Welcome to the Blog of the Duke Center for Research on Prospective Health Care
Friday, December 17, 2010
While we wait to see what the impact of legal challenges to PPACA do to the law, I suggest concerted Government and private sector initiatives to spur better models of care delivery.
Monday, December 13, 2010
In an editorial in this Sunday's New York Times, this issue is discussed with a primary focus on reducing costs by cutting Medicare expenditures and increasing the costs borne by individuals. Neither of these approaches gets to the root of the problem. Lowering overall expenditures for
health care must be addressed as our current weakened economy is straining under this burden. Importantly, it is feasible to both lower costs and improve care! PPACA, while monumental in its scope, focuses largely on insurance coverage but deals lightly, and in my view ineffectively, with the root problem of health care delivery in the US. Our health care delivery "system" is uncoordinated, reactive, and focused on the expensive treatment of disease events associated with late-stage preventable chronic illness. Physicians and providers are currently rewarded economically for interventions, particularly invasive ones. It is recognized that coordinated care which emphasizes prevention and, when needed, interventions over time, and is focused on a motivated and involved patient, provides the most cost effective outcomes. Reimbursement for prevention and coordinated care to minimize disease is insufficient to cover costs. Yet reimbursement must be structured to reward such care. PPACA addresses these issues, but the solutions require the establishment of new bureaucracies, many years, and changes that will be subject to intense political debate. The type of care needed to improve health, outcomes and decrease costs is well understood today, but little is being done to foster its adoption. Care must be coordinated, personalized, preventative, and involve an engaged patient. Unfortunately, current incentives work against such models of care being established. I don't see a timely solution, given the current approaches.
To foster change, I propose highlighting the imperative to do so along with the establishment of a bipartisan Presidentially-appointed committee charged to recommend new models of coordinated care delivery and reimbursement strategies. The Bowles-Simpson Committee is an example of a bipartisan approach to recommend solutions to knotty problems. The report of a Health Delivery Improvement Committee could be expected within six months. Both private insurance and CMS could provide reimbursement incentives to foster recommended changes rapidly. The answer to our current wasteful approach to health care will be far easier to find than overall solutions to a tepid economy, but the former will provide strong support to make the latter solution easier.
Thursday, December 9, 2010
Monday, December 6, 2010
Recently, the Duke University chapter of the Benjamin Rush society held a debate on health care reform.
Moderated by Dr. Christopher J. Conover, the topic was, “How does America achieve affordable, accessible, quality healthcare?” Debate participants included Sally Pipes, Dr. Hal Scherz, Dr. Peter Kussin, and Dr. Gustavo Montana.
The audience was polled just prior to the debate as to whether health care reform would be best addressed by (1) government regulation (2) self-regulation by the private sector or (3) unsure. The same question was asked at the conclusion of the debate. Although no formal statistical analysis was performed, the numbers remained essentially unchanged before and after the debate. One hour of intense discussion among three physicians and a national health care reform expert in the presence of medical students, health care professionals, and members of the public resulted in more of the same – not unlike what we’ve seen in the last two years across both the political and private sectors. . It’s clear people’s opinions on health care reform reflect core moral, political, economic, and philosophical beliefs, and those don’t often shift over the course of an hour-long discussion or a three-minute news splash.
Despite the heated discussion, there were several points that both the “conservative” and “liberal” panelists agreed upon. They agreed that the current system is broken and that PPACA is unlikely to fix it. They agreed that physicians need to be more involved in discussions of health care reform. They agreed that cost-effective care, guided by cost-effectiveness research, is important to improving health care efficiency. They agreed that patient care needs to be coordinated among providers and systems.
Prospective health care provides a solution that cuts across political and personal mores. This approach provides regulation not by government or private companies, but by physicians in partnership with their patients. It provides cost-effective care, not by mandate, but by physician and patient cooperation. It supports rational reimbursement based on documented outcomes. It is a non-partisan, non-government, non-private, but physician and patient based approach that avoids the devastating road-blocks that plague current “debates” on health care reform. Dr. Kussin advocated for an American Solution several times during the debate. If the United States is to find a uniquely American solution to the question of health care reform, it will take all of America, not just one-half. Focusing on the development and implementation of models of reform such as prospective health care provides a real solution for how to provide rationale care, reduce costs, improve outcomes, and increase patient satisfaction. And who can’t agree on that?
Monday, November 29, 2010
The focus of controversy in both recent debates and legislation has been largely about insurance reform. What has been absent from these discussions is how health care reform can 1) change how we approach the delivery of health care and 2) support improved health over the life of an individual. Currently, care is sporadic, reactive, uncoordinated, and based on a reimbursement which rewards treatment of disease rather than prevention of disease. If you have any doubt of this just look at any of the highest paid medical specialties – cardiology, radiology, oncology, gastroenterology, and surgery – all procedure based specialties that are well-reimbursed under our current system. We at the Center believe that we can do better than this reactive, procedure-based approach to medicine. Through the use of personalized health plans, providers can quantify patients' health and health risks, identify strategies to mitigate risks and/or treat disease, deliver personalized care, engage patients in their care, and measure outcomes over time. This set of tools can then be used to more effectively implement coordinated care and more accurately measure performance for reimbursement. While PPACA and its attempts to address inadequacies in health insurance and coverage may be stalled by political turmoil for some time, the health care community can use personalized health planning to start to work towards meaningful health delivery reform now. And as we argue in a recent commentary in Academic Medicine, PPACA’s focus on the development of coordinated models of care, provider reimbursement reform, and personalized health planning is a significant opportunity for academic medical centers to lead the way in health care reform.