A Change Agenda

Two months ago I had the privilege of welcoming 29 new graduates of the California HealthCare Foundation’s (CHCF) Leadership Fellowship to the program’s alumni network. This alumni group now represents over one hundred health care leaders across a wide spectrum of professions, organizations and sectors and offers as diverse a set of perspectives as are represented in all of health care here in California. In welcoming them, I also challenged them to develop their own manifesto or change agenda for health care reform in our state.

I should be the last one to say what the final agenda should be, but here is my first draft list of the issues that need to be addressed:

  1. Bring everyone into a system of care and health which is as aligned with individual preference and need as possible. There are three important elements here. First, everyone needs to be cared for, not as an after thought, but as an intentional part of the plan. But the set of services to be delivered to everyone must be integrated and aligned in a rational and effective manner. Also, these systems must meet individual consumer preferences as much as they can. This does not suggest a different system for everyone, but it does not mean one size fits all.
  2. Accomplish this by a variegated approach to finance and delivery. In finance I believe that only some combination of employer, employee, individual and pubic support makes sense and is politically viable. If there was a thoroughly integrated system of care delivery, then moving to a single payer for these highly rationalized services would make sense. Lacking that, a single payer will tend to maintain the status quo on the delivery side and the motivation for innovation will erode. On the delivery side we must also consider the need to provide a significant amount of care through fully funded public institutions, not insured access to a system that doesn’t work.
  3. Recover primary care. But not as most primary care providers would envision this recovery taking place. Rather, in the newly aligned systems of care, primary care should be restructured radically around consumer needs and preferences; not the desires of how the primary care provider would like to practice. This would mean more patient responsibility and self-care for some and more intensive interactions with providers for others. It would also mean a broader use of a greater variety of health professionals and different types of services supporting the maintenance of health, not just the episodic reporting for disease treatment. New technologies, new practice patterns and most of all a new leadership role for the primary care provider releasing them to add the value to a range of services that the patients they serve need.
  4. Focus specialty care in centers of excellence. The exotic care of the specialist is both the glory and shame of the US health care system. There is none better in the world, but when it is not done frequently and critically it devolves into a false promise that harms patients and generates unnecessary cost. Both of these byproducts are avoidable and could be addressed by concentrating this exquisite care in high volume centers. These would of course be places where research and training were also advanced.
  5. Create new pathways for individual responsibility for health. The consumer revolution in health care looms just beyond the horizon. But not all consumers will need or want health care services in the same manner. New ways of sharing information between professionals and consumers must be mediated using the amazing new capabilities in communication and information technologies. We must also begin to fully implement what we already know about the enormous value of prevention associated with lifestyle choices. The only way for this to have full effect is for it to become a part of a national ethos, reinforced by health care financing rewards and penalties. Finally, we should separate the insurance function for catastrophic illness from the payment for routine and ordinary health care services.
  6. Rebuild the community’s ability to share a part of the health burden.Since the tragedy of September 11, 2001 we have witnessed firsthand just how tattered our public health system has become. We have spent countless billions on emergency preparedness only to see those systems come up woefully short in the aftermath of Hurricane Katrina. We need a new vision for our public health system. It needs to be separated from the provision of care for the uninsured and underserved; this must be done under the first and second points above. The genuinely public nature of this system must be recaptured and integrated into the unique fiber of every individual community. It should begin with analysis and evaluation and report annually how the community’s health is fairing. It must include the emergency response system with the capacity to mobilize all public and private resources in the throes of a disaster. It must create new ways for a community to care for a population which is aging and to reinforce the values or health promotion and disease prevention described above. These are three distinct functions and need to be understood as such.
  7. Recognize need for health workforce as a vital economic resource. Over the next decade states and regions will approach the coming shortfall of health workers in one of two ways. The typical response will see this as problem and fall victim to the shortages. Successful communities will see this growth as inevitable, and focus education and economic development resources on a public growth strategy. To do this will require that we reconsider the traditional separation between education and practice and seek new and deeper ways to integrate the two across the continuum of professions. We also need to do a better job of integrating the professions into effective teams from training onward. Finally, the remaking of health care work begs for a new partnership between labor and management. We will never do what needs to be done by developing new practice arrangements through contract negotiations.
  8. Remove disparities. This is the simplest sounding of all of the issues on this list, but seemingly the most difficult to address. The disparity of health outcomes across ethnic groups in the US is a national shame. The failure is not principally from a lack of will. To address this disparity we need to develop coherent means of experimenting with what works, not just what our current system of care offers. To have such an initiative will require integrated systems such as the ones described above. Such systems would have the capacity to look at inputs, assess the value of outcomes and adjust accordingly. Without such perspectives and capacity the nation will continue to have a collection of well intentioned efforts across the fields of education, delivery, in-patient, out-patient and public health. All of which will be very costly, but add up to little which changes the material well being of those who have been poorly served.
  9. Serve the needs of an aging society. The Baby Boom generation is poised to break the nation’s fiscal bank as it begins its inevitable march through disability to decline and death. If we had a health care system that worked, produced desirable outcomes and used resources efficiently and effectively, the challenge would still be the most daunting task we’ll face over the next three decades. But we do not have such a health care system. We over-invest in the wrong things, under-invest in the right things and maintain a pattern of delivery and finance that adds new meaning to Byzantine. To meet this last and greatest of challenges we need the first eight strategies to become realities. Then we might have a chance to negotiate the future of this aging population in a manner that returns more to the society than it expends.

Leading this or any change requires agreement about the direction of the vision. This is a first cut at what that framework or vision might entail. Once the vision is aligned and established, strategies should dictate how various institutions and professions would position themselves as we move toward such a future.