Friday, July 24, 2009

Seeing the Sunny Side of Health Care

swimming-against-the-stream Over the past few months, we have heard a lot about what is wrong with health care.  Specifically in my home state of Florida, we continually hear that we are mediocre, expensive, and fraught with fraud. Well, all of this is true - in the aggregate.  What we have is a system problem, not a person problem. The health care system encourages organizations and people to do certain things that lead to low quality and high cost care. But luckily, some have the courage to swim against the stream and even more luckily for me, this characterizes the health care community of Tallahassee, Florida.

Locally, two of our leading health care organizations, Tallahassee Memorial Healthcare and Capital Health Plan are consistently regarded as industry leaders. TMH is a private, not-for-profit, integrated health care system that was one of 13 international participants in the Institute for Healthcare Improvement’s successful Pursuing Perfection initiative.  CHP is a private, not-for-profit mixed model HMO that is consistently ranked among the best managed care plans in the country.

Earlier this week, at a one-day conference titled “How Do They Do That? Low-Cost, High-Quality Health Care in America,” some of our nation’s most thoughtful health leaders convened local leaders from 10 communities – including Tallahassee - to share their success stories. The event did not get as much national media attention as it deserved, especially given that Congress is busy remaking 20% of our national economy, but it did get very nice coverage from the dependable Kaiser Health News, NPR’s Morning Edition, and the New Health Dialogue Blog. Additionally, it is comforting to know that but White House Budget Director Peter Orszag was an active participant.

Dr. John Lumpkin, the Director of the Health Care Group at the RWJF and a former colleague of mine, provided an excellent summary at RWJFs health reform blog, The Users' Guide to the Health Reform Galaxy. When it came to lessons learned, he noted:

6a00d8341c975b53ef011572240ae8970bEach team spoke about the cultures, delivery structures and accountability mechanisms that underlie their success. No two are alike – but the way they practice medicine is far more "systemlike" than we are used to seeing in our fragmented U.S. health care “system.” Some patterns: a culture of collaboration to put patients first; considering finances as a constraint, not a goal; the importance of physician leadership; the real or virtual integration of delivery systems across the continuum of care; the importance of strong primary care; the value of electronic health records and the information-sharing it makes possible; and an emphasis on measuring and reporting data on quality and utilization…

I walked away persuaded more than ever that while we are a nation in search of reform, reform will actually happen one community at a time.  We need these lessons about collaboration that were on display at the symposium, the types of lessons that are also emerging from Aligning Forces [for Quality – AF4Q].  These communities show us collaboration on reforming health care is not only possible, it’s happening.  We need to clear the obstacles in their path and stand back and learn.

This last paragraph is echoed by Mr. Orszag, who stated:

"I guess the way I would put it is even if I was a benevolent dictator for a day, I wouldn't feel comfortable at this point, given the state of knowledge, completely overhauling the Medicare payment system," said White House Budget Director Peter Orszag, who has been studying the issue for several years.

These two statements and the comments from the participants are interesting in that they focus more on simplifying the current system (e.g. anti-kickback, Stark, and Medicare payment rules) than they do on creating new programs and complexity. The participants stressed the need for payers, especially Medicare, to mature their payment systems from the current fee-for-service or provider-specific prospective payment systems (e.g. DRGs) to a system based on paying for episodes of care or care for special populations over time. And finally, an interesting take-away from the conference was that local communities control their fates more than they imagine. Of the 10 high-performing communities, half of them used to have high costs and transitioned to low cost over the past decade.

As the old saying goes, all health care is local. Thus, we need to spend less time thinking about national government solutions (insurance system reform is another matter) and more time incentivizing local communities to perform their own performance improvement. There is an extremely helpful role the Federal government can play in improving health care and that is to clean up its own house by not doing many of the things it is doing today and by setting expectations, reforming its payment system, and promoting the spread of knowledge. In this way, hopefully we can bend, without breaking, the cost curve in health care. ~BAA