A Kaleidoscopic View of Healthcare Reform
As legislative debate on healthcare reform intensifies, and as the powerful American Medical Association (AMA) voices its opposition to the government-sponsored insurance plan, I find it instructive (and reassuring) to consider the different perspectives offered by a recent series of editorials in The New England Journal of Medicine. For example, in an online editorial entitled “Achieving Health Care Reform—How Physicians Can Help,” Elliot Fisher et al. suggest that “perhaps we can shift our focus from the conflict over whether a new public plan should be created to a more constructive insistence that all health plans, whether public or private, focus on the development of professionally led, integrated systems.” The authors build on a report from the Institute of Medicine, “Crossing the Quality Chasm,” to implore physicians to build a shared vision that embraces “a new world of coordinated, sensible, outcome-oriented care” and, just as importantly, suggest that a 1.5-percentage-point reduction in annual spending growth is eminently achievable.
Two editorials propose different, but not mutually exclusive, approaches to funding universal health insurance. In “Finding Money for Health Care Reform — Rooting Out Waste, Fraud, and Abuse,” John J. Igelhart cites astounding statistics (e.g., $72 billion or 4 percent of total spending in “improper payments,” of which 50 percent went to providers, suppliers and other Medicare and Medicaid vendors) and warns that this is due at least in part to inadequate funding to combat waste, fraud and abuse. He also warns that there has been a recent increase in organized crime in the healthcare sector due to (a) relatively less severe penalties for healthcare crimes, (b) a lower barrier to entry, (c) easily replicable schemes and (d) a perceived lower risk of detection.
Jonathan Gruber’s “A Win-Win Approach to Financing Health Care Reform,” in which he proposes excluding elimination or limitation of the income-tax exclusion on employer-sponsored insurance, including several approaches to tailoring the program to varying income levels and insurance costs, will no doubt receive a mixed bag of responses.
Arnold Milstein’s “Ending Extra Payment for ‘Never Events’—Strong Incentives for Patients’ Safety” calls our attention to unthinkable negligence and a broken reward system, and makes an effective argument for the inextricable link between safety risks for patients and financial risks for the health system.
Not surprisingly, in “A Strategy for Health Care Reform—Toward a Value-Based System,” Michael E. Porter articulates a vision for “a true national health care strategy centered on value.” He argues that a fundamental flaw in today’s health insurance competition is the zero-sum approach preoccupied with shifting costs (e.g., selecting healthier patients and negotiating discounts) rather than one that competes on value. Porter advocates a continuing role for the employer as a stakeholder in promoting wellness and for the employer’s ability to foster competition more effectively than government can. He also suggests that the current system of tax deductions for health insurance is inequitable. His strategies for reducing insurance costs include spreading the risk through pooling, fostering value-based competition, and a reinsurance system to mitigate the cost of insuring high-risk individuals. He also suggests income-based subsidies to help lower-income people, and bringing in new revenues (and thus reducing premiums) by mandating insurance for younger and healthier people.
Even more important is a restructuring of the delivery system. “This is where most of the value is created and most of the costs are incurred.” The logical beginning is outcome measurement, which Porter suggests should be mandatory, should emphasize the full cycle of care for a medical condition and not episodic intervention and should be multidimensional—going beyond survival to degree of recovery, time needed for recovery and sustainability of recovery, as well as the discomfort of care. Such outcome measures should replace process measures (e.g., compliance with practice guidelines). He points out the inadequacies and inequities around prevention, wellness, screening and routine health maintenance services. He too calls for integration of services around the patient’s needs, “over the full cycle of care for each medical condition.” This focus on value to the patient must be reflected in the reimbursement system and provide the basis for competition for patients. Along these lines, rather than simply automating current practices, electronic medical records must support integrated care and outcome measurement if they are to bring real value. The final component is consumer involvement and in particular patients taking individual responsibility for their own health, which will improve with the emergence of the new, integrated and value-driven delivery system.
Can medicine, science and business overcome the resistance to change to bring their collective ideas and shared vision to fruition? Or will the AMA set the tone for the next few months or weeks?