OP-ED

A Time For Revolutionary Thinking

John Haughom MD whiteWe need to design a system of health care that optimally meets the country’s needs while also being affordable and socially acceptable. Clinicians should be at the center of this debate if care delivery is to be designed in a way that puts quality of care before financial gain.

This challenge is too important to be left to politicians and policymakers. There is an urgent need for clinicians to step up, lead the debate and design a new future for health care. Placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be an ambition for all of us. We need to find the formula that meets the needs of the patients and communities we serve. A sincere collective effort by committed clinicians to design an effective system will lead to a health care system that has a democratic mandate and the appropriate focus on optimizing the outcomes patients and society need.

As clinicians enter the debate, they should keep three things in mind.

Promote the leadership role of clinicians

We need to help politicians and policymakers recognize the role of clinical leaders in shaping a transformed but effective health care system. Clinicians must redefine the debate so that it focuses first and foremost on patients and health outcomes. Cost effective care can and should be a byproduct of optimal care. Accomplishing this will provide a strong common purpose for efforts to address the challenges of designing outcome-based funding structures and improving access to care.

Explain appropriate levels of care

Clinicians must inform both policymakers and the wider public about appropriate levels of care and the appropriate venues of care. A disproportionate focus on the treatment of acute illness and injury, which consumes by far the most resources, will not serve our country well. Primary care accounts for most of the health care that is delivered in the United States. There are nearly 1 billion visits made to physicians’ offices every year in the United States, but there are fewer than 40 million hospital stays. We need to pursue every opportunity to direct care to the lowest cost venue of care that can effectively address a patient’s needs.

Adopt a data-driven approach to care

Any system must be driven by data, focused on outcomes, and designed to deliver the appropriate level and type of care. The current hospital-centric, overly referral-based system often leads to unnecessary referrals and an over reliance on the most expensive diagnostic tests and treatments. It also ignores other major determinants of health. Health problems related to lifestyle, such as obesity, smoking, substance abuse and diabetes will not be solved by more hospitals but rather through access to primary care physicians, innovations in public health, and lessons from the emerging discipline of behavioral modification.

The best outcomes can be achieved only when the system itself is healthy and built on real partnerships between patients and clinicians. Building a health care system centered on clinical professionalism and responsibility is the only way to achieve such partnerships and to ensure that all patients are well served.

Thanks to some pioneering individuals and organizations such as the Mayo Clinic, Virginia Mason, M.D. Anderson, Partners Healthcare, Texas Children’s Hospital, Kaiser and many others, we can now see enough of the future of health care to have a sense of what it will be. And it is exciting. Empowering. Better for patients and communities. The new ideas, vision, tools and methods capable of supporting meaningful change are falling into place.

A frequent companion of challenges is adversity. As hard as it is, one can view adversity as a privilege and an opportunity. During times of great change and adversity, we cannot control circumstances, but we can change how we view them. We need to lean into the adversity. Many involved in the healthcare profession need to see a glimpse of the future, understand their role in it and be sustained by a sense of hope. It is our responsibility — and privilege — to offer this to them.

In a 1913 speech, Sir William Osler said, “To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools, remodeled hospitals, a new outlook for humanity, is an opportunity not given to every generation.”  To paraphrase Sir William’s message, we have an opportunity to witness a new birth of science, a new dispensation of health, a remodeled health system and a new outlook for humanity. Indeed, this is not an opportunity given to every generation. But it has been given to us. It is our revolution.

John Haughom, MD, former senior vice president of clinical quality, safety and IT for PeaceHealth, is a senior advisor to Health Catalyst and the author of Healthcare: A Better Way. The New Era of Opportunity.”

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Paul Nelsonprada マネークリップJakeEdwardJohn Haughom, MDallan. Recent comment authors
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Paul Nelson
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Paul Nelson

I propose that the institutional models for deep-seated healthcare reform already exist: For one use of this view: see

http://www.nationalhealthusa.net/overview/

prada マネークリップ
Guest

子供子供私と 今日はに行ってきました。私は貝殻を見つけて、私の4歳の娘にそれを与えたと言った”あなたはあなたの耳にこれを置けばあなたが海を聞くことができます。”彼女の耳にシェルをして叫んだ|彼女は置か置く。あり内側ヤドカリだった、それは彼女の耳に挟ま。彼女が戻って行きたがっていることはありません!大爆笑私は、これは知っているオフトピック が、私は誰かを教えていた!
prada マネークリップ http://vishalengineeringladders.com/images/prada/20141107163134-21jc.html

JakeEdward
Guest

Accoprding to my point of view We need to help politicians and policymakers recognize the role of clinical leaders in shaping a transformed but effective health care system. Clinicians must redefine the debate so that it focuses first and foremost on patients and health outcomes.

John Haughom
Guest
John Haughom

Not at all. I am saying that if good data shows that a peer physician is doing things that are causing patients avoidable harm or leading to avoidable bad outcomes, as professionals we have a responsibility to address it (based on data). Those types of rules went into place in about in a formal way in the US in 1915 and this type of peer review has persisted since. The only real difference now is that we are getting better, more objective data to base those judgments on. Civilized society has to have some rules like this. If people are… Read more »

allan.
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allan.

We have civil and criminal law. We have contracts and courts that adjudicate disputes. Don’t confuse that with the promotion of business models or ideas such as EHR’s that are promoted and enforced through coercion.

Your line of thought makes one question your willingness not to cross that dangerous line where coercion replaces voluntary action.

Prestor
Guest

I have to say that I can truly relate to Allan’s concern about government systems that take on a life of their own and result in loss of freedom (and thus innovation). I just recently was asked by our health-care exchange to provide documentation of income for my 5 year old daughter. I have to write a letter to explain to them that she is only 5 years old and has no income. The agent agreed that this did not seem like a reasonable request but that the “system” needed it. Is this just the beginning of what we can… Read more »

John Haughom, MD
Guest
John Haughom, MD

Well said, Prestor. The data is pretty clear – our current system is being overwhelmed by complexity and is presenting very real challenges. We can – and I believe we will – find a better way that retains the best of the past, yet deals with the issues. There are enough bright, well educated and committed people in healthcare to do it. I strongly believe they are the solution. Not politicians or regulators. You have to understand how healthcare works to fix it. It is a complicated game, but I believe it is solvable.

allan.
Guest
allan.

“On the other hand, I have seen too much unnecessary suffering from lifestyle related illnesses to shy away from attempts to reform the pre- ACA system” Prestor, in medicine one learns that not everything has a solution. However, sometimes instead of looking for a solution that involves more intervention one can look for the problem. In medicine there is one problem that almost all economists agree upon. Third party payer is bad and many will say third party payer is a central problem of our healthcare system. Where does third party come from and what does it do? Third party… Read more »

John Haughom
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John Haughom

Prestor… If you would be at all interested in a complimentary signed copy of my book, I would be happy to provide you one. No obligation, but it will give us more to talk about. Best… John

John Haughom, MD
Guest
John Haughom, MD

We need to have lunch sometime and discuss it. I am not sure I can say it more clearly than I said it above. I firmly believe the solution to healthcare’s issues is engagement of front line clinicians to solve it. Such an approach will serve patients, clinicians and the country well. Coercion rarely, if ever, works. Thanks, Allan. Have a good week. If we ever have that lunch, it is on me! 🙂

allan.
Guest
allan.

John, lunch is always good, but you won’t coerce me to eat off of one side of the menu will you? 🙂

Coercion can be very subtle and if one has the power it is hard to resist its use especially if one thinks they are right.

John Haughom
Guest
John Haughom

By golly, I think we finally found something we disagree on that we can discuss over lunch! As I am sure you know, the traditional way issues about the quality of care have been handled on medical staffs is through the credentials committees. Having been on such committees and observed the process, I know for sure that if I were in position of needing someone to assess my care with a patient, I would much rather have a respected committee of my peers assess it than police, lawyers and courts. While there are rare instances that criminal law is justified,… Read more »

allan.
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allan.

Thank you John, but I was describing what already exists as I wish to limit the entry of more government imposed bureaucracies. Just because some of these bureaucracies being thought of might be run or supported by physicians doesn’t make the coercion taste any sweeter.

John Haughom
Guest
John Haughom

Somehow we aren’t connecting. I am probably not expressing myself well. As I said, coercion does not work. It will not solve healthcare’s issues. I believe only frontline clinicians can do that. More government will not help. They currently bring us the Post Office, Amtrak and the VA system. All of them have major problems and all are losing money. Why would we want to have them take over the most complicated industry in the world that represents 25% of the US GDP? Doesn’t make sense to me.

allan.
Guest
allan.

John, you have expressed yourself well maintaining a position on both sides of the line. That is why we continue jousting. This time you say “coercion does not work”, but then you also say “Coercion rarely works well” and other times seem to say coercion is needed when a better solution exists or when doctors are involved in the coercive behavior it’s OK. There is a lot of potential for ‘buts’ and ‘ifs’ inherent in your comments about coercion and that comes out loud and clear. You have had ample opportunity to clearly state where you stood without the ‘buts’… Read more »

John Haughom
Guest
John Haughom

Allan… I actually think we are both on the same side of the line. While social media works well, it doesn’t work when you are trying to get sincere and important points across. Those type of conversations really need to happen face to face. Don’t read too much of words like “coercion does not work” vs. “coercion rarely works.” The distinction is subtle but important. I tend to avoid the word “never” because you can always come up with an exception. Coercion is necessary in cases involving things like murder, rape, incest and child abuse because the human behavior is… Read more »

allan.
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allan.

John, we might be on the same side of the line but I fear we are going in opposite directions. I guess you want to be perceived as a person that doesn’t believe in coercion or top down control, but there is an important principle involved. You either accept that principle or you don’t.

John Haughom
Guest
John Haughom

No. The model I envision will always leave room for innovation. It just needs to be based on data, evidence and what is best for patients (based on data and patient desires). As long as physicians center the discussion and discovery on those things, there should be no need for coercion, but plenty of room for continuous improvement as new knowledge and ideas come along (which they will). I guess I would hedge on one thing, and that is that as physicians we all know that there are a few bad apples. I think far fewer than most realize, but… Read more »

allan.
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allan.

“As long as physicians center the discussion and discovery on those things, there should be no need for coercion…”

Are you saying as long as the physician plays ball there should be no need for coercion? That is coercive in itself. …

John Haughom
Guest
John Haughom

Coercion rarely works well at any level. On the other hand, honest engagement generally works and works well. That has been a formula that has served me well for many years. The only caveat I will add is that physicians will have to get better at working collectively. We will not have a role in designing new models of care if we have a half million physicians all going in a different direction. We need to focus our debates on good data, evidence, and most importantly, what is best for the patients we serve. If we do that, we will… Read more »

allan.
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allan.

Then we agree. All that is left is what happens when you find the ideal solution and the government agrees with you. Will that be the one time coercion works well?

allan.
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allan.

John, I too appreciate this ongoing dialogue. If only we could agree as to what amounts to coercion we would be on the same team. I favor some of the ideas you mention, but I quiver at the thought of government directly or indirectly mandating solutions of this nature.

John Haughom
Guest
John Haughom

Allan… Actually, I think we do agree. The reason I advocate so strongly for clinicians to engage is because the last thing we need or want is a governmentally imposed solution. The very flawed ACA is a recent example of that but far from the only one. As long as physicians leave a void, we can very much expect more in the way of flawed programs. Front line clinicians need to design care based on good data and the best available evidence. We may have honest disagreements about what “good data” and “evidence” is, that is a good dialogue to… Read more »

allan.
Guest
allan.

” As soon as we start doing this broadly will be the day that we begin to see a rational and workable system emerge. “

…And if in your opinion or the opinion of our government that the emerging system should be promoted you will fight any coercion to make that system a reality for we recognize that such coercion means the destruction of even a good system and should be forbidden in a free society.

Thank you as well.

John Haughom
Guest
John Haughom

Prestor

Thanks for your thoughtful words. Well said. I strongly agree with you. We need to migrate to an incentive system that incentivizes health and outcomes, rather than for doing procedures. This will greatly accelerate the migration to a profession-based practice that focuses on outcomes.

allan.
Guest
allan.

That is essentially correct. Bu,t that we have a need doesn’t doesn’t mean we have a valid proven solution. We need innovation, but the coercive methods being used inhibit innovation. Government plays to the tune of the voter, not the innovator; to the large companies, not the innovator; to their friends and relatives, not to the innovator.

John Haughom
Guest
John Haughom

Allan and Prestor… I appreciate your ongoing dialogue. This is good for healthcare. We need more physicians engaging in just this type of conversation. I believe healthcare and patients will be better served if good clinicians work at designing good solutions. If we just try, I think patients will listen — maybe not the government, but patients. While designing a workable incentive system based on outcomes will be far from easy, I do believe it is where we need to go and the end result will benefit both physicians and patients. I strongly believe that healthcare is blessed with the… Read more »

Jana
Guest

,,Any system must be driven by data, focused on outcomes, and designed to deliver the appropriate level and type of care”

I feel this is mostly neglected at universities or in academic sphere in general.

MD as HELL
Guest
MD as HELL

We do not need all this healthcare.

Start there with your revolution. People will not buy it. Why should they get it free. It is dangerous to go to the hospital.

Healthcare is sold based on fear. People should not be terrorized into either having or voting for healthcare.

Give people their money to spend as they see fit and get honest charges into place. Help those that need real assistance.

Quit engineering behavior that is none of your business.

People should be free of your meddling.

LeoHolmMD
Guest
LeoHolmMD

Agree. Turning the whole world into a patient is going to send costs into uncharted realms. Prevention, at least medical supply side style prevention, is way oversold. “Health problems related to lifestyle, such as obesity, smoking, substance abuse and diabetes will not be solved by more hospitals but rather through access to primary care physicians, innovations in public health, and lessons from the emerging discipline of behavioral modification.” Let’s just take smoking. The greatest degree of change had to do with 2 major forces: economics and culture. Those smokes are expensive and getting worse. So are the premium penalties from… Read more »

Hu Williston
Guest

I agree the way to improvement is data driven. To that end we need to know how we are spending our health care dollars now, at least the public your and mine dollars. That means publishing what it costs per patient per year for each provider as every charge is tied to some provider number. I was encouraged when the Medicare data became public and looked forward to the same transparency for Medicaid but Oh how quickly the storm blew by. Maybe we can still hope for more in depth mining of this data by journalists such as those at… Read more »

Vik Khanna
Guest

“The best outcomes can be achieved only when the system itself is healthy and built on real partnerships between patients and clinicians. Building a health care system centered on clinical professionalism and responsibility is the only way to achieve such partnerships and to ensure that all patients are well served.” This ship has, unfortunately, sailed and there is not another one coming into port. The revolution we need begins with some truth telling: the “system” we have stinks and is built around the economic self-interest of the (clinical and non-clinical) people who run it; and, our government has been an… Read more »

Peter1
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Peter1

Before we get “revolutionary thinking” from medicine we’ll need revolutionary thinking from our politicians.

We don’t need revolutionary thinking, we need revolutionary bi-partisanship.

Saurabh Jha
Guest
Saurabh Jha

“We don’t need revolutionary thinking, we need revolutionary bi-partisanship.”

What a great and quotable line!

I’m so 100 % in agreement!

John Haughom
Guest
John Haughom

I certainly agree that we need a functional bi-partisan political class. But even if they were more functional, politicians do not understand the process of care.

Clinicians need focus on what they are experts on – managing the process of care. Modern improvement methods coupled with good access to data can and will challenge healthcare for the better.

Granpappy Yokum
Guest
Granpappy Yokum

You honestly think Partners Healthcare with its highway robbery fee schedules is a good model for the rest of us?

Prestor Saillant, Ph.D.
Guest

Although I agree with Robert Cato’s view that “We need to start being more honest about our current situation if we hope to carve out a better one for the future,” I also agree with Dr. Haughom’s emphasis on adopting a data-driven approach to healthcare. A month ago I authored a blog post titled “The big elephant in the health care room” (http://www.ontierrahealth.com/sample-page/) in which I raise the very question of financial incentives as Cato. I proposed that ultimately we need a model of health care that focuses on quantifying and improving health as opposed to the current emphasis on… Read more »

allan
Guest
allan

“a model of health care that focuses on quantifying and improving health as opposed to the current emphasis on quantifying and treating disease.” I understand the treatment of disease, but ‘improving health’ is something that for the most part is outside the scope of the physician other than perhaps telling someone not to drink, smoke, or take drugs and to lose some weight all of which can be done by lay people. While I’m at it we should tell them to get vaccinated as well. But on this subject you say: “Only when doctors begin to see profit from keeping… Read more »

Perry
Guest
Perry

Exactly, Allan.
People don’t need docs to keep them healthy. They need information, incentive and motivation. They also need basic nutrition, housing, and clean water, and yes some vaccines.
The idea that health insurance=healthcare=health is not correct. While health cannot be bought, the basic necessities that promote health do have a price. Until we are willing and able to address those issues, giving every American insurance or a doctor is beside the point.
I doubt anyone is really willing to pay a price for “keeping them healthy”.
They are more willing to pay to limit or cure the disease.

allan
Guest
allan

Thanks Perry, I think the reason Prestor S. didn’t reply with that long list of what only doctors can do to prevent the healthy from becoming sick is that the list is very short. Vaccines are number 1 on that list followed by number 2 which I can’t think of. I am always surprised at some people’s expectations. I am doubly surprised that those expectations don’t disappear considering the fact no one ever seems to come up with that long list. The same is true with the falsity that health insurance equals healthcare. It doesn’t and there is proof of… Read more »

Perry
Guest
Perry

More Koolaid, anyone?

Prestor
Guest

OK Allan and Perry, here is what I was thinking. In the old days, people would wait until they got sick before going to the doctor, and that was a viable model. Then things progressed a bit and people now go in for checkups where doctors attempt to detect early signs of disease. However, this model is still too costly for America and is weighing us down. I keep pointing to “the elephant in the room” that I think we should discuss a little more. Incentives. I find that when we establish the wrong incentives things can get out of… Read more »

John Haughom
Guest
John Haughom

People do get ill and injured. That is simply a reality. And if a family member or friend of mine gets ill or injured, the first thing they or their family member ask is “Who the best physician and hospital we should use?” One of the most-cited statistics in public health is the imbalance of social investments in medical care compared with prevention activities. Approximately 95 percent of the trillions of dollars we spend as a nation on health goes to direct medical care services, while just 5 percent is allocated to population-wide approaches to health improvement.5 However, some 40… Read more »

allan.
Guest
allan.

Prestor, you provided tangible evidence of only one item, asthma. The rest is either hypothetical or already being performed by M.D.’s. Much of the latter stuff can be done by lay people. Your asthma example is none other than what you portray as a “descent into disease-care madness”. Telling patients to change their filters or use hypo allergic things is also part of that medical “madness” you decry. Our list remains the same” 1. smoking control, exercise, weight control, diet etc. plus handholding 2. vaccinations I await your additions. The healthy patient should go to the doctor and what else… Read more »

Prestor
Guest

Allan, I appreciate your feedback so let’s see if we can process what I am trying to communicate a little better. Let’s stick with your list for now. “1. smoking control, exercise, weight control, diet etc. plus handholding 2. vaccinations” This is a general list of things that doctors can tell ill or non-ill patients to do to improve their health and the results of which can be monitored through clinical testing, correct? Do you believe that if a doctor invests his or her time and effort into a rigorous program to promote and quantify outcomes of the items you… Read more »

allan.
Guest
allan.

Prestor, yes, 1&2 are almost the complete list so let me explain from my perspective. True preventative care is very limited. Early diagnosis is looking for disease to be treated so those patients are not healthy patients. Physicians treat illness or look for disease to treat. Who should keep the profit? Physicians work to earn money. Patients hire physicians to, as you put it, keep them healthy, but in reality it is to diagnose and treat disease. The two of them should determine the price. Either of them have a right to utilize the services of an agent. Insurance companies… Read more »

LeoHolmMD
Guest
LeoHolmMD

Correct. Turning doctors into very expensive public service announcements that only play for one person at a time is not going to work.

John Haughom
Guest
John Haughom

I definitely believe we need to quantify more. Historically, we have not had good control over our data, but that is thankfully changing. As healthcare goes digital, and implements EHRs, we will have the opportunity to understand and manage care far more effectively, Analytics will dramatically shift away from reporting toward predictive and prescriptive practices dramatically improving the ability of healthcare providers to help the ill and injured. Even more importantly, it will create the possibility for truly personalized healthcare by allowing providers to impact the biggest determinants of health including behaviors, genetics and environmental factors.

allan.
Guest
allan.

” Historically, we have not had good control over our data, but that is thankfully changing.”

Unfortunately things are not changing for the better because of the meddling that goes along with the coercive use of top down thinking. Physicians are drowning in useless data spending their time looking at a computer screen instead of the patient. The one good thing is if one wants to find a nurse they don’t have to look in all the patient’s rooms. They can immediately find the nurse typing in front of a screen.

John Haughom, MD
Guest
John Haughom, MD

Respectfully, I suspect you have not seen the analytical power that is now possible for frontline clinicians to better support the patients they serve. These tools include modern data presentation tools that allow clinicians to quickly see important patterns in the data that have never been possible before. Would you like a demonstration? They are readily available on the web.

allan.
Guest
allan.

Respectfully, when physicians rely too much on glitzy high tech and not enough on their brains they have a tendency to err badly. Fortunately most physicians know how to rely upon both. But, when the high tech becomes entangled with coercive top down technologies generally all suffer. I need no demonstration of high tech being around it all my life. That being said today the data is being forced into a computer in an awkward way that changes the data and the interpretation. Not all that different than the Heisenberg Principle. If one likes their nurses all in one place… Read more »