Healthcare Futurist: Joe Flower

Courage and Compassion in the Future of Health Care

That was quite a year, that 2009. Wasn’t it? Across the industry, as we move into spring 2010, the strongest desire I hear is to get back to some kind of “business as usual,” to breathe a big sigh of relief that we are past all that sturm und drang, all that public trauma and threat to our bottom lines and corporate structures, get a good night’s sleep for once, and get back to the way things were, with maybe a few adjustments.

Maybe it even seems that we are there already. After all, a year ago half the hospitals in the country were operating in the red, and today we are pretty much back to where we were.

This is a comforting illusion, one that threatens to become an industry trance. We are not back where we were. There is no going back.

Sharp, funny, and far too true: If airlines worked like health care.

Driving down the cost of health care: What would actually work?

If competition the way it is structured at present actually drives the cost of health care up rather than down, what would bring lower costs? What provisions in a “health reform act” would actually drop costs in health care? Let’s leave aside for the moment all the myriad other arguments - some might be seen as too much government intrusion, some would be cripplingly difficult for providers, and so on - and just focus on cost. Given the real structure of health care markets in the United States at this moment, among the various options available to lawmakers, what could be written into federal law and regulation that would actually reduce cost?

Forward Through the Chaos: The Future Beyond Healthcare Reform

(From H&HN Weekly, November 24, 2009)

It’s not easy being a futurist, but I will make a bold prediction: no clear victory, no simple end. What we will get, one way or another, is years of turmoil, re-definitions, new rules and shifting markets—an industry under great, immediate and chaotic pressure.

This makes plotting a direction for your institution more difficult than ever. Yet the next few years will demand and reward far more active, even aggressive, tactical and strategic management than ever.

By January 1 we may have some version of a “public option” plan enacted. Maybe we’ll get insurance co-ops, or nationwide insurance exchanges, or some kind of universal coverage through mandates and subsidies. Maybe we’ll get some kind of patchwork chimera shambling mess of “reform.” Even if there is no bill at all, or even if President Obama pulls a giant rabbit out of a very large hat, still we face what the elder Kennedy brother called “a long twilight struggle, year in and year out.” This is not over and will not be over for a long time.

We are engaged in a political melee, with a wide array of interest groups willing to cry havoc and let slip the dogs for any advantage. And our institutions, at the center of all this, can too easily end up as just so much collateral damage. Institutions already reeling from the recession, the flood of uninsured, the hammered budgets, could well find themselves further hampered in their fight to simply stay alive and do their jobs.

Health care reform strategy: Sell patients like baseball players - seriously

Here’s a health care reform strategy that I have not heard anywhere else. Think about this:

Why aren’t health plans more aggressive in promoting the long-term health of their members, like getting them to eat better, stop smoking, get a little exercise, and all that? Because of “churn.” For something that has immediate consequences, helping their members stay healthy has an immediate payoff for the health plans. But most of the big things that would make you healthier take a longer time to manifest: You quit smoking or start eating better, you will have a much better health profile in five years, but it won’t make as much of a difference in, say, one year. 

“Churn” is the industry term for the annual percentage of  members who leave a health plan, and it can be surprisingly high. If each year 20 percent of a health plan’s members go to some other health plan for whatever reason (they move, lose their job, change employers, get Medicare, find a better deal), then it is not worth it for the health plan to invest in their members’ long-term health. If the health plan invests time and effort (which means money) to get you to quit smoking, and you then quit and become someone else’s customer, they lose that investment - and the other company gains, by getting a customer who is less likely to need expensive long-term treatments.

$700 Billion in Health Care Waste - and We're Doing Zip About It

The future of health care in the United States cannot look good as long as we waste so much of what we spend. I have long cited studies showing that we waste 30%-40% of our health care dollar, and have long claimed that we could beat that and reduce our costs by 50%, cover everyone, and have better quality at the same time. Now Thomson Reuters health care analyst Robert Kelley has pulled together a plethora of substantial studies to produce a white paper headlined, "Where Can $700 Billion in Waste be Cut Annually From The U.S. Healthcare System?," detailing what various studies show about where the waste shows up.

He divides the waste into six categories:

• Unnecessary care : 40% of the total waste ($250 - $325 billion in annual healthcare spending)
• Fraud: 19% ($125 - $175 billion)
• Administrative inefficiency: 17% ($100 - $150 billion)
• Provider errors and inefficiencies: 12% ($75 - $100 billion)
• Preventable conditions: 6% ($25 - $50 billion)
• Lack of care coordination: 6% ($25 - $50 billion)

Meanwhile, the Washington Post publishes a roundup of health care experts seconding what I said two months ago: The bills before Congress are way too cautious about making the real changes that will truly cut health care costs to match the rhetoric about affordability. I warned about this in my post, "'Reform' means higher costs, not lower" and then proposed "Driving down the cost of health care: What would actually work?"

The Future of Health Care - Is It A Rural vs. Urban Issue?

Rural vs. urban? Or something deeper? A provision in the House health care reform bill (HR 3962) instructs the Institute of Medicine to take two years to look at why health care costs so much more in some areas than in others in the last two years of life - twice as many doctors involved, days in the hospital, re-admits, and dollars spent - and make recommendations to change that. Unless Congress instructs otherwise, the IOM's recommendations are to become law. This NY Times article, and some politicians, are framing it as rural vs. urban issue, Iowa vs. Manhattan. But is it? Look at the map that goes with the article. What's up with big urban centers (and medical research and teaching powerhouses) like Boston, Atlanta, San Francisco, and Seattle, that are on the low end of the cost curve?  This is about something deeper in the structure of how you organize health care, how you compensate people, how institutions make their living. It is absolutely fair and reasonable to study this matter. We will never begin to get a handle on soaring health care costs unless we change it.

Why "free market competition" fails in health care

In trying to think about the future of health care, thoughtful, intelligent people often ask, “Why can’t we just let the free market operate in health care? That would drive down costs and drive up quality.” They point to the successes of competition in other industries. But their faith is misplaced, for economic reasons that are peculiar to health care.

More “free market” competition could definitely improve the future of health care in certain areas. But the problems of the sector as a whole will not yield to “free market” ideas – never will, never can – for reasons that are ineluctable, that derive from the core nature of the market. We might parse them out into three:

Why is this the one thing?

When the terrorist attacks of 9/11 hit the United States, and suddenly we were plunged into war, first in Afghanistan and then in Iraq, I don’t remember anyone demanding that the wars be “deficit neutral.” No one talked about whether we could afford them. They were things we just had to do. When George W. Bush proposed giving vast sums to rich people in the form of tax cuts, no one argued that it would be “deficit neutral.” Rather, it was argued that cutting taxes wouldn’t bring in less tax revenue at all, it would bring us more tax revenue, because the economy would grow so much faster. And besides, it was somehow terribly urgent, something we just had to do. When the banks tottered and needed to be shored up with taxpayer money to the tune of nearly $1 trillion, there was no way to argue this would be “deficit neutral.” We might get the money back, we might not. Whether we could afford it was not the question, we just had to do it to save the banking system. Similarly, the “Stimulus Bill” was terribly urgent, and something we just had to do, whether we could afford it or not.

Then we come to health care reform, and suddenly, it seems, this is where we draw the line. The president says that health care reform must be “deficit neutral.” It can’t actually cost us anything in tax funds. And everyone nods sagely and argues over how to do this.

Why?

Why is this the one thing that we can only do if we can prove ahead of time that it will not actually cost anything? Our current system costs us an estimated 44,000 lives and impoverishes millions of Americans every year, and causes untold suffering – why is this the one huge national problem that everyone agrees we can’t afford to solve?

How to Mayo Up

From the American Hospital Association Weekly, 9/15/09

If you’re thoughtful, if you’re thinking about how health care in the United States actually works; if you’ve been following the bouncing ball here about why it costs so much for such mediocre results, you’re thinking: Integrate. Get the docs and the hospitals playing on the same team. Align the incentives.

If you’ve ever tried any version of this patchwork, Rube-Goldberg-style, bee-corralling exercise, you’re thinking, “Good luck with that.”