n. A highly seasoned minced meat usually stuffed in casings of prepared
Congress is obviously in the thick of the sausage making. The August recess is pending. Bills may or may not be moving. The legislative process, especially at this point, is not particularly pretty or, to be honest, as thoughtful as we all might hope. It is the process, though, right? There was essentially no way around something like this intestine stuffing, especially in an effort to fix health care–such a large sector of the American economy. And in spite of the messy work and depending on the day, the observer and the poll, it nevertheless seems likely that something will come out of the kitchen, right? It is also probably safe to say, though, that any reform law is not going to be the panacea–the ultimate health and health care fix. Instead, if a law indeed passes, it's clear that we're going to spend the next five, 10, 15 years adjusting, backtracking, redesigning and working toward better care. In other words, the implementation is going to matter, and it's going to matter a lot. On July 30 in Washington, D.C. at the Hart Senate Office Building, the RWJF-funded High-Value Health Care Project led by Mark McClellan of the Engelberg Center at Brookings hosted a panel discussion focused on just that–the implementation. Specifically, Mark, Carolyn Clancy of AHRQ, John Tooker of the American College of Physicians, Steve Findlay of the Consumers Union and Jim Chase of Minnesota Community Measurement talked to a large Capitol Hill audience about what it will take to make health care deliver sustainable high value.
The panelists agreed that the drive toward high-value health care was indeed a critical part of successful reform. However, they also noted that we don't yet have all ingredients to drop easily into legislation. They acknowledged that performance measurement and public reporting of that information, help for doctors and nurses to improve once they understand the need to improve, and an informed and active public are all keys to high-value care–and thus to successful health care reform. They also acknowledged that the health reform implementation issues are dependent on national as well as regional or local action. And they noted that reforms that might be coming to our states, cities and towns are going to depend heavily on people's ability to transform their local health systems and health care marketplaces. And remember Massachusetts with its state-coverage innovation and the lowering of its number of uninsured? Well, the value question–and structuring payment to reward value, rather than lots and lots of expensive volume–is taking on a special urgency there. It's not hard to see that same experience playing out across the country after national reform. Again, value is key–and payment that rewards value is a necessary component of the value equation. And, yes, the payment question found its way into the discussion as well. But the panel also noted that we don't yet know what kinds of payment might support the necessary delivery system changes. We don't know what kinds of payment will truly drive value. Capitation? Fee for service? Pay for performance? Shared savings? Global payments? Episode-based payments? Some mix of all of these? We just don't know yet. And we probably can't know until we actually try some new fixes. So, the Hill conversation pretty clearly highlighted that value is critical to successful, sustainable reform–but also that we don't have all the ingredients yet. There's going to be a lot of learning, studying and piloting in the implementation. And a big part of that learning while implementing must happen regionally and locally. That realization and those challenges could be pretty sobering–except for a couple of important things. First, there's this important convergence of opinion that these national health care leaders noted–that reform must focus on the value of care. So we're pointed in the right direction it seems. Second, there are those existing unfolding local and regional reform efforts like RWJF's Aligning Forces communities and the AHRQ chartered value exchanges that are working to develop many of these missing ingredients of high value. We're probably very fortunate that there are communities out there already ahead of the curve–laying the groundwork in ways that might just make reform ultimately successful.
Michael W. Painter, J.D., M.D., is a physician, attorney,
health care policy advocate, and 2003-2004 Robert Wood Johnson Health
Policy Fellow. He is currently senior program officer and a senior member of the
RWJF Quality/Equality Team.
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