Disclaimers

I intended to make a few disclaimers when this blog was launched in 2009.  Well, the policy issues of the intervening year—particularly health reform/insurance overhaul and HITECH/meaningful use—evolved with such relentless immediacy that I never found a slow news week for covering the “housekeeping details.”  Since I won’t make a prediction on the blogosphere’s current preoccupation, the mid-term elections, now is a good time to pause for three important statements that will put my weekly commentaries in proper perspective.

First, the opinions expressed in this blog do not necessarily represent positions of my employer or any of the clients that hire me as a speaker, writer, or consultant.  I gratefully appreciate the freedom that Xerox and ACS have given me to speak my mind without any censorship.  In return, I feel that any criticism I express in this forum must be constructive.  The senior executives who asked me to do a weekly blog set the tone by naming it “A Healthy Debate.”  My purpose is to express opinions that get readers thinking and contributing to discussion of important topics.  Every post ends with a request for readers to express their opinions, and every response has been published, also without any censorship.  (I truly value the many readers who have added a comment—especially those with different points of view!)

Second, my criticism of one faction’s positions absolutely does not imply support for any other faction’s positions.  I have been consistently critical of the Democratic approach to health reform, but I am equally dismayed by Republican opposition.  Neither party is addressing the tough trade-offs that must be made under new economic circumstances.  I’ll be happy to support a realistic political platform for reform when I see one, regardless of the party that proposes it.

Third, I firmly believe that the United States should and still can create the world’s best health care system.  I am an industry insider, proud of four decades spent as a medical school professor, health policy adviser, and consultant.  I am motivated by visions of a really good health care system—formally structured to do the right thing all the time, as inexpensively as possible.  Sadly, I perceive that most legislative or regulatory efforts do not steer our system toward this goal.  On the other hand, I am excited by good things being done by a growing number of progressive providers, payers, purchasers, and their business partners.  Their partnerships are showing that a good health care system really could be produced with 17% of the GDP. 

What are your disclaimers when you express opinions about the future of American health care?  What vision motivates your thinking about reform? 

Does it matter if the Affordable Care Act is unconstitutional?

Will federal judges decide the future of health reform?  It’s an FAQ everywhere I go.  My ability to answer the question might be suspect because I am not an attorney, but my friends with law degrees don’t seem to have definite answers, either.   Like the future of the economy—an area where I do have some qualifications—the legal standing of reform is uncertain.   Anyone with a coin to flip can play the game with credentialed experts because nobody knows for sure how the Supreme Court will ultimately decide the issue.  (Indeed, the closest thing to a consensus among lawyers seems to be that it will go all the way to the Supreme Court…if the reform laws are not changed before legal challenges work through the lower courts.) 

From my perspective as a medical economist and health futurist, I don’t think the legal outcome really matters to health care decision-makers who are trying to guide their organizations through turbulent times.  Constitutionality is a red herring that diverts attention from the real challenge to the future of health care.  The economic outlook is dismal for at least another year or two; the odds of a turn-around anytime soon are exceedingly slim.  Consequently, the future of a health care enterprise is likely to be decided by its appropriate and timely responses to stagnant gross revenue.  Governors of the Federal Reserve Board have a lot more to do with the near-term future of health care than justices of the Supreme Court.

The key to a successful future is cutting the waste out of delivery and finance, then reallocating reclaimed resources to better ways of doing business.  After all, the issue likely to go to the top court—whether Congress has constitutional authority to force people to buy health insurance—is moot if uninsured Americans don’t have disposable income to make the purchase.  Even if the Supreme Court upholds the mandate and ObamaCare is not repealed or amended by the Congress, the economy is still unlikely to provide employers and consumers with more money to spend on health care. 

In other words, providers’ and payers’ economic futures are not going to be significantly affected by the ultimate legal outcome.  Health systems need to hedge their bets by quickly learning how to produce care of acceptable quality, as inexpensively as possible.  Our political leaders should have explicitly enacted this approach to reform, but they added fuel to the fire (i.e., mandated insurance) instead.

I believe that real reform is in the hands of providers, payers, and patients—not judges.  Your thoughts on the matter?  You don’t have to be a lawyer to make your case here…

Are your data lost in translation?

This question may seem a bit odd because health care executives don’t tend to think about their data after submitting numbers to third-parties like CMS, professional associations, researchers, and industry analysts.  We assume that outside users of our data will utilize exactly the information we provided when they conduct their studies and prepare their secondary reports. 

Not necessarily!  As a data geek of long standing, I have helped students and clients uncover errors—many with negative consequences—in third parties’ displays and transformations of numbers submitted to them.  For example, facility-specific mortality rates officially reported by HCFA (now CMS) in the 1990s often varied substantially from death counts submitted by the hospitals.  More recently, providers find that their cost and services data are not always the numbers that get published on consumer-oriented Web sites.  An east-coast hospital CEO told me just last week about a significant discrepancy between the actual number of physicians on the medical staff and the count reported in an industry data base.  The publicly available report even showed no physicians practicing in a clinical area where the hospital had four full-time boarded specialists.      

We understand the “garbage in-garbage out” phenomenon, but how do good data get turned into garbage?  (I am giving providers the benefit of the doubt here.  Their numbers can be inaccurate, too, creating a serious problem that must be solved as they start using analytics and other performance improvement tools to achieve efficiency and effectiveness.)  Many errors are introduced as information is “keyboarded” to a third-party’s data base from provider-prepared forms—a problem that should diminish as more data are transferred electronically through all-digital data exchanges.  External reports can also fail to match the time period when the data were collected with the date of the report, giving the impression that historical information is current.  Discrepancies of two to three years are common.  Finally, some of the most damaging errors are created when third-parties transform data with general models or statistical techniques that do not fit the specific circumstances of an organization providing the information.

Growing pressure for transparency and accountability will increase the potential for adverse consequences resulting from data distortion by Web sites and other external entities.  Consequently, health care executives are advised to double-check their numbers, comparing the data they submitted with the numbers published in external reports prepared by third-parties.  In my experience, errors in data translation can be costly in many ways.  What are your experiences with outsiders’ use of your numbers?  

“But what about tort reform?”

My standard speech on the future of health care analyzes implications of five top trends that are shaping the future of health care.  The “malpractice crisis” isn’t one of the transformative forces I address—which almost always causes someone in the audience to ask, “But what about tort reform?”  I believe that professional negligence is a big problem, particularly in terms of the resources that it wastes, but the political process is not likely to solve the problem in the foreseeable future. 

I tell health care leaders to focus instead on trends they can harness to the benefit of their organizations and, above all, their patients.  The transformative trends in my crystal ball are advances in medical science, networked information systems, shifts in demography and epidemiology, new organizational arrangements for health systems (especially partnerships with payers and purchasers), and changes in the payment for medical services (more than just health reform).  Resources and time are stretched to the limits these days, so my economist’s world view suggests we should put our efforts into these areas that offer the greatest potential returns.

Tort reform doesn’t offer high marginal returns; it’s a political quagmire.  We should concentrate elsewhere, remembering that the #1 cause of malpractice claims is malpractice.  Reducing the number of medical errors and other forms of professional negligence is a much more productive way to lower the costs of malpractice.  I’ve got nothing against the Plaintiff’s bar, but I’d love to force malpractice lawyers into another line of work by eliminating any basis for the suits they file.   

Knowing what we know today, health care leaders can do the most to end malpractice suits by adopting proven performance improvement tools, supported by state-of-the-art information technology.  Executives and clinical leaders should strive to make sure that all service delivery is guided by formal, functioning, accountable, and pervasive processes that identify any deviations from their organization’s standard practices, immediately followed by corrective actions to prevent unexplained variations from happening again.    

Admittedly, medical mistakes will still occur, but good information and performance improvement systems dramatically reduce the probability of errors and keep them from occurring over and over—a highly desirable outcome that the legal system is not designed to produce.  Once we have set up systems to do things right all the time, we can then start the equally important task of finding the least-expensive ways to do them. 

So what about tort reform?  The American jurisprudence system unquestionably adds to the high costs of our health care, but improving clinical practice offers a much bigger and faster bang for our buck than trying to change legal practice.  I vote for putting our scarce resources into modern information systems and performance improvement.  What about you?