Let Cool Heads Prevail

Europen and Asian leaders see an otherwise great country struggling to do what most of the developed world has already done – make basic healthcare a right

July 30, 2009 -- Why are we still not able to reform our healthcare system so all Americans have reasonable access to evidence-based prevention and public health measures and services that will actually improve our longevity, our health and our economy? 

This summer I’ve been traveling to interview fellow Americans about their healthcare needs, what needs to change to transform our system and the obstacles to overcome if we are to genuinely improve healthcare outcomes and make healthcare affordable for all Americans.
These are some of the observations from these interviews:
The discussion and debate needs to be not just between Democrats vs. Republicans talking heads but all Americans.
We need less drama and rhetoric and more humility. Our healthcare access, growing uninsured and underinsured and medical-caused bankruptcy are seen as an ongoing tragedy to many healthcare leaders in Europe and Asia. They see an otherwise great country struggling to do what most of the developed world has already done – make basic healthcare a right without spending 1/6th of a nation’s gross domestic product or causing personal bankruptcies when citizens get really sick.
Americans are scared, skeptical and sobered about their jobs, the economy and have lost trust and faith in politicians and healthcare leaders who seem unable to reform and transform healthcare.
In California, Michigan and New York, I also sensed a new American resilience and hope. I witnessed people at Macomb Community College in Michigan agreeing with President Obama’s call for healthcare reform. I witnessed healthcare leaders, doctors and nurses demonstrate they know something must be done to use existing 21st century tools and to change how they are rewarded or discouraged from providing the right mix of healthcare in the right setting at the right time.
And, finally, we need a new Tim Russert to ask the hard questions and demand answers, and a new Walter Cronkite to provide the calm media leadership perspective to get us there.
Increasingly there is a slow but growing national concern that we simply must be changing some of the basics:
E-health – We have finally come to understand that we should be changing from fragmented and paper records to an electronic system of data and information that is built to improve a patient’s health rather than to maximize opportunities to increase a patient’s bill.
It’s the financial incentives stupid! We should be paying for healthcare and evidence-based prevention NOT by incenting the number of visits and procedures, but rather by incenting doctors, nurses and public health professionals to prevent, and, at the earliest practical time, detect diseases before that disease evolves. This delay in diagnosis and treatment combined with us paying unreasonable amounts for treatment is simply too expensive for Americans to tolerate any more.
A growing number of Americans have come to understand that we are actually spending more than any other developed country by not encouraging prevention and instead treating healthcare as a right only in an expensive emergency room setting.
Now that the dust has settled with our latest Oregon legislature which made some progress but still kicked too many cans down the road, what might some reporting by Cronkite and Russert suggest we do now?
Let’s agree that basic healthcare needs to be a right in preventive and primary care settings and not just in the hospital emergency room.
Let’s stop the bickering about what needs to change and instead at least build an Oregon patient-centered electronic health infrastructure so that in the next decade every Oregonian has a confidential, complete and accurate health and medical records that follows us at every preventive and diagnostic point of care. Instead of paper or even electronic silos, let’s have a patient-focused private and secure health record that integrates public health, school health, prevention, medical office and hospital information for providers and patients at the point of care.
Let’s insist that health payers and health insurance plans change their financial incentives to reward real evidence-based prevention and improved healthcare outcomes rather than overly rewarding the number of visits or procedures or duplicate tests we subject patients to.
By focusing on incenting and rewarding and paying for health outcomes, we can change the game. Let’s reward doctors, nurses and hospitals for making healthcare affordable and accessible.
Those are my thoughts. I look forward to hearing from people who are willing to challenge and improve my thoughts and make them actionable for Dr. Bruce Goldberg and the Oregon Health Authority, which are charged with reforming Oregon’s healthcare system.
Mike Leahy is currently an associate professor of health sciences at Linfield College and a clinical instructor in family medicine at Oregon Health & Science University. He was a leading healthcare executive for over 13 years with Kaiser Permanente in Portland and in the Bay area, a former public health director in Alameda County, California and Tillamook, Oregon, and the founding CEO of OCHIN in Portland.
Editor’s Note: In my previous role as the founder of Oregon Health Forum, I met Mike over 20 years ago when he was Kaiser’s VP/Health Plan Manager and chair of the Oregon Health Council which recommended the creation of the Health Services Commission and the Oregon Health Plan. – Diane Lund-Muzikant


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This essay is difficult to unravel as it speaks to "the problem" and "the solutions" as intermixed ideas. We have two principle problems, how to achieve universal access; and how to gain control over the cost of health care. The first part is relatively easy conceptually...the principle barrier is the latter (cost) in that there is nothing on the table beyond wishful thinking that offers a credible strategy to control costs. The author believes that prevention, electronic medical records, pay for performance, and other populist thinking will do the trick (as if "just trust me because I believe it to be true"). I don't think these measures will control costs, but would yield to a "proof of concept" before we impose someone's faulty theories on the rest of us. I remember when rationing was going to achieve sustainable economics. The danger we face, is what we have always done, get enough people to parrot the same unproven populism until it is considered "truth" and off to the races we go. Reform evades us largely because there is no credible strategy to control costs, and perhaps it is at least arguable we should be reluctant to expand rights, with no concept of how to control the economic consequences.

To "sgregg's" comment: Perhaps pertinent is Massachusetts's recent public policy decision to pay for care, in its universal access model, only via "global payments" (once called global capitation in the maligned managed care version.) A physician-hospital organization, or contractual alliance of providers, receives all of the anticipated health claims costs up front, by age and gender of members. Besides inadequate primary care access, out of control costs have characterized the effort in MA, as anyone knew would happen since the compromise was bought by not angering well-off stakeholders with cost controls initially. Now reality arrives with this new policy. As said by a policy expert interviewed this week, now there are at least better metrics to monitor for quality and for "under-utilization"--the denial of needed, covered services by at-risk providers, which does occur, though not nearly as often as consumer activists and some financially-interested specialty providers would have us believe. It is 100% true that real cost management strategies that can actually manage costs must be instituted. We already know what they are, for the most part. It is time to bite those bullets and act. Tens of millions uninsured, many lost lives, and much lost health, is a heckuva price to pay for the marginal utility of the fee-for-service system in avoiding any bit of questionably useful, omitted care for the fortunate majority who have coverage and access. That is precisely the price paid now, sometimes paid by the children or grandchildren of folks who don't want to give up a bit of the wonderful "coverage" they enjoy in our current system. It has become quite personal.

Since almost all health care costs can be attributed to someone's paycheck, it seems to me that the strategy(s) must be seen as likely to reduce the take home pay of a lot of people. The downside of "prevention" as an example, is that it is a supplemental source of income and more importantly a prospecting tool for undiagnosed illness (and more money). No doubt prevention is a "good thing". Far, far less certainty that such expenditures will reduce health care premiums, if not an outright silly assumption. The most aggressive "dreaming" as to what could be deployed to control costs, most commonly does not anticipate the offsetting reaction of those suffering the loss in cash flow. Sometimes the response is more adverse than the originating cost reducing action. Think managements at Providence or Legacy are paid incentives to supervise an annual decline in revenues? If large and small organizations or individual professionals generally make lots more than last year...where is the cost containment? Too much "gibberish" in the marketplace of "talk" in my estimation. Quite the opposite, it is clear we either do not know how to control costs, or do not want to.

Consider what where we have evolved. I just joined the ranks of Medicare. It is a heck of a deal with almost no incentive to avoid, even knowing full well it comes at a cost to current workers and our grandchildren. I would fully welcome sustaining my own requirements to the relief of others, but AARP, and I assume our own government would have a "cat fit" about such a proposition. The only way I can elect another option, is to gain coverage through work. I cannot buy comprehensive individual health insurance after the age of 65. Health reform is about everything but one of elephants in the room, Medicare. Intellectually lots of smart people seem more than willing to ignore it and in effect embolden the same political process that makes Medicare "untouchable". If Medicare needs to be in the mix of any credible health care reform, why would any iniative retain its leadership from the ranks of politics when those members have so clearly expressed its unwillingness to "touch the third rail"? It is this intellectual and even ethical flaw in most reform dialogue that catastrophically pollutes all "solutions" to follow.