(From Hospitals and Health Networks Weekly, January 28, 2009)
Merely covering all Americans in some fashion to pay for the system we have now would fall far short of creating a system that works. In fact, that would take far more than federal legislation, but the legislation can lay the foundation for true and lasting change. What would be the bare bones of legislation that would create a new, better health care system?
A new president and a new Congressional majority, all with a mandate for health care reform. A public crying out for health care reform—and informed by a sentiment that can often best be described as boiling rage at the current payment system. The popular, respected and very ill Senator Ted Kennedy trying from his sickbed to pull together a bill and a coalition of support for a health care reform bill, the measure he has called “the cause of my life.” An economic downturn threatening the jobs and health care coverage of millions of Americans—but especially of baby boomers, most still short of retirement and Medicare age.
It would be hard to imagine a more potent mix for a health care reform bill that would promise universal coverage of some kind or another.
Beyond universal coverage, there are several must-haves for any legislation brings about a working health care system.
First would be the goals: not only to include all Americans (“more health care”) and to make sure that no one is denied coverage for any reason (“more health care security”), but to nurture higher quality in the system (“better health care”), at lower cost (“cheaper health care”). Not lower inflation; lower cost. Not a little bit lower; a lot lower.
Impossible? Too much to even aim for? Tell that to the dozen or so medically advanced countries that have better health outcomes than the United States does, at half or two-thirds the per capita cost—with or without private health plans. We could do it, and we could do it without draconian measures, without long lines or access problems—if the country and the Congress can stare down the political influence of those who benefit from the extraordinary largesse allowed by the current lack of a real system.
Insurance: Medicare for everyone (why is it “socialist” to pay for health care for people under 65, and not for those over 65?) might be the most efficient way to bring health care to all Americans. Short of that, though, if one goal of a universal coverage plan that embraces private health plans is “health care security,” we will need a strong dose of basic insurance reforms.
For one, we would need penalties for financial rescission. That’s when you run up a lot of health care bills because you have developed cancer, for instance, and suddenly the insurance company decides that there is some mistake, no matter how trivial, on the detailed, 15-page form you filled out years ago when you applied, so you are no longer a customer, and you are responsible for all your medical bills out of your own pocket. A number of district attorneys and attorneys general around the country have labeled this all-too-common practice criminal fraud, and strong penalties for it must be written into federal law.
We would also need to end medical underwriting: Health plans must offer their product to all comers, regardless of “pre-existing conditions,” with rates differing only for age group and geographic location, like car insurance. The logic of true insurance is to create the largest risk pools possible, yet current industry practice is precisely the opposite, to attempt to slice up the pools as narrowly as possible, making insurance unaffordable or impossible to get for precisely those who need it most.
Medical loss ratios could be legally capped at 85 percent; that is, only 15 percent of premiums taken in could be consumed by marketing, processing, profit and other expenses.
Health plans operating under such constraints would not be the vast engines of profit that they are today, but they could contribute considerably to their policy holders’ health care security by guaranteeing coverage, aggregating health care customers and using their buying power to push providers to improve.
Transparency: We need an agency that operates in health care the way the Securities and Exchange Commission is meant to operate in the financial world. Both providers and payers would be required to submit and certify certain types of data, both financial data and medical outcomes data, for public display. It’s a basic rule of management: What gets attention improves. Any improvement in health care must be based on real data about what works and what doesn’t, at what cost.
Digitization and automation: Through a greatly expanded, layered combination of reimbursement incentives, tax credits, loan guarantees, mandates and penalties, the federal rules must drive the industry to digitize and automate. There are rich fields of possible improvements in health care, and most of them depend on digitization, either to implement or to measure. Paper-based health care is opaque to improvement.
Measurement: The same incentives should drive measurement that is as much as possible ubiquitous, automatic and invisible. The same way that the grocery chain where I shop knows what type of wine I favor—through my shopper’s card and purchases, though no one ever asked or wrote it down—providers should be able to discover and analyze every detail of their procedures, to discover what works and what doesn’t.
Evidence-based medicine: It is one of the great mysteries of 21st-century health care why we remain willing to pay for any other kind of medicine. Organizations that have emphasized working from evidence, like Intermountain Health Care, have shown remarkable results.
Eventually, the reimbursement system should pay for what has been shown to work (including so-called alternative therapies and short-term behavioral interventions) and not for what has been shown useless (such as many back surgeries, whose usefulness has been debunked in the peer-reviewed literature). There are mountainous problems with implementing evidence-based medicine as a basis for payment across health care, but any new legislation should push firmly in that direction.
And this is why there is no “Tort reform:” heading here. Malpractice suits are a huge problem in health care largely because there is no other feedback loop enforcing quality. In a context in which providers work in teams, using evidence-based guidelines, standardized practices except where an individual case calls for variation, and digital records that communicate clearly between different providers and documented each decision, malpractice would simply not be the problem it is today.
Stupid events: It was a big step last October when CMS announced that it would no longer pay for “never events,” such as accidentally removing the wrong leg. But there are many procedures done and paid for in health care that may be “medically indicated,” but are just wrong to any common-sense perspective.
For instance, I hear, from people in long-term care of the frail elderly across the country, of a surprising amount of unnecessary, unhelpful, often risky and certainly expensive procedures performed on their patients, such as giving artificial hips or knees to permanently bedridden people of extreme age. It is difficult to see how to write into law a prohibition against paying for such procedures, or how to cleanly differentiate them from what is truly necessary, helpful and worth the risk, but these procedures represent a type of excess that we can no longer afford.
Prevention and primary care: Any comparative study of health care systems shows that a strong primary care system, and a strong system of preventive measures, not only results in better health and saved lives, but save money. We greatly underpay our primary care providers and stint on reimbursement for preventive measures. Increasingly we even discourage insured people (through co-pays and deductibles) from getting their physicals and tests and vaccinations. These trends need to be reversed.
Group services: We reimburse providers only for one-on-one services. Yet for many lifestyle-related conditi
ons (such as obesity, smoking, diabetes or stress), bringing patients together in problem-solving and mutual support sessions, in combination with their usual doctor’s appointments, have proven highly effective. Improved reimbursement rules would reflect this.
Bundled services: Imagine giving one price for, say, an uncomplicated birth, a mitral valve replacement or a diabetes management program, including all necessary tests, diagnostic procedures, therapies and even rehab. Selling such “products” would mean that the buyers (patient, employer, health plan or government) would be paying for what they are actually buying—a properly birthed baby, a fixed knee, a managed case of diabetes—instead of a list of tests, therapy sessions or devices that may or may not be necessary.
Bundled services are not just convenient for the buyer; they represent a major path to rapid improvement for the providers, for this reason: No buyer can judge whether any individual item on the list was necessary or effective. In most cases, though, a buyer can clearly and easily judge whether the whole product worked, whether it did what it was supposed to do.
Not everything in health care has the desired outcome. Health care, in fact, largely consists of narrowly rescuing us from disasters, and it doesn’t always succeed. In fact, eventually it fails—once per person. But it is possible for health care to succeed much more consistently to do the things that it needs to do to guarantee the best possible outcome—including evidence-based medicine, persistent teams, checklists and lean management. Bundled services would not only provide a way for the customer to evaluate the service, they would also force providers into the same kind of serious quality-building work almost every other industry now takes for granted.
“Neo-caps:” Bundled services for chronic care (such as managing diabetes, congestive heart failure or chronic obstructive pulmonary disease) not only provide an opportunity for continuous improvement, they also allow the provider to intervene earlier, and with a broader range of tools, to keep the patient’s health at an optimal level.
Such interventions might include, for instance, behavioral therapy and social interventions to help patients deal with difficult home or life situations that keep them from controlling their disease, or nutritional counseling, cooking classes and even eating clubs to help people learn to change their diet—all far less expensive and difficult to manage than later, acute intervention in the emergency department.
Control of drug prices: It makes little sense for the largest buyer of drugs in the world to refuse to negotiate or control or in any way impact the price of the product. There are plenty of mid-points between mandating prices and simply accepting whatever prices the drug companies demand. For instance, the price the U.S. government pays could be pegged to the average prices negotiated by other major countries such as France, Germany and Canada. At the same time, the prices of some life-saving drugs are now so high that citizens are forced to impoverish themselves in order to fight their disease. That is not right in a free and wealthy country.
R&D: We need (among other things) vigorous detailing of whole classes of drugs, not just the newest and most profitable; research into the effectiveness of hundreds of devices and therapies; and research into and promotion of the use of checklists throughout health care. Most of the most promising areas of possible improvement in health care are simply not being backed with vigorous, impartial research that could affect the system as a whole.
Much of potential for “real health care reform” is down in the nuts and bolts, the gears and sensors and switches. Any health care reform bill will be filled with pages and pages of detail, and much of current law and regulation actually discourages or forbids the kinds of change that we need in health care. Perhaps this time around we can begin to get it right.