The Decade Long Challenge Ahead

The US Senate has just met the challenge of bringing the health care reform legislation to the floor for a vote. It has endured a month long assault from the right for not having enough detail, being far too lengthy, and endangering America’s health; none of these attacks have been accompanied with constructive alternatives. There were many ways that policies from the right side of the aisle could have strengthened this bill had they been offered. For instance, the nation would be better off with a plan for engaging more individual responsibility around health behavior and financial prudence. But because the right chose to work toward a political defeat for the administration rather than a better bill, these contributions are absent.

Instead of constructive action, most of what has been offered is a brand of negative fear mongering which has successfully eroded some of the public’s support for action. This erosion has been abetted by a more recent, but growing assault from the progressive left. As the proxies for a single payer- a public option and then age lowering for Medicare eligibility disappeared- the left has become shrill that their concerns would be damaged by the bill if it became the model for the law. The absolute necessity for the nation to have a victory on this legislation has seemingly kept the caucus together and perhaps by the first week or two of the New Year the nation will have the framework of new health care system. A framework that has been a long time coming and is arriving in just the nick of time as we reposition social polices for the new realities of a rapidly changing world. We need better health care, but we also need the resources that our profligate system wastes too freely.

The criticism that there is little in the reform to lower costs is of course right in one way. The legislation will not immediately lower cost. The only immediate options for lowering costs would be to limit access- we already use this tool both by having a large pool of uninsured and restricting access to treatment. The plan is actually aimed at correcting these two flaws, not expanding them. The other way to lower costs would be to have the providers roll back prices to a level that looks more like the cost of care in other parts of the world. I imagine I do not have to explain why this proposal would have emerged DOA. Mending health care cost, quality and accessibility will take a decade or more and will tax the creativity of those within the system, the engagement of those consumers that are served, and policy and market based leadership that can fuel such a massive reengineering undertaking. It will not be driven exclusively by a government agency for fear that there will be too many genuine cries that we have socialized medicine or turned health care over to the post office; nor will it be left exclusively to the profiteering of the market, because too many of the faults of the so called system we have today are driven by the moral hazard of individuals, professions, and institutions doing good for the public while watching out for themselves. The long-term lifting in this reform will take a creative blending of the best we have to offer from both the policy world and the market. We have always worked best when we seek pragmatic tools for action and leave the ideology to the side. 

Health care in the US is a giant ship; the sixth largest economic undertaking on the face of the globe, and turning it will take awhile. There is much in the details of the plan that will help. But here is my general framework for what lies ahead. In rough generalities we do four big things in health care – prevent the onset of disease and illness,diagnose the disease once it presents itself, treat the impairment or disorder with the best therapies aiming for a cure, and manage the patient’s health when no cure is possible.

Prevention needs to be advanced and enhanced not only because it reduces system usage, but a healthier and fitter nation will have more successful students and a more productive workforce. But prevention pays off over the long term and few of the intermediate health care institutions – hospitals, medical practices, and insurance companies- will have adequate incentives to stay the course. Individuals and governments have the most direct benefits from improving prevention and we need to get to it.

Most of our current system of care addresses acute disease care through diagnosing and treating. This is where most of the training of health professionals is focused; it is where most of the money is spent, where technology is advanced and where television and movie coverage of health care focuses their lens. It is also an area where we lead the world, but it has of course been a two edged sword. All of that technology creates demand, whether we really will benefit from it or not. Providers plead defensive medicine as to why they need the latest and greatest device, even we if don’t really have conclusive data that it is the latest and greatest. Soon we have a tyranny of the standard of care that generates much of our out of control approach to health. While direct efforts to rein this in will be met by shouts that death panels are the next step, there will be a need to develop incentives to do the right things and disincentives to do the not very smart things for providers and consumers alike. Not to worry, this is America after all and if you still want to do dumb things and can afford independent access to them, then we defend your right to make such decisions, not just on my dime anymore, thank you.

In my view the big opportunity for real cost savings in the short run, say three to five years and more as we go out another ten, is in managing disease and disability better. Today we use very expensive and somewhat inappropriate acute care institutions – hospitals and medical practices – to both diagnose and treat (they do a great job) and manage what cannot be cured (they cost a lot and really aren’t set to do this second job). We have lots of new information technology, growing consumer demand for inclusion and self-treatment, extensively trained professionals outside of medicine and a reason to get chronic care out of the hospitals – it is very expensive and has become a dangerous place to be if you don’t have to be there. Creating these new practice models is what we should spend a fair amount of effort on if we want to see a quick return, both in terms of costs and quality.

We have a fair amount of information as to what works. But having rational data does not change a practice model. There are other factors that impinge on this process, including skills to change the practice, financing structure, prerogatives of the professionals involved, available technology, consumer preference, and physical lay out of the practice.

To change the various practice models in health care will require the engagement of the professional, legislative, academic, regulatory and others in leadership roles to work together to imagine a different future, experiment with redesign, measure the progress and change the environment which can encourage a more intentional and rapid transformation. The nation is waiting.