Thursday, July 23, 2009

Talking to Americans About the Health System

I’ve wanted to take a break from the endless drumming on health reform for, as I said two weeks ago, there’s more to our business than reform. Then I had a couple of energizing experiences that both evolved and reinforced this idea.

For a project we’re working on with Geisinger Health System, we’re having long, complicated conversations about discussing health reform with the general public. The major news outlets have the political and policy stuff well covered. Where is there room for another voice (and is it needed) on the topic?
In researching the project we found an interview from October 2008, with Geisinger CEO Dr. Glenn Steele that inspired and brought clarity to the project. In a blog post/interview with the New America Foundation Dr. Steele discusses what in the Geisinger system is “generalizable” and scalable to the larger US health system. The interviewer writes, “Dr. Steele isn't all that focused on reform from Washington in the next administration. If he has a wish list for the next president, he isn't sharing it. "What can Washington do? Who the heck knows?"

Who the heck knows?

Then it hit us what we—in all our propellerheaded geekiness—were missing. While payment reforms and insurance structures are important and certainly impact providers, providers can only lightly influence what will ultimately come out of Washington. However, regardless of legislation, they can and should act independently to modify their processes and systems to constantly revolutionize quality and cost-effectiveness of care. I mean, in radical, forward-thinking ways that are not just “quality improvement” but actual delivery system reform. The REAL reform.

If you’re interested, Google “Geisinger Transitions of Care” and “Geisinger Personalized Medicine” and you’ll quickly find articles and resources that discuss powerful transformations of the healthcare landscape. Stuff that will impact patients, improving their quality of life, care experiences and drive down their lifetime cost of medical care.

Also, last week I spent 2½ days in and around Mankato, MN working with ISJ Regional Medical Center of the Mayo Health System. The visit culminated with a 2-hour-plus discussion with the system CEO about the remarkable accomplishments and potential of their integrated system of critical access hospitals, physician offices, outpatient facilities, the ISJ Regional Medical Center hospital in Mankato, and the Mayo Clinic.

The long and the short of it being citizens in small communities throughout rural southern Minnesota have access to a level of care that is simply not found many other places in the US. Docs in clinics and at these critical access hospitals are all integrated on a common (Mayo) electronic health record, taking advantage of Mayo Clinic best practices and patient care materials, successfully leveraging specialty care outreach from Mankato and Rochester, all well-positioned to accept case rate risk for episodic and chronic/ongoing care.

Digesting these two projects the question quickly becomes, “How do you engage the average American in a conversation about health care delivery reform?” Can you? Here’s where the mainstream media can’t and won’t be effective. Worse, voters’ eyes glaze over when the policy bickering goes high-octane. Add to that the $1 trillion question posed in yesterday’s New York Times–What’s in it for Me?—and the uncomfortable answer that comes with it, and you have a serious health care communications dilemma.

Right now, the answer feels like “small bites” and “straight talk.” We (the collective “health care marketing communications” We) struggle with the conversation around quality, wondering if we can have engaging conversations about Core Measures, HCAHPS scores, and mortality rates. It seems to me that perhaps that’s focusing on the wrong end of the elephant.

If people understand that the transition from hospital to home is a very important step in their care and that has to be planned carefully at their time of admission (if not before) perhaps they’ll engage and drive improvement. If people realize that simply having a computer in your physician’s office doesn’t mean they are getting best practices cues for managing your type 2 diabetes then they have to demand a more enlightened approach to care.

But that seems like asking way too much. So then maybe it’s more about helping them understand the difference between providers—hospitals, networks and systems—which are actively revolutionizing care to improve quality, satisfaction and cost-effectiveness and those who are not. Then, we are left to hope, in the presence or absence of enlightened payment changes emanating from Washington, they choose more evolved models over less evolved ones. But sadly, we all know, hope is not a strategy.

So then we have to get even further.

Can’t say that nut is completely cracked yet.

Tuesday, July 21, 2009

Getting Back To Things

Sorry for the long, cold silence. I am just back in the office after a wonderful week of vacation and family time. So much has happened in 2 weeks and the debate here so interesting and useful. It's great to see.

Then there's "The Bill": The 1000-page piece of garbage that came out of the House last Friday that Pelosi is just daring the White House to oppose. What a disaster.

I don't want to leave the blog silent during this time, but my vacation has buggered my production schedule, so, I'll direct you to two fantastic essays - One is an analysis of the steaming pile of health legislation penned by oft-cited guru Jeff Goldsmith. Read his pointed analysis here.

The second is a great Opinion piece that appeared in today's Wall Street Journal discussing how the House Bill angles to disembowel ERISA (one of the few pieces of health-related regulation that works very well).

I've been working on some projects with Geisinger and Mayo Health System that are truly inspiring and will be the subject of the next post. I just need a little more time to get caught up and produce.

Spin on!


Tuesday, July 7, 2009

How Big is 1 Trillion?


That’s 12 zeros. I heard a mathematics professor on NPR once explain, “imagine your kid’s first grade class, 1 teacher, 15 kids, comfortable but not spacious room; chalkboard at the front, ABC’s on the wall above. Consider that the number 1,000.”

Now we have to make the journey of multiples of 1,000. Imagine that same room, and that teacher, but now with 15,000 kids. That’s 1 million. Imagine that room with 15,000,000 kids. That’s 1 billion. Imagine that room with 15,000,000,000 kids (15 billion kids, wow!). That’s a trillion. Crowded, eh?

So I have to chuckle at today’s big news story: “Hospitals Reach Deal with Administration - $155 Billion in Health Savings Offered.” To quote, “The nation's hospitals agreed last night to contribute $155 billion over 10 years toward the cost of insuring the 47 million Americans without health coverage, according to two industry sources.” Contribute? They make it sound like a tax-deductible sponsorship for some PBS programming. Where’s it to come from? Medicare and Medicaid reimbursements and $40 billion in compensation for uninsured patients.

There’s an old joke about morals and prostitution that points out once you’ve established that you’re the latter, what’s left is quibbling about the price. “Hospitals” (“Agreeing to the plan were the American Hospital Association, the Federation of American Hospitals and the Catholic Health Association”) have bought a ticket to the party for $155 Big. So, if 155 is the 15 kids in that classroom, all we need is to get 6.5 more kids into that classroom to pay for the public plan (estimated cost $1 x 10 to the 12th power).

Apparently the hospitals have agreed to swallow hard if the final legislation includes a public plan and will take Medicare-or-less rates without a fight. And you thought the recession hurt hospital perfomance...seems like they’ve put $155 billion on the roulette table in hopes they can pressure the Administration to find a not-a-public-option.

By coming to the roulette table now, hospitals allegedly saved themselves $45 billion in cuts (the Administration’s threat was $200 billion) and they got to the table before the docs and the insurance industry. It seems everyone has to take a number and, when called, take a few lashes.

Jeff Goldsmith recently posted about the dangers of the public plan as the pathway to universal coverage. Quoting at length:

“The idea that you can simply insert a new public plan into the existing insurance market without the presently insured noticing any difference is political fiction, not market reality. Think of the private health insurance market as a $900 billion pool of money held back by a vast earthen dam consisting largely of provider/payer contracts. This pool has shrunk by some estimates by as much as 9 million lives due to the recession, due to people losing employer provided coverage.

Obviously, some of those newly insured through health reform will choose private plans and the size of the lake behind the dam could thus grow. Even with no public plan, it is absolutely appropriate for health reformers to demand concessions from private insurers for creating all these new customers.

However, if you also drill, say, a 3 foot wide hole in the dam, (the width of the hole depends on the cost difference between the new public plan and existing private offerings) both lives and dollars will gush out. Depending on the width of the hole, many previously private health plan enrollees will defect to the public plan, and the composition of the risk pool remaining behind the dam will change in completely unpredictable ways. Health plans will have to lower their premiums to avoid being run out of business, and many will gush red ink until they can revise their existing network contracts, many of which contain multi-year rate guarantees.”

Clearly there is an imperative for reform. The stress of the Baby Boom generation on the federal budget is soon to be overwhelming, nearly doubling Medicare Part A expenditures between 2000 and 2030—a burden that, if unchecked, will make it hard for the government to do much else and force a heavy tax burden onto American workers. The growth health costs is certainly impacting small business’ ability to fuel economic recovery and sustain long-term growth. I personally try to avoid being suckered into the “moral imperative” debate often tied to the uninsured but I do believe there are macroeconomic impacts to personal bankruptcies tied to medical care. Add to all this the matter of the US’s overall poor health for the dollar and certainly there is little basis for opposition to reform.

But is $155 billion a necessary Faustian bargain for American hospitals? Here’s one where I would have liked to seen more of a fight. Getting behind real payment and delivery reform in return for a slow, phased path to universal coverage – but only after the fixes suggested by the Health CEO’s for Health Reform parameters were implemented. Let the Government wield a heavy axe of deadlines on those recommended changes as the cost of patience. Hospitals, submit to overall cuts only after having failed to work with Medicare/Medicaid and the private insurance community to make real cost reduction systemic. Otherwise, signing off on $100 billion in cuts is essentially negotiating future update factors without changing anything that will actually improve the system.

Enough on this topic for now. There’s more to our business than reform. Stay tuned for a new theme later in the week.