< Limits of Health Care Intervention

Not so fast, McDuff.

Shakespeare, Hamlet

Radical interventions into any established culture has its limits, whether that culture in political, nationalistic, or health care.

We have learned this the hard way, in the Middle East, Vietnam, and now in health care reform. In the U.S., American medical culture has long been one of physician independence, fee-for-service and fees for lines of hospital services, separation of hospital and physician worlds, and reliance on clinical experience and judgment rather than data outcomes. Changing this culture fast is not realistic, nor is it proving to be.

Over the last 30 years or so, since the advent of comprehensive managed care, rapidly rising health costs, costly technological advances, sophisticated computer measurements, and shifts of institutional care. During this period, care based on "value" ( outcomes/dollars spent) and on data demonstrating that value, rather than physician and hospital fee-for-service resting on the pedestal of clinical experience, has been on the ascendancy.

The perception has grown that "value" care is unstoppable , and that we shall soon see large integrated health-care corporations, with control of health plans, hospitals, and outpatient facilities with salaried primary-care doctors and specialists functioning in closely knit teams, beholden to federal programs, such as Medicare, Medicaid, and health exchange plans, dominate the health care landscape.

A prime example of this approach is Kaiser Permanente, which controls its health plans, its hospitals, its physicians, and recently announced it is establishing a new medical school, whose philosophy shall be teamwork among its various elements and constituencies.

This view of the future may be the wave of the future, but it has limits of intervention.

A December 14 healthleadermedia report said when it comes to navigating the transition from the fee-for-service healthcare provider model that emphasizes “value”, i.e. efficiency and outcomes rather than quantity of care, health care CEOs are talking the talk but are very understandably slow to take on the increased risks.

A recent study by HealthLeaders Media CEO, “Population Health: Investing in a Risk-Based Future,” revealed only 41% of respondents said they are fully committed and underway with programs to manage the overall health of a population, while another 28% said they have pilot programs underway. But the report also revealed 42% have risk-based revenue of less than 10%. The healthcare leaders, mostly hospital CEOs, were leery of payment shifts out of fee-for-service, disruptions created by “value”, the use of data alone to judge performance and to pay for it, and said their staffs and physicians were undergoing “change fatigue.”