What are the foundations of meaningful reform?

The push for health reform has changed course substantially since the new Congress and administration took office in January. Originally envisioned as an industrial-strength effort to make medical care less-expensive and consistently good, the reform movement has shifted its aim to the much narrower target of insurance overhaul. The goal seems to have shifted from improving the medical marketplace to requiring Americans to purchase insurance, without forcing long-overdue changes in delivery or payment.

A few remnants of the original push to improve the system—a very different goal than expanding the number of Americans with insurance—may survive as demonstration programs (thus allowing elected officials to claim that cost and quality reforms are included in a reform law if one passes). Prospects for any fundamental changes in the delivery system have all but disappeared as the legislative year ends, although creating an expert commission to address cost issues still has some significant support at both ends of Pennsylvania Avenue.

Some writers for the trade press apparently sense reform’s loss of momentum and purpose. Journalists who interview me on a regular basis have shifted their line of questioning from the likelihood of reform now to what needs to be done in the future. Just last Friday, one magazine writer asked me to identify the three top goals that should be addressed next time because meaningful reform is not going to be accomplished this year.

In my opinion, real reform must be built on three foundations:

• All delivery organizations must use pervasive performance improvement processes, based on state-of-the art information technologies that ensure medical care is done right all the time, as inexpensively as possible.
• Health systems and health professionals must operate on the same balance sheet, eliminating the waste created when hospitals and doctors work for different economic units.
• Fee-for-service reimbursement must be replaced with a payment mechanism that rewards quality and value, not volume, of goods and services provided.

I believe that we’re wasting valuable time if reform does not focus on making all three fundamental changes. We should be figuring out how to do these things together, as quickly as possible. Several successful health care organizations give us good models for building a world-class medical marketplace. Simply forcing more Americans to buy insurance is not social or economic progress if health care is still overpriced and unreliable. What would you do to move us in the right direction?