Health Care Reform -- Sifting Through the Noise

So it's August, and summer has finally arrived here in the Northeast. Congress is in recess so they can connect with the public. As someone who is responsible for the effective use of some local healthcare resources, I find it sometimes difficult to really understand everything being said out there. And what is with all that yelling? Of course people feel disenfranchised. And others fear change because things could get worse.

I will make a couple of observations, and share why I think a good deal of the noise is on the wrong topic.

First, there are three levels of change that are needed in healthcare, and they are not all about the money.

The first change that is needed is in system design. Without changing the system, most of the reform proposals will put more people who indeed need care into a system that will consume ever more resources more quickly. This will exacerbate the financial problem. The system needs to be redesigned to reduce waste, and increase efficiency and quality. Those are easy words to say, but there are great examples in this country and internationally of doing this right.

The second change that is needed is in the payment system and its financing. The payment system needs to be aligned with the outcomes we really want, and its financing needs to be simpler and more fair across the entire healthcare industry and the geography of our nation. Disparities in payment for different kinds of care and across different regions of the country must end.

The third change that is needed is in our culture. And that culture is in two large and overlapping dimensions — the culture of healthcare providers, and the culture of our view of our health and how it is sustained. The culture of healthcare providers and healthcare consumers both needs to move away from the "more is better" idea that is now known to be not true. Consumers and providers need to agree that limiting some interventions and tests actually produces better health and quality of life. Providers need to help patients accept the large degree of uncertainty that still exists in healthcare, and consumers need to accept more responsibility for the choices they make to sustain their health.

A recent New York Times op-ed piece summarizes the existing examples of low-cost high-quality care that exists in the United States. If all America spent at the rate of these 10 areas, we would spend 16% less on healthcare. And the growth rate would slow. A current initiative by the Institute for Healthcare Improvement to study the most important features of low-cost high-quality care provides rich data and ideas for improvement.

So healthcare reform must acknowledge the complexity of the delivery system. Of course improving access to those without it is a core social value, and needed quickly. And eliminating lack of coverage for pre-existing conditions is critical. Shifting payment to reward practices that are low cost and high quality is an absolute necessity. And changing the conversation between providers and patients to focus on value in reducing utilization will help drive the culture to support good practice.

Finally, I agree with former Oregon governor John Kitzhaber that we as an American society should provide for the basic needs of our population with a publicly financed system. Not all medical interventions are of equal value. American citizens should be able to purchase insurance products that cover beyond the publicly financed core set of services.
 

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