Phases of Reform

There are four big things that are done to produce heath: prevention, diagnosis, treatment and management. Prevention has great leveraging ability to bring about enormous change in health status, but its impact is felt over a long time horizon and we do not have a complete set of tools to drive changes in individual behavior -- which is key to effective prevention. Moreover, the public policies needed to fully engage all effective preventive strategies can intrude on individual freedom and choice, raising an array of political issues. Of course, most of the focus of the current US health care system is on the diagnosis and treatment of disease, including training and payment. Finally, management of disease, particularly chronic disease, is an effective, but underutilized component of the overall health landscape in our country. Switching from managing the nation's large and growing chronic disease burden from our expensive acute care practice models to new management modalities in the community has been demonstrated to lower costs significantly, improve the quality and safety of the care and, when fully understood, enhance the patient's experience as a consumer.

To rebalance health care away from its almost exclusive focus on diagnosis and treating to include more emphasis on prevention and use of management is what the best aspects of the current federal health care reform are about. But even without this policy change, there is still movement by some individuals and families to improve their overall health by deploying their own version of healthy lifestyles. Every time you notice a fitness center, read an article on eating healthy or see a new farmers market, you see evidence of the market responding to consumer driven interest in prevention. Some individuals are also managing their care differently as well. Some of these examples are in the acute care range such as health tourism to obtain affordable surgical procedures, but much of it comes about around improved private efforts to manage or "live with" a chronic condition in a way that produces a better set of outcomes that have been chosen more by the patient than by the professionals.

This rebalancing of the prevention, diagnosis, treatment and management continuum will continue in our country, because it beats the other two options for reducing the costs of care. Option one, restricting access, makes consumers angry. We have built beautiful health care castles on the hills around the nation and then told many people that they cannot have access to them. They usually do not get this information until they desperately need the care. The villagers are upset with the folks in the castle, providers, and their guardians, insurers, and they now have pitch forks and torches. Restricting access is not a good long term policy. Many of the things that go on in the castle are the best in the world, but they are expensive and their use should be managed better.

The second option for lowering costs would be to pay those who provide the inputs less. An across the board cut of 20% would save the country the billions that are needed and would encourage, in a rather draconian manner, innovation on the part of providers. But this has little likelihood of passing the needed political hurdle as evidenced by the annual "blinking" that occurs when Congress is asked to address issues of physician and hospital reimbursement.

So the option of rebalancing, over time, is probably the best one available, for all concerned. To get there, we are likely to go through three overlapping phases. First isimprovement. We have been at this one for the better part of the past twenty years. Though the initial motivation for these efforts to improve the quality and safety of care came from outside the system, they are now richly owned and enforced within the professions and institutions that deliver care by private organizations such as JACHO and NCQA and public entities such as CMS and state Medicaid programs. They are a part of the fabric of every health care institution in the nation, and there has been considerable progress. But the more we measure and understand, the more we are aware of the size of the challenge that remains.

Improving the system as it is has a natural limit to how much of the rebalancing it can promote. If we are still admitting a senior to the emergency department to manage their congestive heart disease and this results in an expensive and dangerous journey through the ICU, step-down and a med-surg floor to discharge, then improving the medication error rate, the transitions between services and the education at discharge will improve the quality of that episode, but we could have managed the patient differently and prevented the admission in the first place. Making this change through improved integration is what much of the current health care reform is about. Policies to create Accountable Care Organizations (ACOs), moving primary care to Patient Centered Medical Homes, making meaningful use of health information, paying for value of what is purchased, and a host of other changes drive toward this integration. Thinking, functioning and financing with a systems perspective is essential to achieving a rebalanced health system.

Finally, while a thoroughly integrated system of care can make it possible to move services away from unnecessary diagnosis and treatment to improved management, it cannot do the full lifting that will be necessary to broaden services to have a more prevention oriented approach to health. To do this it will be important to move outside the sickness and treatment system. Thinking about health in this broader way will take time and changes that move from the individual level to the broadest levels of policy.