Sunday, December 30, 2007

Government vs Market reform - Systematic Reform of U.S. Health Care – One Man’s Meat

I’ve been reading George Halvorson’s new book Health Care Reform Now! (Wiley, 2007). Halvorson is chairman and CEO of Kaiser Foundation and Hospitals, a $35 billion health plan in Oakland, California. Kaiser has invested heavily ($3 billion) in a system-wide EMR and in targeted improvement of 5 chronic diseases – diabetes, asthma, coronary artery disease, CHF, and depression - which consume 70% of U.S. health care dollars.

Halvorson thinks of U.S. health care as a disorganized colossus that needs to be reorganized under a national corporate umbrella with systematic gathering of data, process re-engineering, continuous improvement, and infrastructure vendors who put the delivery of care up for bids.

He envisions an ideal health care system patterned after General Electric’s Six Sigma improvement model. His view isn’t my cup of tea. It makes doctors functionaries of large health care organizations, threatens private practice, and restricts physician freedom. Still it’s a view that needs to be understood.

Halvorson says eight developments make reform imminent.

1. A Common Provider Number – All doctors will soon have a single number identifying each individual doctor for all payers and all care. The number can be used to track your performance nationally. Halvorson states “Health care reform becomes possible when we have real performance data about care.”

2. Computerized Databases – All payers have computerized data bases. All databases are standardized and electronic. This assures uniform data flow and can be used to track each patient’s incident of care.

3. Electronic Claims Data Portability – You can transfer data between health plans just as banks can transfer data. Halvorson says this is a “data bonanza for health care.” Data transfer creates databases for each individual patient and each doctor, Further, community databases can track patterns of care and caregiver performance.

4. Government Transparency about Payment Data - Halvorson says government’s willingness to share Medicare and Medicaid data is a huge transparency step forward because you can now compare physician performance.

5. Universal Awareness of Quality Issues – Halvorson says widespread awareness that the health care infrastructure is “badly flawed, perversely incented, inadequately coordinated, incredibly inconsistent, strategically unfocused, and too often dangerously dysfunctional” will facilitate reform.

6. Buyers Are Ready for Change - Halvorson believes primary buyers of care – government and employers – are ready for change. There are no “happy buyers,” he asserts, and employers are cutting benefits, and markets and industries are ready to try anything that works.

7. Internet Functionality Used for Care - In purchasing, banking, investing, and education, the Internet has made “massive inroads into how we do business.” Halvorson foresees e-scheduling, e-visits, e-follow-ups, e-reports, e-reminders, e-consults, and e-home visits. Halvorson says, “Paper can’t do the job. We need the web to reform care.” The Internet could make an e-normous difference if only we could weed out e-relevant misinformation.

8. Lawmakers are Ready for Reform - Halvorson cites 20 states - California, Colorado, Connecticut, Florida, Hawaii, Kansas, Illinois, Maine, Maryland, Massachusetts, Minnesota, Missouri, New Hampshire, New Yoke, Ohio, Oklahoma, Pennsylvania, Rhode Island, Vermont, and Wisconsin – that have introduced State Health and Universal Coverage Initiatives.

Fourteen states – Kansas, Kentucky, Massachusetts, Michigan, Minnesota, New Jersey, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, ashington, and West Virginia – have mandated employer health insurance coverage.

And one state. Massachusetts has imposed a “free rider surcharge” on employees who don’t provide coverage.


It’s possible a single provider number, data from EMRs and PHRs and retrospective claims , data portability, and payers seeking change will make for real health reform soon. It’s possible data-based large virtually integrated groups, acting synchronously and strategically, focusing in continuous improvement, will bring about reform.

But it’s unlikely, given the reality that 90% of America’s doctors now practice independently, mostly in small groups. It would require a massive physician cultural shift. But likely or not, Halvorson insists the technological and management tools are there, and it is “doable.”

I find Halvorson’s vision Orwellian. He is saying in the future Big e-Brother will be watching you. What Halvorson says may be logical, but it frightens me because it compromises the freedom of American physicians and patients..

What do you, America’s independent practitioners, think of Halvorson’s vision? Is it doable? Is it desirable?


james gaulte said...

Definitely Orwellian and Utopian. Not doable and in my view definitely not desirable.

epistemocrat said...

These reform efforts "make sense" today and would probably help now in many ways, but converting to such a centrally dictated, planned, and managed structure stifles innovation, limits choice, and dismisses the important reality that entrepreneurial solutions will emerge much more rapidly- from places and in ways that we never would have imagined- in the future within a polycentric system that allows doctors and patients to contract and interact much more freely than they will in a monocentric system. Within a "consumer-driven system," in the light of what Regina Herzlinger and others describe, these mentioned solutions would be adopted anyway (and subsequently improved upon).

It is hard to embrace the reality that better, more innovative solutions that increase the quality and quantity of our healthcare resources exist in the future that we cannot see nor imagine right now, but they are out there; the reality is, though, that bottom-up approaches to healthcare delivery trump top-down systemic reform efforts when it comes to the rate at which trial-and-error solution searches (bright, innovative physicians, for instance) discover new ways to provide better patient care for lower prices.


Richard said...

You and your commentors seem to place the concerns of doctor freedom above those of better patient outcomes. You seem to claim that we make faster progress without any system for teamwork among specialists serving a single patient than we would with a shared electronic medical record and a focus on outcomes. If that were so, wouldn't we expect to see outcomes in the USA leading those of the other industrialized nations with their national health services? We don't. Instead, we see much worse outcomes at much higher prices.

I agree that if the AMA and other organizations of independent practitioners get to choose, Halvorson's plan is doomed to fail. Still, there is some hope, given the widening recognition of the poor outcomes and very high cost of the way we do health care now, that the payers will enact the kind of reforms that Halvorson has in mind, despite the opposition of wealthy doctors. How do you folks assess the consequences of efforts toward universal coverage in Minnesota and the other US locations where it is being tried?

Do you defend our current practices which support expensive emergency care by cost shifting while neglecting inexpensive prevention and early intervention? Do you defend the virtually complete lack of coordination among specialists serving each patient and the inaccessibility of the patient medical record to both the doctor and the patient? Do you defend the absence of data about outcomes which would permit payers and patients to make sensible choices among treatments and providers?

I do not.

If I misunderstood your positions, then let us choose a systematic argumentation scheme and delve more deeply into this dialog with vigor and persistence.

Richard said...

You may be interested to see which I found inspiring. It also seems to support Halvorson's thesis while adding the notion of forming cooperative communities of people who happen to suffer from the same illness.

My suspicion is that if a thousand people dealing with their own illness share freely their experiences with and understanding of that one specific disease, they may well come to understand it better than their doctors do. If so, then perhape we can develop another path to advances in medical practices.

epistemocrat said...

With consumers in charge of the their healthcare dollars, coordination between specialist, providers, and patients will emerge as providers try to meet their patients' healthcare needs.

janemariemd said...

Halvorsen's proposals will not encourage cooperation between doctors, nor will they have any major impact on the costs of care. A shared electronic medical record is nice, but by itelf will not impact the quality of care. As long as the current system of paying for healthcare remains intact we will not see major improvements in the care of the general population. If anything, doctors will be forced to answer EVEN MORE OFTEN to bureaucrats about the care they provide, rather than to patients.

Richard said...

janemariemd says "As long as the current system of paying for healthcare remains intact we will not see major improvements...."

But indeed that is what Halvorson says and why he suggests changing it so payers and consumers can see outcomes and so providers can see both the fuller picture of what is happening with this patient and the comparison with how well other providers are achieving good outcomes with similar patients.

Do you say that with convenient access to the rest of the patient's medical record, the providers will ignore it? Won't the threats of the infrastructure vendors, on behalf of the payers, when outcomes are bad because the provider ignored the medical record, cause a change in that behavior?

I think folks who were sharp enough to get through med school can figure out what to do, given the opportunity to get the relevant data.

Now if you are just saying the politicians are too stupid to see the logic, or too weak minded to pursue a sensible plan for universal coverage, I would hesitate to object to your reasoning. Perhaps we do need some smarter, more effective elected officials.

janemariemd said...

Perhaps you have read the book; I have not. From Dr. Reece's summary I don't see where it indicates that Halvorson is proposing changing the way healthcare is financed, such that there will not be the monetary incentives for more healthcare, more drugs, more specialty referrals, etc, that exist now. I am pessimistic; I do not believe any major players in this country, be they politicians or the doctor's groups or the AARP, are going to really support and promote this.

I am not suggesting for a minute that providers will ignore a more complete or accessible record. I do think you overestimate the impact of this on patient care. Whether I have easy access to a complete medical record electronically, or have to have the patient sign a release for a paper copy, get it in the mail, and sit down and read it in my spare time (the present state of affairs)--I still have to find the time to look at it, and this effort is not paid for with the current payment system. I would welcome alternative healthcare payment approaches, but I haven't seen any opinion leaders put any forth. Even with a complete, electronic record, doctors will continue to order expensive interventions and tests if they and their patients think their is a chance of the smallest benefit to the patient, and it is in their financial interest to do so. THIS is what needs to be changed.

Finally, I do not believe that crunching of billing data can give us lots more useful info about good and bad outcomes. Many patients have neither a good nor a bad outcome after a healthcare encounter; their health remains the same; but the care may be inappropriate nonetheless. For example, I have a patient who saw a pulmonologist some 15-20 times over several years, and had lung function tests done in the office AT EVERY VISIT, and I don't doubt that there were charges for those tests and visits. But the patient's more pressing problem was evolving dementia, and it was many months before that was finally recognized (and not ever by the pulmonologist). Billing data will not show that this patient had a good or a bad outcome; it just shows the excessive utilization. This patient, by the way, chose to go to the pulmonologist this frequently. Although I am all for giving patients all the info about healthcare they would like, I'm not sure obtaining healthcare is like buying a car or a house. It seemes to be a much more complex endeavor.

Richard said...

Dear janemariemd,

I read the book. Since you care about this and you make a lot of sense, I suggest that you read it as well. I did not believe that such a noble cause would be easy to effect, and I still do not. On the other hand, Halvorson has set up health plans multiple times and done well. His plan is fairly straightforward, and his arguments are convincing to me. I was vastly impressed. I believe that he deals with each objection which you so rightly raise. Indeed the fact that he does so explicitly validates your thoughts about the problems with any such plan.

As we so often say, just RTFM. In this case I firmly believe that you will actually enjoy the experience. Please reveal your conclusions if you do read it.

Richard said...

Dear janemariemd and other commentors,

If you wish, I will order up a copy for you if you promise to read it. You can reimburse me if you like and if you find it worth that expense. If not, please pass it along to someone else or send it to me and I'll reimburse you for that as well.

Have I put my money where my mouth is? (Not literally, as that would be unsanitary.)