Reform or Overhaul?

Democrats can claim a victory in the health care arena.  I just question which battle they won.   The party’s leaders consistently touted broad, system-wide reform for nine months following the 2008 elections, but political rhetoric shifted after the swift-boating and town hall meetings in August.  “Insurance overhaul” replaced “health reform” as the Democratic battle cry in September.  The semantic switch occurred with such speed and consistency that it was surely orchestrated by skilled political advisers. 

It was not a case of journalists seeking another word because reform was becoming hackneyed.  Reform and overhaul are not synonyms.  I think the difference is significant, and it needs to be understood to put the new law in context.  According to my dictionary, Merriam-Webster’s 11^th Collegiate, reform is the act of improving something by changing its form or removing its faults and abuses.  It’s a radical challenge to the established order.  Initial discussions of a health reform law adhered to this transformative meaning.  Conversely, overhaul means to renovate or remake.  It restores an existing structure rather than creating a new one.  It’s non-threatening.

Overhaul is something done to a classic car, like a ’57 Chevy or a ’64 Mustang.  These were great vehicles in their day.  However, a restored old car is still an old car.   An overhauled classic may look as beautiful as it did 50 years ago, but it gets lousy gas mileage, isn’t designed for safety, won’t fit in most parking spaces, and makes no sense for everyday transportation in 2010. 

Transportation, on the other hand, is being reformed.  The unstaged, untouched photo below illustrates the point.  The SUV in the background is an overhauled version of the classic car: poor mileage, hard to park, expensive, etc.  The mini-car and the motorcycle in front of it symbolize transportation reform in the true sense of the word.  They are efficient and effective vehicles for getting around on today’s overcrowded roads.  You can rent an SUV for the occasional trip that requires something big, but the smaller vehicles represent real progress.    

From my point of view, the new law represents nothing more than an overhaul of the old health care system with all its problems.  I can’t fault the political leaders who created it.  They openly abandoned reform six months ago and delivered as promised.  However, I am deeply disappointed that the newly legislated overhaul does so little to create health care equivalents of vehicles attuned to today’s different needs and limited resources.  I am confident that our industry’s forward-looking providers, payers, and purchasers will form partnerships to reform health care.  I just hope that the overhaul law doesn’t get in their way.  What do you think?  Does the new law take us where you want to go?  

Photo by Jeff Bauer, ©2010

Reform As a Party Game

Do you remember the party game someone starts by whispering a few words into the next player’s ear?  The message gets passed from player to player until it has gone around the room.  The final version is compared with the original message—and the end result is almost nothing like the original.  The difference is usually worth a good laugh, too.  The course of health reform over the past 15 months reminds me of this game.  However, the game is not over, and the final result will not be funny. 

We all should remember the message that started the game: health care has gotten so expensive that something must be done—now—to stop the rising costs.  Less than a year ago, everyone in Washington agreed that cutting expenditures on health care was absolutely essential to economic recovery.   A bipartisan approach to solving health care’s problems seemed possible because Republicans and Democrats were “on the same page” of cost containment.

How the message changed as it got relayed through the party!  House Democrats just passed a Senate bill that will dramatically increase overall spending on health care.  According to estimates of the Congressional Budget Office, the law the president signs today will increase spending on health care by nearly one trillion dollars over the next decade. 

The law’s presumed deficit reduction gives a false impression that health care spending is being brought under control—but nothing could be farther from the truth.  Under the law being signed today, spending on health care will still rise by nearly a trillion dollars between now and 2020.  The federal government simply doesn’t plan to incur more debt to fund the increase.  Providers, payers, employers, taxpayers, and consumers will make up the expensive difference.     

More Americans will have health insurance under the law (not necessarily the same thing as getting access to health care, but that’s another matter).  Nevertheless, containing cost—not expanding access—was the important message that got lost at the reform party.  The game is not over because Senate approval of House “fixes” provides additional opportunities for changing the outcome over the next week or two.  And then the courts will be asked to have their say.   

Nevertheless, have we made progress if the endgame has nothing to do with the message that positioned reform as a top political priority in the first place?  How are we going to eliminate the inefficiencies in our health system and reallocate the wasted resources to providing quality care to all Americans?  Shouldn’t we put top priority on building an efficient and effective health system?  I’ve spent the last 20 years proposing answers to these questions.  Please let me know what you think!

A Report from the Front Lines

One of the problems with reformers in Washington is how little time they spend with professionals who actually deliver health care every day. One of the benefits of my travels as a speaker is interacting with real caregivers on a regular basis. Last week, I had the pleasure of working with 75 members of the California Healthcare Leaders Network (http://futurehealth.ucsf.edu/Public/Leadership-Programs/Home.aspx?pid=145) sponsored by the California Health Care Foundation (www.chcf.org).


The participants in this forum—all clinicians by background—are exemplary professionals in the day-to-day business of meeting people’s needs for care and cure throughout California. They are Chief Medical Officers of delivery systems large and small, Chief Operating Officers with doctoral degrees in nursing and pharmacy, leaders of quality assurance programs for major health plans, directors of Community Health Centers, full-time primary care practitioners, etc. You and I would be happy to have any of them as our caregivers. They represent the best in American medicine—the exact opposite of the maligned providers many politicians want to reform.

These front-line professionals come together several times a year to hone their leadership skills, to network, and to share thoughts about improving the delivery of health care. After 12 hours of intensive interaction with them, I was thoroughly impressed with their commitment to producing top-quality care at lower cost for more residents. I did not hear a single comment suggesting their objective was to earn more money or turn the system to their personal advantage (common themes in medical meetings in the not-too-distant past).

Rather, I heard them express heartfelt frustration about numerous roadblocks that prevent them from taking the time to work with patients whose needs require more attention than the current system allows them to give. These caregivers wish that our health system’s resources could be redirected toward patient-centered medical homes, prevention, chronic disease management, accountable care organizations, and other reforms that would actually improve delivery of health care in the United States. They wonder how aspirations to build a world-class health system got derailed into narrowly focused insurance overhaul in less than a year.

How I wish the powers-that-be in Washington would spend quality time with real professionals who are trying to solve real problems on the front lines of the battle for health care! These clinical leaders from California have great ideas…and they ask hard questions about what can be done to rid our system of the perverse incentives that get in the way of doing what really needs to be done. How can we redirect health reform toward building a really good health system, regardless of the outcome of the “Hail Mary” play that the Democratic leadership is planning to run within the next few days? Please help answer their question by adding your comments.

What about the patient?

The reform debate has been so focused on economic disequilibrium created by providers and payers (mostly payers, as of late) that an observer could be forgiven for forgetting patients are also part of the equation. Yes, something definitely needs to be done about the high costs of medical care and health insurance, but is the typical patient just a helpless pawn in a game controlled by two powerful players that only care about their own profits? Can problems of cost, quality, and access be solved solely by reforming the business practices of hospitals, physicians, and insurance companies?

I spend a lot of time interacting with providers and payers, and they make a convincing case that the typical patient is also part of the problem. For example, physicians report that patients frequently demand a drug or a test that isn’t appropriate, but writing the order is less of a hassle than taking unbillable time to educate the patient about the risks of overmedication or running the risk of losing the patient altogether as s/he goes down the street to another doctor who will provide what the patient wants. Powerful public outcries against scientifically sound proposals to formalize evidence-based medicine and reduce the frequency of screening mammography offer further evidence of patients’ contributions to the high costs of care. These problems deserve at least as much consideration as the cost-increasing impact of defensive medicine.

Democrats’ final, frantic push for reform-cum-insurance overhaul is highlighting supply-side market failures without saying anything about the expenditure-increasing impact of excess demand. I believe that providers and payers absolutely must make major improvements in the way they do business, but I am frustrated by reform proposals that do not expect patients to improve their health behaviors, too. Providers and payers are way ahead of Congress in addressing this problem through medical homes and care management programs. Purchasers (employers who provide health benefits) are also taking steps in the right direction by with innovative programs that shift insurance from entitlement to engagement.

I am disappointed that these impressive efforts to promote appropriate, cost-effective care don’t get the same political attention as stories about people who can’t get insurance. A lot of Americans with insurance coverage are squandering resources that could be allocated to those without it—assuming that we can find the political will to balance the right to health care with the corresponding responsibilities. Taxing Cadillac plans might transfer income, but it doesn’t align rights and responsibilities. Do you think reform should look more carefully at patients’ contribution to the problems and participation in the solutions? If so, how?

Quality: Promoting Performance or Process?

Last week’s reform summit focused the political spotlight on existing proposals for solving problems of access (i.e., availability, affordability, and coverage of insurance). Lesser discussions of cost and quality were also restatements of previously stated positions. The meeting of the parties was civil, but it was not a meeting of the minds.

If even one participant responded to the President’s request for new ideas—a precondition for progress, in my opinion—I missed it. Consequently, to complement last week’s new idea for getting expenditures under control by fixing medical spending at 17% of GDP (see 2/22 post), here is a new idea for improving quality: let’s replace pay-for-performance with pay-for-process.
Pay-for-performance (P4P) has caused many providers to improve care, but it has not eliminated bad care. Meeting an 80% performance standard, a common threshold for P4P quality indicators, is an improvement for many providers. However, 80% falls far short of doing the right thing all the time. I’d like to think that 100% appropriate performance is possible in a country that spends 17% of GDP on health care.

Pay-for-performance is viewed cynically by providers. It is frequently called pay-for-reporting because collecting the numbers presumably gets more attention than improving the care. Recent analysis even suggests that costs of reporting may exceed the financial rewards, reinforcing the cynicism. P4P is also compared to the equivalent reform in K-12 education, No Child Left Behind, where teaching students how to take the assessment test has become more important than teaching them how to learn.

Rewarding, even requiring, an operational performance improvement process (PIP) deserves serious consideration as a better approach to ensuring top-quality care. Assuming Americans don’t want anything less, I seriously suggest that health reform replace selective P4P with PIP encompassing the delivery of all care. Reimbursement and regulations should give providers a strong incentive to use data-driven, standards-based processes (e.g., ISO 9001, lean management, Six-Sigma, TQM/CQI) that identify unexplained variations and immediately initiate actions to prevent problems from happening again.

A comparison of performance-based and process-driven approaches helps make the case for shifting reform’s focus from meeting minimum standards to optimizing all care. Under P4P, hospitals receive extra payment for being able to document that aspirin was given to 80% of all heart attack patients within a specified period of time. Under PIP, hospitals would only be rewarded when every heart attack patient was evaluated and treated according to a protocol on the appropriate use of aspirin.

This new idea puts even more urgency on adoption of information technology and casts a different light on the emerging definition of meaningful use. But quality is #1, isn’t it? What do you want to reward—P4P or PIP?