BY DAVIS LIU, MD
The future direction of American health care is unclear. Certainly the cost trend as it exists is unsustainable with health care costs being a major concern of the private sector, the government, and individuals. How does the nation manage costs while ensuring high quality medical care, access, and service? Proposals include increasing competition among insurers, providers, and hospitals to drive down prices or giving more financial responsibility to patients via higher deductibles and co-pays with the belief that they will demand price transparency, shop around for the best price, and as a result slow health care costs.
What if both ideas are wrong?
While it is possible these plans might work, I cannot help but notice the similarities in the challenges for patients in navigating the health care system and consumers figuring out how to purchase and use technology. Walk into your neighborhood electronics store. Individuals are overwhelmed with the number of product choices, manufacturers, differences in technical specifications and features. In the majority of situations, consumers are unsure of what they are purchasing. They want something that just works, whether surfing the internet, making home movies, or being connected with loved ones. The gap in knowledge between an expert and a consumer is great and often unintentional and unapparent.
Within the technology world, there are two groups of thought. The first group offers technology in a closed system, like Apple, where the focus has been on just making things work. There are a limited number of product types and designs. For example, its current smartphone, the iPhone 4 comes in only two types. Aside from the base memory of 16 GB or 32 GB and two different prices, the phones are otherwise identical in features with the same apps, cameras, and ability to record video. Although the specifications are available for anyone to see, the focus is rarely on the technical elements of the products themselves and more on what they can do for you. Walk into any Apple retail store and the products are situated by function. Staff ask not how much computing horsepower, storage space, or CPU speed one needs, but what one plans on using the smartphone or computer for.
In contrast, Google’s sponsored Android platform, which runs smartphones from a variety of manufacturers gives consumers maximal choice. Companies like Motorola, Samsung, HTC, and LG offer a variety of combinations of styles, features, and ironically even different software versions at various price points. Verizon and AT&T wireless offer no less than 10 different Android based smartphones. The amount of choice and options could be intimidating. While potentially an Android smartphone could be cheaper than a comparable Apple iPhone, people often fail to account for all of the time and energy spent on researching, thinking, and also potential worry and buyer’s remorse that the right choice was made. The time and energy spent does cost, either monetarily or emotionally.
Which one would you choose? A system which just works, gets the job done, and has been designed to fulfill most of your needs? Or alternatively, a different system which provides more choice, more options, and in many cases, requires more time to research and become an expert to make the best decision?
If you look at proposals and trends in health care, it appears many are advocating for Android.
To manage costs, consumer driven health care, where patients have more financial responsibility via the addition of deductibles and higher co-pays are felt to be the answer. The patient is the party accountable to having the right tests done, finding the right doctors, reviewing and maintaining their medical chart using personal health records, and shopping around for the best price when it comes to imaging and other procedures. After all, who has the most motivation to make the best choice but the individual who’s life depends on it?
Increasingly there is research that shows people are decreasing health care costs. Unfortunately it is not the behavior of avoiding expensive excessive care (opting to see a primary care doctor rather than the emergency room for non-emergent evaluation) but skipping preventive tests, prescription medications, follow-up evaluations to treat chronic conditions at the early stage to prevent future complications. If true, the implications of these small inconsequential choices by patients could be problematic years later.
Also similar to Android philosophy, others argue for more competition. With the consolidation of insurers and in some case providers and hospitals over the years, understandably many are concerned that prices are driven higher through monopoly power. Instead, the belief is that having many insurers, providers, and hospital networks will improve health care as they compete for patients on areas of service, quality, and access. The market will reward those who are best in providing all three. With the large number of competitors, groups will be unable to have pricing power and therefore costs will be managed.
Providing patients plenty of choices is proposed as the key to fixing the health care crisis. Perhaps this is the reason for the creation of insurance exchanges in the recent health care reform legislation. Patients will have the opportunity be to select health insurance plans which are not tied to their place of employment. Let them figure out which insurance plan is the best. Have them figure out which doctors take their insurance and are the best. They can select from their menu of different hospitals and determine the best one for their needs.
Is there another way? Would patients prefer a different system which is integrated and seamless and where patients can focus on simply getting better and not spending time and energy trying to figure out where to go and who to select?
One example might be where I work, at Kaiser Permanente in Northern California, a vertically integrated organization with health plan, hospitals, and doctors working together to provide care that is convenient, simple, and personal for our members. Dr. Atul Gawande in his June 2009 New Yorker piece, the Cost Conundrum noted places like Grand Junction, Colorado, were able to provide high quality care at lower costs when doctors worked together. Other organizations which were physician led and accountable also had similar outcomes.
Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.
This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.
Perhaps this is the reason for the creation of Accountable Care Organizations in the health care reform legislation. Whether the legislation and regulations can foster and replicate similar organizations and outcomes remains to be seen. What I can tell you is that within my organization, doctors, nurses, and support staff are working hard to improve how care is delivered to our members much the same way I suspect software engineers and designers at Apple focus on their technology to make it intuitive and so it just works.
Perhaps there is no illustration better of the potential of American health care than the words from a patient.
Here’s why I chose Kaiser for my medical needs at age 25:
1. I liked their Web site.
2. It was easy to set up appointments over the phone and via the Internet.
3. They have a 24-hour Advice Nurse phone line which is helpful if your parent is not “just a phone call away”.
4. Through the Web site you can choose a primary care physician and OB/GYN by location, gender, and bio. If you don’t like your choice you can always change it later.
5. You can email non-urgent messages to your doctor through the Web site and your doctor has to respond within 48-hours.
6. The Kaiser Web site will send you an email when test results are available online.
At age 29, here’s why I know Kaiser was the best decision I ever made:
1. When I was brought to the Kaiser emergency room after my first seizure the staff was able to retrieve my complete medical history, which aids staff in making decisions about my care … even when I’m unconscious.
2. After scans revealed I had a tumor in my brain, the head of neurology came down to see me and had me admitted to the hospital that night.
3. My newly acquired neurologist arranged for my transport to the neurosurgery center for the Sacramento region.
4. Once I got there I worked with Kaiser’s neurological equivalent to Dr. House, except this doctor was way nicer.
5. My neurologist, neuro-surgeon, oncologist, neuro-oncologist, OB/GYN, primary care practitioner, orthopedic doctor, and physical therapist are all informed about my medical status.
6. I never have to seek, or wait for, a referral. If a new specialist is needed for my care I get to see him/her as soon as I’m able to get a ride.
7. I can get lab work done at any Kaiser facility and the test results are sent electronically to the requesting doctor within minutes/hours (or a few days if it’s analysis of brain tissue).
8. Kaiser specialists network with peers from other medical institutions and often seek second and third opinions for you. They’ll even tell you who disagreed with them and why. If you want to get the second opinion yourself they are respectful of your decision and make sure you get all required materials to make this happen (e.g., charts, scans).
9. After my most recent brain surgery, my tissue was analyzed by pathologists in Sacramento and Oakland, then sent to Kaiser in Redwood City, who sent it along to UCLA.
10. While my friends and I did a lot of our own research, Kaiser made it easy for us to get treatment. We never had to figure it out all by ourselves and my doctors/nurse practitioners answered every question I had … even the silly questions.
The future of American health care is unclear. Do Americans what Apple or Android for health care?
Let’s let them decide.