Saturday, July 7, 2007

Consumer-Driven Care -On Dangers of Dismissing Other Points of View

The other day a dear friend and dedicated health care reformer, who thinks differently about health reform than me, and I dismissed the other’s point of view on health reform.

My friend dismissed my idea that health care consumers, working with doctors, are key to improving quality and decreasing costs. He’s not a fan of “consumer-driven care” and feels, at best, it represents market driven zealots putting lipstick on a pig. Consumers, he asserts, don’t have enough “transparent” data to judge what’s or who’s good or bad, and that “fee-for-service” invites abuse by doctors to enrich themselves.

My friend is dismissive of Republican front runner’ Rudolph Giuliani’s rhetoric,

"The problem with our health insurance is it’s government – and employer dominated. People don’t make individual choices. It’s your health. You should own your health insurance. We should be giving you a major tax deduction - $15,000 for a family – so you can buy your own health insurance. Health insurance should become like homeowner’s insurance or like care insurance.”

Informed consumers, even working with doctors of integrity, do not, he argues, change the “structural” problems – i.e. inconsistent quality, mediocre outcomes, and improper incentives-- of American health care.

Solving these problems requires “data leverage” from the outside – government agencies or health plans exerting pressure through use of computer-generated management information to require better resource use. In certain situations, large multispecialty groups, this leverage or pressure ideally comes from physician leaders who downgrade pay, don’t recruit, or banish physicians who don’t prescribe generics, meet quality indicators, or follow clinical protocols. We should, my friend avers, discipline doctors in order to make them play data ball.

In my turn, dismissed the idea that a health care system focusing on data from “metrics,” and “best practices,” can significantly improve care by measuring quality indicators and outcomes and paying for performance. I reasoned we’ve lived through 30 years of HMOs “managing” and “measuring” quality and utilization through gatekeepers , and judging those who are good and who are bad, who overuse and who underuse, or who should be included or excluded from networks.

Managed care, after all, failed because patients and doctors revolted at the restrictions.. The problem, I argued, may not be “structural” but cultural because managed care ignored the two most important independent variables of American life – public opinion and the freedom to do what one wants and to chose the doctor one wants. I’m a big believer in persuasion, rather than force, in helping change people’s minds.

Speaking of managed care, I tend to be dismissive of Sen. Hilary Clinton’s eloquent rhetoric,

“There is an economic imperative to rein in costs. There’s a moral imperative to extend coverage to all Americans and there is a practical necessity to promote wellness and prevent disease whenever possible. There are three parts to this approach. First, lowering costs for everyone. Second, improving quality for every one. Third, insuring everyone.

Well said, but how? Comprehensive care management, cost controls, best practices monitoring, government mandates?

My friend, whose opinions I deeply respect, asserts we might be able to accomplish everything Senator Clinton promises because we live in new age of IT. We can now use new IT “platforms” to measure, calibrate, and reward “good” doctors with “good results” who, when placed on salary or paid to perform in a cost-efficient manner with other members of clinical teams, will have no incentives to do more, but to do “well.”

IT may change doctors’ economic behavior, but it will change their culture or practice behavior – doctors’ desire to be their own boss and to work solo or in small groups – nor will it change patient behavior – which has more to do with outcomes than what doctors say or do. Health outcomes are about 15% related to health systems, and 85% related to a nation’s culture (Sagan, L (1987), The Health of Nations: The Cause of Sickness and Well-Being. New York. Basic Books. Satcher, D, and Pamies, R (2006), Multicultural Medicine and Health Differences. Columbus, Ohio, McGraw-Hill)..

Scott McStavic, a retired hospital executive, calls this cultural component “The Other Behavioral Medicine.” This “medicine” consists of patients’ dietary, exercise/activity, stress, and self-care habits.

Here is how McStavic explains the “The Other Behavioral Medicine,”

"The more we have learned about what causes or at least creates higher than normal risk of disease and injury, the more we have identified individuals' behaviors as the real problem. And the more we have learned about them, the more it appears that a few such behaviors represent both the most costly causes and the most promising changes that should be sought. Each of these tends to be a major, or at lease significant risk factor in a wide range of diseases or injuries, and a major source for savings if reformed into healthier alternatives.

The four biggest behavioral problems in the population seem to be:

•dietary habits

•exercise/activity habits

•stress/time management habits

•self-care/management habits

If any one of these four sets of habits can be transformed from risks to benefits, the effects on the incidence and prevalence of disease could be dramatic. And for employers, the effects of such transformation are likely to be far more valuable than managing any single disease or injury.'

McStavic didn’t mention our culture’s penchant for fast foods, fast cars, fast sex, fast access to high tech care, and fast violence – as quick and dirty solutions to seek pleasure, work off our anxieties, and solve our problems. If we could control these habits, we could probably effectively control costs and outcomes. And if doctors could be more effective “health care coaches” and be paid for that role, we might have better health outcomes at the margins.

Unfortunately, changing “habits” is about changing culture. It becomes a matter of public persuasion – a tactic that has been effective in reducing smoking rates. But this may take decades. Our democratic culture says we can eat and live as we please; legally drink and smoke as we please; drive as fast as we please, sleep with whom we please, weigh what we please; exercise as much or as little as we please, stress or emotionally abuse ourselves as much as we please; and depend on “quick-fix” prescription and non-prescription drugs and medical technologies to correct misuse of our pleasures. We are a nation who believes in quick technological fixes when things go wrong.

“Metrics” has another problem – doctor rejection of EMRs – which may be essential if we are to have interoperative communicating systems across our nation. Here is how Bill Bysinger explains doctor EMR rejection.

"It has been almost 20 years since electronic medical records systems were introduced into medical practices, yet we have the lowest adoption rate of all the developed countries in the world. Most of Europe, Japan, China, Australia and even Russia have adoption rates above 50 percent and in many countries above 90 percent.
We are supposed to be the world leader in adopting technology, but recent studies have put our practice EMR adoption rate at somewhere between 15 percent and 18 percent.

I submit the root cause of the problem is the culture of the health care industry. Health care in the U.S. especially at the practice level is a cottage industry. Medical practices don’t make business decisions based on productivity or process improvement, which dominates other industries. Instead, they make decisions based on how much money do they have to spend and what will it do for the providers personally (and immediately).
All this adds up to process improvement and quality not being well understood. Therefore when technology like electronic medical records are introduced in the medical practice market, most physicians are afraid to invest and have no idea how to use automation to make process improvement or generate profit.

My friend and I don’t totally dismiss all of each others’ views. We agree reforms on the extreme left or extreme right aren’t the answer; and we agree a single-payer government run system will not decrease costs or improve quality, though it will improve access and relieve financial anxiety. Superimposing a single payer system on the current system is a formula of a cost explosion of unprecedented proportions..

My friend and I do not use the term “socialized medicine.” It is too pejorative. “Perjorative” is a code word reserved for the far right. Besides, our health system is already “socialized” to a large extent. Government pays for 47% of care, and universal care for children would push it past the half-way point.

Although government-dominated systems may not improve care, they will relieve anxiety about access, ease financial pressure, and assuage societal guilt. When something is “free, ” it diminishes the angst (and increases the demand). The trouble with government is that it’s too far removed from the clinical marketplace to make intelligent even relevant decisions, doesn’t realize the consequences of its actions, e.g. paying primary care doctors too little, thereby causing their exit from the physician population, and the costs, waiting lines, inefficiencies, and rationing, inevitable consequences of single payer systems in other countries.

But my friend and I do not summarily turn off the idea of either a government or market system because we know we’re going to have both. Besides dismissing each other’s ideas is the mark of closed minds – a trait we were both guilty of the other day.

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