Sunday, August 3, 2008

Governor Phil Bredesen: Three Health Care Reform Principle

In a July 31, 2008 blog posting entitled "Think Gas Prices Are High? Watch Out For Health Care," Governor Phil Bredesen outlines three principles for "Americans of many different political stripes [who] are ready to stop tinkering and instead devise a fresh and national solution to our health-care challenges."
Summarizing the three principles:

Principle 1: Incentives.

"The first principle is to once and for all fix the incentives.....One way to start would be to develop a national standard for what constitutes optimum quality health care in treating some of the more common and expensive diseases: diabetes and various forms of heart disease, for example. With a legally sanctioned standard, payments to providers could be revolutionized to pay for high quality and value — not just quantity."

Principle 2: An Rx for everyone
The Governor argues that we need to "build a solution good enough for all Americans." He cites as examples Social Security or Medicare and contrasts these with the "patchwork and means-tested government programs" that genearally don't "enjoy broad public and political support." He points out that this is not equivalent to "government largesse" but instead should be a benefit "earned by and owned by every American." This is a "national health care solution."

Principle 3: Incremental change
The Governor argues for "incremental change" and argues that one first step "might be federal underwriting of the costs of some of the most expensive diseases..... By insuring some of these costs, we could quickly transition our nation to managing many diseases in organized systems of care and paying for quality and outcomes, not procedures and pills."

These are some tough challenges but carry some popular, consumer-focused concerns. They could be used to tackle some of the big challenges (although all such plans to cover one or another disorder risk lobbying by many special interests). They require a radically different approach to managing the health information that individuals and their care providers need. They require a new view of quality based on meaningful metrics and not diagnostic and procedural claims along.

Governor Bredesen's "three principle" principle.
This is not the first time our Governor has boiled down complex issues into a short list of guiding principles. Three seems to be a magic number.

Take, for example, the three ideas he promoted in his HIMSS keynote of 2007. Paraphrasing his three ideas:
  1. Build version 1.0 first. He commented on the complexity and broad approach without establishing early wins.
  2. Focus on an achievable goal with broad implications. He mentioned e-prescribing and medication management as issues that affect nearly everyone. (Indeed, over year later, arguably the incredible progress that has been made through adoption and the merger of SureScripts and RxHub are the result of industry and congressional action more than emphasis by NHIN.
  3. Focus on adoption. He argued that attenion should be paid on how technologies should be focused on providing new value to providers and patients in "average" communities and not the more advanced and early adopters of technology innovation.
Governor Bredesen gave another three useful principles in a Democratic respose to a Saturday morning presidential radio address on June 11, 2005. Entitled Medicaid 2.0, the address, focused on three principles that are consistent with his most recent blog posting and should reassure those who think a comprehensive approach necessarily means government spending run amok. His principles are:
  1. Everybody pays something. Using the same "shopping in the store" metaphor for moral hazard mentioned in his more recent July 31 posting, the Governor said that "until everyone has a little skin in the game, the system will continue to be inefficient. "
  2. Pay for the important things first. Using acid reflux as an example of what not to pay for, the Governor said "Medicaid 2.0 needs to pare down what it pays for so that everyone has access to basic health care before we bring in the fancy trimmings." Again, looking from the perspective of a health care executive, his most recent address focuses on high overall spending conditions like diabetes and heart disease. (Eight years ago, this writer learned that from a pharmacy benefits management perspective, high spend drugs where not always for high-impact health conditions: non-sedating antihistamines and acid reflux medication topped the list.)
  3. Pay for what works. Although the Governor noted in 2005 the growth in "me too" drugs, the notion of "paing for what works" is very much in the national spotlight and the topic of much discussion under the rubrick of "comparative effectiveness." For more information, refer to recent Roundtable on Comparative Effectiveness activities of the Institute of Medicine.
Lists of three really work - particularly if over time the lists form an internally consistent pattern and drive towards an important goal. This writer is aware of three lists from one enlightened governor: one list focused on health care reform priorities and methods, a second on information technology, and a third paralleling the first and focusing on Medicaid. Some of the entries on the list can be achieved within a year (effective e-prescribing and medication management, for example). Others will take time and depend greatly innovations in quality, payment reform, and the evidentiary basis for care.

The challenge I believe, is to turn a short and easily understood set of guiding principles into an effective plan of action that demonstrates clear progress for the average American. The current fragmented approach drives well-intentioned individuals and organizations into spending an inordinate amount of their resources navigating a bureaucracy made unmanageable by four decades of modification. There is little value in uneccesary complexity. Maybe its time to "think in threes."


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