I don't know Ezekiel J. Emanuel, MD, PhD personally. I read everything he published while framing and evolving the Affordable Healthcare Act. There was even a free Coursera course to help familiarize interested parties in the successes and limitations of the final policy. Because I was spending so much time working in DC I had the opportunity to drop in on discussions at the Brookings Institution, Kaiser Foundation, and other panel think tanks--I began learning about health policy from the architects of change.
A discussion about MACRA at the National Press Club in Washington DC was the first working discussion I had about the pending reform from CMS. You can actually see me in the lower right corner of the screen from time to time. I wrote about it here...What you don't hear is my question posed at the end. I asked Dr Emanuel what he meant by "we". Did he mean his physician colleagues? Specific stakeholders in government or industry? I don't think he meant the patient. Perhaps his non-response of a chuckle is all the answer I needed.
I read the editorial below with keen interest. Have we finally recognized new truths? A new way of doing business? Or are we all still admiring the problem. There is nothing new here. Healthcare costs are escalating out of control. You don't need a soothsayer for that pithy insight.
MACRA, is intended to pay healthcare providers for value--code for the outcomes of their patients--rather than fee for service (tests, hospital visits, etc). But for the foreseeable future we are billing fee for service but paying providers for the outcomes of their patients. The architecture of the healthcare payment model will be slow to recreate. For now we need it for risk adjustment and recording physician behavior for starters.
Healthcare providers are stuck in the crosshairs. A recent article in the New York TImes, How Medical Care is Being Corrupted does a nice job articulating the evolving dilemma. Performance measures are great but not so much for the patient in front of you--zoom out to the population level--now perhaps we are getting warmer.
But financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.--PAMELA HARTZBAND and JEROME GROOPMAN
I continue to write about healthcare as a public utility. The idea fascinates me. For one it doesn't ignore what would happen to GDP, unemployment, and inflation if like magic--healthcare costs began to decline as a share of GDP. What happens to the economic model if we were actually successful and instead of approaching and surpassing 18% GDP we dropped to 16%?
We use the threat of 20% GDP as a motivation to address waste in healthcare but what do you expect if we increase our toxic outputs into water, air or support inadequate food policies or agriculture policies?
We are not expecting any solutions, magic bullets, or paradigm shifts. Because if we were, we would be talking about real change--prevention. A health model instead of an "illness" model. I think the time for revolution in healthcare is now. We can even trace the changes directly into the public utility model of electricity.
Like healthcare, utilities address large economies of scale--long-term capital investments--but deviates at protection for consumers. At the turn of the century this made sense. The industry (railroad, electricity etc) had a captive customer base in exchange for low-cost service. Healthcare was not the economic powerhouse of today. You could become a physician by sheer will alone--no training required.
But thankfully healthcare outcomes began to improve. The treatment was not necessarily as risky as the disease. Change is happening across the electrical grid as well. Solar power and increase efficiencies allow customers more independence, the scale of growth will likely never return to full capacity. If we nail prevention in healthcare, the demand for services will decrease. Both industries are fighting hard against reform that will threaten business as usual.
The similarites don't end there. Healthcare and electricity are often considered a "commodity"--price and function are the primary concern. Think of utilities wanting to recoup their 20 or 30 year investments. Sound familiar? Pharma is faced with trying to recover R&D costs or offer a return to investors. Could that be one reason the point of sale is so distorted? Six figure pills to treat chronic diseases?
I can even think of a dialogue to address the "innovation" will die drumbeat.
Change always comes from the edge. The interface if you will. Healthcare is no different. It will be the patient that drives value and will guide the evolution of a new model.
Not algorithms that incentivize care based on carrots and sticks. Or cost saving practices returning more profit to share holders--ignoring the patient role.
Lets look to participatory models, not value chains. We need powerful grids of interconnected care models--think prevention, food policy, agriculture policy, and sustainable investments in social correlates. Go ahead and think about new business models. I'll leave the light on...