Good for the Ego

It was nice to power-up the computer today and find other people echoing yesterday’s post about the President Obama and the reality of health reform. Even the Wall Street Journal today provided a timely supplement to yesterday’s post with 230-words on how “Medicare, Medicaid Deficits Loom over Health Priorities.” While not certainly visionary, I’ll take validation in being swift!

I think I’d like to use this as a jumping off point for a riddle that has left my brain twisted for the past few months. Beyond then-candidate Obama trotting out well-worn standards such as health IT, I was troubled that the near-entirety of the healthcare reform conversation during the campaign focused on financing; worse, financing issues around the most profitable, vital pool of patients in the payer mix, people with employer-sponsored coverage. While Senator Obama advocated universal coverage for children and a “pay-or-play” structure that would presumably compel a shrinking of the ranks of the uninsured; neither candidate said anything meaningful about the true cost drivers in the system. So, it felt to me like we were talking about all the wrong stuff.

Yesterday I mentioned the McKinsey & Company study that discusses the prospect of healthcare costs devouring the country’s entire economic output. Obviously, the drivers of such a problem have very little to do with employer-sponsored insurance.

I’ve revisited two documents recently whose pedigrees couldn’t be farther from each other—Why Not the Best? The Commonwealth Fund Commission on a High Performance Health System report of July 2008, and an article from the November 2008, Reader’s Digest, 18 Big Ideas to Fix Health Care Now—struck by a key common conclusion: So much bad health and health system costs are the result of things we don’t pay much attention to.

The Commonwealth Fund report dissects “Preventable Mortality,” defined as “deaths before the age 75 caused by at least partially preventable or treatable conditions, such as bacterial infections, screenable cancers, diabetes, heart disease, stroke and complications of common surgical procedures.” They pursue this point from an epidemiologic perspective, advising that U.S. mortality could be (seemingly) easily improved to levels achieved by leading countries, translating into 101,000 fewer deaths per year.

On a slightly different tack, the Reader’s Digest article cites the Kaiser Foundation Health Plan report Health Care Reform Now! A Prescription for Change pointing out that, “common chronic conditions (including coronary artery disease, diabetes, congestive heart failure, asthma and depression) are responsible for 75% of our health care spending.

75%. Wow. The Kaiser report suggests, “If just 1% of people with these conditions were successfully treated we could shave at least $77 billion off the health care tab.”

Type 2 diabetes is a lifestyle disease. Successful management of CAD is economical with diet, exercise, anti-hypertensive drugs and statins. CHF clinics have shown they manage patients better than cardiologists and PCPs, aggressively monitoring health data and confidently juggling ACE inhibitors, BETA-blockers and other meds at safe, effective levels that normally scare other physicians. I’ll park a conversation on America’s trouble with mental health care and the issue of depression in the Remote Lot for now.

So, there’s a two-pronged problem. First is human behavior. How can we get Americans to improve their diet, put down the remote and get moving? Financial incentives through experience rating on premiums? Second is the institutional health system. The truly integrated health system, the Geisinger and St. John’s Clinics of the world, are the exception, not the rule. The ability to take a systematic approach to these chronic conditions is extremely limited. Acute care, community, tertiary hospitals are factories cranking out hip replacements, heart operations and cancer treatments. The delivery system is not engineered to impact the key drivers of cost and cost escalation. Not to mention, the need to sustain and renew the hospital physical plant significantly distracts from such public health initiatives.

I’ll throw it back to you. What is the appropriate institutional and federal/payer response to getting control of fuel that’s feeding cost escalation? Should we go back to the 90’s and get all IDS (Integrated Delivery System) again? Do we further rely on payment systems to penalize and reward? Do we follow Michael Porter’s advice and steer patients to programs that deliver better quality based on outcomes and value?

If we don’t get at the core of the problem, the only levers the economy will have left to pull are financing ones, and that usually translates into lower rates. CMS will cut Medicare first and then all the private insurers with contracts based on Medicare fee schedules will follow suit. Then, it’s just a race to the bottom.

That sounds horrible.