Change In Health Care
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One of the reasons the operating model in health care doesn’t change much over time is pretty simple: most of the people who think about it, write about it, work in it and study it have trouble seeing the model any differently than they see it today. I was struck, therefore, by Hebrew Senior Life’s Len Fishman the other day when he and I served on a panel at the 30th annual meeting of the Massachusetts Health Data Consortium. We were told to discuss health care 30 years from now — me from the plan perspective, and Len from the long term care perspective. I went pretty far out there in my remarks, imagining, among other things, a world in which there were no health plans at all(!). Len did too. His presentation on the future of long term care could not have looked more different than what we have today. He literally re-imagined the whole thing. It was startling — and refreshing.
This question — is the future just like the past, or something different — was raised again for me earlier this week when Brian Rosman — a good guy with whom I almost never agree — posted a blog on the Health Care for All Web site that basically said that more publicly available information on health care cost and quality could/might/will lead to higher costs and higher prices, because no one really cares about costs, and if they do, they’ll flock to higher cost options, because they’ll think they’re better than lower cost ones.
It might be, in the short term, that more publicly available data on cost and quality will lead to higher costs. Hard to imagine, given how high costs are now, but certainly possible. Also hard to imagine, given the amount of chatter, mythology, rumor and competitive intelligence about who gets paid what by whom that already existing among people “in the biz.” For the most part — and I’m being overly simplistic here to make a point — the group who will learn something new when the MA Health Care Quality and Cost Council data becomes public is, well, THE PUBLIC. And I simply cannot see how a state policy maker — or a practicing doc — or an advocate like Brian — or an employer — or a health plan — or even a provider organization — won’t be better off over time knowing what’s really going on under the covers.
I was re-reading, for about the fourth time, Atul Gawande’s first book — Complications — the other day, and I came across his discussion about the rise of the patient in making difficult decisions about his or her own health care. Gawande points out that before the mid-1980s, the idea that a patient would have anything to say about his or her treatment or care was preposterous. Patients didn’t make health care decisions, doctors did. Period. And yet, here we are, twenty years later — in a far more powerful and complex system than the one we had in 1985 — and patients do have a much bigger say in what they get and what they don’t than they did twenty years ago. Today, clinical decision-making is more transparent — and shared — between patient and caregiver than it was twenty years ago. And I would argue we are better off as a result.
This whole cost/quality thing in health care needs to change. We need to take some chances. We need to presume that smart people — and I don’t mean just consumers, I mean everybody — will make better decisions about value, about cost and about quality — than they make today, if they have more and better data. It has always worked this way as far back as I can remember. There may be bumps and bruises in the short term. There always are. But I see no reason why it won’t work over time this time, too.
I would like to make several points on this.
First, I think greater use of information technology can be potentially transformative. Once interoperable electronic medical records are in widespread use, it will be easier to develop more robust P4P approaches, more accurate risk scoring at the individual patient level, and we should have much better and higher quality information about what works and what doesn’t in healthcare. There is probably also lots of potential for home monitoring to replace care provided in doctors’ offices. As retail clinics expand and proliferate (AMA opposition notwithstanding), NP’s may displace PCP’s in providing much of our routine primary care in the future.
With respect to price and quality transparency, I think the key will be the extent to which health plans use it to restructure incentives including lower co-payments for patients who choose the most cost-effective providers and bonuses for referring doctors who steer their patients to the most cost-effective specialists, hospitals, imaging centers and labs.
Finally, I think health plans should not be afraid to move away from Medicare’s rates and practices in structuring their own payment rates and approaches. I heard a CMS official at a conference last week who made a couple of interesting points. First, he said that Medicare’s current payment system (DRG and RBRVS based) is designed to reward resource utilization and not value. Second, he said CMS will soon be starting a pilot project to reimburse certain surgical procedures on a bundled basis that would provide one payment for a full episode of care. The pilot will last for three years and then take as much as another year to evaluate to see if it should be expanded or not. By contrast, he said that private insurance companies that currently participate in the Medicare Advantage market are free to do this on their own if they can get providers to agree to it. In short, insurers have much more freedom to experiment and innovate than CMS does. They should take fuller advantage of that freedom.
I just returned from a week long trip with my family to Jackson Hole, Wyoming. We went hiking, fishing, rode horses and simply enjoyed the outdoors. During my vacation I read a book Last Child in the Woods - - Saving our Childrem from Nature-Deficit Disorder by Richard Louv. This book discusses the abscence of nature in our children’s lives as we’ve become a “wired generation”, leading to trends in childhood obesity, depression and ADHD. I hope you challenge your readers on the importance of getting our kids outside to be active and creative/dream as its essential for the physical and emotional health of both parents and children.
Charlie, good to meet you. During my almost-deadly and very costly cancer adventure last year HPHC earned my undying(?!) admiration. When your Helen McNabb first called to introduce herself and said she was there to just help in any way possible, I was highly skeptical, but I soon learned it was the truth. I was amazed, and now I miss no opportunity to tell people how great HPHC is. It was one of the first posts when I started my blog last year.
Regarding a possible initial increase in costs as the system changes, e.g. through transparency: we must not fall prey to the error of the local minimum, trapped in a seeming low spot that’s actually just a vale among mountains. We need to get off the mountain entirely.
I’m not for a moment belittling the cost issue. At 58, I’m entering the high-dollar-consumption phase of life, and I tend to opt for higher-copay plans.
But yes, given how unacceptable the system is today, let’s get out the flashlights and begin the necessary (if unpleasant and sometimes stinky) work of seeing what’s going on in the basement.
Last night I wrote a long comment on the “Paul & Charlie show”. It’s not visible yet but have a look.
Good to meet you, and thanks for the fight you’re fighting. As Bob The Builder was saying long before Barack, “Yes we can.”
Barry - My only caveat to your post would be that I think it’s hard for plans to innovate on payment methodology - except on the margins. We innovate in lots of other ways - service, outreach, member ID and outreach, medical management, and the like - but innovating on payment - when so much of the toolkit is written by Medicare - is hard to do. And CMS can say whatever they want. At the end of the day, they drive payment policy in the U.S.
e-Patient Dave - many, many thanks for your very kind words about Helen McNabb and your awesome post in December, 2007 on your blog about HPHC. We hear from people when we get it wrong - as we should. It’s very rewarding to hear from someone when we get it right. Thanks again - and congrats on beating the Big C.