Saturday, January 10, 2009

obstacles to reform -Eleven Elephants in the Health Reform Room

The Big Elephant

The term “elephant in the room” refers to a complex situation where something major is going on, it’s on everybody’s mind, and impossible to ignore – like an elephant in the room. Everybody is talking about the Big Elephant in the Health Care Reform Room, but few are talking about the bevy of smaller elephants needed to make the Big Elephant Whole. Nobody knows exactly what to do about these small elephants.

Small Elephants
In the case of health care, these smaller elephants may be hard to define. They defy easy solutions. Reformers describing these small elephants are like the blind men in the “Blind Men and the Elephant, “ a poem of John Saxe (1816-1887. The blind men, feeling the elephant, came to different conclusions. Those feeling the elephant’s side concluded it was a wall, the tusk a spear, the trunk a snake, the knee a tree, the ear a fan, and the tail a rope.

In 2005 I published a book The Voices of Health Reform, consisting of 42 interviews with national reform authorities. In that book, I concluded there were 11elephants in the room. Here I update them.

#1 – Fragmentation and conflicts among health care interest groups render reform intractable – Anything one does to the Big Elephant goads a series of small elephants, i.e. interest groups, who enjoy the benefits of the status quo and who employ powerful lobbyists.

#2 – Single-payer backers, still committed, are seeing practical opportunities for sweeping change slip away - In D.C. (short for Darkness and Confusion), this lost opportunity might be dubbed the Great Recession, Great Slippage., or the Lost Opportunity.

#3 – Medicare, in its present form, is unsustainable - This is rarely talked about, because Medicare was looked upon as the gateway to universal coverage, and nobody knows yet how to avoid Medicaid and its step-siter Medicaid from bankruptcy without raising taxes.

#4 – These days the consumer-driven movement occupies everybody’s minds – But rarely is it everybody’s mouths. It is a no-no to talk of the marketplace and of consumer responsibility as a solution to what is promised and perceived as an entitlement.

#5 - Regional and geographic differences matter - This is hard to address when one is talking about national reform. Yet it is obvious to all that care, costs , and outcomes will not be and will never be the same in San Francisco, Minneapolis, Boston, Miami, and New York City for cultural and demographic reasons no matter how much Wennberg and followers bewail this reality.

#6 – Hospital and physicians collaboration remain an “iffy” proposition - Hospitals and doctors compete for market share. Federal rules and regulations and calls for bundling of services and elimination of duplication will not smooth over or end this competition.

#7 - The consumer movement means different things to different health care stakeholders and opens up enormous opportunities for other community institutions - The U.S. is an innovative and entrepreneurial and bottom-up nation, and there are always marketplace niches to be exploited and filled.

#8 - Many American physicians increasingly consider themselves a disenfranchised minority - This is partly because doctors constitute a small voting bloc, partly because of abusive third party reimbursement practices, and partly because of intrusions on physician autonomy and clinical judgment. If you doubt what I say, read's open letter to the American public, signed by over 12,000 physicians, and results of a survey of 320.000 American physicians conducted by The Physicians’ Foundation.

#9 – Medicare and managed care organization are placing their bets on the pay-for-performance movement - This is a bad bet because it depends on universal use of EMRs in physicians’ offices as the monitoring, judging, and rewarding mechanism. P4P cannot and will not work because it represents third party overkill and belief you can judge physician-patient interactions through remote and retrospective computer oversight,

#10 – Health care systems are difficult to manage because they are composed of individuals and independent organizations acting in their own best interests at the boundaries of care - It may be sad to say, but patients will do what they have to do to get the best care, and physicians will offer that care in the patients’ and their own interests. Medicine is a personal and emotional thing, and saying “No,” is an extraordinarily difficult thing to do and where there’s a will there’s always a way at the edges of care.

#11 - Information technologies are often seen as the Holy Grail of health reform, but these technologies will not work if they ignore the Electronic Elephant in the Room, the reluctance of small physician practices to install awkward, unfriendly, expensive electronic medical records. It is true that 75% of American households and 100% of doctors have broad band access, but this does not mean patients trust the Internet to pick the best doctors,or doctors rely on the Internet to carry out best practices, or that computer data can be used to enforce physician compliance.

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