Friday, February 26, 2010

It is up to us, not the US

A conversation with a reporter yesterday helped me clarify my thoughts about federal health care legislation. In my view, the most effective role of the federal government would be to provide national standards by which the health insurance companies operate (e.g., with regard to pre-existing conditions, rescission, and lifetime limits), require the existence of insurance exchanges, and establish the conditions under which universal access to insurance is made possible. Other items I would suggest for federal legislation are summarized below.

I am hoping the US government will not attempt to control the costs of health care by making legislative decisions with regard to clinical matters. Not because we should abandon cost control; but because federal efforts in this sphere are likely to be crude and not clinically appropriate. You just have to look at the process by which the USDA food pyramid is influenced by food product lobbyists to imagine how the government would attempt to regulate the design and provision of care among medical specialties, equipment and supply manufacturers, and pharmaceutical companies.

As should be evident to readers of this blog, I think it is possible for the participants in the health care system to accomplish major changes in the rate of medical cost inflation. Two articles have this theme. One is by Business Week's Catherine Arnst. The other is by Lucien Leape, Don Berwick, and others in Quality and Safety in Health Care. Both are worth reading, and they overlap in recommending several areas -- reducing infections and other preventable harm; empowering patients and families to participate in their care; and disclosing and apologizing for mistakes.

Beyond these articles, there is a remarkable consensus on these items, and yet hospitals and doctors often fail to implement them. Even hospitals that house some of the most accomplished authors in these fields often do not follow the advice of those colleagues when it comes to making improvements in the delivery of patient care.

It is not unusual for industries facing structural change to be slow to move. Why? Because the leaders of those industries were promoted based on their success in the past financial, political, and social environment. They were hired for their ability to maintain the status quo, rather than for their ability to make change. Eventually, though, societal forces make themselves felt. If an industry does not adapt, the government will step in. The medical profession has to decide whether it wants to take charge of this process or abdicate to Congress the right to act in its stead.


Jim Conway said...

Paul, thanks for this great post. Thanks also for the Arnst article. I hadn’t seen it.

I had the opportunity to work from home yesterday and watched a good part of the President’s meeting. I was struck again that so many of the defects, harm, terrible outcomes that were being discussed by these congressional leaders were well within the scope of the healthcare industry to resolve NOW, if we REALLY wanted to. For so much of this we don’t need new laws or regulations but just agreement on the aim (IHI Triple Aim), execute against what we know, and get to it with urgency.

Over the last few weeks I have been again criss-crossing the nation visiting and learning from patients and families, medical students, staff, leaders, boards, and community leaders. They are blowing past the BHAGs they have set for themselves and/or their organizations, celebrating amazing improvement and results, and they are digging in with even more resolve. One trustee said to me “Jim, what preventable death is ok?” They don’t need many more ideas, roadmaps, or bills. Instead, they need help and support from government as they drive forward.

Yet, I still confront far too many who are too early in this journey; the finger pointers, crape hangers, those who can discredit any data. They say we can’t work on quality and safety until Washington does their piece or because they don’t have the money. Some still assume “this too shall pass.”

In my career I have been struck by the power and courage that comes from great leaders. We can continue to look to Washington for an outbreak of an epidemic of courageous leadership (talk about BHAGs). Within healthcare and specifically in the Commonwealth, lets continue to show what real “re-form” in the hands of community of leadership can be. I couldn’t be prouder of the story we are writing in MA and seeing in many places across the country. I also couldn’t be firmer in the need for even greater urgency to advance what we already know NOW.

Jim Conway
Senior Fellow, IHI
Member, MA Quality and Cost Council

Anonymous said...

Excellent post, Paul. I wish to highlight two sentences in it:

1)"Beyond these articles, there is a remarkable consensus on these items, and yet hospitals and doctors often fail to implement them."

2) "Eventually, though, societal forces make themselves felt. If an industry does not adapt, the government will step in."

These are the critical points.
I would only add to your suggested governmental role, the item of transformational payment reform away from fee for service.

As for the medical profession, it has already spoken. Actions (or lack of them) speak louder than words.

nonlocal MD

Anonymous said...

Thank you for such a succinct and timely post.

One comment regarding other industries: many of the top global firms build into their organizations incentives to encourage innovation and experimentation. In medicine innovation is far too frequently seen as disruptive and therefore expensive. There are few incentives both at the provider level as well as the leadership level.

We see what "maintaining the status quo" has brought us in healthcare. It is time to start encouraging and harnessing the ideas from within.

Local MD/MBA

David Barone said...

More of such calls to action are needed by the current leaders in healthcare, and likely, by new leadership that is so needed in much of the healthcare industry. It is the role and duty of those in charge of the care delivery system to improve the quality and productivity by significantly cutting into the enormous wasted resources and inefficiencies. If they – the experts - cannot do it, do we really expect the political establishment to figure it out? Do we really want a committee chair in the Senate to suggest how to best coordinate care? It is a fair assumption that no sufficient consensus can be achieved in Washington before the consequences of no-action are unbearable.
The health insurance industry requires a serious dose of reality, and the pending legislation address many of the issues, although it should also include mandated coverage to 100% of the population (not to confuse with a ‘single payer’). The congress should also encourage – through the tax code - greater participation of patients in their care by discouraging policies that do not include significant out-of-pocket participation (e.g. large deductable payments, while eliminate ceilings), while requiring complete price transparency by payers and providers.
The providers system must figure out most of the rest.
David Barone
Principal, Boston MedTech Advisors

76 Degrees in San Diego said...

Venn diagrams! For any collaboration involving two or more entities, it takes a lot of work to get to the desired overlap! BIDMC collaborates with Harvard Vanguard in a way that incentivizes good clinical and efficient healthcare. But, I am sure that HV is much less that 50% of your book of business and vice versa. Lets say you throw in a payor into the mix...but again, your collaboration is only a small portion of the business of each. So you have to go through this construction again with each payor-provider combination. Plus, there are federal government restrictions on what that payor (insurer) can offer. So, to really get to the point of having parallel incentives for patients, payors, financers, and providers, it becomes a lot of work for each construct, frought with antitrust issues because each is an independent economic entity and functions in their own markets. Of course, if BIDMC, HV, and a payor were a real combined nonforprofit entity, it could be easier in a sense. "Change is good - you go first" - Dilbert

Anonymous said...

From Facebook:

Jim: Paul, what you say makes a boatload of sense, but it seems like the medical profession has already abdicated its leadership as is evidenced by the mess we find ourselves in and their role (or lack of role) in it. It seems to me that the people, we, are increasingly frustrated and if true change doesn't come either by herculean industry effort or legislative fiat, it will come from anger. There are too many interests that benefit from "other than health" concerns.

76 Degrees in San Diego said...

OK, maybe it is the time for BIDMC to get the ball rolling with it's own healthplan!

Like you said, "It is up to us, not the US"

(US governs us).

Engineer on Medicare said...

There was a transformation in the defense industry in the '90s. The transformation process included several rules and practices that could apply to the health care industry.

1. The Golden Rule: He who has the gold makes the rules.

2. Cost is an independent variable. It may be established as a requirement; not simply a result of adding up what the providers say it should be.

3. Serious competition was invoked, based on performance relative to requirements, cost, and value to the customer.

Since the government controls much of the gold (medicare, medicaid, and the subsidies that the providers want to provide coverage to some users), the government gets to set the rules for that population of users.

Stephanie, RN, MBA said...

Timely indeed. I also listened on the television and the more I hear, the more cofused I get!
Stephanie, RN, MBA

Michael Kirsch, M.D. said...

Over the past 2 decades, physicians have been taught that when we don't address issues that demand reform, someone else will fill this vacuum. This process has usually not favored the medical profession or the public. Although this scenario has repeated itself many times, I do not sense that physicians, and others, have overcome inertia. This reality is partially responsible for the state of the medical profession today. Physicians rightfully complain about many aspects of the health care system, but where have we been?

Umbahli said...

This makes me wonder about what things would be like if we were socialized to embrace change. It seems that the medical profession should be filled with people who understand that there is nothing BUT change. Everything is always changing--we are always physically changing so taking charge of the process is the only hope!?

76 Degrees in San Diego said...

There are a few insurer-hospital-physician partnerships in parts of the country. But, forming these at this moment is extremely capital intensive and complex. The practitioner caring for her/his patients within today's structures barely has time for much else(and most have family responsibilities). Give them some credit for how much time they do put into our profession.