Time for reflection

Dave Barry provides a humorous look at 2008. This one's good for a lot of laughs!

Democracy is being put to the test

The Obama Administration is open for questions. If this is going to work, we need people from all backgrounds to weigh in. To this point, I've only focused on the healthcare category of questions. 1) Some of the submitted questions are very good. 2) Others are not helpful at all. For example, Bill in KC writes "We all recognize the insurance industry is the problem...". My guess is that Bill has not taken the time to inform himself on the real state of our healthcare system. He has limited his research to soundbites. 3) Still others are clearly driven by personal agendas. Not a big surprise there.

It's the latter scenario that bothers me the most. We are where we are because people are looking out for themselves and not looking at the system as a whole. I call it social irresponsibility and an inability (or unwillingness) to see the big picture. I only hope that we can cut through that as we move down the road of reform. I might not be the smartest guy on the block, but I know for certain that we will not reach the potential of real reform if we continue to allow thinking that is myopic and/or selfish.

Rebuilding Primary Care - The Key to Reform?

I just read an article in Healthcare Price, Cost & Utilization Benchmarks, Volume V about employer wellness programs. It was a very informative article that explained how current wellness efforts tend to fall short and how they could be made more effective. I took a lot from the article, but there was a stat quoted that really froze me in my tracks. The article cited a 1998 issue of The Journal of Family Practice when it stated that those with a regular PCP have 33% lower costs than those that do not have one. Wow! I don't know if that's true today, and you have to consider the source when evaluating an issue like this, but if it's true then...Wow! It seems to me that rebuilding our primary care delivery system might be an important key to effective reform.

It's hard to argue that strong, evidence-based primary care will go a long way to containing costs. With that said, we really need to look at reallocating the reimbursement for healthcare services. Specialists are very important to the system, but the gap between their compensation and that of PCPs simply does not make sense. I'll bet many of them know that deep down, they just don't want to shoot themselves in the foot. In their shoes I might do the same thing, but that doesn't change the fact that we have an expensive healthcare system that needs a fixin'. Let's get to it!

Reporting quality - PQRI

It's official. My practice is going to jump into the vast Physician Quality Reporting Initiative (PQRI) pool in 2009. CMS is paying a 2% bonus to those physicians that successfully report quality measures. We didn't participate in 2007 or 2008 because, as an OB/GYN practice, we would not see enough Medicare patients to earn a bonus large enough to justify the additional cost of reporting. Primary care physicians have a much greater bonus potential because of the makeup of their patient panels.

However, we feel it's time to start reporting quality measures. We will certainly not get rich by doing this. We're doing it because it's the right thing to do, and our software vendor has made it less cumbersome to comply with the reporting requirements. Screening for breast cancer, osteoporosis, and colorectal cancer are all things we currently do, but we might actually do them better as a result of PQRI. Measuring quality should be a requirement of all practitioners, and it is likely that it will eventually be mandatory.

I hope we make it through the year with an increased awareness of our quality levels. The $3,000 or so that we might earn will be enough to pay for raises for a couple staff members, but any improvements in quality will save Medicare a far greater amount. Considering the state of Medicare and our healthcare system as a whole, I'd say that's pretty important!

The outdated way CMS values imaging services

In the latest issue of Health Affairs, the article "Paying Accurately for Imaging Services in Medicare" does a great job of spelling out how distorted the payment calculations for services such as MRI and CT really are. Why is this important? According to the article, the volume and intensity of imaging services per beneficiary grew 61% between 2000 and 2005, vs. 31% for all other physician services! Hmmm?? Do you think this should be an area of focus for healthcare reformers? To be fair, there is definitely an improvement in patient outcomes as a result of better imaging technology. However, I'm not aware of a study that has quantified how much of the increased spending has lead to better outcomes.

CMS calculates a cost per minute figure to estimate the input costs of running an MRI or CT machine. However, doing so involves making assumptions on the number of scans done in a given time frame. CMS currently assumes that the equipment is used 50% of the time that practices are open, which is probably a low figure for most practices. As a result of current methodology, cost per scan, and therefore reimbursement, are overstated by an amount that is certainly not negligible.

In my mind, CMS should update its methodology for calculating cost per minute in order to more fairly value these costly studies. The 50% usage figure should probably be increased to 75% or more, if nothing else, to encourage practices that purchase the equipment to be more efficient. It might help bring the supply/demand profile back closer to reality over time by discouraging further spread of this service among additional practices.

We must come up with ways to monitor utilization of practices in which the ordering providers have a financial stake in the imaging equipment. The in-office ancillary exception to the Stark Law has left the door too wide open for inappropriate financial gain. Given my position, I tend to have a physician bias and an appreciation for physicians wanting to supplement their income with ancillary services. However, the "bad apples" are ruining it for the other honest, ethical physicians that order tests solely based on medical necessity. We all know this is a problem. Now we just need to stop allowing special interests to block progress in this area, and start making some important changes to bring spending back in line.

Does this apply to you?

The opening paragraph of a very important and timely article:

In one of the many letters he wrote to his son in the 1740s, Lord Chesterfield offered the following advice: “There is time enough for everything in the course of the day, if you do but one thing at once, but there is not time enough in the year, if you will do two things at a time.” To Chesterfield, singular focus was not merely a practical way to structure one’s time; it was a mark of intelligence. “This steady and undissipated attention to one object, is a sure mark of a superior genius; as hurry, bustle, and agitation, are the never-failing symptoms of a weak and frivolous mind.”

He said that a very long time ago. If only he could see our ADD society now!

The Christmas Spirit

In a show of goodwill toward their fellow man, Barack Obama, Tom Daschle, Kerry Weems, reps from Humana, United Healthcare, AMA, AHA, AHIMA, MGMA, Mayo Clinic, and Geisinger Health assembled to witness what they knew would be something special. The Angel of the Lord came upon them and the Glory of the Lord shown round about them. And they were so afraid and the Angel said unto them "Fear not, for behold I bring you tidings of great joy. For unto you born on this day in the City of David, a Savior Jesus Christ the Lord." Glory to God in the highest and on Earth peace and goodwill toward man.

An overwhelming sense of peace and joy came over them. Feelings of selfishness and greed left them. In an unprecedented show of teamwork, they all sat around the great table, admitted their past failures and shortcomings, and talked about what the ideal healthcare system would look like. After three days, the design of the ideal healthcare system emerged. In the years that followed, citizens started getting healthier, the uninsured now had coverage, emergency rooms were surprisingly empty, and everyone was happy. The high per capita healthcare costs were nothing but a distant memory.

Merry Christmas to all!

Be careful of what you wish for...

In this NY Times article about healthcare house parties, we get to see results of some discussions among every day people about what's wrong with our healthcare system. I think it's important to involve everyone in the discussions about healthcare reform. However, I have a couple concerns about this particular discussion. Some excerpts:

They also agreed that health care was a right; that insurance should cover “everything,” not just some services; and that coverage should be readily available from the government, as well as from employers.

They want want want, but they don't understand what that will cause us all to have to give give give. If anything, we need to remove the "insulation effect" of health insurance. If we're going to move to a value-based purchasing system, we must remove the insulation. We need to understand what we're buying, folks. If someone else is paying for it, I can promise you that the average citizen will not do their homework when looking for care.

“If we wanted a baby,” Ms. Li said, “insurers would not cover the maternity care if conception occurred within six months after we purchased the insurance. We were shocked.”

Considering the fact that the average pregnancy costs in the neighborhood of $6,000, with high risk pregnancies easily running into the $10s of thousands, do you not understand why an insurance company would want to discourage people from picking up coverage only after learning they were pregnant or shortly after deciding to get pregnant?

Bottom line: I don't expect everyone to spend as much time as I do researching healthcare reform and looking for areas of improvement. However, if you want your voice to be heard on this issue, or any issue for that matter, do us all a favor and dig a little deeper rather than just relying on what you heard on The Nightly News.

Healthcare systems around the world

Are we sure we want to look at other countries in order to model our healthcare system here in the U.S.?

Competitive forces at work

Here's a good example of competitive forces at work. According to the Wall Street Journal article, the big retail pharmacies such as Walgreens and CVS are battling it out for business in the discount generic arena. WalMart started a trend with their $4 prescriptions and others have been pressured to follow suit.

This is an example of what competitive forces can do to keep prices in check. How can we make that same thing happen in the market for physician and hospital services? This will be a key question that we must answer in our discussions on healthcare system reform. Healthcare consumption decisions have to be based on value if we want to contain costs and maintain acceptable levels of quality. We have allowed healthcare to become a very large industry that has been immune to the power of competition. How did we let that happen? I suppose none of us let it happen because it has occurred over generations. We're simply perpetuating it.

Building value into the system is one of the single most important goals we should have right now. If we do it right, putting competition to work will make addressing other problems such as hospital infections and defensive medicine easier because things like that will be taken into consideration as part of the value decision. Michael Porter would be a great resource for this. His book from a few years ago, Redefining Health Care: Creating Value-Based Competition on Results did not receive the attention it deserved. He was just ahead of his time and I think the book will have new life very soon.

A reform wake up call

What's wrong with a health insurance plan that has a high deductible, coinsurance, or copays? If someone can't afford to cover a $20 copay, shouldn't we be more concerned with why they can't afford the copay than the design of their health insurance plan? Shouldn't we also be looking at whether said person is taking the steps they should be to maintain their health?

Much of our healthcare crisis is due to a spillover of issues from the rest of our society. Yes, we have issues in the system needing addressed such as unnecessary complexity and overused procedures. However, we have some deep societal issues that must be addressed if we want to spend less on healthcare. Teen pregnancy, gun violence, obesity, laziness, and increasing stress levels are big issues that seem to get brushed to the side when we talk reform. Come on folks! We're all contributing to this mess. We need to stop acting like it's someone else's problem to fix.

What are each of you going to do to contribute to the solution??? If you can't answer that, then let me remind you that this is a democracy and we're all in this together.

Thought of the day

Never mistake activity for achievement. John Wooden

What if?

• What if MRIs were reimbursed at the same rate as a complex level 5 physician office visit?
• What if nurse practitioners and other non-physician providers were responsible for preventive care and patient education, freeing up physician time for the activities that require their expertise?
• What if all providers and hospitals operated on the same web-based EHR platform, allowing them to communicate much more efficiently?
• What if physicians, insurers, and patients acted like they had common goals?
• What if physicians specialized in the treatment of conditions instead of organ/body systems?

More What if?

Not-for-profit hospitals have a target on their backs

According to an article in the Wall Street Journal, Senator Chuck Grassley is pushing for legislation to hold not-for-profit hospitals more accountable for the billions in tax exemptions they enjoy every year. I think that's a worthwhile cause. We've been hearing more stories of questionable practices by some not-for-profits in the last few years.

I just hope it's done the right way. Requiring that a hospital devote a certain percentage of it's revenue to charity care is a little sticky. How do you determine the magic level? In good economic times, that number might make less sense than during bad times like we're seeing now. The measures used to increase accountability must take into account all of the contributions that not-for-profit hospitals are supposed to be making to their local communities. A good example would be community health education initiatives. In other words, I think we have to be careful not to give too much weight to simply giving away free care.

The idea of placing limits on executive compensation in the not-for-profit realm is a good idea for the most part. However, I have to question what that might do to the hospital's ability to recruit talent. We've all seen how lower pay keeps the best leaders in the private sector and away from government. With that said, I think you can still get quality CEOs for under $500,000. You won't get Jack Welch, but then again I don't think the Cadillac option is necessary.

Overall, this is a good task to take on. I wish Senator Grassley luck as he takes on some pretty powerful special interests.

Thought of the day

"A rich person is not one who has the most, but is one that needs the least."


Excerpt from Interview with God.

Balance billing

As this news article suggests, balance billing by physicians and hospitals is a hot topic these days. Unfortunately, most of what I've read on the topic is incomplete. There's more to the story than most media outlets portray.

Balance billing is the practice of billing the patient for the portion of the provider or hospital charge not covered by insurance, when the patient's insurance is not one that the hospital or physician accepts. There are a couple points to keep in mind before one can make a decision on how they feel about the fairness or unfairness of balance billing:

1. Insurance companies often assign very low rates when paying for out of network services. Many insurers claim that the rates are "usual and customary", but in most cases it is questionable. As a result, providers and hospitals feel they need to balance bill in order to avoid losing money on the service.
2. Providers and hospitals often set their charges at very high rates, in some cases up to 3 or 4 times what they typically receive from the insurance companies that they do participate with. That leaves the uninsured and those straying out of their insurance company network with very high bills.
3. If we're going to buy into the current insurance model in which networks are established to ensure that participating providers are appropriately credentialed and certain quality levels are maintained, then it's only fair that discounts should be given for in-network but not out of network providers.

The point I'm trying to make is that we can't just say that physicians and hospitals are greedy and balance billing must be outlawed. Instead, we must set a reimbursement floor so that insurance companies cannot set out of network rates at artificially low levels. We must also set a ceiling on provider/hospital charges. I'm thinking 200% of Medicare rates sounds reasonable. If those two things happen, balance billing would not draw near the attention that it is currently.

Let's Party

Universal healthcare; paying based on outcomes; reducing defensive medicine; electronic medical records; medical home; patient-centeredness; better coordination among providers, etc.
Everyone's talking about these things. The conversations are starting to sound alike. How do we get past the talk and move forward with action? If anyone else has the same desire for action, let me know. Maybe we can organize a healthcare reform party like the Obama/Daschle team has suggested. Who's bringing the beer?

The Downward Spiral that is our society

Where do the entitlements end? At what point do we stop relying on others and start taking responsibility for our own lives and our own health? The social programs that we have are a testament to the greatness and generosity of our nation, but they will also be our downfall if we don't soon take a step back and assess the current balance we have between government, personal, and social responsibilities. It has been my contention all along that there is a negative correlation between the level of government responsibility and the level of personal responsibility of the citizens. I do not want to get political with this, because I come from the Realist Party, which is situated right smack in the middle of those other two parties. Shawn Hannity I am not. Not even close. I'm just a citizen that does not appreciate gross laziness and social irresponsibility, and I'm not afraid to say it regardless of how un-PC it might be.

I know a woman that recently became pregnant with her fourth child. The previous three have been paid for by you and me through tax dollars. I don't know about you, but I don't have any visitation rights. She has claimed that she is hoping for twins. Wait, what?? You want what?? Maybe my problem is that I have a conscience and I would never expect any of you to pay for anything of mine, unless I haven fallen on such hard times that it is not humanly possible for me to stay afloat on my own.

Ok, I've had a bad day and I'm taking it out on all of you. It's just that I can't stand to see our society continue down the path that it's heading. The tragic part about it is the fact that it's happening gradually enough that there isn't a compelling reason to do something about it in the near term. The other tragedy is that our political system is not set up to allow our elected officials to do anything about it because it would be political suicide to call your constituents lazy freeloaders.

Thanks to all that read this far! There are still good people out there. Work hard. Do your part and keep your fingers crossed that we will find a leader that is not afraid to ask the tough questions and make the tough decisions. Maybe the one coming into office in January will surprise us all!

Question for the single payer folks?

Just a simple question: How much will it cost (to the nearest $100 million) to make the transition to single payer and how long will it take (to the nearest quarter)? Ok, that was two questions. Sorry!

It's odd, but no single payer proponent has been able to address those questions when I ask. Those of us trying to run a business know that you can't take on a big project without answering fundamental questions such as those. Then again, I don't know too many businesses with multi-trillion dollar budgets and almost unlimited borrowing capacity.

What if?

• What if health class was revamped to give middle school and high school students the start they need to take charge of their health for life?
• What if the government funded a massive, viral marketing-style campaign using social networking media, among other outlets, to portray teen pregnancy as the life-robbing resource-drainer that it is?
• What if we recruited well-to-do celebrities, sports stars, scholars, etc. that came from bad inner city conditions to be role models that instill hope in inner city kids that currently have none?
• What if everyone slowed down to stop and enjoy the path they're on, rather than focusing so intently on the destination?
• What if all health insurance/managed care companies had the same medical/reimbursement/administrative policies, and sought their competitive advantage instead by maximizing the health of their members and efficiently running their businesses?

More What if?

Interview from God

I recommend that everyone take five minutes out of their hectic lives to review this Interview with God. I'm not a religious fanatic, but I found a lot of value for all Americans in the message.

If you don't think you have 5 minutes to spare, or if you start to check it out and feel restless, you need the message more than ever!

Thanks to Michael Wade for calling my attention to it.

The Power of the Media II

Here's a good supplement to my post about the power of the media. The media has more influence on our lives than most of us realize. In her post, Dr. Weber talks about how the barrage of negative stories we get hit with can shape our day to some extent. I think we all know that most media organizations are willing to sacrifice solid, balanced news reporting for stories that attract viewers, but add no value to our daily lives.

When the right people get around the table to reform our healthcare system, I hope they don't let any reporters in the door.

What if?

• What if Medicare and Medicaid were consolidated into one program based solely on need?


• What if everyone paid attention in grade school and made something of themselves, thereby reducing the chances that they would need to rely on government social programs later in life?


• What if Medicaid limited the number of births of the same mother it would pay for?


• What if healthcare providers posted their fees at the reception desk or in the waiting room?


• What if the government paid for preventive and catastrophic coverage for every citizen, and citizens were responsible for everything in between?
  

More What if?

Still more What if?

Let's change the game

Imagine a world where healthcare producers thrive by minimizing costs and maximizing quality. As this article points out, if we head down the right path with reform efforts, the most financially successful healthcare providers and facilities will be the ones providing the best value (quality and cost), not the ones charging the highest amount. Healthcare consumer decisions must be based on value in order to unleash the competitive forces that all other industries offer. There's a lot of status quo and resistance to change in the healthcare realm. It's time that we shake things up and change the game.

Thought of the day

If healthcare is a right, then maintaining one's health should be each citizen's duty.

What is "quality"?

There's a lot of talk in the healthcare realm about quality and how it can be measured to allow patients to select providers and healthcare facilities on a value basis. One thing that must be considered in the discussion is the fact that people have different ideas of what quality really means. Developing good clinical measures is clearly the most important task here, but a patient's perception of quality is often a more powerful factor than the clinical quality itself.

If an office has a friendly receptionist and nursing staff, some patients are going to be more inclined to be satisfied with the care even if the clinical service provided was of a slightly lower quality than other practices in the area. Other things like wait times and interactive websites also play a role in the patient's perception.

In the end, clinical quality matters most. However, if we're going to be successful at getting patients to become better consumers, we're going to need to educate them on what quality really means.

The analysis of my blog

I used this site to analyze my blog and I am concerned with the results, not because I feel they got me wrong. They nailed it. I am the "responsible and hardworking type" who is "attuned to the details of life". I am "conservative by nature" and I'm "happy to be let alone and to be able to work at my own pace."

Wow! I'm ashamed to say it, but that really is me. The only things missing were: "likes a good Starbucks buzz" and "is annoyed by lazy people".

The future of employer based health insurance

I am in favor of continuing the employer-provided health insurance model, but three drawbacks need addressed:

1. We must take steps to remove the "insulation" factor that prevents employees from being exposed to the true costs of their care. Despite all of the grim reports of employers dropping health insurance benefits, there are still plenty out there paying most of the premiums for their employees while keeping plans with low deductibles. Individuals must see the real costs of care or they will not be effective healthcare consumers. Despite the negative spin in the media, higher deductible plans are the "shot in the arm" that we need right now. We should all be actively seeking the best value for our healthcare dollar. Although, as I've said before, other measures have to be taken to make that a reality.


2. Insurance contracts must have a duration longer than one or two years. Otherwise, the incentive for insurance companies to pay for and promote preventive care is not strong enough. With employers switching carriers every couple years, an insurance company cannot easily realize the benefits of keeping it's members healthy. As a result, many insurance plans do not cover preventive care, or have reduced coverage in that category. That is very short term thinking and it certainly doesn't encourage individuals to get the care they need.


3. Individuals must develop a better understanding of their insurance coverage. These days, many insureds don't understand the dynamics of their health plans. It's no wonder because the average health insurance policy is complex and lengthy. Let's reduce the complexity and educate members so that they are not in the dark. Currently, it requires additional staff resources on both the insurance company and healthcare provider sides to answer patient questions. Make policies more understandable and the need for those resources decreases. At the same time, individuals need to step up and attempt to learn the ins and outs of their coverage. I've noticed that very few people do that.

The Power of the Media

Does anyone else worry about the role the media plays in shaping public opinion? It has become very difficult to distinguish between facts, fiction, spin, and half-truths these days. Tremendous momentum can build when major media outlets cover a story, regardless of whether their take is with or without bias.

This story is yet another example. The title alone, "Consensus emerging on universal healthcare", could lead a reader to believe that we're reaching the end of the discussion and universal healthcare is close to becoming a reality. Most of us that have been following it closely know that we are far from reaching the conclusion that universal coverage is the answer. There are too many questions yet to be answered. For instance, as the article mentions, America's Health Insurance Plans (AHIP) is willing to go the universal route if coverage is mandated. However, President-elect Obama has stated that he does not want mandated coverage. This is a big issue to be reconciled before "consensus" can "emerge".

I am troubled by the ever expanding role that the media is playing in our lives. I can only hope that enough people are digging deeper on some of the important issues of the day and coming to their own conclusions after looking at all sides of the story.

Change.gov

Time will tell whether this is a sincere effort to promote real democracy, or politics as usual. If it's the former, I think they're really on to something.

Principles of Responsible Healthcare Reform

• No single stakeholder group is solely responsible for our high cost system. Physicians, healthcare facilities, insurance companies, patients, the government, etc. are all part of the problem, but they must all be part of the solution.


• The patient must be at the center of all healthcare decisions. If patients are cared for in the most effective and efficient manner, with all clinical decisions based solely on medical necessity, it will be easier for the stakeholders involved to be paid what they deserve.


• The American people must take more responsibility for their health. Health must be a higher priority for every individual than it currently is. We owe it not only to ourselves, but also to our fellow Americans to maintain healthy lifestyles. The healthy subsidize the unhealthy, and it would be socially irresponsible to allow one's health to deteriorate at the expense of others.


• Health insurance complexity must be eliminated. All payers and policies must follow the same medical policy standards. This will result in reduced staffing needs on both the insurance and healthcare provider sides. It will also make it easier for patients to understand their coverage.


• Managed care should not mean creating administrative hoops for healthcare providers to jump through. It should involve a collaboration between payers and providers to ensure the health of the population.


• We must move toward a system where patients become true consumers that seek out the best value (i.e. cost and quality). To do so, both quality and cost must become more transparent and the data must be reliable and easily accessible.

A Very Important What If?: Health Dashboard

What if each person had a "dashboard" of key health indicators that helped them know where they stand in terms of their health? I've often heard that "what gets measured, gets done". If these indicators were at the forefront of someone's mind, said person might be more inclined to think about their health more often and make better choices in order to keep those indicators at acceptable levels.

I'm not a clinician but I'm thinking that the indicators should include, at a minimum: blood pressure, BMI, and cholesterol levels. Each individual's dashboard would have those three, with some individuals having additional measures based on their circumstances (ex. blood sugar levels). The dashboard would include the current levels of each indicator, the desired levels, and the best and worst readings for the individual in a given time period. This must be coupled with education about the indicators, their relationship to health, and ways to keep them at acceptable levels.

Obviously the measures are not new and many providers are already measuring and recording them for their patients. What I am suggesting is that we change the presentation of the message by taking steps to put the numbers in front of the patient. In most cases, this information is tucked away in the patient's medical record and reviewed periodically by the provider. If we want patients to take more responsibility for their health, traditional methods will not suffice. Personal health records (PHRs) would help achieve this. However, this is something that could happen without PHRs.

This will also require that all individuals have access to preventive care. I'm not a big proponent of forcing universal healthcare on the country, but I could compromise and say that all individuals should be given 100% paid preventive care. For those with insurance, it would be covered as part of their policy with no copays or deductibles. For those without insurance, it would be covered under a government preventive care plan. Medicare also needs to beef up its preventive care coverage because right now it's inadequate.

Making this a reality will require some changes to the primary care delivery system. Preventive care does not require the expertise of a physician. We need to make better use of midlevels and nurses to carry out preventive/patient education responsibilities. Ideally, these activities would be integrated with physician practices to the extent that patients with poor indicators could be easily transitioned to a physician for treatment when necessary.

The bottom line: The U.S. healthcare system and the health of the population will never come close to reaching its potential without individuals taking more responsibility for their own health. One of the biggest tasks of effective reform will be to educate and empower individuals to do so. We need to change the way we view our own health, because right now many of us don't pay any attention to it. We should pay as much attention to our physical/mental health as we do to our financial health. As many have come to realize, the two clash from time to time.

This will be a major undertaking, but it's one of the few investments in today's world that will have a huge return.

Education and Value in Healthcare

I've come to realize that an overwhelming majority of patients don't understand their health insurance policies. They don't know what copays and coinsurance are, and some don't even know what a deductible is. There's still a mindset among many that insurance is supposed to pay for everything. In the distant past, it did pay for nearly everything with little or no out of pocket on the patient's part. That is not a reality anymore. More cost is being shifted to patients and I'm not sure that's a bad thing.

Many think HSAs are failing to achieve what they were designed to do: create more value-conscious healthcare consumers. The problem is, cost shifting needs to go hand in hand with education and empowerment. That hasn't happened. In my mind, the HSA concept is a good one. However, it shouldn't have been rolled out without first developing the necessary educational tools for the general public. It was also rolled out before shopping based on value (i.e. consumer evaluation of cost and quality) could become a reality.

Now we simply need to get caught up. We need to make the insurance realm less complex with more standardization of coverage and medical/reimbursement policies. We also need to continue down the road of making value more transparent within the industry. Progress is being made as more people realize the need to make quality and cost information available.

What have we learned? - Solving problems requires not only addressing the issues, but also looking at the entire picture to be sure that all bases are covered, as well as making sure that the components of the ultimate solution are carried out in the right order.

What if?

• What if Barack Obama decided that his best contribution to healthcare reform would be to bring the system stakeholders to the table to hammer out solutions, not letting them leave until they do so?
• What if we stopped blaming each other for the problems of our system and started working together to fix the mess we created?
• What if we stopped playing politics with healthcare?
• What if the government imposed a tax on fast food?
• What if all insurance companies were not-for-profits?

Previous What if?.

Disruptive innovation in healthcare

If you are interested in healthcare system reform and you haven't checked out the September/October issue of Health Affairs, I strongly suggest that you do so. It has article after article of hard hitting, highly relevant proposals regarding what is needed to successfully reform our high cost system.

Several of the articles highlight the stubbornness of many within the current system. Most of the current stakeholders have been protecting their "turf" for quite some time, while costs have gone up and the patient-centered focus has been replaced with a provider-centered focus. The topic of disruptive innovation comes up often in the issue. Specifically, there is a need to break through the stubbornness and develop new business models that more precisely match treatments with conditions. At the same time, patients need incentives to seek the best value, which currently happens in nearly every other industry.

In order to contain costs, tasks within the delivery system must be pushed down to the lowest level possible while maintaining an acceptable level of quality. Generalists can perform some work currently done by specialists, nurse practitioners can perform some work of generalists, non-licensed staff can perform some of the work of nurses, and patients can handle some of the load currently handled by paid staff at all levels. The current physician practice model is not the best value proposition in every situation. For example, physicians should not be providing preventive care because it can provided just as well by nurse practitioners at much less cost. Not everyone can afford a BMW, so we need some Toyotas in the system.

In "Cost-Reducing Innovation In Health Care", James C. Robinson and Mark D. Smith discuss the need for deregulation within the system, including: "consideration of provider scope-of practice and licensure rules, insurance mandated benefits and 'any willing provider' statutes, the federal ban on 'gainsharing' between hospitals and physicians, impediments to new market entry, and laws that prohibit for-profit firms from competing with their tax subsidized,
nonprofit brethren." Over time we have built quite a monster, and now it's time to take a fresh look at things.

Health Affairs is a good source for insight on reform. We need new ways of looking at things and the healthcare sector needs to be willing to adapt to allow for long overdue improvements. There will be some pain to endure for many stakeholders, but the only alternative for those that remain stubborn could be irrelevance.