Last week Don Berwick announced his resignation as Administrator of CMS. In his parting speech, Dr. Berwick listed his top 5 reasons as to why there is so much waste in the US health care system.
These five reasons were as follows:
1. The over treatment of patients
2. The failure to coordinate care
3. The administrative complexity of the health care system
4. Burdensome rules
5. Fraud
In a post on this week’s Health Care Blog, Dr. John Halamka argues that a common solution which would at least in part address each of these issues is the electronic health record. I think the point he is making is on the right path but that it would be better served taking it one step further: an electronic health record in the context of Prospective Health Care. Prospective Health Care is a coordinated approach to health care and wellness which involves personalized health risk assessment and the development of a personalized health care plan to ensure maximum patient involvement and engagement in their care. IN this model, the personalized health plan is coordinated between the patient, a health coach when appropriate, and the provider system.
By focusing on an electronic health record itself, we risk missing its necessary precursor – a strategic approach which addresses the needs of each patient by tailoring their health care plan to meet their individual needs. An electronic health record is a tool which would help implement and optimize this type of approach, but would be insufficient on its own.
In the context of each of Dr. Berwick’s five reasons for waste, Dr. Halamka suggests that electronic health records would mitigate each of these factors.
To address over treatment of patients, Dr. Halamka suggests that EHRs could automate alerts and reminders as to what his patients need. If such alerts and reminders are not tailored to the specific health and wellness needs of individual patients in the context of their personal health plan, one could see how these types of systematic alerts and reminders could potentially exacerbate over treatment rather than curb it.
In terms of coordinated care, EHRs will certainly allow multiple providers greater ease of access to a patient’s health and treatment information and provide the opportunity for improved communication between different providers working with the same patient but unless the patient in question has a personal health plan in place to drive the strategic approach to their individual care, there can be no guarantee that these different providers are working with the patient towards a common goal. If providers are not working in tandem the opportunity to reduce waste is missed.
Dr. Halamka also gives examples as to how the next three contributors to waste, complexity, rules, and fraud, could be mitigated by EHRs as well – mainly by streamlining some of the administrative complexities of the health care system by having EHRs that automate care plans, provide feedback at the point of care, and process payments based on measured outcomes. He also suggests that the data generated by ERHs would allow analysts to look for patterns of care that are outliers and thus potential indicators of fraud. For each of these instances it would still be important for EHRs to be utilized in the context of personalized health planning to ensure that patients are receiving and providers are being reimbursed for providing patients optimal care for their individual health and wellness goals.
While EHRs are an important tool to help drive appropriate treatment of patients, coordination of care, and reductions in administrative burdens and the potential for fraud to help eliminate waste, they can only do so optimally in the context of prospective health care.
Showing posts with label Personalized health care. Show all posts
Showing posts with label Personalized health care. Show all posts
Wednesday, December 14, 2011
Wednesday, May 18, 2011
False competition: an obstacle for prospective healthcare
By Sanjay Kishore
This past week I traveled to DC with 10 other undergrads passionate about health policy. During my visit I had the intriguing experience of visiting Housing Works, a prominent homelessness and HIV/AIDS advocacy organization famous for its history of activism, social justice, and civil disobedience. While we thought we were going on a simple tour, I soon realized that I would walk away with much more perspective on the state of health policy than when I entered.
As it turns out, the Washington Post had published an article the previous night quoting a local councilwoman who said she was considering reallocating HIV/AIDS funding to other obesity-related medical conditions affecting her district – none other than primarily diabetes, heart disease, and hypertension. Since she was the swing vote for passage of the budget, it was likely her demands would be included in the final bill. As I stood in the office of Housing Works, I saw the HIV/AIDS lobby begin to mobilize. Conference calls were made, frustrations exchanged, talking points drafted, and responses strategized. As student aides for the day, we too played a part. Our role? Drafting a letter to the councilwoman forcefully explaining that HIV/AIDS funding could not be cut by a single penny. And write we did, composing a message to be used as a call to action that would surely fill the legislator’s inbox.
To Housing Work’s credit, their rationale was this: instead of distributing money to different diseases (take from HIV, give to diabetes, etc.), why not create a better health system that addresses all of these health problems holistically? This seems completely rational - yet, there was a caveat. To accomplish health system strengthening, they wanted more overall funds devoted to health without reallocating money away from HIV/AIDS.
This example speaks to the challenges prospective health care faces as it encourages policymakers to combat chronic disease. Perhaps these funds would have helped eliminate “food deserts,” improve access to community exercise facilities, and allow free physicals in disadvantaged neighborhoods. But it would have been at the expense of helping individuals with other health needs. The reality is clear: in the midst of a $3 trillion deficit, governmental resources for health are limited. And paying more for one disease (in this case obesity) means paying less attention to another (HIV/AIDS)
Is this a false competition? Perhaps. Though we all stand for health as a human right, over-specialization may be hindering our collective progress. Can students play a role in facilitating collaboration and uniting narrow interest groups? You bet. Creating a stronger health system is not just a talking point – it’s a solution that will require compromise and force us to seek common ground. One thing is clear: it’s going to be a lot harder to de-politicize a movement to alleviate chronic disease than perhaps anyone of us youth ever thought.
Wednesday, April 6, 2011
In Physicians we Trust
An article on a new physician trust measure in the recent issue of Annals of Family Medicine sparked some interesting commentary from Jessie Gruman. She challenged the idea of whether this was a measure of physician “trust” or good old-fashioned doctor-say patient-do. Using her personal experience with cancer, she explains her concerns about the article’s criteria being used to evaluate her doctor’s level of trust in her.
This is an interesting example of semantics, which is something we’ve been discussing here at the Center. Just as we ask the question, “How are we defining personalized medicine?” The same question applies here. “How are we defining physician trust?” Taken out of context, the Thom et al. Physician “Trust” measure sounds exactly as Jessie Gruman describes it – at best a paternalistic, non-participatory approach. But it’s important to remember the context in which the measure was used – HIV-positive patients on opiods for chronic, non-cancer related pain. Not cancer patients. These are two very dissimilar patient populations with significant differences in the social and cultural factors influencing their health behaviors and decisions. A scale designed for HIV-positive patients with chronic pain doesn’t make sense in an oncology setting and was never proposed by the authors.
That being said, I understand Gruman's gut reaction. The title of the Thom et al. article is misleading. Instead of “Physician Trust in the Patient,” the article title could have been: “Physician Trust in the HIV-positive Chronic Pain Patient” or “Physician Assessment of Abuse Potential in Chronic Pain of HIV-positive Patients.” And the issue of patient engagement remains. Despite the challenges these providers and patients are facing – namely, risk for drug abuse and addiction – these patients still need health care where they are involved in the process. Then a question like “How confident are you that the patient will follow the treatment plan you recommend?” might read something like: “How confident are you that you and your patient can develop a treatment plan together that the patient will follow?” It’s a subtle shift, but it brings the patient into the process of his/her care. It also attends to some of Gruman’s concerns. If nothing else, this is a perfect example where being clear in our terminology makes all the difference in how we interpret, understand, and utilize scientific information. We’ve still got a ways to go.
This is an interesting example of semantics, which is something we’ve been discussing here at the Center. Just as we ask the question, “How are we defining personalized medicine?” The same question applies here. “How are we defining physician trust?” Taken out of context, the Thom et al. Physician “Trust” measure sounds exactly as Jessie Gruman describes it – at best a paternalistic, non-participatory approach. But it’s important to remember the context in which the measure was used – HIV-positive patients on opiods for chronic, non-cancer related pain. Not cancer patients. These are two very dissimilar patient populations with significant differences in the social and cultural factors influencing their health behaviors and decisions. A scale designed for HIV-positive patients with chronic pain doesn’t make sense in an oncology setting and was never proposed by the authors.
That being said, I understand Gruman's gut reaction. The title of the Thom et al. article is misleading. Instead of “Physician Trust in the Patient,” the article title could have been: “Physician Trust in the HIV-positive Chronic Pain Patient” or “Physician Assessment of Abuse Potential in Chronic Pain of HIV-positive Patients.” And the issue of patient engagement remains. Despite the challenges these providers and patients are facing – namely, risk for drug abuse and addiction – these patients still need health care where they are involved in the process. Then a question like “How confident are you that the patient will follow the treatment plan you recommend?” might read something like: “How confident are you that you and your patient can develop a treatment plan together that the patient will follow?” It’s a subtle shift, but it brings the patient into the process of his/her care. It also attends to some of Gruman’s concerns. If nothing else, this is a perfect example where being clear in our terminology makes all the difference in how we interpret, understand, and utilize scientific information. We’ve still got a ways to go.
Monday, April 4, 2011
P4 Medicine – How do we get from current practice to future progress?
In the current issue of Nature Reviews in Clinical Oncology, Stephen Friend and Leroy Hood – the man who first described predictive, personalized, preventive, and participatory medicine as “P4 medicine” emphasize that clinical trials of the future will need to be designed so they fully capitalize on P4 medicine. Specifically with the advent of high-throughput genomic medicine, Friend and Hood note that science is experiencing a paradigm shift: what we once thought were single diseases, are in reality multiple distinct molecularly defined disease states. The natural extension is that trials previously needing 10,000 patients to show a benefit will now need tens of thousands of patients to have adequate statistical power to detect the same level of benefit. Even in large academic medical centers, the authors note, it will be difficult or even impossible to rapidly accrue proportionally small patient subsets in which personalized interventions can be feasibly explored and tested. The authors suggest the use of patient driven networks to obtain the patient numbers needed for these trials.
We at the center typically think about patient-physician interaction and patient empowerment, activation, or participation when we talk about the “participatory” P of P4 medicine. Friend and Hood extend the definition of participatory to include efforts by patients to enroll themselves in networks whose goal it is to provide access to clinical trials that would otherwise be beyond the reach of single, brick and mortar institutions. Given the authors’ backgrounds, they are understandably preoccupied with the genetics and molecular aspects of such trials, but their concept still applies to models of personalized medicine that may not involve molecular data.
Even for purely non-genomic based disease models, we are beginning to appreciate the importance of individual variation in response to therapy. We already have the tools to perform personalized, risk-based prevention and treatment for many disease states using family history, biochemical markers, and patient preference. For prospective health care to reach its maximum potential in the future, we will need to develop new models that allow iterative improvements in personalization and intervention outside of current models of clinical trials. Much in the way that the physiology-based practice of medicine of the 21st century came to embrace evidence based medicine (EBM), personalized medicine will likely require some analogous, personalized equivalent to maximize its full potential . One possibility is patient driven networks as proposed by Friend and Hood. Another is novel statistical modeling that would allow us to personalize interpretation of conventional clinical trials.
Friday, February 25, 2011
Your cancer treatment decisions aren't about you - but they should be
By Michaela Dinan and Leigh Ann Simmons
There's been a lot of discussion about the role of the patient in health care decision-making. Yesterday, results from a study of Medicare patients showed where you live and which doctor you see influences whether you receive elective surgery. For example, if you have early stage breast cancer and live in Victoria, Texas, it’s very likely that you’ll have a mastectomy. If you live in Muncie, Indiana, not so much.
In a similar vein, Jessie Gruman analyzed her cancer treatment experience to discuss how health care decisions get made. By all accounts, Gruman is what we’d call a “highly activated” patient. She’s engaged in her care because this is what she does for a living. She’s motivated by her diagnosis. And yet still, upon reflection of her experience Gruman identified moments where her physical state was so poor that she was unable to fully participate. In fact, she has almost no recollection of a doctor visit where they decided to stop her chemotherapy treatment.
So what's going on?
Shannon Brownlee, the lead author of the Medicare study said their findings demonstrate the physician-centric nature of the U.S. healthcare system. She noted that, "....patient preferences are not always taken into account when medical decisions are made." Who, us? We care about our patients. That’s why we keep telling them to eat right, exercise regularly, reduce stress, take their medication, and [fill in doctor’s orders here].
And therein lays the rub. We’re telling them. But what are they telling us?
Unfortunately, not much right now. But they could be telling us so much more. In fact, the Brownlee et al. Medicare study is a perfect example, because the Accountable Care Act provides for an element of personalized medicine that we believe is critical – a personalized health plan. The mere act of developing a personalized health plan with patients addresses several barriers we’re experiencing to good health in this country – understanding obstacles to adhering to prescribed treatment, identifying goals that are important to the patient to support strong engagement over time and so the physician has a frame of reference when making treatment recommendations, and involving the patient in the process of care so they become invested not only in their health, but also in the partnership with their provider (hear, hear Dr. Zeiger). Because let’s face it. It’s human nature for many of us to take action on something if we’re involved in the decision-making rather than if someone simply tells us we “have to” or “should” do it. Furthermore, in cases like Gerson’s, if the provider has a document that includes data on the patient’s preferences, goals, and challenges, making the decision to, say, stop chemotherapy when a patient is too ill to be fully engaged becomes more about the patient than it might otherwise.
So let’s start making it about the patient. Bring them into the fold. Recognize they are experts on themselves. Involve them in the decisions about their care. And then we’ve truly entered the realm of personalized medicine.
There's been a lot of discussion about the role of the patient in health care decision-making. Yesterday, results from a study of Medicare patients showed where you live and which doctor you see influences whether you receive elective surgery. For example, if you have early stage breast cancer and live in Victoria, Texas, it’s very likely that you’ll have a mastectomy. If you live in Muncie, Indiana, not so much.
In a similar vein, Jessie Gruman analyzed her cancer treatment experience to discuss how health care decisions get made. By all accounts, Gruman is what we’d call a “highly activated” patient. She’s engaged in her care because this is what she does for a living. She’s motivated by her diagnosis. And yet still, upon reflection of her experience Gruman identified moments where her physical state was so poor that she was unable to fully participate. In fact, she has almost no recollection of a doctor visit where they decided to stop her chemotherapy treatment.
So what's going on?
Shannon Brownlee, the lead author of the Medicare study said their findings demonstrate the physician-centric nature of the U.S. healthcare system. She noted that, "....patient preferences are not always taken into account when medical decisions are made." Who, us? We care about our patients. That’s why we keep telling them to eat right, exercise regularly, reduce stress, take their medication, and [fill in doctor’s orders here].
And therein lays the rub. We’re telling them. But what are they telling us?
Unfortunately, not much right now. But they could be telling us so much more. In fact, the Brownlee et al. Medicare study is a perfect example, because the Accountable Care Act provides for an element of personalized medicine that we believe is critical – a personalized health plan. The mere act of developing a personalized health plan with patients addresses several barriers we’re experiencing to good health in this country – understanding obstacles to adhering to prescribed treatment, identifying goals that are important to the patient to support strong engagement over time and so the physician has a frame of reference when making treatment recommendations, and involving the patient in the process of care so they become invested not only in their health, but also in the partnership with their provider (hear, hear Dr. Zeiger). Because let’s face it. It’s human nature for many of us to take action on something if we’re involved in the decision-making rather than if someone simply tells us we “have to” or “should” do it. Furthermore, in cases like Gerson’s, if the provider has a document that includes data on the patient’s preferences, goals, and challenges, making the decision to, say, stop chemotherapy when a patient is too ill to be fully engaged becomes more about the patient than it might otherwise.
So let’s start making it about the patient. Bring them into the fold. Recognize they are experts on themselves. Involve them in the decisions about their care. And then we’ve truly entered the realm of personalized medicine.
Wednesday, February 23, 2011
Why Matthew Herper has it wrong
In his column today, Matthew Herper brings up an important issue in personalized medicine. Namely, pharmaceutical companies need to proceed with caution as they pursue research, development, and sales of drugs tailored to "niche populations," or those for whom the drug will work only if they have the unique genetic variation of the disease being treated. Certainly, as we develop drugs in an era where we know more about how people will respond based on their genetic make-up, we will have to simultaneously create new research and financial paradigms that can sustain this important and necessary work.
However, that's not the end - or even the beginning - of the story.
Where Herper loses me is his narrow definition of personalized medicine. What he's talking about in this piece is pharmacogenetics (or pharmacogenomics) , which is one facet of personalized medicine. But personalized medicine is a much broader field of health care. In fact, given the relatively few targeted therapies that have actually made it to market, I would argue that pharmacogenetics is really a small piece of the personalized medicine pie.
We and others have defined personalized medicine as a predictive, preventive, participatory, and prospective approach to care that is individualized to patients based not only on their unique molecular information, but also on their unique clinical, social, behavioral, and environmental data. Planning for health is a critical component of personalized care. While many patients may have similar goals - continued health and wellness, weight loss, reduced blood pressure, improved insulin sensitivity - how they reach those goals is customized based on their unique profile identified through a comprehensive health risk assessment. Furthermore, a key component to the success of personalized medicine is engaging patients in the process - whether that means getting them on board with taking that tailored prescription medication, or getting in the recommended 2.5 hours of physical activity a week. Thus, tracking markers of health and disease, as well as compliance with recommended therapies over time, helps to keep both patient and provider mutually informed about how a patient is doing - and whether preventive action might be necessary to avert an event. Finally, when we get to the point in personalized medicine where we're using tailored pharmaceuticals, the patient likely has already developed disease - at least as far as where pharmacogenetics currently stands. Personalized medicine, if practiced as we're describing, is aimed first at preventing disease, and then mitigating the negative consequences of disease after it has developed. This is the true promise of personalized medicine - disease prevention that will reduce the skyrocketing rates of chronic diseases that cost the U.S. $2 trillion annually.
I agree with Herper - something "big and dangerous" did happen in personalized medicine today: An exciting drug discovery prompted debate over the promise of personalized medicine without considering personalized care beyond pharmacogenetics. By equating the two, we undermine the true possibilities of a personalized approach to care that goes well beyond what drugs to prescribe. And if we don't start implementing the features of personalized medicine that are readily accessible to us today at relatively minimal cost, then that truly will be a giant mess.
However, that's not the end - or even the beginning - of the story.
Where Herper loses me is his narrow definition of personalized medicine. What he's talking about in this piece is pharmacogenetics (or pharmacogenomics) , which is one facet of personalized medicine. But personalized medicine is a much broader field of health care. In fact, given the relatively few targeted therapies that have actually made it to market, I would argue that pharmacogenetics is really a small piece of the personalized medicine pie.
We and others have defined personalized medicine as a predictive, preventive, participatory, and prospective approach to care that is individualized to patients based not only on their unique molecular information, but also on their unique clinical, social, behavioral, and environmental data. Planning for health is a critical component of personalized care. While many patients may have similar goals - continued health and wellness, weight loss, reduced blood pressure, improved insulin sensitivity - how they reach those goals is customized based on their unique profile identified through a comprehensive health risk assessment. Furthermore, a key component to the success of personalized medicine is engaging patients in the process - whether that means getting them on board with taking that tailored prescription medication, or getting in the recommended 2.5 hours of physical activity a week. Thus, tracking markers of health and disease, as well as compliance with recommended therapies over time, helps to keep both patient and provider mutually informed about how a patient is doing - and whether preventive action might be necessary to avert an event. Finally, when we get to the point in personalized medicine where we're using tailored pharmaceuticals, the patient likely has already developed disease - at least as far as where pharmacogenetics currently stands. Personalized medicine, if practiced as we're describing, is aimed first at preventing disease, and then mitigating the negative consequences of disease after it has developed. This is the true promise of personalized medicine - disease prevention that will reduce the skyrocketing rates of chronic diseases that cost the U.S. $2 trillion annually.
I agree with Herper - something "big and dangerous" did happen in personalized medicine today: An exciting drug discovery prompted debate over the promise of personalized medicine without considering personalized care beyond pharmacogenetics. By equating the two, we undermine the true possibilities of a personalized approach to care that goes well beyond what drugs to prescribe. And if we don't start implementing the features of personalized medicine that are readily accessible to us today at relatively minimal cost, then that truly will be a giant mess.
Monday, February 21, 2011
A Cancer Patient’s Plea for Personalized Medicine
A compelling piece was published in Forbes Magazine recently. Adriana Jenkins, who passed away this month, writes from the perspective of a dying cancer patient to advocate for the passing of a law to encourage drug makers to developed Personalized Medicine drugs for cancer and other deadly diseases. Her perspective, as both a patient and an individual who worked in biotech for 15 years, is both unique and moving.
Monday, February 14, 2011
Personalized health records promote horizontal integration within ACOs
ACOs, or Accountable Care Organizations, continue to be a hot discussion topic in health care reform. In the current issue of JAMA, Duke’s own Barak Richman and Kevin Schulman provide a unique business perspective on the implementation of ACOs. One of the issues they raise is the potential for the establishment of ACOs to result in health care system monopolies. They warn that health care systems might align under the promise of market dominance and not necessarily with the intention of improving health care quality or efficiency. In order to prevent a misaligning of goals, they urge that evaluation of ACOs should maintain focus on health care quality and efficiency.
Another recommendation they suggest is for health care systems to align under a horizontal vs. vertical or “bricks and mortar” approach. Whereas vertical networks focus on established hospitals and other infrastructure, horizontal networks would connect more fluid, geographically diverse care specialists. To me it seems like this idea mirrors themes in social and professional networking. Horizontal networks may take less time, investment, and have the potential to spread much more quickly than conventional geographically constrained networks. However, in my opinion a key challenge to the horizontal vs. vertical approach is how seemingly unconnected groups will be able to share information and provide coordinated care. I think that a potential solution would be the establishment of personalized health care records. Electronic personalized health care records would follow the patients, contain all their health care information, including their personalized health plan, and provide a virtual medical home that could provide a universal medium for exchanging health care information among horizontally connected providers. Without a universal medium to maintain coordination of care and ensure that information is efficiency conveyed, it may be difficult to envision how horizontal networks could provide cohesive care. In an ongoing era of rapid technology development, a personalized health care record would provide a potential means of increased portability and exploration of new options for new health care delivery models.
Another recommendation they suggest is for health care systems to align under a horizontal vs. vertical or “bricks and mortar” approach. Whereas vertical networks focus on established hospitals and other infrastructure, horizontal networks would connect more fluid, geographically diverse care specialists. To me it seems like this idea mirrors themes in social and professional networking. Horizontal networks may take less time, investment, and have the potential to spread much more quickly than conventional geographically constrained networks. However, in my opinion a key challenge to the horizontal vs. vertical approach is how seemingly unconnected groups will be able to share information and provide coordinated care. I think that a potential solution would be the establishment of personalized health care records. Electronic personalized health care records would follow the patients, contain all their health care information, including their personalized health plan, and provide a virtual medical home that could provide a universal medium for exchanging health care information among horizontally connected providers. Without a universal medium to maintain coordination of care and ensure that information is efficiency conveyed, it may be difficult to envision how horizontal networks could provide cohesive care. In an ongoing era of rapid technology development, a personalized health care record would provide a potential means of increased portability and exploration of new options for new health care delivery models.
Tuesday, January 18, 2011
Medicare Jumpstarts Wellness and Prevention Efforts
As of January 1st of this year, Medicare must now provide free annual wellness visits and personalized prevention plans to their beneficiaries as stipulated by PPACA. An article by Francine Russo in this month’s Time Magazine discusses what these wellness visits and personalized prevention plans might look like in practice and some of the barriers providers might face in implementing these new measures. The wellness visits and prevention plans described in the article focus exclusively on lifestyle interventions aimed at improving diet, increasing exercise and limiting smoking – a far cry from utilizing an array of risk predictions tools to quantify all of a patient’s individual health and disease risks over time – but an important and critical movement in the right direction. The article points out the difficulty physicians might have in finding the time to fit a comprehensive personalized prevention plan that is thorough enough to be effective, yet compact enough to squeeze into their already packed visits with patients. These types of behavioral modifications are notoriously difficult to initiate and maintain over time. With this new tenet of health care reform going into effect, physicians will now be reimbursed by Medicare for taking the time to work with patients to try and address these lifestyle issues. Such a large undertaking will require the coordination of care between physicians, patients, and nutritionists, lifestyle coaches, etc. in order to be effective. These changes in reimbursement may be just what was needed to kick-start the wellness and prevention movement.
Friday, December 17, 2010
PPCA Uncertainty but the Central Issue Remains
Earlier this week, a Virginia judge ruled a key provision of PPACA to be unconstitutional. The individual mandate, requiring the purchase of health insurance by all is a key requirement within PPACA that provides the financial resources to support other benefits. Without this provision,the viability of the law is in doubt. This issue will certainly come to the Supreme Court for resolution, but the resulting decision and it's impact on the legislation will not be known for some time. In my view, this uncertainty about PPACA should focus us even more sharply on the importance of addressing the most fundamental need for health care, how care is delivered and the role people can play in improving their health. Health is an individual resource and value and personalized health planning can be accomplished without legislation. Innovation in care to make it coordinated and personalized can be created without legislation and it is hoped that insurers, CMS and private enterprises will develop capabilities to accomplish these goals for their own merits. Improving the approach to enhancing health and care delivery is essential to the success of PPACA and the legislation does have features to facilitate such approaches but needed change can and should occur regardless of that law. Such changes make good sense and good business as they will be very cost effective.
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.
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
To fix our economy, we must reform health care delivery
The dominant political debate of the day regards the form of tax legislation needed to prevent major tax increases beginning in January 2011. Underlying this debate is the weakness of our economy and the loss of employment for so many Americans. There were many drivers of the economic "melt down" in 2008 but one that has gone out of focus recently is the tremendous burden of health care costs. And with the passage of last year's health care reform legislation (PPACA), costs will increase even more. Regardless of the outcome of new tax legislation and potential stimulus spending, deficit reduction remains a necessary yet menacing challenge. What needs to be discussed more rationally and addressed quickly is how we stem the continued escalation of health care expenditures, particularly with the passage of PPACA and the increased coverage of many more Americans.
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.
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.
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