Op-Ed: After Reform

Gary Campbell

Our current national health policy is certainly not the result of a well-conceived, comprehensive approach to health care; rather it is the result of decades of incremental legislation, regulation, and market changes. Put this antiquated legacy system against the backdrop of the worst economic crisis in 80 years, the cost of health care approaching 20 percent of our gross domestic product, health insurance premiums in Colorado approaching 20 percent of median income, and the burning platform for change looks more like a raging inferno. While the national health care reform enacted this week is historic in its proportions, it will by no means be a panacea. The passage of national health care reform legislation, as President Obama, states, “is not radical reform, but it is major reform. This legislation will not fix everything that ails our health care system. But it moves us decisively in the right direction.” Over the next few years, there will be tens of thousands of pages of rules and regulations that will interpret the 2,000+ page legislation and spell out more clearly how it will be administered. So it is impossible to determine with certainty today exactly how the legislation will affect us in the future. But against a backdrop of five fundamental issues that must form the basis of a rational national health policy, we can assess how far we have come and how much more there is to do:

1) Is health care only about curing sickness and repairing injury or is it also about keeping people healthy? The health care reform legislation does not address this issue in any significant way. Clearly, the current model emphasizes sickness care, and the legislation does not change that. But, in reality, 20 percent of what we know as “health” is the result of genetics, another 20 percent is the result of the environment, 50 percent is driven by lifestyle behaviors, and only 10 percent is the result of sickness care. To reform our system, we must continue to maintain our focus on medical care delivery while we simultaneously work on opportunities to “move upstream” to truly manage health. Incentives and economic rewards for health care providers must encourage health care and not simply sickness care.

2) What level of access to health care do we desire for which portions of our population? It’s a tough question to answer, but it’s fundamental to the issue —you either believe in equal access to health care for everyone, or you believe in a system that includes two or more tiers of health care delivery, with access based upon one’s ability to pay, geography, or other factors that differentiate the “haves” from the “have-nots.” Over the next five years, the new law will remove or decrease economic barriers to health insurance for an estimated 32 million Americans. That is certainly a huge step forward toward universal access, and it is the highlight of the legislation. The resulting financial strain on states will be eased because the federal government will fund the cost of the expanded insurance programs from 2014 through 2016, after which time states will assume 50 percent of the cost. Ultimately, the additional cost of expanded Medicaid coverage will hit Colorado hard, and we have several years to prepare for that. There remain many opportunities to work at the state, regional, and local level to further and more affordably improve access to care for all Americans.

3) How will we organize health care providers to effectively and efficiently deliver the desired level of access to health care? Today, many people do not have a personal physician and instead rely on episodic care from urgent care centers and hospital emergency rooms. While there will ultimately be free or subsidized health insurance for 32 million more Americans, there is a great need and tremendous opportunity to better organize health care service delivery for all of us. We must ensure people get the right care, at the right time, and in the right location. A big unknown at this time is whether there are enough primary care physicians willing to assume an influx of patients to ensure all 32 million get care in the right location. We must act promptly to increase the number of primary care physicians and develop a more economically sustainable means of providing primary care.

4) How will we finance health care for those for whom we wish to assure access? This is the most difficult question, particular in the context of the current economic difficulties we face as a nation and as a state. The legislation calls for increased taxes and improved efficiency in the Medicare program as the primary ways to pay for the expanded access. Medicare payments to providers will be cut by $500 billion over the next decade. These cuts in Medicare payments will certainly impact all health care systems and physicians, and will force difficult decisions for all.

How will we measure and reward effectiveness and efficiency of health care delivery processes? Today’s economic rewards tend to incentivize more care rather than better care. The legislation takes some tentative steps forward by calling for pilot programs beginning in 2013 to shift incentives from the quantity of services to the quality of care. But it will be up to health care systems and physicians to take the lead to produce real change. This will require health care providers to work in an aligned and integrated manner to drive greater health care value for all Americans.

Unfortunately, after all the rules and regulations are written, it seems likely that the 2010 version of health care reform will once again turn out to be a series of politically-expedient incremental tweaks to our broken non-system, more than a premeditated transformation of our health care delivery system. But regardless of one’s politics and potential misgivings about the health care reform legislation, it is the law. The challenge now before all health care providers is to work with community leaders, local and state elected officials, employers, and insurers to make the other changes needed to finish the job and reinvent health care in this country. We must:

  1. Hold on to what is good about our sickness care system while we move “up-stream” to truly manage health.
  2. Build systems of care that enable all Coloradans to have the same access to the right care delivered in the right place at the right time.
  3. Break down the silos, and bridge the conflicting incentives to create integrated health care organizations that will drive “A” and “B.”
  4. Change our focus from “more” to “better.” Rather than competing on who has the most patients, the most CT scanners, and the biggest hospitals, we need to compete on who can provide the best quality outcomes at the lowest cost.
  5. Work for creative win-win-win partnership arrangements based upon optimizing the value of health care services to all.

Centura Health is committed to work collaboratively toward the above solutions, and we are looking for partners who also want to invent the future of health care delivery. We have an historic opportunity to change the course of our country’s future, and as the old saying goes—if you’re not part of the solution, you’re part of the problem.