Saturday, July 10, 2010

Part Two. Interview with Arnold Milstein, MD, Professor of Medicine, Stanford, Co-founder, Pacific Group on Health, Leapfrog Group

Preface: Mercer Chief Physician and US Health Care Thought Leader Arnold Milstein, MD, has been appointed a tenured Professor of Medicine at Stanford University, where he will establish a new research center dedicated to accelerating innovations in health care delivery in the US and globally that improve the value of health care.

Because of its length, this interview will appear in four parts. Part One, Ambitions and Objectives at Stanford; Part Two.The Potential Role of Government and Impact of Health Reform Law; Part Three. Clinical Innovation Business and Care Models; Part Four, Other Clinical Models Lending Themselves to Accountability. What Dr. Milstein is saying takes time to digest and is best read in three parts to leave time for pondering.
In these interviews, I do not necessarily agree with the interviewees' point of view, in this case, top-down management of physicians.

Q: Will you be working closely with the federal government?

A: Given the Institute of Medicine’s recommendations on priorities for comparative effectiveness research, funding for testing the effectiveness of care delivery innovations will originate from the federal government is likely. We also might find ourselves working with the government to the degree that care innovations discovered at our research center would benefit the Medicare and Medicaid population.

Q: The reason I asked about the government was I was just reading a government-directed report from the Council of American Medical Innovation. The report is called “Gone Tomorrow, A Call to Private Medical Innovation to Create Jobs, and End Cures in America.” The report claims the U.S. is falling behind other nations in health care innovation. According to Richard Gephart, former Congressional leader from Missouri, “Advancing a national strategy for medical innovation that engages all sectors – public, private, and academic- through a empowered federal office is an effective first step in turning around our health and economic crises.” Do you agree?

A: It’s a worthy government priority. The well-being of Americans depends on increasing their yield from our investments in clinical innovation. Comparisons of the U.S. health system to the systems of other countries show that we’re not getting enough in return for our much higher levels of health care spending than are other wealthy countries. With a coherent national clinical innovation investment strategy, we can unlock the creativity of U.S. clinicians and make the U.S. health care system a basis for global competitive advantage.

Q: What are your hopes and expectations this new health reform law?

A: For the past 6 years, I’ve served as an adviser to Congress on the Medicare program. I received a sobering education in federal health care politics. I realized that any health reform legislation likely to be signed into law was going to be “half a loaf”.

The new reform law is a step in the right direction, but falls short of what ultimately will be needed. It was not a failure in legislative drafting; rather, it reflects how political campaigns are financed. Industries that have the most at stake invest the most heavily to influence legislators to limit reform to changes that will least disrupt them. We now have a health reform law that covers most of our uninsured and moderately encourages physicians to align with larger organizations generating more health with less money. Congress will need to twist the legislative dial from “moderately” to “strongly”.

Q: These days there is a lot of talk about “disruptive innovations.” Do you think this new health reform law will be disruptive to current medical practices?

A: It will not induce highly disruptive changes in the ways that care is delivered. Its effects will be gradual. An example is Medicare’s new bundled ACO payments to doctors and hospitals. Wider bundles that encompass longer time periods than a single patient encounter will shift accountability for quality and total costs more squarely onto the shoulders of doctors and hospitals. Unless other big payers harmonize with Medicare, ACOs will stimulate incremental but nonetheless valuable clinical innovation by physicians and hospital administrators.


kevinh76 said...

"Wider bundles that encompass longer time periods than a single patient encounter will shift accountability for quality and total costs more squarely onto the shoulders of doctors and hospitals."

There we go! Shift accountability. How about making the consumers/patients accountable? This has already been tried and failed. Pay doctors fairly and hold them accountable for quality for the pay they receive. I want to deliver quality health care services. But hold me accountable for costs? No way! Not unless I get to be paternalistic when the daughter of an 80 year old with advanced dementia, bedridden insists on "everything" for her Mom including ICU, ventilator and CPR despite numerous conversations about appropriate end of life care. (I guess I should also mention that the patient is an immigrant on Medicare/Medicaid who never worked a day in the United States or payed a single cent in taxes yet has access to all the expensive, unnecessary treatment her daughter can demand). So the government gives them this entitement to "everything" and I'm supposed to be the bad guy and say no or take a pay cut? Wow, that's real innovative! I guess we need a Stanford Professor to tell us this time it's different and the genius flowing out of his ivory tower will change human nature.

kevinh76 said...

Perhaps the good Professor should seek the counsel of one of his Stanford colleagues who actually treats patients, Abraham Verghese, MD.

Writing on The he said:

"What helped create our present mess is a payment system that rewards procedures and expensive  diagnostic testing, but does not reward primary care; it has necessarily resulted in a profusion of people and places who do things that are well reimbursed and a dearth of physicians doing primary care.  We don't need comparative effectiveness research as much as we need a retooling of the payment system and some caps on spending.  Let's pay for what works right now, and stop paying for what's not needed."

Given that he helped create this mess with his MEDPAC activity, I have a feeling he will continue to persue his failed cost shifting theories.

Richard L. Reece, MD said...

Kevin, I appreciate your perspective. Your comments add balance, which to date has been heavily weighted towards "free" government entitlements and away from market and personal responsibilities. I look forward to your comments on part 3 of this interview with Dr. Milstein.

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