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Category: Health Policy

Where Health Care Value Can Lead

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By BRIAN KLEPPER

It seems inevitable that, in the near future, an innovative health care organization – Let’s call it The Platform – is going to seize the market opportunity of broader value. It will cobble together the pieces, and demonstrate to organizational purchasers that it consistently delivers better health outcomes at significantly lower cost than previously has been available.

To manage risk and drive performance, The Platform will embrace the best healthcare management lessons of the past decades: risk identification through data monitoring and analytics, driving the right care, quality management, care navigation and coordination, patient engagement, shared decision-making, and other mission-critical health care management approaches. It will practice care that is grounded in data and science, and is outcomes-accountable.

But The Platform will also appreciate that a few specialty vendors have developed deep expertise in dealing with clinical or financial risk in high value niches – where health care’s money is – like management of musculoskeletal care, chronic disease, maternity, surgeries, high performing providers, or specialty drugs. It will understand that it often makes sense to partner with experts who can prove and guarantee high performance rather than trying to learn to achieve high performance within each niche. The Platform also will realize that simplicity is a virtue, and that bundling specialized services under one organizational umbrella is easier for health plan sponsors to manage and for patients to negotiate than an array of individual arrangements.

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Reflections From the Ukraine

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By MIKE MAGEE

The English translator of Tolstoy’s epic Russian novel, “War and Peace”, Richard Pevear, writes in his introduction, “The book is set in the period of the Napoleonic wars (1805-1812) and tells the interweaving historical events of two very different families of the Russian nobility – the severe Bolonskys and the easygoing Rostovs – and of a singular man reminiscent of the author himself – Count Pierre Bezukhov. It embodies the national myth of ‘Russia’s glorious period’ as Tolstoy himself called it…”

On page 348, in a moment of intense introspection, the very same Pierre broodingly reflects, “What is bad? What is good? What should one love, what hate? Why live, and what am I? What is life and what is death? What power rules over everything?”

Pierre’s mind provides this very dark response, “You will die – and everything will end. You will die and learn everything – or stop asking.”

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Matthew’s health care tidbits: The Stupidity Vaccine

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

For my health care tidbits this week, I think we need a new vaccine. We need one that prevents stupidity.

Look I get that some people don’t think the flu vaccine is effective and don’t think the effects are too bad, so they don’t get one every year. Many people don’t get a vaccine for shingles. But as someone who had shingles long before the recommended age for the vaccine, let me tell you, you’ll wish you had the vaccine should you get it. And even sensible liberal Maggie Mahar a long while back was pretty suspicious of Merck’s Gardasil vaccine for cervical cancer–although since then it’s been replaced both by a more effective updated version and by Cervarix and the long term results are really good.

But since COVID-19 appeared the cultural and ideological identification among most Republicans has been that only wussy liberals take the COVID vaccine. This is stupid and indefensible. Even Donald Trump thinks so! But when he told his cult members that, they booed him! And so the US is stuck on not enough people vaccinated to repel variants or stop ICUs filling up. There are now hundreds of thousands of unnecessary deaths among the unvaccinated with no end in sight.

But this isn’t stupid enough. Now we are seeing senior political leaders attacking vaccines for diseases we’ve had under control for ages. We’ve already seen outbreaks of measles in recent years, including one at Disneyland. Last month 17 Georgia state senators proposed banning school mandates for all vaccines including MMR, chickenpox, DtAP, Hep B, Polio and more. It’s amazing that these people don’t believe in science, yet they are probably happy to use a smartphone or get in an airplane.

Sadly there appears to be no vaccine for stupidity on the horizon

What Would Newt Do? Making Value-Based Care Victorious

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By MICHAEL MILLENSON

Health care’s much-trumpeted transition “from volume to value” care remains more tepid than transformational, according to a new study. Looking at 22 health systems nationwide, RAND researchers found that compensation continues to be “dominated by volume-based incentives designed to maximize health systems revenue.”

Although confusing payment schemes bear part of the blame, there are deeper problems that appeared in sharp relief when I chanced upon a long-ago PowerPoint from a prominent political strategist and early advocate of “data-driven reimbursement.” 

I refer, of course, to Newt Gingrich. His recommendations from 2007 about designing transformational change in health care provide a perspective that remains useful today in addressing what is ultimately a political problem. Frankly, value-based care (VBC) advocates perform dismally.

Going Along the Gingrich Roadmap

Back in 2004, Gingrich and I both served on a commission seeking to improve the quality of long-term care. This was during a period when a neutered Newt, out of power, was undergoing a political makeover by championing bipartisan health reform ideas such as electronic health records (EHRs) and evidence-based care. He even shared an award from NCQA with then-New York Sen. Hillary Clinton. 

What Gingrich also shared, often, were his thoughts about what was necessary to drive the kind of sweeping alteration of the status quo represented by his leading Republicans to their first House majority in decades. Reviewing that roadmap, it’s not surprising that VBC advocates remain far from their destination.

The journey starts off in the right direction, with VBC advocates following Gingrich’s advice to “focus on large changes.” Trying to upend the way physicians have been paid since Hippocrates made his first house call certainly qualifies. But ambition has to be articulated as part of an organizing and attractive vision.

In 1997, in a book called Demanding Medical Excellence, I summarized the urgency of what we now call value-based care this way: 

Tens of thousands of patients have died or been injured years after year because readily available information was not used – and is not being used today – to guide their care….(The health care delivery system) must be restructured according to evidence-based medical practice, regular assessment of the quality of care, and accountability.

In a similar vein, Gingrich in 2007 emphasized “a clear and compelling vision for quality” that would appeal to patients and medical professionals by promising safe care (no preventable deaths or injuries); consistent clinical excellence (appropriate and effective evidence-based care); and clinicians and staff partnering with patients.

Language That’s Bureaucratic, Not Bold

In contrast, the coalition sponsoring last month’s Health Care Value Week positioned transformation as a series of “models” addressing a bureaucratic checklist of health care “challenges.” The same type of language is used by the Centers for Medicare & Medicaid Services.

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Matthew’s health care tidbits: #What is insurance again?

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Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

For my health care tidbits this week, I was reminded on Twitter that many Americans really don’t understand health insurance. A spine surgeon no less in this thread (no jokes about arrogance please) was telling me that he was paying ~$8,000 a year ($4,000 in insurance and $4,000 in deductible) before he got to “use” his insurance–which, as his medical costs were low, he never did. Others were complaining that the cost of employee premiums were over $20K. They all said they should keep the money and (presumably) pay cash when they do use the system. It’s true that most people don’t use their insurance. That’s the whole point. When you buy house insurance, you don’t expect your house to burn down. You are paying into a pool for the people whose house does burn down.

In the US we are on average spending $12k per person on health care each year. But spending on most people is way under that and for a few it’s way, way over. If you take the rough rule that 50% of the spending is on 10% of the people then 35 million people account for $2 trillion in spending–that’s ballpark $60,000 each. They are the ones with cancer, heart disease, complex trauma, etc, etc. The rest of us are “paying” our $4,000, $8,000 whatever, into the pool to cover that $60,000.

There are only two ways to lower that cost for the healthy who aren’t “using” their insurance. One is to exclude unhealthy people from that insurance pool, which makes the costs for everyone else much less. We did that for years with medical underwriting and it was nuts because it screws over the unhealthy. Fixing the pre-existing condition exclusions was the only bit of Obamacare everyone agrees on–even Trump. But now we are ten plus years into this new reality, some people have forgotten how bad it was before.

The other way is to reduce the costs in the system and lower that $4 trillion overall. How to do that is a much longer question. But it isn’t much connected to the concept of insurance.

The Social Science of Covid

By MIKE MAGEE

As we enter the third year of the Covid pandemic, with perhaps a partial end in sight, the weight of the debate shows signs of shifting away from genetically engineered therapies, and toward a social science search for historic context.

Renowned historian, Charles E. Rosenberg, envisioned a similar transition for the AIDS epidemic in 1989. He described its likely future course then as a “social phenomenon” with these words, “Epidemics start at a moment in time, proceed on a stage limited in space and duration, follow a plot line of increasing and revelatory tension, move to a crisis of individual and collective character, then drift toward closure.”

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My 22 Oldest Jokes and Why They Still Matter in 2022

By IAN MORRISON

I have been studying American healthcare for more than 40 years and I have assembled a large number of one-liners over the years. As we enter 2022, I thought I’d share my 22 oldest jokes and why they still matter. 

Coming to America 

  1. I grew up in Glasgow, Scotland.  In Glasgow, healthcare is a right, carrying a machine gun is a privilege. America got it the wrong way round. 

Gun violence continues to ravage the United States. We have more guns than people. Kids get gunned down in school playgrounds and classrooms routinely. It happened once in Dunblane, Scotland in 1996 when a local shopkeeper walked into Dunblane Primary School and opened fire, killing 16 5- and 6-year-olds and their 45-year-old teacher.  It so galvanized public opinion, according to Smithsonian Magazine:  “By the end of 1997, Parliament had banned private ownership of most handguns, including a semi-automatic weapons ban and required mandatory registration for shotgun owners”. 

Last time I looked, gun violence was the second leading cause of death in children in the US.  In America when we have mass shootings all we get are thoughts and prayers. 

And when it comes to healthcare as a right, even if we Build Back Better, it won’t be a right for millions of American residents, especially those who are undocumented. 

  1. I am a Scottish Canadian Californian which gives me a unique perspective on healthcare (and all things to do with healthcare, including death and dying) because the Scots see death as imminent, Canadians see death as inevitable, and Californians see death as optional. 

This is one of my oldest jokes and it remains true.  In Silicon Valley, where I live, my affluent VC friends want to live forever and are working out and taking supplements to achieve that. In contrast, my British friend Dr. Richard Smith (former Editor of the BMJ) is sitting on the Lancet Commission on the Value of Death.  Enough said. 

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Climate Change: The Future of the Quality Movement

By MARIE DUNN

A little more than 20 years ago, the IOM report To Err is Human catalyzed the profession around the realization that our health care system was killing around 98,000 people a year from medical error. I am part of a generation of professionals that learned to adopt systems thinking; to measure, monitor, and improve; and to ultimately improve quality of care. 

Today, we face a different set of challenges. Health care is in the midst of a global pandemic, a reckoning with systemic racism, not to mention the great resignation. But also, we face a climate crisis. Are these things connected? Is there something we all can do? The answer is undoubtedly yes, and I write to advocate for climate change to be included on this list of strategic and moral imperatives for health care leaders everywhere. 

Why is that?

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Can Democracy Survive In The Absence of Health Care Security?

By MIKE MAGEE

In my course this fall at the President’s College at the University of Hartford, we began by exploring the word “right” at the intersection of health care services and the U.S. Constitution.  But where we have ended up is at the crossroads of American history, considering conflicting federal and state law, and exploring Social Epidemiology, a branch of epidemiology that concentrates on the impact of the various social determinants of health on American citizens.

What makes the course timely and relevant is that we are uncovering a linkage between health and the construction or destruction of a functional democracy at a moment in America’s history when our democracy is under direct attack.

This was familiar territory for Eleanor Roosevelt. She spent the greater part of World War II creating what she labeled in 1948 “Humanity’s Magna Carta” – aka the “Universal Declaration of Human Rights (UDHR.)”

Embedded in the declaration was a much broader definition of health. It reads “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The Marshall Plan, for reconstruction of war torn Germany and Japan, embodied these principles, and successfully established stable democracies by funding national health plans in these nations as their first priority.

Although our nation signed the UDHR, it carried no legal obligations or consequences. In fact, the U.S. medical establishment’s bias was to embrace a far narrower definition of health – one that targeted disease as enemy #1. They believed that in defeating disease, health would be left in its wake.

In contrast, neighboring Canada took the UDHR to heart, and as a starting point asked themselves, “How do we make Canada and all Canadians healthy?” Where our nation embraced profiteering and entrepreneurship, leaving no room for solidarity, Canada embraced the tools of social justice and population health.

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Policies, Techies, VCS: Musings From a Futurist

By IAN MORRISON

I should’ve been in Paris last week on vacation with my wife, instead I listened in to the Policies Techies VCS:  What’s Next For Healthcare conference (I’ll explain why later).  Matthew Holt and Jessica DaMassa did a magnificent job of assembling the Who’s Who of digital health tech to wax lyrical about what the new kids on the block were up to, where it is all headed, and what it will mean for the system. (Full disclosure Matthew and Jess are friends of mine, I hired Matthew from Stanford almost 30 years ago to join the Institute For The Future (IFTF) and have watched proudly as he has become a Health 2.0 impresario.  Jess simply deserves a gold medal for wrangling Holt and all the other tech Bros with wit, charm and intelligence).

This is a tumultuous time for digital health technology because of the pandemic and the related rise of digital solutions not to mention the very frothy investment market and massive deal flow over the last 24 months.   There are a lot of exciting new faces.  But, many of the companies on display have been at this for some.   And for many of the old guard, like Livongo and now Transcarent Founder Glen Tullman, Athena Health and now Zus Founder Jonathan Bush, and Amwell CEO Roy Schoenberg and others this has been a much longer journey.

(Parenthetically, as a young management engineer in Canada, a position, I was not qualified for, I wrote the justification for an all-computerized hospital at the University of British Columbia in 1979!  I still find it just incredibly pathetic that it has taken us 40 years to suddenly “discover” digital health. I wrote The Second Curve which forecast (among other things) the rise of digitally enabled health transformation 25 years ago!  So it is hard for me to get really excited that this is either “new” or “next”.)

So, while a lot of us have been in this movie for a long time, there is something very different about the current crop of offerings.  In particular, technology has advanced considerably and there are clearly new cloud and SaaS tech enabled care solutions.  There is a new cadre of talented and committed investors and entrepreneurs who believe they have the capability and capital to scale meaningful enterprises that will disrupt incumbent healthcare players and better serve consumers and providers.  And the timing seems right as the pandemic forced consumers and the health care system to confront new ways of doing business.

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