality of life. In addition, the system should give competitive advantage and financial reward to healthcare providers who get the best results for the best price. The resulting quality improvements and cost savings would be astronomical.

 

I would vote for plans—be they single-payer/government-controlled or private-sector insurer based—that return the greatest savings to the consumer through lower out-of-pocket expense (including taxes and shared responsibility payments), while providing the broadest coverage and supporting policies/plans/procedures that promote continuous improvements in quality and efficiency.

Universal Healthcare, Free Markets, Taxation, Smart Economic Growth, Government, and Insurance Problems

This post is a continuation of my last post, in which I debate with someone the issues of universal healthcare, worthiness, free markets, taxation, smart economic growth, problems with healthcare insurance today, and more. As always, I welcome your feedback.

In this round of the debate, he began by referencing the following statement I made in a previous post: “The best kind of Capitalism fosters 'smart economic growth' through the right combination of small company entrepreneurial (technological) innovation and big- firm market capabilities, without restrictions on free trade, brings about a higher standard of living for just about everyone in that country.”

He then said: This is essentially what I have been espousing, with the state keeping the corporations from manipulating a free market, and leaving the rest alone. Incentives for productive entrepreneurship being profit, and the disincentive for unproductive entrepreneurship being hunger, no further incentive is required.

Next, he pointed to a reference I made in my previous post to France Lappe’s book, “Democracy’s Edge,” and he said ...

I would flatly disagree with Ms. Lappe, arguing that free markets are NOT the product of democratic gov’t, but that only a democratic gov’t will ALLOW free markets. The apparent battle between the free market and the gov’t issuing from the gov’t failing to keep the welfare of the people their priority by interfering with the free market, and allowing the corporation to interfere.

‘If our government begins to spend money wisely and without corruption; if it implements policies to control waste, inefficiency, fraud, greed etc’ will be a point we disagree on, as I have no confidence this or any other gov’t is capable of doing so. None has so far. Gov’t is inherently evil, as it attracts those who desire power over others, however altruistc, or not, their motive.

Those who find themselves in a poor economic situation, through no fault of their own, should be taken care of through charity. That’s the problem with entitlements, the recipient is “entitled” to the benefit, automatically deserving, while with charity, if the recipient is of no inclination to improve their lot, is ungrateful, or is deemed unworthy for some other antisocial reason, the charity may stop. The advantage to the donor of charity is that it promotes an individual’s humanity, and their sense of community. Something the IRS does not. We are a charitable people, and the gov’t has taken advantage of it. We need a drastic REDUCTION in taxes. The gov’t has stolen our humanity and used it to buy votes.

I am convinced that most of the blame for our current health care problem lies with industry providers. Their inefficiency, incompetency, and exaggerated opinion of the value of their service, has put their pricing well above what the market will bear. Add to this funds spent on research (much of them by the gov’t) to develop methods/ equipment/etc. that we as a people can’t afford. In a free market, prices automatically level at what the market will bear. The health care industry has exceeded that level. There will be a correction, one way or another. If the gov’t gets involved, they will dictate fees and services, and we will get $1 of service for $2 in taxes, that will cost $3 to deliver. In other words, much like what we have now, only instead of not being able to afford health insurance, we will be taxed for it, whether we can afford it or not.

And then I replied ...

Where we agree on the following:

1. The benefits of smart economic growth
2. The state keeping the corporations from manipulating the market
3. Our Gov’t having an inherently negative side because it attracts those who desire power over others with less than altruistic motives.
4. The need for a drastic reduction in taxes (and I’d add: on the middle class especially)
5. The Alexander Tyler quote
6. Stopping those who can afford to pay at least a portion of their healthcare, but who manipulate the system to receive free care through taxpayer handouts.

Where we disagree:

1. Since we agree that government is needed to keep corporations from manipulating the market, and since we agree that our gov’t fails to do (and actually encourages corporate manipulation), then we don’t have a free market; instead, we have a corporate controlled market that has emerged due, in part, to lack of good gov’t policies and the existence of bad ones.

2. I do not blame any group—not the healthcare providers, patient, insurers, employers, big pharma, labs, medical device makers, nor researchers—for the current healthcare crisis. Yes, we do agree that there is plenty of greed, incompetence, inefficiency, ineffectiveness, ignorance, inertia, corruption, etc., but these human shortcomings are manifested by virtue of our badly broken healthcare system. But I see it as a system’s problem that actually rewards poor performance (e.g., fix it and fix it again when it breaks), despicable processes (e.g., insurance practices exposed in the movie SICKO), as well as excessive pricing and other ways to “play the system.” I contend that we need gov’t controls to fix the system because no one else will do it, but I don’t trust our current gov’t to do it either!

My hope is that we will develop a healthcare strategy that will change this by making gov’t responsible to the people. I don’t see the need for tax increase to accomplish this, but I don’t have the numbers to support this claim.

He responded ...

Our first disagreement isn’t one. We appear to agree that our current criminal electorate, acting outside the boundaries of the Constitution, and failing to act inside those boundaries, has created the problem by interfering in the operation of a free market.

Our second disagreement remains, as I see no possibility of one of the agencies largely responsible for the problem, successfully solving it. I suspect that soon (2-4 years) we will have some form of UHC [Universal Health Care]. I doubt it will be fiscally sound (Medicare, social security), or will provide care of any quality (Veteran’s Administration).

I have no confidence in a man who “believes” the Cuban gov’t, or ours for that matter. Mr. Moore does not believe any of what he “exposes”. He has merely found a lucrative market for his fictitiously manipulated “research” among those of liberal/socialist persuasion.

The only way we can SUCCESSFULLY solve the problem is to find a way to force the gov’t to act responsibly, and within the boundary of the Constitution, by “promoting the general welfare” not financing it. A tall order indeed

To that, I responded ...

OK, you don't trust Michael Moore. So here are problems with the current healthcare economic models, as related to insurance, which create a chaotic system and encourage destructive practices (with references from this page of our Wellness Wiki):

• Cost-shifting — Charging higher prices (above cost) to one group of patients in order to offset lower prices (below cost) to another group of patients based on their insurance coverage.
• Price discrimination — Charging different patients different prices for identical healthcare goods or services irrespective of cost.
• Cherry-picking — Choosing to provide insurance coverage to the young and healthy, and treatment to the most profitable patients, while not providing the same level of coverage and care to others.
• Retroactive coverage cancellation — Payers cancel coverage retroactively for people who need expensive care in order to escape its obligations to members who become seriously sick.

A more sane payment system would encourage continuous quality improvement, while controlling costs and insuring everyone through shared risk. It would recognize the responsibility of all stakeholders in creating a sustainable healthcare system that brings greater wellness to all in an effective and affordable way.

Methods having been proposed include pricing transparency, informing consumers of the value of care providers render in terms of performance and cost, and pay-for-performance. There are serious issues with each of these proposals, but they may contribute to the development of a better payment system. In addition, it may be useful to give consumers incentives for maintaining healthy lifestyles and complying with sound medical advice.

Anyway, I happen to agree in part with your final point: The only way we can solve the problem SUCCESSFULLY is to find a way to force the gov’t to act responsibly, and within the boundary of the Constitution, by “promoting the general welfare” not financing it. A tall order indeed.

The disagreement, or should I say confusion, with that strategy is that, even if our gov't is forced to act responsibly, it has to spend considerable sums to promote general welfare through writing and policing the implementation of radical new policies that foster the delivery of high-value care, as well as supplementing coverage for those who simply cannot afford it. In other words, I just don't know how anything can be accomplished without the wise expenditure of tax monies. Do you?

He responded ...

No, nor do I expect the wise expenditure of tax revenue, it is seldom done.

A few things not adequately addressed that would require relatively little revenue:

• The monopoly of healthcare by the AMA through the FDA.
• The ineptitude of the FDA. That is, the FDA should not approve alternative health care practices not endorsed by the AMA. That which is not approved, or endorsed, will not be insured, and, in fact, may be criminally prosecuted.
• Policing/regulation of the insurance companies (corporations).
• Policing/regulation of the provider companies (corporations).
• Eliminate gov't sponsored research, except in the most dire national situation.
• More gov't control of medical licensing. (doctors mostly police themselves).
• Criminal charges and sentences for fraud/theft equitable to any other common robbery. The only difference between “white collar” and “blue collar” crime is how it is dealt with. Theft of your life savings through fraud is just as violent as a mugging.
• Elimination of regulation defining what groups are eligible to negotiate with insurance and/or care providers. Most states currently have strict regulation, which is obviously a protection of the insurance/provider companies.
• Here is an idea that just popped into my head. Reduce the tax bill of all individuals by the amount they spend on their own, or their family’s, non-elective health care. I’ll have to think about that.

Worthiness in Capitalism, Free Market Forces, and Government and Individual Responsibility

I began this series with a post that examined the issues about universal healthcare and worthiness, which led to a heated discussion that continues on another forum. In this blog post and my next, I will represent a debate I had with someone arguing for a “free market” approach to healthcare in which human value is measured by one’s wealth and government monies ought not to be used to ensure care for everyone.

Following I present his initial points and give my replies.

Point 1) He wrote: “Our value to our society is measured by our wage.” In other words, the value of a human being—the essential/basic/inherent worth of a person—according to the American Capitalist model, is measured by how much money one makes/has.

[My reply] Yes, this is a shameful reality of our society. The more wealth you have, the more “worthy” you are considered and the more “valuable” a person you are. That’s crap! The wealth you have, the more you can buy … PERIOD! It has nothing to do with your inherent worthiness or human value. In fact, human worthiness and value are just concepts; there are no such things. Even the concept of “deservingness” is made up.

Yes, there is such a thing as “buying power,” but the question is whether it should apply to the delivery of essential healthcare. One’s opinion on this matter, I suggest, depends on one’s wealth. People who can afford excellent insurance and cover out-of-pocket costs would say they deserve (are worthy of) better healthcare than a homeless person. That’s because our Capitalistic system promotes such an irrational belief. The reality is that they can afford better care only because that’s the way our economic system operates. But if they have a financial catastrophe, they will be reduced to the realm of the unworthy … the undeserving … and, I bet, will suddenly change their perspective on who should have access to good care.

That means everyone, no matter how much money and possessions one has, is worthy of the best possible healthcare.

Point 2) He wrote: “My friend, you have a serious psychological problem with the ordinary general sloppiness of human existence. Saint that you are, you are never going to make it tidy. People are just messy.”

[My reply] While I never claimed to be a saint, I do try to think and act wisely, although I’m not always successful. Being human, I realize that I, like everyone else, am a fallible creature with all sorts of weakness I must recognize and deal with in order to develop my potential. So, yes, humanity is “sloppy,” people tend to think irrationally and overreact emotionally, seek pleasure and escape from life’s pains/frustrations in self-destructive ways, be short-sighted, be greedy and self-centered, engage in wishful thinking, let their egos get in the way, be self-deceptive, and so on. I’ve spent the past 40 years studying human nature and almost two decades treating psychological disturbance, so I know much on the topic. Anyway, you’re right: Humanity is never going to be “tidy” (that would take mass enlightenment and major social evolution).

Point 3) He wrote that: "[I appear to condemn] the American Capitalist model as some villain passing judgment on us…It is, after all merely a modified economic extension of natural selection, a process that does a fine job improving the species.”

[My reply] Well, I’ve never said that any model can be villainous our pass judgment; only people can act in ways defined as “villainous” and pass judgment on others. But the American Capitalist model does encompass rules and processes that enable people to claim certain groups to be more worthy of good healthcare than other groups based solely on one’s material wealth. I do have a problem with that.

As far as natural selection goes, I take issue with your claim that our modified economic extension of natural selection has been improving our species. After all, our species is as messed up as ever and, with all the negatives in the world today (from global warming to religious warfare to political corruption to the concentration of wealth), we are doing a poor job in converting them to positives.

What it has help improve, however, is the quality of life for many people, which is good, even though the degree of improvement is increasingly lopsided in favor of the wealthy and against the middle class, but that’s another issue.

Point 4) He wrote: “I'm not interested in living in a mud hut so I can afford to pay my tax bill to support universal health care.”

[My reply] Neither am I. Although I don’t have the means to do the actual research and number crunching, it seems to me that reducing waste in our healthcare system by delivering high-value care consistently, by focusing on prevention and effective self-maintenance, and by minimizing unnecessary administrative overhead, as well as by reducing waste and (legal and illegal) corruption in government and reallocating our national resources, then we could pay for universal healthcare without increasing taxes.

BTW, I do think a system such as QALY should be instituted as a means of controlling costs, and that we should focus more on developing more effective and efficient ways to

He then wrote:

It appears you support a socialist economy in general, since "the American Capitalist model" also passes judgement regarding housing, education, clothing, food and drink, etc. In a Marxist "Shangrila", what motive would the species have for improving their condition. Without struggle, there is no advance. What motive for anyone to excel at anything, when the wealth they earn is confiscated "for the public good" and those without ambition, industry, or moral conscience, are considered deserving of their share.

The beauty of a free market system is that if you have no worth to society, you are immediately made aware of it by your poverty, and thereby motivated to develop some worth. I find nothing shameful about it. The poorest among us are living longer, healthier, wealthier lives than we have in any other period in human history. While there are those few that are unable, through no fault of their own, personal charity is the moral solution. The problem being the gov't has usurped this very human role with their handouts and ridiculous taxes. They have stolen our humanity, and used it to buy votes.

If we are going to use a totalitarian method, let's cap the earnings of everyone in the medical profession at about twice the median income. That would be just as fair as socializing health care (and may be one of the end results).

I applaud your altruism. I am afraid, however, that your lofty goals would require as much bureaucracy as we have now, possibly more. The only way to bring waste, inefficiency, fraud, greed etc. under control, is with free market forces. The corruption in an unconstitutional gov't is the biggest hindrance we have in reaping the rewards of a true free market. They are no more likely to surrender their power to socialism.

…I am a person of moral conscience, and have no desire to burden my countrymen with my problems.

The EARNING of wealth is the measure of our worth to society. If you have value to society, someone will pay you for it (without the gov't putting a gun to their head).

And I responded:

According to Baumal, Litan and Schramm’s new book, “Good Capitalism, Bad Capitalism,” the Capitalistic model, in general terms, is an economy in which a substantial proportion of its means of production (farms, factories, etc.) are in private hands rather than owned and operated by the govt. They argue that the best kind of Capitalism fosters “smart economic growth” through the right combination of small company entrepreneurial (technological) innovation and big- firm market capabilities, without restrictions on free trade, brings about a higher standard of living for just about everyone in that country. I’m certainly not at all opposed to this. On the other hand, there is “state-guided” Capitalism, in which government tries to guide the market by supporting particular industries it expects to be winners, and “oligarchic” Capitalism, in which most power and wealth are held by a small group of people. There are pros and cons to each form, but the first two are the best way for Capitalism to serve the greater good, and American Capitalism has that potential. But what’s needed to sustain it, they contend, is three preconditions: (1) Adequate incentives for productive entrepreneurship, (2) disincentives for unproductive entrepreneurship, and (3) continued rivalry among and innovation by large firms. All this require government regulation, but that’s not socialism.

What seems to be happening is that American Capitalism is becoming oligarchic by virtue of not having truly free democratic markets.

Although Baumal, et al. say nothing about “free markets,” Frances Moore Lappe, in her book, “Democracy’s Edge,” argues that there is no free market. She writes: “In complex societies like ours, markets that work to create wealth for all are the product of democratic governments. The market depends on truly representative government—the obvious point that is lost on those who see the market and government in eternal battle. Also …we’ve been taught that there’s only one way [or organize a market]: Make business decisions using a single criterion—maximum return to shareholders. So every decision returns wealth to people who already have it. … [No wonder] the richest 1 percent of American households now control more wealth than the bottom 95 percent combined. … We’ve been made to believe that this game of concentration…’is fundamental to the success of capitalism because it weeds out the weak and allows the fittest to survive … [but what] it really does benefit is a select few who know how to play this new game while it threatens almost everyone else.’” (pgs 63-64).

Now I don’t claim to be an economist, I don’t promote a “totalitarian method,” and I never thought of myself as a socialist; but it seems to me that our government has an important role to play if our form of capitalism is to benefit the masses …and it is failing miserably. I’d rather see a government bureaucracy assure healthcare for all, than assuring the continued concentration of wealth.

If our government begins to spend money wisely and without corruption; if it implements policies to control waste, inefficiency, fraud, greed etc.; and if people were charged for healthcare based on their ability to pay … I believe we could support universal healthcare without the tax increases you fear.

In many ways, we actually seem to be in agreement.

My problem with defining human worth in monetary terms is a philosophical/psychological issue, as well as a moral one. If poor people have no worth to society, as you say, then do they have any worth … or are they just worthless nothings who better get motivated to become worthy by making good money, or else die of untreated illness because their poverty make them undeserving of the care received by people with financial means? Lack of wealth ought not make someone undeserving of the essentials of life (food, water, shelter, education, healthcare, opportunity, etc.).

Click here for part 4 in this series.

Worthiness, Socialized Medicine, and Individual Responsibility

My last post examined the questions: Who is worthy of having adequate health insurance and high-value (safe, cost-effective) care; what makes them deserving? And who, on the other hand, is unworthy; what makes them undeserving? I linked to this post on another forum, which led to an interesting conversation about personal responsibility. Following are excerpts from that conversation. I welcome your comments.

One person commented:

Everyone deserves unobstructed medical attention for illness and injury; curable, chronic, and/or terminal. In that I see an absolute fulfillment of the constitutional mandate to see to the 'general welfare'. One step beyond that is preventive care, more opinionated and intellectually based; but I none the less would consider that the 'general welfare'. Every other service for everyone associated as medical service should remain privately financed and marketed (like child bearing and voluntary procedures).

One critical issue within that position is how to deal with self induced health impairments. This health class should have a name, definition, and social remedy. Let's call it IHIs. It's tough because it's smoking, poor diet, drug addiction, STDs, poor dental care, high risk sports, etc. I'm thinking IHI classification puts an individual into a special insurance category requiring addition premium or mandatory savings both during and for some time after such circumstances.

I replied:

Yes, dealing with the kind of self induced health impairments (IHIs) is a thorny issue.

A logical case can be made for having those with the financial means pay out of pocket for at least a portion of treating health problems clearly determined to be voluntarily induced. That is, delivering care to people with adequate maturity, knowledge, intelligence and rationality, but who make a conscious decision to engage in high-risk behaviors and suffer the consequences, would cost them more, so they are held accountable for their actions.

Unfortunately, many (most?) of these people are either (a) immature (e.g., teenagers enticed by tobacco and alcohol marketing, as well as peer pressure, and then get hooked); (b) ignorant, confused or unintelligent (they don't fully realize or understand the risks of eating too many greasy french fries and failing to exercise regularly, or they have trouble self-managing a chronic condition requiring a complex medication regimen and lifestyle changes); (c) irrational (e.g., they deceive themselves into believing they can stop taking drugs, or they are self-destructive due to a psychological problem); or (d) they lack the funds and support needed to live a more healthy lifestyle (all their time is taken working day and night at minimal-wage jobs, or they lack affordable transportation, to visit the dentist every 6 months, or they can't afford fresh fruits, vegetables and lean meats when pasta is a fraction of the cost). Or, they just might be unlucky (e.g., the got an STD because the rubber broke).

In other words, this is a complex issue and a great deal of thought should go into defining the conditions for the kind of punitive costs you propose.

Also consistent with your suggestion would be a policy of taking punitive action against the manufacturers, distributors, retailers and marketers of unhealthy foods and ineffective medications and supplements. And what about tobacco companies and alcoholic beverage producers who promote their products to college students, and even the promoters of dangerous sports?

It seems to me, therefore, that establishing a reasonable two tier system--one for folks who self-manage their health effectively and another for those who don't--is a daunting task, but one worth examining.

On top of this is the question of whether contraception, abortion, and child bearing should be paid privately.

Nevertheless, the bigger issue in my mind (and discussed in my blog) isn’t about penalizing certain people for poor behavior; instead, it’s about enabling and rewarding the delivery of high-value health and healthcare services. I contend that minimizing waste, inefficiency, and ineffectiveness--while maximizing transparency of quality and cost, along with wellness education and services, and rewarding positive results--would actually save so much money that there would be no need of the kind of two-tier system proposed.

Another person commented:

Providing the kind of general welfare you propose is way beyond what our founding father meant by this or far beyond any logical interpretation. Providing for the general welfare means our legal citizens ability to pursue their lives and work safely, securely, and free of government inference and detailed mandating. It in no way means the government should tax everyone to pay for things that everyone has the freedom to choose. This includes medical care.

Per the Census Bureau's 2005 / 2006 census report:

• 10,231,000 non-citizens are uninsured (See page 21 of the census report) - the increase from 2005 to 2006 in this area represents 38.3% of the .5% increase in uninsured PEOPLE
  
• 17,742,000 uninsured Household earned $50,000 and more in 2006. (See page 21 of the 2006 census report) These People certainly could afford to acquire their own health insurance.

Socialized health care means we taxpayers will be taxed and pay out billions and billions for illegal aliens and citizens who can afford health insurance but "choose" not to. Where will these billions & billions will come from? Much higher taxes or major reductions in other government programs or a combination of both - or simply higher taxes!

I am unwilling, as well as, unable (I am retired and on a rather fixed income) to pay for the healthcare of illegal aliens and those citizens who want me to pay their way!

And last, but not least, please provide valid, relevant, accurate, and complete statistical data which clearly shows those countries who have socialized healthcare provide healthcare of equal or better than is currently provided in the US.

This does not mean major improvements are desperately needed in our present healthcare systems! But these are improvements not a replacement! I will not hold my breath waiting on the healthcare industry to make these needed improvement, because of government regulations and interferences! The politicians are a major part of our healthcare problems, not a solution among them! :-)

I replied

You said: Our government [should not] tax everyone to pay for things that everyone has the freedom to choose. This includes medical care.

While I agree with your premise, I don’t believe it’s about “freedom of choice.” There are many reasons for people not having coverage, including:

• Health insurance is unaffordable to many, including individuals who are unable to get affordable individual coverage due to cost or pre-existing medical conditions.
• Many employers do not offer health insurance coverage.
• People who lose their jobs often lose their health insurance.
• Some workers are not eligible for health insurance offered by their employer.
• Workers and individuals do not take-up coverage that is available.
• People may be poor but not eligible for public coverage, for example, childless adults are generally ineligible regardless of income.
• Individuals are eligible for public programs, but are not enrolled.

(references: Why are people uninsured #1 and Why are people uninsured #2)

You said: 17,742,000 uninsured Household earned $50,000 and more in 2006. … These People certainly could afford to acquire their own health insurance.

It seems to me that the number of folks who can afford insurance and simply chose not to get it is very small. Take your example of a family earning $50K/yr. In NY, an HMO family plan with steep copays and deductibles and no dental, offered through a small business, cost a family over $11K/year in premiums alone, which increases every year. That’s a sizable expense even for a family earning $50K, on top of out of pocket dental costs, as well as copays and deductibles. I don’t see that many fail to buy insurance because they’re looking for a “free ride.” I say this in light of the fact that the uninsured tend to have worse health and, when they get sick, they have to wait for hours in a emergency room or go to a community clinic safety net facility. This is not a glamorous option.

Another group, btw, are the “underinsured” who purchase coverage and then are shocked to realize that what they have doesn’t come close to paying their medical bills. According to a recent consumer reports study, 24% of Americans have health insurance that barely covers their healthcare needs, not to mentions the 16% with no insurance at all. This leaves a huge number of people unprepared for major medical expenses.

You said: Please provide valid, relevant, accurate, and complete statistical data which clearly shows those countries who have socialized healthcare provide healthcare of equal or better than is currently provided in the US.

I don’t believe such clear-cut data has ever been collected to make the case one way or the other. But there is convincing data that the US lags behind many industrialized countries in delivering primary care, access and quality … while at the same time costing much more than other countries. See, for example, The Commonwealth Fund (Sep 20, 2006). New National Scorecard: U.S. Health Care System Gets Poor Scores on Quality, Access, Efficiency, and Equity. Available at this link.

You may also want to visit this link to a page on our WellnessWiki for more facts and figures about the healthcare crisis.

As far as not holding your breath waiting on the healthcare industry to make needed improvement due to government regulations and interferences, I don't blame you! It will take strong leadership, new mind-sets, innovative policies, and consumer pressure to change the system in the kind of profound ways I propose.

And what about dealing with undocumented workers (illegal immigrants) who are hired by American employers to do back-breaking work at below minimum wage? I understand when our citizens complain about the cost of giving them free healthcare. But consider the alternatives: We can let them die in the streets without any aid and pray they don’t pass contagious disease due to lack of treatment, waste huge sums of money building walls around our country in the naïve hope that we can keep them from crossing our borders, etc. And we could punish employers who hire them to do back-breaking menial labor few of our citizens would do, but that wouldn’t help much since we need them and they need us for work to feed their families.

Alternately--and I realize this is controversial--we can adopt a national policy that makes the U.S.A. the world center for promoting health !

Why? Well, if we could afford to do so, not only is it the moral thing to do, but it would also be one of the most powerful things we can do to fight terrorism. Imagine what would likely happen if we showed the world that a primary function of our nation is to improve the health of all peoples at home and abroad. This would be a major step toward winning the hearts and minds of all peoples, including those who aren’t very fond of us right now; and, at the same time, it would make it much more difficult for terrorists to demean us and recruit individuals who want to destroy us.

So, assuming what I just said is valid, then how can we afford to be the leaders in promoting greater health and better healthcare for everyone around the in our own country and around the world?

There are many things we can do to get the money needed; some of which require a shift in our national priorities, policies and processes. Three of the more obvious strategies would be to:

• Take some of the money currently being spent on weapons and the military to fight the “war on terrorism” through destruction and death, and use these funds constructively to improve health in the world.
• Remove waste from our current healthcare system by fostering wellness and the delivery high-value care, which would save huge amounts of money, some of which could be used for “world care.”
• Work with foundations and collaborate with other countries.
  

Click here for part 3 of this series.