Inaugurating Health Care Reform: Constructive Managed Care in 2010 (Part I-c)

January 22, 2009

With the election, the issue of healthcare reform is back on our plates.

With the election, the issue of healthcare reform is back on our plates. According to Jonathan Oberlander, PhD, "For the first time since 1993, momentum is building for policies that would move the United States toward universal health insurance," but “although there is widespread consensus that the U.S. health care system is broken, there is no consensus on how to fix it."

Paul Starr reminds us that in 1993, key stakeholders endorsed health care reform only to see their support fizzle.

[Cross-ref.] Paul Starr, "What Happened to Health Care Reform?" The American Prospect no. 20 (Winter 1995): 20-31.

Oberlander isn't sanguine either—"political barriers to reform remain immense.... Perhaps because they proved to be politically lethal for the Clinton administration, serious proposals for controlling health care spending are scarce. The health care industry is not interested in reform that would reduce its income. Policymakers are therefore emphasizing savings that might be gained from disease prevention, the implementation of electronic medical records, and other unproven (but politically safe) cost-control measures.” (Great Expectations — The Obama Administration and Health Care Reform).

In a NEJM roundtable discussion Oberlander states that while this may be the most optimistic time for health care reform in the last 20 years, it's another matter entirely to go beyond the politically safe, "faith-based cost control" measures mentioned above. Asked if we have the temerity to make the tough decisions," he responds: "Never underestimate the ability of the American health care system to avoid unavoidable decisions." Nevertheless, I think that he and many political pundits miss the central issue in healthcare reform — It's about encouraging the right care at the right time and place through measurement and management.

Let's learn the lessons of the past and stay away from rate-regulatory or micro-management "solutions"; they will never be durable. Instead, consider:

1. Moving from fragmented care towards reestablishing the 'medical home' concept.

2. Strictly enforce confidentiality.

3. Healthcare's a helping profession; advocacy is required.

4. Even as specialty society-approved clinical standards and guidelines are applied, allow clinical autonomy to be preserved; ie, avoid cookbook medicine; it is an anathema.

5. Tort reform will help reduce the need to order every test in the book.

6. Those in healthcare management and regulatory authorities must be adept at acuity-adjustment, episodes of care and normative and comparative statistics when evaluating outcomes and comparing effectiveness.

7. Healthcare reform, like a stool with three legs requires balancing "cost-efficiency," "quality" and "access." We must change the modus operandi of insurers (which includes payers and even the "Health Care Fed") from reactivity to proactivity and from cost-minimization to cost-optimization.

8. In so doing, realign incentives so that we encourage the right care at the right place and time. And while we're at it, let us stop paying for physician-induced demand, iatrogenesis, and hospital-acquired infections. How does one accomplish these objectives? Outcome measurements, 'apples to apples' comparisons (ie, acuity adjusted data analysis), normative and comparative statistics and a longitudinal view of health care using the construct of an episode of care (all care over time, regardless of setting for a diagnostic grouping (such as 3M's clinical risk groupings--CRGs, APR DRGs, APGs, etc).

9. Remove financial barriers to access. By definition, that means providing universal coverage, independent of employment and of less burden to states (as opposed to the Fed). [See "Getting There from Here; How Should Obama Reform Health Care?" The New Yorker by Atul Gawande; Feb. 1, 2009]

10. Patients must be informed, empowered and regardless of their misfortune, and treated with dignity at all times.

To do all of this we need to understand both the art and science of medicine. That, in turn requires we study the proper* use (or failure to use) a bio-psycho-social model, evidence-based medicine, a longitudinal patient record, case-mix and clinical process and outcome data.

*Supportive, fair, and non-incriminatory.

In all, this will look like "Constructive Managed Care" (or some such similar appellation).