Whether apparent or not, fraud and abuse affect every person’s healthcare. Stopping the thieves will save the system hundreds of billions of dollars per year. That’s why eliminating fraud is essential, as described in the next chapter.
A twenty-first century health system can assure every American access to continuously improving, affordable, state-of-the-art care, just as we always expect to see better TVs or cell phones. It requires a new business model in which each producer or provider strives to produce the finest quality product or service in the most efficient manner, and the government creates a regulatory framework that assures these products and services are integrated into an efficient system that offers real choice to consumers.
Appropriateness
Perhaps Americans’ most important healthcare concern is to receive the right care for the right reason that achieves the right outcome. In fact, there is no other reason than this to seek professional care. People trust and depend on the medical profession to consider their unique needs and to have the expertise and tools necessary to assure personalized care.
In the past, physicians made a diagnosis according to patient history, physical exam, lab tests, and X-rays. Then, based on treatments approved by the Food and Drug Administration (FDA) that had been tested on others, they prescribed a treatment plan, and both patient and physician hoped for the best. This hit or miss process should be a thing of the past.
Thanks to breakthroughs in science and technology, we will soon be able to radically transform healthcare so that treatment is no longer based on population medicine, but on personalized medicine.
This can begin with modernizing the FDA, which should create a science-based regulatory framework to approve medical products based on the scientific knowledge of their mechanism of action in individuals, not just on the observation of outcomes in large populations. By implementing this framework within large and diverse healthcare delivery systems, modern information management systems can monitor performance of medical products after regulatory approval. This can allow us to continuously define and communicate to patients and physicians the safety and effectiveness of those products.
We must also create a strategy for individual wellness that enables healthcare providers to use emerging tools of science and technology to identify risk or susceptibility to disease, and to personalize prevention strategies relating to lifestyle, nutrition, access to early detection, and continuous health management. Numerous creative interventions are now being developed that empower individuals to continuously engage in managing their own health using wireless at-home systems. Those systems can monitor health parameters and provide guidance for prevention interventions to Internet-based and employer worksite programs that promote wellness.
Appropriate care is the key to optimal quality at the lowest possible cost. For example, the FDA recently commissioned a study to use genomic data to help define the optimal dose of Coumadin, a blood thinner widely used to prevent blood clots. By using this new technology to better provide the right dose for patients, the right outcome was achieved. Fewer patients were under-dosed, which could cause continued clots resulting in strokes and other serious problems, and fewer patients were over-dosed, which could necessitate emergency treatment for bleeding. In spite of the cost of doing the genomic test in all patients, the projected cost savings for one year due to reduced complications requiring additional medical care reached hundreds of millions of dollars. The real story is not just saving money, but saving people the horrendous burden of an unnecessary stroke or hemorrhage.
HOW CAN WE ASSURE THAT CARE IS AVAILABLE, AFFORDABLE, AND APPROPRIATE? THE FOUR BOXES OF HEALTH AND HEALTHCARE THAT MUST BE CHANGED
To create a system of better healthcare at lower cost, we have to stop fighting over how much it would cost to expand the current system and talk instead about real change in the four distinct but interrelated boxes of health and healthcare:
The Individual. A personalized health system will only work if the individual is empowered and engaged. This requires people to be equipped with the knowledge and access they need; they also have to understand, accept, and be incentivized to make responsible choices.
In this system, you will have more individual rights but also more responsibilities. You will have access to more information and choices but will be expected to become partners in your own health and healthcare. Even the best doctor, of course, can’t help a patient who is unwilling to comply with medical and preventive recommendations.
The Culture and Society. We need to maximize positive cultural and societal patterns for a healthy community. This includes changing the policies, institutions, and environment that impact the choices made by individuals.
For example, given the current epidemic of childhood obesity, we should insist that schools serve healthy lunches, offer healthy snacks, and include physical education as part of the daily curriculum. Likewise, if we encourage healthy diets but high-risk neighborhoods have no access in their local stores to fresh fruit and vegetables—or if healthy food is prohibitively expensive—we will probably not have much impact.
The Delivery System. We have to create an effective, efficient, and productive health delivery system. This means we must adopt new technologies, new models, and a new culture. A future where the healthcare system focuses on the individual, where learning is constant and in real-time, and where innovations are much more rapidly driven through the system will require a different type of delivery system. There will be more partnering, increased reliance on IT-ASSISTED knowledge and expert systems, and an emphasis on health professionals acting as consultants to one another.
The System of Financing. Finally, we need a financing method that enables not a single-payer system, but a 300 million-payer insurance system. There is no one-size-fits-all solution to expand insurance coverage, particularly because there are so many reasons why some Americans lack insurance. Some of the uninsured can afford insurance but have chosen not to buy it; some are temporarily uninsured because they have moved, lost a job, or their employer stopped offering coverage; and some are chronically uninsured and are essentially locked out of the system. The savings from better health and better quality care can be used to insure every American through a robust, competitive private market that leads to more choices at lower costs.
A PRO-JOBS, PRO-GROWTH PLAN FOR HEALTH REFORM:
The Center for Health Transformation’s Plan for Better Health and Healthcare
The solution is to build a system that gives every American more choices of greater quality at lower costs. This will not be found in the giant healthcare bill passed by Congress. This encompassed the secular-socialist model of more spending, more regulations, and more bureaucracy.
At the Center for Health Transformation, we have been working for the past seven years to develop transformative solutions. If Americans want to build a system that is available, affordable, and appropriate for every American, we should take the following innovative, practical steps:
Reward health and wellness. The Centers for Disease Control and Prevention reports that 64 percent of adults are either overweight or obese. The CDC also states that diabetes is a major factor in killing more than 220,000 Americans every year. These two conditions, which cost our system hundreds of billions of dollars annually, mostly stem from poor individual choices. We must focus on health—then healthcare—and individuals must take an active role in becoming healthier. Tools like the Gallup-Healthways Well-Being Index can help identify and focus on communities most in need. Leadership like that shown by First Lady Michelle Obama with her “Let’s Move” initiative is also essential.
We should give health plans, employers, and Medicare and Medicaid more latitude to design benefits to encourage, incentivize, and reward healthy behaviors. We should incentivize individuals to participate in worksite wellness programs, focus on prevention, and adopt healthy lifestyles. We should create broader incentives to purchase healthier foods in the food stamp and WIC programs. We
should also increase federal funding to public schools that 1) have physical education five days a week for every K-12 student, and 2) provide breakfasts, lunches, and vending machines that promote healthy foods.
Meet the needs of the chronically ill. Most individuals with chronic diseases want to control their own care. The mother of an asthmatic child, for example, should have a device at home that measures the child’s peak airflow and should be taught when to change her medication, rather than having to go to a doctor each time.
Being able to obtain and manage more health dollars in Health Savings Accounts is a start. A good model for self-management is the Cash and Counseling program for the homebound disabled under Medicaid. Program participants can manage their own budgets and hire and fire the people who provide them with custodial services and medical care. Satisfaction rates approach 100 percent, according to the Robert Wood Johnson Foundation.1
We should also encourage health plans to specialize in managing chronic diseases instead of demanding that every plan be all things to all people. For example, special-needs plans in Medicare Advantage actively compete to enroll and cover the sickest Medicare beneficiaries and stay in business by meeting their needs. This is the alternative to forcing insurers to take high-cost patients for cut-rate premiums, which guarantees these patients will be unwanted and ultimately untreated.
Speed medical breakthroughs to patients. Breakthrough drugs, innovative devices, and new therapies to treat rare, complex diseases and chronic conditions should be sped to the market. As discussed above, we can do this by cutting red tape before and during review by the FDA, and by deploying information technology to monitor the quality of drugs and devices once they reach the marketplace. Faster time to market will save lives and money.
Make insurance affordable. The current taxation of health insurance is arbitrary and unfair, giving lavish subsidies to some, like those who get “Cadillac” coverage from their employers, and almost no relief to people who have to buy their own policy. More equitable tax treatment, in addition to other market improvements, would lower costs for individuals and families. Many health economists argue tax relief for health insurance should be a fixed-dollar amount, independent of the amount of insurance purchased. We should give Americans the choice of a generous tax credit or the ability to deduct the value of their health insurance up to a certain amount.
Make health insurance more secure. The first step toward genuine security is portability, which is also the best way to solve the problems of pre-existing conditions. Employers should be encouraged to provide employees with insurance that travels with them from job to job and in and out of the labor market. Moreover, individuals should be allowed to buy health insurance across state lines. When insurers compete for consumers, prices will fall and quality will improve.
Help small businesses. The self-employed, small businesses, and certain organizations are legally prohibited from banding together to purchase health insurance. This limits not only the freedom of private citizens to collectively organize, but it creates an enormous barrier to obtaining health insurance. We should allow individuals and small businesses to pool together, giving these associations greater bargaining power for more affordable coverage.
Inform consumers. Patients and consumers need to have clear, reliable data on cost and quality before they make decisions about their care. In fact, they have a right to know this information. But finding such information is virtually impossible. Sources like Medicare claims data (stripped of patient information) can help consumers answer important questions about their care. Government data—paid for by the taxpayers—can answer these questions and should be made public. Websites like those created by former Governor Jeb Bush in Florida, Governor Sonny Perdue in Georgia, and insurers like WellPoint, as well as dozens of other resources, effectively inform consumers about the quality of the doctors and providers they see and the products and services they need. Genuine public access to valuable information data will push providers, health plans, public programs, and all other stakeholders to improve.
Allow doctors and patients to control costs. Doctors and patients are currently trapped by government-imposed payment rates. Under Medicare, doctors are not paid if they communicate with their patients by phone or e-mail. Medicare pays by tasks—there is a list of about 7,500 of them—but doctors do not get paid to advise patients on how to lower their drug costs or how to comparison shop online. In short, they get paid when people are sick, not to keep them healthy.
So long as total cost to the government does not rise and quality of care does not suffer, doctors should have the freedom to repackage and re-price their services. And payment should take into account the quality of the care delivered. A number of private insurers are experimenting with more effective and more pro-health payment systems, but the sheer size of Medicare gives it the potential to make a decisive difference.
Migrate every doctor to best practices. In order to ensure that health is the driving focus of our renewal efforts, we should determine what methods are actually saving lives and money, then design public policy to encourage their widespread adoption. For example, according to the Dartmouth Health Atlas, the definitive authority on healthcare quality and variation, if America’s 5,500 hospitals provided care at the level of Intermountain Healthcare in Utah or the Mayo Clinic in Minnesota, Medicare alone would save 32 percent of total spending ever year—with better health outcomes.2 We need to make best practice minimum practice.
We should create a private-sector-led best-practice initiative that educates the industry on documented, evidence-based best practices that work. This initiative should support the development and diffusion of knowledge in order to expand care, improve outcomes, and lower costs—and explicitly should not be used by government to ration care.
Paying for quality care. Our current payment system pays doctors and providers for simply delivering care regardless of the outcome. Doctors, hospitals, and other providers that deliver better care are mostly paid at the same rate as those who provide poorer care. Like any other rational market, we need a reimbursement model that takes into account the quality of the care delivered, not simply that it was delivered.
We must incentivize the use of best practices, chronic care management tools, and information technology. We need to eliminate the vast geographical differences in reimbursement, and to promote the development and use of primary care and its providers. The delivery reform proposal released in November 2008 by Kaiser, Intermountain Healthcare, and the Mayo Clinic provides a range of options that would be vast improvements over the status quo, including bundled or episode-based payments, Accountable Care Organizations, and chronic care coordination payments.3
Don’t cut Medicare. Obama’s health reform bill cut Medicare by around $500 billion. This is wrong. Medicare is undoubtedly unsustainable, as the government has promised far more than it can deliver. But this problem will not be solved by cutting the program in order to create new unfunded liabilities for young people.
A sound roadmap to shore up Medicare was released in 2000 by the National Bipartisan Commission on the Future of Medicare. Central pieces of that report have been implemented, most notably the prescription drug benefit, but others, particularly those that address the program’s long-term solvency, have been ignored. Reviving many of these recommendations, along with new proposals, can save Medicare for future generations. Solutions include:• Introducing premium support to stimulate competition among providers and private insurers.
• Increasing beneficiary choice.
• Introducing the same competitive features of the prescription drug benefit and the Medicare Advantage program to other areas, such as durable medical equipment and Part B drug pricing.
• Targeting assistance to lower- and moderate-income seniors.
• Incentivizing beneficiaries to seek out Centers of Excellence that deliver the highest-quality, lowest-cost care. Consumer demand will help address the egregious geographic variance in
cost and quality.
Protect early retirees. More than 80 percent of the 78 million baby boomers will likely retire before they become eligible for Medicare. This is often the most difficult time for individuals and families to find affordable insurance. We can build a viable bridge to Medicare by allowing employers to obtain individually owned insurance for their retirees at group rates; allowing them to deposit some or all the premium amount for post-retirement insurance into a retiree’s Health Savings Account; and allowing employers and younger employees to save tax-free for post-retirement health.
Transform Medicaid and drive innovation in the states. Governors and legislators know their constituents and understand the special needs of their local communities far better than anyone in Washington. They should have much more freedom to improve their Medicaid programs in their own communities. Key priorities should be to mainstream Medicaid beneficiaries into private insurance coverage, be it with an employer or an individual policy; to utilize modern information technology systems; and to identify and adopt the best practices in Medicaid across the country so that other states may duplicate and improve upon them. These kinds of changes will turn Medicaid from the disaster that it currently is into an effective, efficient program.
To Save America Page 19
