Friday, April 1, 2011

Health Care Reform Now! A Book Review

Lately I’ve been reviewing books of health reform, First, it was Why Obamacare Is Wrong for America. Then it was The Truth about Obamacare. Now it’s the turn of Health Reform Now! A Prescription for Change ( John Wiley & Sons, 2007,$27.95).

The author of Health Reform Now! is George Halvorson, Chairman and CEO since 2002 of Kaiser Foundation Health Plan and Hospitals in Oakland, California. Before that he was president and CEO of HealthPartners in Minneapolis, where, as editor-in-chief of Minnesota Medicine, I was privileged to know him and interview him.

Why review this 2007 book now?

After all, four years have passed, and it predates the debate and passage of the health reform law. It even precedes the campaign and election of President Barack Obama.


For the simple reason that its contents contain many of the “prescriptions,” i.e. ingredients for change, that the Obama administration recommends. These include reducing the fragmentation of American medicine, organizing doctors into larger more managed entities, using data to measure quality and outcomes, installing electronic medical records, building a marketing infrastructure to make the market work, and, of course, assuring universal coverage.

Halvorson is different than most writers on health reform, including me. He leads a large, integrated, sophisticated organization, with both hospital and outpatient components, Kaiser covers the health care spectrum. With its cadre of over 10,000 salaried physicians and associated health professionals, he and his organization can implement changes easier than government. They can show what works and doesn't work in the real world, rather than in a theoretical world, setting.

Above all else, George is a “systems thinker.” He believes the most fundamental “foundational” fault of America health care is the “almost total lack of systems thinking in health care.”

He says we focus too much on individual procedures and personal exchanges. He laments that we rarely track or measure relative outcomes. We think too much in terms of paying for individual performance rather than organizational or system performance for populations of patients. If you give the matter any thought at all, systems thinking is a part of the Obama health doctrine.

To get from here, from individualism, to system-wide thinking, Halvorson in his opening chapter says we must accept a “few hard but useful truths":

One, care costs are unevenly distributed, e.g. five chronic diseases – diabetes, congestive heart failure, coronary artery disease, asthma, and depression take 70% of all health care dollars.

Two, excessive fragmentation, fostered by paper records, overspecialized care silos, disincentives for change, abound.

Three, economic incentives significantly influence health care, but they are the wrong incentives. We have no incentives for improvement, for measuring outcome, for cure, for performance.

Four, systems thinking is almost never on the radar screen, no data to track overall performance.

To correct these deficiencies and to make the system work, Halvorson recommends these “next steps and expectations”:

Specific quantifiable goals, using data to measure outcomes and improved health measures.

Standards for population health, which will require a personal health record (PHR) and electronic health record (HER) database, towards which Kaiser has committed some $ 3 billion dollars.

Data-supported, informed choices, supplying consumers with data about outcomes of various disease, , performance of various providers and systems , and satisfaction and experiences of patients.

Competition on basis of quality and cost embedded in the brave new world of web data to reward best data and maximize care value.

Benefit plan design to appropriately incentivize and support consumers and employers to make the right decisions about coverage, care systems, caregivers, and care.

Link payments to performance, which is embodied in many of the pay-for-performance (P4P) models now being tested by the government and health plans.

As I re-read this book in light of what is contained in the Patient Protection and Affordability Act and the turmoil that has ensued and the opposition that has hardened since its passage, I realize the American public does not readily accept much of what Halvorson proposes, or what is in the health reform law itself.

An average of seven major poll results as of today indicates 38.9% favor Obama and the Democrat’s health plan, 53.0% oppose it, and 67% want it repealed.

Much of what George Halvorson advocates is in the Obama plan and features managed competition. There is a huge difference, however. Halvorson focuses more on market forces, rather than government oversight and centralized control, as an antidote to correct the flaws in today’s fragmented system.

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