The last few offerings on this page have focused on the demand and dynamics for reform in health care. With the promise of a new administration in Washington, it seems everyone has been sending memos to Mr. Obama. The opportunity to join in is just too tempting. Here are my suggestions.
Health care should not be the first priority. Health care is complex and expensive and while our economy will not return to good shape over the next three decades until we address fundamental reform, there are no quick fixes for the things that are really broken. Better to focus on the economy, such as job producing investments in basic infrastructure and even the first new rails to address the environment, than a wholesale effort at reform of health care. If he needs another opinion, he should ask his new Secretary of State about the wisdom of taking this slow.
There are a few access and financing changes that can and should move right away. Access was expanding during the Clinton years, driven by a growing economy and an expansion of public coverage programs that worked. The current administration has delayed expanding the State Children’s Health Insurance Program though this part of the safety net needs to be expanded. Another idea that has gained attention and needs to be advanced is the chance for early buy-in to Medicare either at age 55 or even better, at age 50. If this is priced correctly it should be budget neutral and serve as a substitute for commercial plans that have a limited risk pool and often now will not even underwrite those willing to pay for the service. The access should be limited to enrollment in managed Medicare plans. While anathema for many on the left, premiums for individuals should be on a sliding scale of ability to pay. This move would provide some certainty about coverage for a very large part of the population. Finally, in the short run, ensuring that adequate support is provided directly to the nation’s system of community clinics would help keep this safety net available and focused on serving unmet needs.
Last month I used this space to suggest that the reform of the models of how we organize care delivery should be at the heart of any successful reform. Merely financing more people in an already broken and underperforming system is not a wise policy. I identified four rate limiting dimensions to that reform. These dimensions included what is financed, scope of practice regulations, skills and expectations of professionals, and the hegemony of professional organizations. These are dimensions that need to be aligned by market or public policy and effective institutional leadership. But efforts to align them need a focus if they are to produce a meaningful payoff.
There are four candidate domains in health care that might become the focus for the reform. I am using the word domains deliberately to avoid identifying the particular organizations that currently deliver care. When the hospital or medical practice becomes the focus, then the strategies tend to become ways to “save” the hospital or “make” the current practice of medicine work. This obscures the real task, which is how to organize and deliver the highest quality set of services at the lowest possible cost, along a continuum of service that meets consumer demands. Increasingly, I believe the relevant domains in health care to be routine primary care, expensive specialty care, on-going chronic care, and expensive end of life care.
The domain I would choose for focused investment in change would on-going chronic care. Large improvements in health care in terms of clinical outcomes, costs and consumer satisfaction could be derived from remaking the management of the chronic disease burden. There are four keys to remaking this process.
The first is to not medicalize the approach to the management of chronic disease. The US health care system is the most expensive in the world, and it is the most expensive social service system in our nation. Once we use these incredibly expensive inputs to accomplish any task we will create an unaffordable, non-sustainable solution. Moreover, the tools that the system has at its disposal to manage chronic care tend to be invasive, high tech clinical interventions, usually done in the hospital; these are not only expensive, but tend to intervene so late the possibility of successful prevention or management is lost before it has a chance to work. In effect, we bring the ailing chronic care patient to the location where specialized knowledge can be applied and compensated for its effort. We need to break this cycle before it breaks us.
To do this we need to take the knowledge out to the community in a much more aggressive manner than has been tried to date. The key to this is a broader, more democratic use of medical information technology. We have most of the tools available in the growing availability of the electronic medial record and health care knowledge which is increasingly better organized and accessible in Web 2.0 formats. There is more than one way that the knowledge and tools to manage chronicity could be piped out of the hospital and emergency room and into the consumer’s hands, and we need to aggressively experiment with the technology until we find all of the viable pathways for the knowledge to be delivered to patients that need to manage their chronic conditions differently.
Having the technology without engaging the end user or consumer will assure failure from the outset. The key to this engagement would seem to be better market knowledge of these health care consumers. A critical piece of this knowledge should be segmentation by education, skills, resources, preferences, and a host of demographic markers. We have been so focused on delivering what we have to offer in health care that we have rarely, if ever, taken the time to learn what consumers need, want, or desire. Much of the “retailization” of health care is moving on our inattention to the consumer. Knowledge will not be enough to fully engage the consumer; there will need to be incentives, but these do not necessarily need to be financial. Convenience, control, access, and peace of mind all drive consumers to have a different relationship with consumer goods retailers and commercial banks and brokerages every day. Health care needs to understand the code to unlock the engagement of these markets for their services.
Finally, we will need new professionals or paraprofessionals to support the consumers in the development of new ways to take care of themselves. Last year, there were millions of self-help groups and visits to alternative and complimentary providers in the US. Almost all of these encounters were outside of the formal health insurance or payment system and, for many established health professionals, outside of the accepted model of care. We need to get over this. The next challenge for the health professions is to learn how to disseminate their knowledge and competence in ways in which the end user - the consumer - does not need to be sitting on an exam table in a medical practice or admitted to an emergency bed to receive it. Sometimes the paraprofessional will be the patient or a family member, sometimes it may be another community member or friend; increasingly they will be individuals who are compensated for the service, but who work outside of the regulatory structures we that are currently in place.
As the burden of caring for a growing population with one or more chronic conditions increasingly confronts our society, we will need innovation and creativity as much as we will need additional resources to meet the associated challenges.