Wendy Everett is president of the New England Healthcare Institute. She thinks that the candidates for President from both parties agree on the important stuff for health care–dealing with chronic care prevention. I can’t say that I’m totally in agreement with her political analysis, but her ideas about chronic care and prevention for the basis of bipartisan action are interesting (and as Wendy used to be my boss at IFTF I thought that it would be polite of me to let her have shot on THCB!)
The presidential candidates are doing a disservice to the voters and to themselves when they emphasize their differences over how to fix the broken health care system. They can argue all they want about the likes of universal coverage, tax incentives and employer mandates, but that cacophony obscures the fact that the candidates, regardless off party, actually share a major position on health reform. Though little-noticed to date, there is a breakthrough bipartisan consensus that the key to health reform is to redirect the system to prevention and management of chronic illnesses.
This unanimity is huge. Chronic diseases – including conditions such as diabetes, asthma and hypertension – are a major threat to both our health and our economy. More than half of all Americans already suffer from one or more chronic ailments, and the rate is rising as the population ages.And the price tag is staggering. Some 80 percent of the more than $2 trillion in annual health expenditures already goes to taking care of patients with chronic diseases. A recent Milken Institute study found that in 2003, chronic care cost the country $277 billion for treatment and another $1 trillion in lost worker productivity. If nothing is done to halt the rise of chronic illness, the Milken Institute projects that treatment and lost economic output will rise to $4.2 trillion by 2023.
And yet much of this cost is completely avoidable.
With preventive programs such as early screening and health counseling,
many chronic conditions can be delayed or prevented. But sadly, our
health care is geared to sick care – providing costly treatments rather
than keeping patients healthy. We pay doctors to remove disfiguring
skin lesions but provide little incentive for regular screening or
counseling to avoid skin cancer in the first place. Gastric bypass
surgery is an increasingly popular option for obese patients, but where
was the diet and fitness counseling before the weight problems
developed?
It’s as clear as day that better prevention and management of chronic
conditions are absolutely key to health reform. Keeping people healthy
will save money and save lives. So where in the din of disagreement
over health reform are the presidential candidates on this? You
wouldn’t know it from the headlines, but they are in sync, Democrats
and Republicans alike. The bipartisan consensus around health reform
emerged last fall at a forum in Boston sponsored by the New England
Healthcare Institute. The forum featured a panel of health policy
experts from the presidential campaigns, and they all agreed that
increasing health care coverage and controlling health care costs was
necessary but not sufficient. The real key, they agreed, was to
constrain costs by tackling the chronic disease epidemic with
prevention and management programs.
As Christopher Jennings, a top health care advisor to Senator Hillary
Rodham Clinton, put it, “”You cannot deal with the issue of coverage if
you don’t deal with the issue of costs, and you can’t deal with the
issue of costs of you don’t deal with the issue of prevention and
chronic care management.’’
Accomplishing this will require fundamental change in the way the
system reimburses doctors and other primary care providers, according
to Douglas Holtz-Eakin, a former director of the Congressional Budget
Office who is now policy director for the John McCain campaign. “We
have a system where we pay people to do things to patients instead of
having them well,’’ he told the NEHI forum. “We have to pay people for
diagnosis, for prevention, for coordination, and ultimately for better
outcomes.’’
Dr. Rahul Rajkumar, a health care advisor to Barack Obama, said that
transforming health care through better prevention and management of
chronic illnesses must be “”a shared project’’ with innovative thinking
across the board, from payers to providers to patients.
Timothy Murphy, who was secretary of Health and Human Services for
Massachusetts Governor Mitt Romney and is now advising the Romney
campaign, applauded the “unison about the issues of disease management,
prevention and wellness’’ among the presidential campaigns. And disease
prevention is a hallmark of Mike Huckabee’s health reform proposal.
So bingo, a bipartisan consensus on where to focus health reform:
Controlling costs through the prevention and management of costly
chronic diseases.It’s a shame that this bipartisan consensus has not
gained political traction or public attention. In the heat of a
campaign, it’s just too easy to trumpet for universal coverage rather
than to advocate for wholesale change in the delivery of health care.
The candidates and the media find it more compelling to focus on
dramatic differences. But in the end, this critical area of agreement
may be more important than where the candidates disagree. So spread the
word and get out the vote: there is a bipartisan route to real health
reform regardless of who is elected the next president of the United
States.
Which brings us to the crux of the issue: what exactly should be done
to help fix health care? We have identified a series of policy actions
that we call the NEHI Nine:
In prevention, first we need to find out what works; then we should
promote those services with financial incentives for physicians and
patients; and finally, we ought to make a serious national commitment
to reduce unhealthy behaviors through a wide variety of initiatives in
government programs, employer health benefits, and community and public
school outreach.
For chronic illness, we need to encourage and reward the use of proven
best practices in both clinical and employer settings; promote health
information technologies that improve the management of chronic
illnesses; and expand research to identify high-quality and cost
effective delivery systems for chronic care.
And in primary care, we need to provide payment for innovative ways to
deliver primary care, including by non-physicians, by medical teams,
and in non-face-to-face encounters; increase payments to physicians to
reimburse them adequately for both prevention and treatment services,
especially for obesity, diabetes and other chronic conditions; and make
the redesign of primary care a high priority for the U.S.
Only by realizing these fundamental reforms will the U.S. health care
system be equipped to confront and contain the scourge of chronic
illness that is threatening our health, our health care system, and our
economy.
Categories: Uncategorized
“you might consider supporting the cultural shift to more individual responsibility in health care”
You hit the nail on the head there… a cultural shift. I believe that’s what it’s going to take – but not just for the individual, but all facets of society; primary care, food production and delivery, media and marketing.
But aren’t all major, substantive cultural changes preceded by a major event or disaster of some kind? I think the US needs to experience some hard times, we’ve had it too easy and its showing on our waistlines.
MG, I have to wholeheartedly agree with you, provided that I did understand you right.
When I obtained my MPH during my last year of medical residency, I was at times a little annoyed how certain buzzwords are patched together to form “solutions” or “suggestions” that border to the meaningless in their generality (Susan, are you going for a public health degree, or already obtained it? … just kidding).
I think some people saw a libertarian slant when I emphasized personal responsibility in my first post on this page. I do not think that personal responsibility and a caring society are mutually exclusive. In practical terms, I favor a single payer health care system, but I also think that prevention should be enhanced by:
-incentives for compliance (for instance, financial incentives for diabetics who lower their HbA1c, or for people of normal weight)
-providing all reasonable help for the above (e.g. health counselling by schooled personnel, nutrionist’s advice, tax breaks for fitness clubs)
-creating a society that pressures the individual to take care of one’s individual health
The last one does not sound good, does it? Less freedom, more collective coercion? But if you think what society already expects from all of us – be productive if you are able, take care of your children, eat with your mouth closed etc.) – you might consider supporting the cultural shift to more individual responsibility in health care. You would have to make the effort of pushing a major policy iniative. And it wouldn’t work well without general coverage (how can you bring your HbA1c down if you cannot always afford your medicine?).
“In prevention, first we need to find out what works; then we should promote those services with financial incentives for physicians and patients; and finally, we ought to make a serious national commitment to reduce unhealthy behaviors through a wide variety of initiatives in government programs, employer health benefits, and community and public school outreach.”
I don’t mean to be glib but these recommendations are so open-ended/devoid of details as to inspire either apathy or mockery. Some of the suggestions (“we need to find out what works”) are either way too broad in scope/unrealistic for 7 reasons and others (“reduce unhealthy behaviors through a wide variety of initiatives in government programs, employer health benefits, and community and public school outreach”) involve a much larger and more serious philosophical discussion about how Americans live and the choices they they make.
I don’t buy it either. This analysis commits the “capital sin” in health care, i.e., confusing financing, and equity and efficiency in financing health systems, with delivery of medical care.
From the point of view of organizing the delivery of medical care, clearly emphasizing chronic disease prevention is good, whether or not it saves money to “the system” (it does not necessarily — the fact is, the cheapest is to let people die).
Whichever is the case, focusing on prevention is good all else being equal — it may help people live healthier and longer lives.
It is also good, all else equal, to have good doctors rather than bad doctors, and electronic medical records than not have them. And it would be truly wonderful if everybody ate their broccoli and quit smoking.
But the “all else equal” clause is not met in America. We know all too well that, when it comes to financing health care, in America nothing else is equal. And broccoli, chronic disease prevention, and EMR have little, if anything, to do with a healthy financial structure, that American health care sorely lacks.
Drowned in information and rhetorical confusions, we’ve long ago decided to finance health care through a perverse system reliant on private insurers who penalize the sick and the poor, cut costs (of running their business) with deductibles, co-pays, and obscure exclusion clauses that even the most shrewd and expensive lawyers fail to understand, and dump the worst off on public programs, who end up always underfunded.
To make matters worse, we “encourage” competition by showering the private sector with generous subsidies so they do us the favor of “entering” high-risk pseudo-free markets, e.g. Medicare Part D.
All this for what?
Here’s a hypothesis: maybe all this sophistry helps keep alive the even more corrupt donations of private insurers and drug companies to politicians, who can then preach from the podium the obvious benefits of healthy lifestyles and chronic disease prevention…
Until we get honest about these facts, more and more Americans will continue to suffer from unnecessary disease and premature deaths.
“Call me simplistic, but let’s say a physician is there to fix things, e.g. like a garage. Whoever owns the car is responsible for making sure changing the oil, the timing belt, and don’t wear out the clutch (the repairman should give good advice when asked or when there is obvious car neglect).”
rbaer, I WOULD call you simplistic,:>) if you are thinking this is up to an individual and not a government. When an individual’s care for their car only affects them, the government does not get involved, but when the use of their car affects society (drunk driving, safety, pollution) then government steps in to make them accountable. Anti drunk driving ads don’t work unless there are road checks and punishment. Safety concerns only work when there is legislated safety inspections and mandated safety standards. Pollution control doesn’t work unless we legislate manufacturers and perform emissions checks.
Bad health behavior affects us all and will need a government with leadership (hard to find these days)to make those people accountable. I’ve given up the prospect of trying to making people change but do advocate for taxing bad behavior. Then at least the bills get paid by those who think they should not have to contribute at least good behavior to the rest of society.
Once one takes a view of healthcare that is preventive, and incentives hit the patient’s wallet, change is possible. We need to stop affixing blame and begin seeking solutions which make sense to the individual. This will not be a quick fix, but leadership in this area could provide opportunity for this country and its healthcare industry to innovate in ways that are not possible elsewhere in the world…let us hope that there is adequate corporate/employer will to make this happen. Neither the AMA nor the individual stakeholders have sufficient incentive or power to drive this change. And no presidential candidate(s), however well-meaning, can make this happen without aligned business models to make it work.
I don’t buy it. Call me simplistic, but let’s say a physician is there to fix things, e.g. like a garage. Whoever owns the car is responsible for making sure changing the oil, the timing belt, and don’t wear out the clutch (the repairman should give good advice when asked or when there is obvious car neglect). What to do for the maintenance and care of the human body – e.g. eating healthy, exercising, self breast exams etc. – is known to most, and accessible to everyone. And if you have health coverage, one can and should ask the doctor: what can I do better to stay healthy/to treat my condition? It is certainly wrong that physician counselling is not well paid in comparison to procedures, but this can and should be adjusted. And one has to question in general whether physician compensation should be so heavily based on productivity – a mixed model that has a base salary plus more modest incentives for physicians that are highly productive, and additional incentives for doctors with good patient ratings for RELEVANT matters such as communication skills and accessability may do wonders. And nothing against LPNs or RNs doing individualized health education – that may be a great idea, but let’s face it, very many patients smoke/overeat/are noncompliant with blood sugar management or chronic medications against their better knowledge.
I do believe that the culture in the US has to change – away from quick, convenient, externalized “fixes” (multivitamins, drugs, surgeries, evasive excuses and justification) to a patient who is, regardless of educational and financial status, actively interested in his/her physical well-being.
“Chronic diseases – including conditions such as diabetes, asthma and hypertension – are a major threat to both our health and our economy.”
Diet, pollution, stress. While we identify these diseases and know how to prevent them, corporations that profit from causing them and profit from treating them, will not co-operate to prevent them, and even lobby to keep poisoning our bodies. I would feel a little encouraged if the AMA spent part of its lobby/income-promotion money to help get us going in the right direction – fat chance.
“we ought to make a serious national commitment to reduce unhealthy behaviors through a wide variety of initiatives in government programs, employer health benefits, and community and public school outreach.”
To understand how hard hard it is to reduce unhealthy behaviors we just need to look at the drought here in the south. We are in a crisis for water yet our politicians will not make the tough and unpopular decisions, and the public will not conserve voluntarily even with disaster staring them in the face. Water use has largely not changed and wise water use policy is a distant hope mostly blocked by the Home Builders Association and a mindset that water should be cheap – even when there is none. The solution so far has been promotion for us to pray – the usual southern reaction when nobody wants to take action.