Monday, November 17, 2008

Think Big? Think Small?

Note: I'm moving to a new policy blog site:

The New York Times recently posted two contrasting positions from Ezekiel Emanuel (National Institutes of Health) and Stewart Butler (Heritage Foundation). Emanuel's position is entited "Think Big" while Butler's is entitled "Think Small." The articles are a wonderful, cross-referenced exposition of this critical issue. Both resonate
First, Emanuel's major points:
  1. Think big. "In health care, big plans are necessary not only to motivate people but as a matter of sound policy." It's about a system of care, or, as he says "reform must include changing the delivery system and how we pay for care. "
  2. Health policy is fiscal policy. "Forget Social Security or defense, health care costs are the long-term driving force in federal and state budgets." He points out that Orzag and rumored candidates for new positions (Summers, Cooper, and Furman are mentioned) all get health care. (Certainly this fan of Jim Cooper's believes he does like few others).
  3. Comprehensive care is cheaper care. "One of the secrets of health care reform that has not yet sunk in, is that bigger changes to the system actually cost less. " Emanuel references a previous blog posting about a Lewin Group Analysis.
  4. Institutionalize tinkering. Arguing that no plan is perfect, Emanuel believes that "good reform will make addressing these issues easy by not requiring major legislation for each adjustment."
  5. Everything is connected. He is persuasive, arguing that "health care is so big — $1 out of every $6 in the economy, dwarfing automobiles and all other economic segments. Everything is affected by health policy, and every decision should be examined for its impact on health care reform." It works both ways, every issue affects health care and health care policies affect every other issue. He identifies this relationship through example "Similarly, every favor to a constituency should be linked to support for the health care reform agenda. If the automakers want a bail out, then they and their suppliers have to agree to support and lobby for the administration’s health care reform effort."
Butler's pragmatic advice is equally pursuasive. He makes four points:
  1. Make a strong commitment to bipartisanship. Citing bipartisan proposals and state-led initiatives, Butler urgest the President-elect to "tell the more triumphalist liberal supporters on Capitol Hill to chill, and that he’s looking for common ground."
  2. Find better ways to use the money we are currently spending on health. He state that "rather than throwing tens of billions in new money at the health industry in an effort to expand coverage." and emphasizes on the critical need to reallocate the $200 billion tax expenditure on the tax exclusion. The Baucus proposal, released in white paper form last week "opens the door" to this possibility.
  3. Allow states flexibility to redesign existing health programs and use money more efficiently to reach the goal of maximizing affordable coverage. This was covered in one of his previous posts entitled "States are Good Guinea Pigs."
  4. Remember that Americans are very conservative about their health care. Given the President-elects own appeal to this conservative instinct when discussing Senator McCain's phase-out of the employer deduction, it would seem that this awareness is embedded. At the same time, we have a President-elect who often stated that he spent the last year of his mother's life contesting plan exclusions and other bureacratic issues. Perhaps our new President will be the first to have first-hand experience with the difficulties under our current system.
Both of these remarkable thinkers make sound points. Is there a chance to pursue both? Can Medicare be extended and stretch while at the same time allowing some experimentation and differentiation in the states? Is such differentiation even possible given the (as of this date) projected net decreases in State expenditures this year of over $66 billion?

Thursday, November 13, 2008

Learning from a Possible Automotive Industry Bail-Out

Note: I'm moving to a new policy blog site:

As I write this, the "old" automotive industry - GM, Ford, and Chrysler (most notably GM) - dominates the headlines. They are out of money, we are told. They need loans to innovate. Millions of jobs are at stake. Something must be done.

This is not news. I remember the gas lines of the Carter administration. The first car my wife and I bought was a Dodge Omni Miser introduced as part of Lee Iacocca's government-led Chrylser "bail out" and purchased in by us 1981. It had a four-cylinder engine, a heater, a stick shift, and that was about it. No radio of any kind. It was a great car.

Yet over the ensuing decades, little in the "old" automotive industry seemed to change. Rather than improve mileage significantly, a coalition of manufacturers, unions, and image managers kept us focused on immediate gratification. But in the ensuing decades, an entirely different "new automotive industry" emerged funded largely by foreign producers who created factories and jobs primarily in the "right to work" states. While the "old industry" encumbered greater legacy costs from generous benefits, and aging workforce, and products appealing to those who did not consider energy costs, the "new" automotive industry developed a younger, healthier workforce, products often (but not always) focused on greater economy, and more flexible manufacturing methods. The point is not to compare the "old" and "new" but to recognize that there are two distinct automotive industries in our country and that one is doing better than the other.

Far wiser people have made recommendations, but there are several common themes:
  1. The "old" manufacturers seem to have forgotten they are in the transportation business and not just the automobile business. (This case has been made recently by Robert Goodman who in turn cited a 1972 Stewart Udall article in the Atlantic Monthly).
  2. The "old" manufacturers are not making sufficient quantities of the kind of products people need for transportation
  3. The "old manufacturers are not making products that are affordable to the people who need them
  4. The "old" manufacturers are not addressing thorny problems of workforce equity. These range from exorbitant salaries for their senior leaders, generous benefits packages that for decades place few responsibilities on beneficiaries, and inadequate benefits for the many mechanics and service workforce essential for their industry but employed by dealers, garages, and suppliers.
  5. Advocates for the "old" manufacturers are having trouble breaking free of the very bonds with industry, unions, and selfish public expectation that got us into this mess.
There seem to be parallels between my experience with my automobiles and my experience in the health care system. While I waited for gasoline in the 1970s, I watched the "cost-plus" health care financing methods and saw the inequities even then between those who had access and those who did not. After buying my Omni Miser, I saw the first glimpse of accountability through TEFRA and other health care financing changes. And then, like the auto industry, I saw things stall out. I saw an increased focus on profits, I saw more unnecessary complexity, and I saw organizations competing over the wrong issues at the expense of the long term social and economic good.

Perhaps we can learn from the various "bail-out" proposals for our automotive industry? To what extent do we finance the status quo. (Interesting that one of America's larges corporations is asking for federal financing to "innovate." As Thomas Friedman asks "If we give you another $25 billion, will you also do accounting?"

Aren't there parallels?
  1. Do the organizations that deliver, manage and finance care understand that they are in the health care business and that this business is a system of care focused on the individual?
  2. Are these organizations enabling us to experience the degree of health we need?
  3. Are these organizations delivering these services in a way that is affordable?
  4. Is compensation and workforce development aligned with incentives to improve or is it designed primarily to enrichen the few at the top?
We are in the middle of a rich debate. Should GM be allowed to drift into bankruptcy? Should they be allowed simply to get additional funding from us? Should support be tied with strings managed by our federal government? Should we learn from the "new" automotive industry as we examine what went wrong? Should we look at the automotive industry in the context of the broader transportation crises in our country? A country where railroads are crumbling, bus transportation is second-rate, and mass transportation of other types is virtually non-existent?

I believe we need a transportation policy. Without a clear view of transportation as a whole, an infusion of money will not address a problem that has been apparent for decades. Similarly, I believe we need a health care policy that places the plight of our providers in the context of a populace that is increasingly undermedicated, uninsured, and prone to unhealthy life styles.

Neither the automotive crisis nor our health care crises can be solved by money alone. Neither can be improved overnight. But in each case, a clear understanding of purpose, a focus on what we really need, a renewed commitment to affordability, and a recognition of the workforce seem to be good places to start.

As a country, we are now in the "bail out" business. We must focus on the price we must pay, but even more important, we should focus on fixing the fundamentals. This will not be easy.

Tuesday, November 4, 2008

Unsolicited Advice for the President-elect

This blog has moved to:

As I write this, Americans are still voting in one of the most polarizing and critical elections in modern history. Although our preferences for presidents and other elected officials may differ, we Americans face a common reality, and it is this reality, I believe that must be the cornerstone of the inevitable re-evaluation that comes with an election of this significance.

Here are a few principles I would recommend to the new Administration.

Stop the hype

It is perhaps disingenuous to call for a cessation of exaggerated claims after one of the most acrimonious and expensive campaigns in history, but recipients of the many email press releases and announcements of HIT "accomplishments" are no strangers to the very real disconnect between what people say they are doing and what really works. Debate must be moved forward by a realistic assessment of our past accomplishments, not by exaggerated claims made by vendors, agencies, delivery organizations, and even the HIT "Illuminati." Let's build our delivery system on the basis of what we know can work rather than on what we hope will happen.

Never advance health information technology for its own sake.

Translated. Fix the health care system first, then draft health IT legislation. Information technology is a way to enable processes and realize goals. As Carol Diamond and Clay Shirkey recently wrote in Health Affairs: "If you computerize an inefficient system, you will simply make it inefficient, faster."

Acknowledge scarcity
There is little money for HIT at the federal, state, local, organizational, or individual level. We must do more with less. Demand for health outstrips supply. Priorities must be set. Every effort must be directed towards avoiding a catastrophic recession.

View health care as a central component of our economic infrastructure, not as a service.
Health care - like education and public safety - is essential for economic prosperity. We invest in schools and teachers to help create an educated populace; we invest in law enforcement to ensure the safety necessary for public prosperity. We invest in health to ensure that our citizens are not limited unduly through avoidable illnesses or inadequate treatment. Health care is about the individual! If we start with the goal of a healthier individual, we will realize healthier families and communities and, in the process refine our health care system to assure the achievement of these central aims. We would put an end to delivery silos that do not make sense and would move naturally toward a system where knowledge, coordination of care, self-sufficiency, and evidence dominate.

Build on what works

A lot of good ideas have been advanced over the past eight years (and some rather flawed ones). It is critical to build on the ideas that are gaining momentum and where additional effort can align these efforts with near-term outcomes. These would include ongoing efforts to achieve price and quality transparency, a growing consensus on the problems with our current privacy infrastructure, and our emphasis on prescription medications. Each of these efforts need a lot more work than press releases would imply. But they are important and positive legacies.

Give providers a stable mechanism for payment

If providers have a reasonably reliable forecast of what they are to be paid to do, and if these forecasts treat everyone more or less the same (i.e. fewer networks, differences in payment, coverage for everyone), I have every faith that providers will invest their own funds on systems that work to achieve their aims more efficiently. Right now, we ask providers to invest heavily in EHRs that often cannot realize their potential because communication with labs, pharmacies, and other care providers is not optimized, because critical workflow issues have not been resolved, or because they cannot support ongoing expenses to accommodate an ever-changing payment system growing in complexity. is not available or because

Develop the health care workforce
The aging population will create unparalleled demand for a flexible workforce capable of meeting growing needs. At the delivery level, we do not have sufficient home health aids, nurses, nurse aides, and other care workers required to meet the demand. In many cases, these very care providers are not able to pay for health care coverage for themselves or their families. At the administrative level, cut-backs and early retirements in government threaten to eliminate critical organizational memory at the very time where we must work even harder to simplify program administration and advance coordination. A commitment to a workforce must be a top priority.

Kill all unnecessary complexity
Complexity without measurable value is arguably the most immediate target for change. Every unnecessary administrative step saps our health care system of dollars that could be spent on care. Clinicians are told repeatedly they must standardized care based on best available evidence. I agree. But should not intermediaries do the same thing? If so, will we continue to see the hundreds of different formularies, prior authorization rules, network negotiations, and other administrative nuances that make every plan different than another? Progress is being made here, but there is still much work to be done, and the message must be made loud and clear that best practices will drive both the administration and payment of care as well as care delivery itself.

Incorporate health care services training into our educational system

At the community college level, teach the next generation of computer technicians what HIPAA means and what the differences are between servicing a convenience shop computer and servicing a system in a health care setting
At the work force level, create more programs that produce flexible health care workers who pursue lifelong learning and who are adept at both the humanism and technologies required to provide care for our aging society

Focus on functions, not products

There has been a tendency to objectify nascent efforts instead of viewing these efforts as unique and evolving combinations of specific components and discrete services. When we speak RHIOs, PHRs, and even EHRs we are really talking about combinations of services like medication histories, clinician notes, laboratory values, and alerts alerts. These in turn rely on core principles like data integrity, auditing, non-repudiation, authentication, and authorization. Principles should guide the use of specific services and efforts must be made to encourage secure "data liquidity" to ensure the right information is made available at the right time. By focusing on these services rather than on products, we advance the public trust without immobilizing innovation in the bureaucratic morass or product certification or accreditation.

Simplify NHIN
If there is to be an NHIN, there are about 12 core services that I believe should gain top priority. My priorities are to be found on my blog and has been discussed in a trade press article.

Enormous amounts of effort have been expended over the past eight years to create a more effective health care system. But somehow, things have gone awry. I often make the analogy to a soccer game. Health care is like a soccer game with 10 teams and 14 balls. Everyone is running around kicking, but since there appear to be no rules or order, the "game" is mere exercise. It makes no sense beyond that. The efforts of these countless hours and many projects have contributed to the collective wisdom. We now must be honest with ourselves and ask:
  • what is the primary problem we want to solve? (I'd claim it is a healthier society)
  • what preconditions are required to ensure that technologies can make a difference?
  • what have we done that gets us closer to a solution?
  • what have we done that has only worsened the "problem" and distracted us from our goals?
I think it is time to take a deep breath and think very hard about what it is we want to accomplish; then ask ourselves how we can help; then re-visit our principles and revise our policies; and only then, start programs and legislation to ensure we get what we now know we need.

And more than anything else, we should - individually and collectively - promise each other that if we are doing things that do not help, we will cease our efforts in these directions and turn towards more positive things.