Brian Klepper
What Will It Take To Re-establish Stability and Sustainability to American Health Care? Will It Be Driven Through Policy or the Marketplace?
Effecting meaningful health care change is about two things. The first - and easier problem - is knowing what to do to fix the system. After all, the problems are structural and well-understood, and they’re obvious to many students of the system.
But the much tougher health care problem has to do with power and money. We know that one-third to one-half of all the money America spends on health care annually - that number is now between $800 billion - $1 trillion - is unnecessary or inappropriate. That waste comprises a significant portion of the financial baselines of most health care organizations, and most real reforms would remove those unnecessary dollars from the system. It’s doubtful that the health care industry - which fields the largest and most influential DC lobby of any economic sector - will willingly agree to have its revenues and margins reduced.
So change, if it can occur at all, must be driven by the one group that is even larger and more powerful than the health care industry. That would be the non-health care business community. They wouldn’t do it because of social justice, but because the turmoil in an unstable health care economy could cascade to all other sectors, threatening the national economic security.
So this section provides a summary of what I have learned over the last 9 years working on this problem. There are structural issues of establishing a floor of coverage for basic care for everyone in the country, investing in IT, establishing clinical and administrative standards, transparency, tying payment to performance, rebalancing our reimbursement system, and many other issues. But there are also the thornier problems of power and politics, and how to achieve significant social reform in a political environment that is so susceptible to perverse influence.
My conclusion, sadly, is that to fix our big problems like health care, obesity and the environment, we’ll first need to fix the ways American policy is shaped and passed. That’s the predicate problem, but one that we must confront if we’re serious about our health as a nation.
Wednesday, October 24, 2007
Getting To Meaningful Health Care Reform
About a year ago, the Executive Director of a national business association called with a straightforward request. Develop a document that could make a logical structural argument for health care reform, then list out the specific problems in the system and the action items that would be required to re-establish stability and sustainability to American health care.
This section resulted from that effort. It is still a work in progress, at least in terms of the justifications.
But it tries to
Wednesday, October 24, 2007
Overview
The intensifying health care crisis has recently elicited reform proposals from the White House, several states, Congress, Presidential candidates and the movies. While each abstractly acknowledges the need for cost control, most are focused on providing basic or comprehensive universal coverage. Aside from making sure that everyone in America has insurance, few proposals describe what actions will be required to re-establish stability and sustainability in our health care system.
It seems
Wednesday, October 24, 2007
Perspective On The Health Care Crisis
It is not news that American health care is in crisis. Between 2000 and 2006, health insurance premiums grew almost five times as fast as the rest of the economy, almost four times workers earnings and more than twice the growth of business net income. That rising cost is pricing individual, corporate and governmental purchasers out of coverage, with impacts for mainstream and low-income Americans.
Enrollment in private sector health coverage represents about half (56% in 2004) of all health
Wednesday, October 24, 2007
Principle 1: Establish Universal Coverage For Basic Health Services
Problem
Social justice issues notwithstanding, the rapidly rising tide of uninsureds and underinsureds threatens to overwhelm and financially destabilize health care safety net professionals and institutions, and to precipitate significant turmoil throughout health care, the nation’s largest economic sector.
Actions
A. Establish Funding For Basic Care Services. Establish universal coverage for “basic” health services – basic must be defined – funded through taxes, for everyone in America. To
Wednesday, October 24, 2007
Principle 2: Modernize Publicly-Financed Health Care Programs
Revamp Eligibility Criteria
Problem
As former Oregon Governor John Kitzhaber MD has persuasively argued, public programs like Medicare and Medicaid define eligibility categorically (e.g., age, gender, parental status) instead of in terms of financial need, creating inequities and squandering precious public resources.
Action
Establish a commission to review and recommend reforms to public health care eligibility criteria so they promote health and equitably reduce the nation's burden of
Wednesday, October 24, 2007
Principle 3: Retool Health Care’s Management Infrastructure
Problem
America’s health care system currently lacks a cohesive management infrastructure for enterprise-wide performance tracking and management.
Action
Establish the functions described below under the auspices of a new or expanded national agency.
Transparency/Accountability
Problem
Our current inability to identify problems and opportunities throughout health care has resulted in waste, inappropriateness and sub-optimal quality. Broad awareness that excesses are difficult to identify
Wednesday, October 24, 2007
Principle 4: Promote “Meaningful” Consumerism
Provide Information For Better Health Care Decision Making
Problem
Information is not yet generally available to allow health care purchasers at all levels to make informed decisions. That is, without information health care cannot have a functional market.
Actions
Publicly report pricing and performance information on health care vendors in ways that are meaningful to purchasers and fair to those being evaluated.
Publicly report pricing/performance/value information for informed
Wednesday, October 24, 2007
Principle 5: Rebalance America’s Health Care Justice System To Protect Patients Without Compromising The Health System’s Viability.
Problem
In its current form, America’s health care justice system is capricious, unreliable, and onerously expensive. It does not discourage error or encourage error proofing. Health care providers unilaterally loathe it and seek change, while the health care bar generally opposes reforms. At the same time, serious national health care quality standardization efforts still have not taken root and, even if they had, they have not been incorporated into health care justice processes. That said,
8:00 AM
End Notes
The White House National Economic Council, Reforming Health Care For The 21st Century, February 2006.
Office of the Governor of California, “Gov. Schwarzenegger Tackles California's Broken Health Care System, Proposes Comprehensive Plan to Help All Californians,” January 8, 2007.
Office of the Governor of the Commonwealth of Pennsylvania,“Governor Rendell Unveils Historic “Prescription for Pennsylvania” to Provide Access to Affordable, Quality Health Care For All Pennsylvanians,” January 17,
Is Meaningful Health Care Reform Achievable?
No economy can indefinitely support a business sector that grows continuously at a multiple of general inflation.
Tom Emerick
Former VP, Benefits
Wal-Mart
We need a sustainable healthcare system, in the same sense that we need a sustainable environment.
Daniel Callahan
Hastings Center
‘As a business decision,’ treating Mr. Watson ‘wasn't a great one,’ Dr. Kussin concedes. He notes that ‘our hospital has always told us to spend what we need to take care of people.’ But as a physician who has also served as a senior administrator, he says, ‘This amount of money has never been put on the table before for one patient. When does a hospital have the right to say, 'Time out'?
From an 8/2/01 article by Ron Winslow in the Wall Street Journal, “One Patient, 34 Days in the Hospital, $7,000 Syringes and a $5.2 Million Bill“ detailing a case in which the 69 year old patient died after 34 days. Most of the charges were paid for by Medicare.
Health care in America is a sizable and growing middle-class jobs program. There are tens of thousands of well-meaning people working throughout the health care system, none of whom ever see a patient or deliver any actual medical care. They preside over an infinity of rules, regulations, forms, redundant processes, contract outsourcing, financial brokering, benefit plan tinkering, analytical processes, incompatible data systems, and dead forests of paperwork. Health care administration in America is a Tower of Babel that reaches to the moon, built up over decades specifically to cope with a ‘system’ designed by historic accident, regulatory redundancy, and ever more ingenious entrepreneurial ambitions. The recurring impulse among everyone who tries to simplify and clarify the US health care system is to dream up a business scheme that ultimately complicates and obfuscates it further. The end-result of every attempt at ‘reform’ is the creation of more jobs.
JD Kleinke
Oxymorons, 2002
The complexity of medical care exceeds the inherent limitations of the unaided human mind ... The intellectual foundation of medical care is based on the assumption that whatever a physician decides is, by definition, correct. While many decisions are, no doubt, correct, many are not, and elaborate mechanisms are needed to determine which are which.
David Eddy, MD, PhD
The key to unifying progressive forces is the realization by all progressives that our health care delivery system will continue to have a combination of private and public sector involvement.
Norbert Goldfield MD
National Health Care Reform American Style, 2000
If you can establish evidence-based analysis and value-based purchas-ing, you are getting to the heart of this whole issue of the value of health care. Consumers love it. If you can make that work for pharmaceuticals, you have an almost immediate positive effect on cost inflation. Its a model that ought to be applied to hospitals, diagnostic tests, surgery and other physician services.
The coalition that makes this happen ultimately is ... people who are paying for the care, getting the care, and driving the treatment decisions.
Former Oregon Governor
John Kitzhaber MD
The Road To Meaningful Reform
Health Affairs, 2/11/2003
