Saturday, December 15, 2007

2015, The Hopeful View

"There is likely not one solution that solves the problems in [U.S.] health care 100%, but 50 solutions that each solve the problem 2% are just as good." paraphrased from Alan Sager

The professor of my Health planning and management class suggested that one way to conceptualize the challenges of planning an effective health care system is to think forward to 2015, and imagine a perfect system. From there, think back on what needed to have taken place to realise this goal. The perspective that there could be 50 solutions that each help a little bit is helpful in emerging from a state of inertia/paralysis, because your solution doesn't have to solve everything. At the same time, it's valuable to think about your corner of the solution in terms of the other 49-- your solution cannot cripple the solutions of others.

The key ideas in a positive and hopeful picture are full financial protection, identification and stabilization of needed numbers of institutional caregivers (hospitals, nursing homes, home health agencies, health centers) and professional caregivers (doctors, nurses technicians, and others), overcoming non-financial barriers to care, substantial improvements in efficacy, appropriateness, and quality of health services, and cost controls that stabilize health spending at 16 percent of GDP. What were the events inside or outside of health care that precipitated these changes?

The Picture I Imagine

In early 2009, when a democratic president was inaugurated, there was already momentum for change. Over 60 million Americans were uninsured, 150 million were underinsured, and few people felt that their health care addressed their most important needs. Health care spending was spiraling towards 19% of GDP.

This picture meant there was a public openness to new ways of thinking about health care, and to ideas that went beyond the usual debate about coverage and cost control. I'm going to look at 5 people in health care, and the solutions that they managed to implement fully before 2015. You can use your imagination to think through all the other stories that would have had to have been taking place simultaneously for everyone to truly be covered.

Snapshot 1: Administrative Efficiency
Christine was one of the many people in midst of this change. She lobbied for changes in business law to simplify billing and to create a clear relationship between spending and provision of care. From her perspective, this was the major source of waste in the health care system.

Together with thousands across the fifty states, she led change in medical schools, so that business studies were included as an integral part of medical school. She understood that we would only enjoy the fruits of these changes in the long term. Many doctors encouraged this change because they felt that they would like to make informed choices about health care spending. Certain medical schools felt that this curriculum encroached on already scarce time to teach future doctors clinical skills.

She also encouraged a symbiotic, rather than antagonistic, relationship between health care providers and insurance companies. That is, an agreed amount of risk was standardized and balanced between providers and insurers. This meant that responsibility for payment could not be shifted between providers and insurers. Essentially, this represented large scale capitation. It meant that doctors in this system were responsible for providing care using a finite budget. As practices under this system were fairly large, insurance companies felt that the system would not interfere with their profits, as at least a few of the patients would need expensive care, and it would be the doctors, not the insurance company's problem to think about these "problem patients". On a large scale, this greatly simplified administration and allowed doctors to earn more from relatively fewer patients. Patients received better care. Nurses were able to practice nursing and not be bogged down with coding etc.

Snapshot #2: Coverage
A collaboration between health care advocacy organizations effectively lobbied for universal coverage and genuine financial protection. Financial protection was initially unpalatable for a large portion of the population, who felt that they would have to pay for other people's health care. However, momentum came from the large portion of the population who were angry and frustrated at the increasing costs of health care as a percentage of GDP. They felt that until people were able to go to the doctor when they needed to, the ultimate cost would continue to increase. Rationing care and financial protection became intertwined: both were needed if the absolute cost of health care was to stabilize.

Compromises included strict guidelines for beginning and end of life care, where doctors were protected from lawsuits within the new framework. Guards were put in place to protect middle-class taxpayers. The Medicaid (MA) and Medicare programs were expanded. A federal free care pool was created and grown. A three year program began in which highly paid medical professionals did not receive salary increases. This money was used to build a free care pool and create financial protection for all uninsured individuals seeking care. An amnesty period was followed by coverage. This coverage did not include care that was considered futile, and in this way was a painful cost control.


Deep change required some level of desperation. It required a sense that radical change was required. It required political will and compassion. It required difficult choices not to do certain expensive tests unless indicated. It required patients to give up their right to sue.

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