Friday, January 16, 2009

Interviews - Interview with Matthew Holt, Founder of The Health Care Blog and Health 2.0 Conferences

Political leaders who aspire to greatness first decide what needs to be done and then set about making it politically feasible. If the current health care reform initiative is limited to questions of coverage, without serious attention to cost control and coordination of care, the “crisis” in health care will continue to plague us for years to come.

Victor R. Fuchs, PhD, professor emeritus of economics, Stanford, “Health Care Reform – Why So Much Talk and So Little Action?” New England Journal of Medicine, January 15, 2009

The only truly promising way to save money is to change the way health care is delivered. In the United States, 85 percent of doctors work in small, fee-for-service practices. Many of these doctors are very good and hardworking. But they are autonomous, not members of teams. They do not systematically share information with one another. They are unable and unwilling to be held accountable for the quality and cost of care they delivery.

Alain Enthoven, professor of management, Stanford “Health Care with a Few Bucks Left Over,” New York Times, December 28, 2008

Prelude: It may seem odd to start on interview with Matthew Holt, a San Francisco-based policy wonk, blogger, and entrepreneur with quotes from two Stanford professors but not when you realize Matthew is a recovering health care Stanford academic. Holt’s professors at Stanford, Victor Fuchs and Alain Enthoven, still influence his thinking, but as you see, he is very much his own man.

Q: Let me begin by saying I enjoy your tart, irreverent, but always readable pieces in The Health Care Blog, which the Wall Street Journal has dubbed as the “granddaddy of all medical blogs,” no doubt because of 2003 start, which makes your blog ancient in the blogging world.

A: Thank you. I enjoy your stuff as well.

Q: How did you come to be such an astute observer of the U.S. health care scene?

A: It’s all part of a professor turning the wrong way in a class. I was a graduate student doing a term paper at Stanford. I was just going to be there for one year, and I was going back to the U.K. I was about to do a paper on the Japanese economy and its investment in the U.K. That subject was taken, so I turned around and asked, “What about the Japanese domestic economy? What about the Japanese health system? “A visitor from Japan showed up and wanted help comparing the Japanese Health System to the U.S. health system, and my interest in health care began. Alaine Enthoven was one of my teachers.

Q: And after Stanford?

After getting a couple of Masters Degrees at Stanford, I ended up at the Institute of the Future. My experience there exposed me to the thinking of the American private sector. I spent about 5 years at the Institute, and I did a lot of work on technology forecasting, particularly in health care. That accounts for my interest in combined health care policy and IT effects on that policy.

Q: What is your official title now?

A: I tend to say I am the founder and author of The Health Care Blog, and the co-founder of the Health 2. Conference. Most of my day to day stuff is running the operations of that Conference but I also write for the blog.

Q: When did you start the blog – now considered the granddaddy of all health care blogs?

A: I started it in 2003, and we recently celebrated its 5th anniversity. Other health blogs were started about the same time, and they didn’t get enough credit. At the time, all the blogs were pretty much writing for each other and most were narrowly focused. But as far as consistently writing about health policy, IT, and interconnections we’ve been around longer than anybody else. It’s nice to be considered a granddaddy when you’re only 5 years old.

Q: Would it be fair to say you’re a follower and admirer of Alain Enthoven – now considered the father of the managed competition approach to health care policy?

A: Yet, but I don’t agree with everything he says. I’m more of a lefty. I believe more in social insurance as the basis for managed competition. But I was definitely influenced by his lecturers and writings at Stanford. You can inject competition and innovation into health care, as long as you get the incentives right. If you inject competition into the system the wrong way, you get what we’ve got now. I think the management in more important than the competition, particularly in how you structure the incentives.

Q: And what about the influence of Fuchs?

A: He is a great economist, and he helped me understand the problem rather than what to do about it. Fuchs had a very clear understanding about the effect of supply driven health care, i.e, if you create more surgeons; you’re going to have more surgeries.

Q: How much do you think you’re influenced by your background as an Englishman?

A: Not that much. But I certainly do like to make international comparisons when I’m looking at how the world works.

Q: As one of the founders of the Health 2.0 conferences, you must think Health IT will go a long way towards fostering more rational and informed solutions to health system problems.

A: Health IT is only going to improve health care if you correct the underlying structure. You can put a lot of technologies in the wrong places and make the situation worse. Look at imaging, for example. We’ve spent a lot of money on imaging in the last 15 years, and it’s not entirely clear it’s done us much good.

Having said that, I think there is something that’s very important that's changed in the world of IT health care. Otherwise it's great. IT technologies have got to the point you can distribute IT tools very cheaply, and now you can insert communication tools into the revolution. These two things make it possible for a “team,” patients and doctors and all sorts of other people, to work with each other to get towards certain outcomes. I think one of the things we’re learning now is there are much more effective ways of sharing information that strictly relying on the physician-patient relationship.

A multifaceted environment is developing. That leads to a series of choice and conflicts. What types of tools should we be using? Who should be paying for them? What outcomes are we trying to get out of them? I’m optimistic we will resolve this issues, and we’ll be able apply computer power effectively to health care. But health IT will not be a panacea. It’s a good thing for health care and for the future of medicine. But it is not pain free.

Q: How important do you think the entry of Microsoft, Google, and other IT giants into the health marketplace are?

A: I think it’s important. It’s part of integration of health care into everyday life and everyday business. It shows that health care is not that different from other aspects of daily life, and it encourages smaller companies without big backing to enter the marketing arena. It gets consumers to understanding new opportunities.

Q: Your Health 2.0 conferences have been a smashing success and have been heavily attended by big and small players alike.

A: My partner and I work like dogs to put them on, and it’s good to see people like them. Most importantly, these conferences offer a forum for useful exchange of information. The conferences help get more information tools into the hands of consumers.

Q: I’ve been interviewing a lot of people about health reform, and the phrase I keep hearing is “We are cautiously optimistic.” Does that fit your view? Are you cautiously optimistic?

A: I’m more optimistic now than I was six months ago. The key issue is the United States is that nobody is really concerned about reform unless it adversely effects their own arrangement. We needed a big recession to drive reform – and we have now have it. If the U.S. middle class thinks it’s going to become the U.S. lower class, and they will be unable to pay the bill when they go to the emergency room, then something might happen. We’re not going to see coverage of the uninsured unless the recession gets really bad. And you need about 15 to 20 other things to fall into place.

Q; I recall Fuchs saying it would take a World War, an economic depression, an unprecedented natural disaster, or something of similar magnitude to bring about universal coverage.

A: I spoke to Fuchs recently, and he said we’re not quite there yet. We may be 40% of the way there. My major concern is that we’ll get a small chunk of people covered that are now uninsured, and we’ll think things are better, and ten years later well wake up and find things are as bad as ever.

Incremental changes should not cause us to declare victory. I’m a huge believer if you don’t get everybody in the system and every dollar accounted for, then the health care system will find a way to keep pricing up and costs up. Which means eventually some will get tossed off the lifeboat, like the uninsured have been for the last 50 yers. You have to make the whole system more cost effective – a huge task because you’re going to gore someone else’s ox.

Q: But what if we don't have enough doctors to cover the uninsured when they're covered? What about the primary care shortage? What good is coverage if you don't have access to doctors?

A: The shortage is important, but primary care will end up by being replaced by things that don’t look like primary care. I think we’ll end up with lower level people providing care. Much of these tasks will be taken over by computer-aided non-physician personnel.

I don’t see how we can develop a core of 300,000 primary care doctors. We’re not going to have the same proportion of primary care doctors that other countries enjoy. I don’t think it’s even sustainable in those other countries. People are going to have to take better care of their own health, and health care it will have to be put in a lower-cost environment.

Q: You’ve been heavily exposed to the West Coast medical environment with the Kaisers and other giant multispecialty clinics. Do you think that model represents the wave of the future?

A: I don’t think so. I think if you change the way you pay for health care, reward FPs for doing the right thing, paying for preventive care, managing chronic disease, not doing unnecessary things, you will see other arrangements coming together. Until you get those incentives in place, it doesn’t make a lot of sense to try to export Kaiser to other regions of the country. The start-up and infrastructure costs are huge, and physician resistance is high.

Q: Any concluding remarks?

A: I’ll continue to do The Health Care Blog and the Health 2.0 conferences, and I hope you will continue to do your stuff. Let’s keep the pot boiling.

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