July 17, 2009
Over the past few weeks, I have had a serious case of “news junkyitis” for everything I could find out about healthcare reform as Congress and the Obama administration debate what to do for our country’s healthcare crisis. I’m trying to be hopeful that real reform will happen–that we will make some substantial changes to how we conceive of, deliver, and pay for healthcare in America–but I am starting to lose faith. And I’m growing desperate enough to wade into the blogosphere for the first time in my life. Thus, I hope to use this space to share ideas, ask questions, learn from others, and debate the very real and very complex issues that face us all as we wear the multiple hats of patients, family caregivers, coworkers, and voters who want a better way to do healthcare in America. I come to this blog wearing many different hats myself—for example, as a patient who routinely goes through the frustrations of repeated labwork, scheduling appointments too many months away, dealing with too many specialists who don’t talk to one another, managing multiple chronic conditions, and taking far too many medications—all while trying to make myself exercise more and lose weight (which I am currently failing at miserably). I’m a patient advocate for a few dozen folks each year who need some assistance with everything from researching their cancer treatment options online to having someone drive and hold their hand at a scary test they have to go through. I’m also a concerned son who is lucky enough to have two retired parents who are in pretty good health but live far enough away on the East Coast to make me worry about what will happen as they get older. Yes, I have an important-sounding title at Intel—the current one is something like “Global Director of Health Innovation, Strategy, and Policy”—but I’m really just a proud and passionate social scientist in the Digital Health Group, who started our research programs 10 years ago to explore personal health technologies for disease management, independent living, and wellness at home. I’m a researcher who has spent the past 17 years studying doctor-patient interaction, telehealth technologies, and doing fieldwork in homes and hospitals to think about how to deliver care differently. And I’m a proud co-founder and member of the Center for Aging Services Technologies, or CAST, in Washington, D.C. which is a great coalition of leaders who want to reinvent long term care in this country with more options about how people live, work, and play as they age. All that being said, I make no claims to being an expert on all things healthcare (and I’ve never met one, because “healthcare” is so complex that no one person is an expert on all of it). My life experiences both inform and obscure my perceptions of the world and of this reform debate. As I mentioned at the beginning of this blog, my faith in healthcare reform is being sorely tested by the following top-of-mind concerns: 1) Prematurely Rushing Towards “Mission Accomplished”: I fear we’re rushing towards a healthcare reform bill that doesn’t address the fundamental changes we need in care delivery, payment, coverage, incentives, tort reform, social responsibility, and infrastructure. To declare “mission accomplished” on healthcare reform prematurely—without really making fundamental changes—would have terrible consequences for our economy and push out the hard problems of reform for another decade or more. We can’t defer these challenges again to another Administration and generation. We have to use this historic moment to really set a new vision and infrastructure for doing healthcare differently in America, that is more focused on health, prevention, behavior change, and personalizing care to whatever settings and cultural contexts drive the best outcomes. Real reform requires a going-to-the-moon kind of engagement of public attention and investments—and a new social covenant for how we will operate as citizens, consumers, patients, employees, and family members. If that means taking a bit longer on health reform than we thought, then so be it. It is the largest, most complex part of our economy, after all. 2) Ignoring Delivery and Payment Reform: Congress and the media are so focused on “coverage”—and showing that they have a way to cover the uninsured (which is fundamentally important!)—that they have skimmed over the much-needed reforms in delivery and payment that will reduce the costs enough to increase quality and access for everyone. If all we do is suddenly bring the uninsured into an already overburdened, inefficient, and reactive delivery system, then we’re simply bankrupting ourselves faster and putting even more stress on already shaky fault lines. Let’s not just add more people to the waiting rooms, more appointments to the doctor’s over-scheduled roster, and more costs to the payors. Let’s figure out how to drive the kind of preventive, proactive, and personalized healthcare system that treats people at home as much as possible, that pays clinicians for successfully managing the care of their patients instead of managing the medical bureaucracy, and that delivers care in a wide range of locations and contexts (in home, in community clinics, virtually via telehealth technologies) instead of using our most expensive hospital resources to treat the epidemic of chronic disease and non-urgent needs. 3) Asking Everyone Else to Change and Sacrifice, But Not Me: As I struggle to find an affordable hotel room in D.C. next week where everyone (me included) is descending upon Congress to try to have their voices heard in this debate, I’m struck by the “not me” mentality that I think will kill healthcare reform if we don’t change our perspectives. I hear each interest group or constituency holding forth about how critical it is that no one change their situation, but that all the other aspects of healthcare need reform. If we all simply come in trying to protect our own turf while asking everyone else to pay the price for healthcare reform, then we are doomed to failure. We—again, me included—ought to be stepping back from our particularly narrow points of view as activists, lobbyists, or representatives of a specific issue or group to wear a broader hat: as a patient who will need care from this system we are reforming. So if only for a moment, we need to stop being Politicians, Lawyers, Researchers, Employers, Tax Payors, Lobbyists, Reporters, Doctors, Nurses, Payors, and so on…and be a person who wants to rely upon this healthcare system for care, possibly even to save our life. And we ought to use this moment of reform to design a care paradigm that we would want to use and pay for ourselves. Then, when we put those other hats back on, we have to be prepared to change our behaviors, expectations, and culture—and many of us will literally need to pay more money somehow—to come up with solutions for our 21st century healthcare needs. If the Providers and Payors and Patients and Lawyers and Employers are each unwilling or afraid to change the way we do things—and if no one is willing to sacrifice—then real reform is dead already. If we’re not willing to look inwardly to ask what each of us—wearing all of our various hats—is prepared to do for our country, then we’re looking for health reform in all the wrong places.Policy@Intel
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8 Responses to Searching for Health Reform In All The Wrong Places
I love the concept you described of a healthcare system that is “preventive, proactive, and personalized.” The soundness of such a system seems so logical, yet it is so far removed from what we have today. There is much to be proud of in the American healthcare system (e.g. the dedication of our doctors and nurses, the technological advances we’ve made in treatments and medicine). However, the oft stated sentiment that we have the best healthcare system in the world can blind us to the fact that our system is not as preventative, proactive and personalized as it should be.
USA healthcare has been a prime example of both market failure (to control costs and improve provider efficiency) and outcome failure (to improve patient health and wellbeing). The USA is paying far more per capita for healthcare than any other advanced nation, and ranking down near 27th in life expectancy. As the author essentially states, gathering more victims into this monstrously inefficient overpriced sucker pool is hardly progress.
I agree as well, it’s NIMBY as applied to healthcare. one problem is that cost derives from the patient, who will always choose care over cost constraints. I think your concept of a “to land on the moon and return home” over a multi year goal is better than just a watered down “bill”.
a few questions: Wouldn’t it be better to walk before we run by starting with a defined population and figure how to cover and pay for them, then build from there?
second: do we consider medicare, a form of socialized medicine, to have worked? (over the long term?)
should we consider base level-no frills care covered, and then people can opt to pay an insurance premium for supplemental coverage?
there ought to be a formula that could be determined that works.
thanks for blogging on this topic. and for investing time into it, for all of us and for future generations,
I do agree that we have to walk before we can run, and that folks dealing with co-morbidities of multiple chronic conditions make a good starting place. Perhaps the so-called “dual eligibiles” who can receive both Medicare and Medicaid. Problem is that, historically, Medicare hasn’t been set up for innovation of new care models. There is talk in the reform debate of trying to get more innovation infrastructure and investment in CMS, which would help. I don’t have enough historical perspective to know how to assess whether Medicare has worked or not (compared to what?). But I do think Medicare has been a slow follower, not a fast leader…and if CMS could become an accelerator as opposed to a hindrance of innovation, that would be quite an accomplishment.
Let me open with a brief caveat – I am from Europe (Ireland) and we have a completely different healthcare system. I have lived in the US for over 5 years now and I am lucky enough to have good health insurance, but the whole concept of Healthcare Insurance Affordability is alien to me.
The insurance is going to be as expensive as the costs of the services provided + administration costs of the insurance company + profit. Its the whole cost of Healthcare that needs to be tackled, not just the insurance costs.
I know what the concept of universal access to healthcare results in without changes in how its delivered – waiting times of months, years to get access to specialists – two tier systems of healthcare delivery – one for those who can afford it and another for those that can’t.
In Ireland, I know we had GPs (Primary Care Physicians) who limited the number of patients they would see, but charged a retainer to those that they would see!!
The US does have a good healthcare system right now, for those who can afford it, but as has been previously pointed out, its a race to the bottom on this topic.
As a non healthcare professional, I don’t want to minimise the work that they do, but there needs to be fundamental reform (re-engineering) in how Healthcare is delivered. These professionals know how to do it – they are just being held back by special interests and those afraid of change e.g. segmenting the work done by Healthcare Professionals into pieces in such a way that the expertise required is low cost, but with the proper checks and balances.
I hope we see the necessary steps taken soon to prevent the inevitable bankruptcy that will occur – one which I think we will see in the next 20-30 years.
Great post Eric. I think you have hit it right on the head. Somehow folks going into the reform debates have to go in with a thought of how I can help change the system but be prepared to change as well. I recently had some upclose interactions as I worked through some of my own health issues and it is still shocking to me that banks can share financial information yet my personal health information has to get entered on paper (gasp!) for every PCP, specialist and hospital that I go to. There are so many efficiencies it boggles my mind. Yet I am thankful for the insurance options I enjoy today and the care I’m able to receive as a result. We live in a blessed country. I’m also excited about the prospects for providing more coverage and options for folks via technology disruptions, new business models, social media, etc. That is where I think Washington needs to focus. Success to me is not passing a bill with x amount of dollars to insure the under or un-insured although I think having a security net for these folks is important. It is to establish a framework of insurers, doctors, patients, hospitals, IT professionals, etc. in a way to talk about the future systems based on the way the world is today. A great read that has inspired me is Clayton Christensen’s latest work “The Innovator’s Prescription” does a great job I think in providing some future solutions to the problems we have today and the problems we’ll face in the future if don’t change. I’m also excited and proud that Intel is taking a long term view towards being a significant part of helping to solve one of the world’s most difficult problems in providing better healthcare for mankind.
The outcome from any health care reform should be to reduce the rate of increase of cost to be lower than or equal to rate of GDP growth in the long run. To achieve that we need to look at the biggest cost drivers to health care cost. Below are the 3 important ones
1. Hospital Care
2. Physician Services
3. Prescriptions.
Chronic diseases are one of the biggest drivers causing Hospital Care and Prescription costs to go up and hence reform should incentivize healthy lifestyle and preventive care. If we are held responsible for our health related decisions and are provided avenues to get the preventive care then we can reduce hospitalization and early detection result is reduction of cost. An article mentioned that if US can go back to the average weight of 1960s we can take a trillion dollar of the cost curve today.
Although we should remember that there are those who get chronic diseases as a result of genetic or other predisposition and there needs to be a solution for these patients, where the stress should be on early detection and possible care to keep them out of hospital. Here regular checks through preventive care and technology to support the needs of these patients remotely will help reduce costs.
The second driver is the rising cost of hospital care which rises because of two reasons
1. Providing services to people who come to emergency rooms and pay nothing at all for those services and that cost is amortized to the rest of paying customers. If we can have medical booth with doctors checking patients remotely, it can not only achieve cost reduction but also preventive care availability at remote locations. India is trying such implementation at remote villages. 2. Extra tests and manual errors both can be reduced as mentioned in the next sections
The third driver of cost increase is all the extra and duplicate tests physicians have to do to safeguard themselves from getting sued. These frivolous lawsuits are causing also the cost for physician services to go up along with hospitalization costs. So reform should address Tort reform in some form. Technology should help prevent duplicate tests as patients move from primary care to specialist etc and reduce error as complete patient’s history/ information will be available easily to hospital and physicians.
The final driver for cost increase is the regulatory/paperwork requirement. As mentioned IT should be able to standardize and automate paperwork reducing errors.
Other areas for reform are
a. Insurance markets should be opened up, so that insurance companies should be allowed to compete nationwide.
b. Reform should also include some structural changes in Medicare and Medicaid over time so that costs not reimbursed here does not cause higher costs for the rest of the private insured customers.
healthcare at home? if this means buying a toy with some h/w content we put in there this may seem like a good solution (for say elderly emergency feedback) but there are many, many other changes I would recommend…
=>1. make preventative healthcare a requirement.
this includes weight, exercize, diet management help. doesn’t mandate specific actions as much as the process and engagement on personal goals (Intel is already starting this with the Mayo clinic engagement and this seems productive/useful). I realize this can degrade into Intel becoming a health nanny or worse. But somehow we need to get preventative behaviors to correct long term (and perhaps short term) care and needs.
=>2. get intermediate healthcare between doctors 8×5 and ER care 24×7.
California (maybe other states) simply have no alternative to ER for getting seen for minor “repairs” that occur at night or weekends. Getting these people out of the ER and into “ready-med” care (what they call this in Michigan where I have seen some…) will reduce healthcare costs (many in the ER are NOT uninsured but simply have nowhere else to go.)
=>3. stop the goofy in/out of network nonsense that boost cost
Ever notice that your healthcare while limiting you to specific hospitals and doctors, causes you to get out-of-network providers to captive markets like ER physicians-on-call, lab testing, and anesthetists — all at in-network hospitals and doctors offices? They get away with this because you are in a captive market with no choice. When you are wheeled into surgery is the last possible place/time you will realistically ask whether the anesthesiologist or other workers are in-network. This is possible to fight after long efforts with insurance intermediaries and unsympathetic doctors/hospitals. This alternative universe happens in multiple insurance providers BTW (Cigna, UHC, etc). I am not making this up!
=>4. out-of-network costs are not merely paying a higher co-pay or percentage…Eliminate the phony cost structure.
When your insurance carrier rejects your claim of in-network by some trickery you will pay not merely 80% instead of say 90% but 80% of the UN-negotiated price demanded of the doctor/hospital. Say you spend a few days in the hospital and the surgically adjust you. You are looking at 80% of say 30K$ un-negotiated price rather than say the base price radically reduced by the insurance carrier (to say 8K$). Insurance carriers negotiate MUCH lower prices from providing physicians. Where does this 30-8=22K$ “cost” go? was this never real? Why was this charged in the first place? what is the “real” cost of the hospital or doctor visit?
=>5. Lastly and probably the hardest one is eliminating bureacratic layers between the real provider (doctors not insurance) and you.
I cannot imagine a cost structure that makes sense putting lawyers and actuaries and people to deny claims between you and care providing. This just makes no logical sense even though the elimination (universal healthcare and government provided care) seems to scare the heck out of many Americans.
Even some system to eliminate all the people that deny healthcare or try to tell you and your doctor what is permitted seems doomed without some restrictions on care by price by need. A 90 year old likely shouldn’t get the same effort as a 5 year old to repair some kinds of problems based on the likelihood of success and many other factors. How we manage this effort without gimmicks (fancy boxes and tests and herculean procedures most of which may not really improve healthcare), how we manage, prioritize, ration, these are terms that scare people silly. We need rational discussions since healthcare everywhere is rationed by some principles (wealth, workplace insurance coverage, government employment, evil bureaucratic rules (to some) etc.).