By GEORGE HALVORSON
The COVID crisis has shown us clearly that major portions of the American care system are extremely dysfunctional and some are now badly broken. We need to put in place a cash flow for American health care that can help our care sites survive and ultimately thrive, and we need to put that approach to save the sites in place now because a vast majority of hospitals and medical practices are badly damaged and some are financially crippled and even destroyed by their response to the crisis.
We have learned a lot in the COVID crisis that we need to use now in building our next steps and our collective response to the crisis.
The COVID crisis has shown us all that our care sites do not have good patient data, do not have good patient linkages, usually do not have team care of any kind in place, and most are so dependent on current piecework fee volumes from patients that they quickly collapse financially when that volume is interrupted.
We should be on the cusp of a golden age of care delivery that uses all of the best patient support tools to deliver continuously improved care — and we now know that the piecework way we buy almost all of our care today will keep that golden age from happening for the vast majority of American patients for the foreseeable future until we change the way we buy care.
We need to buy care in a way that both requires the use of those tools and rewards caregivers and care teams when they use them.
We need a dependable cash flow for care to anchor that process.
We are unlike most of the rest of the industrialized world in not having a dependable cash flow now to buy care. We rely on a hodgepodge and mishmash of unlinked, unaligned and uncoordinated payment sources now and that lack of coordination in payment creates a vast and damaging lack of coordination in the delivery of care.
We can make a huge improvement in that entire process and we can give our health care system a stable and functionally useful future cash flow by becoming a much more highly skilled purchaser of coverage and care. We need a flow of money to make that happen.
We actually can create that flow relatively quickly and fairly easily by imposing a payroll tax on every employee that exactly copies the approach we use now for our Social Security payroll tax process and then using that money in a health care purchasing pool to buy health coverage for every person who is not on Medicaid.
The numbers work.
A growing number of people want to set aside all of our current health care financing approaches as a country and set up Medicare For All as a Canadian like single payer system to cover every American and pay for our care.
When we spend three trillion dollars a year on health care and still have thirty million people without insurance, the possibility of covering everyone using the most direct and simple approach has some obvious appeal.
That Medicare for All approach being proposed to Congress today would be funded with a half dozen taxes that would include making income tax more progressive and inheritance tax levels significantly higher than they are now.
If we do have enough political momentum and enough alignment as a nation to actually replace everything in our health coverage world with a national Medicare for All system that is financed by those new taxes, then we should seriously consider going even further and spend the same amount of money buying better coverage and better care for everyone by setting up a Medicare Advantage program for Everyone and using that approach and program to cover all Americans.
Medicare Advantage has better benefits, better care coordination, better quality reporting, and a higher level of focus on better care outcomes and better care connectivity than standard Medicare.
Standard Medicare buys care entirely by the piece. Buying care entirely by the piece rewards bad care, bad care outcomes, bad health, and inefficient care connectivity.
For decades, health policymakers considered Kaiser Permanente the lode star of delivery system reform. Yet by the end of 1999, the nation’s oldest and largest group model HMO had experienced almost three years of significant operating losses, the first in the plan’s history. It was struggling to implement a functional electronic health record, and had a reputation for inconsistent customer service. But most seriously, it faced deep divisions between management and the leadership of its powerful Permanente Federation, which represents Kaiser’s more than 17,000 physicians, over both strategic direction and operations of the plan.
Against this backdrop, Kaiser surprised the health plan community by announcing in March 2002 the selection of a non-physician, George Halvorson, as its new CEO. Halvorson had spent most of his career in the Twin Cities, most recently as CEO of HealthPartners, a successful mixed model health plan. Halvorson’s reputation was as a product innovator; he not only developed a prototype of the consumer-directed health plan in the mid-1990’s, but also population health improvement objectives for its membership, both firsts in the industry.
In its wisdom, the Supreme Court of the United States may decide to overturn the Obama administration’s health reform legislation.
The Supreme Court of the United States may decide not to.
Mitt Romney may unseat Barrack Obama and wrest the Presidency away from the Democrats. Or he may not.
In a way, these things may not actually matter.
There may be uncertainty on Wall Street and in the media about the fate of the Affordable Care Act (ACA) and the upcoming presidential election, but the mood in the crowd gathered at the 9th session of the World Health Care Congress last week in Washington was curiously upbeat.
There was a sense that health care is making progress.
And that is a good thing.
Innovations like accountable care organizations (ACOs), scientific management principles like cost containment and quality improvement and the movement for better health information technology will make their presence felt, regardless of what happens in the courts and on Election Day.
Unlike TEDMED, which brought together official Washington, the tech industry, entertainment and medicine — at the Kennedy Center last week, the World Health Care Congress is a meeting pretty much limited to health care industry insiders at larger firms.
As is generally the case, the speakers list read like a who’s who of very important healthcare names. Kaiser Permanente CEO George Halvorson, Intermountain CEO Charles Sorensen, Aetna CEO Mark Bertolini, Economists Ezekiel Emanuel and Jonathan Gruber, former OMB Director Peter Orzag, TEDMED curator (Priceline.com) Jay Walker talked about the power of the Internet to fundamentally rewire the way people think. Verizon CEO and NantWorks Founder Patrick Soon-Shiong were on hand to talk up a new collaboration. Xerox CEO Ursula Barnes introed the tech giant’s push into healthcare. Journos like Health Affairs Editor Susan Dentzer and NBC correspondent Nancy Snyderman provided media star power.
George Halvorson is the CEO who initiated and oversaw the biggest (private sector) EMR implementation ever. What’s Kaiser Permanente doing to expand on that? How is the new technology changing their thinking about care? How fast does George think the rest of health care is changing (very) and can others catch Kaiser (he thinks it would help Kaiser if they tried)? And what about getting other non-Epic apps on that KP system? I spoke with George at HIMSS12 yesterday, and his views are well worth a listen.
Sepsis is the number one cause of death in American hospitals–higher than cancer or stroke. Your chance of dying from a sepsis infection can triple if you choose a hospital that doesn’t have a good sepsis response team.
Care outcomes always vary from site to site and from caregiver to caregiver. For instance, if you have cystic fibrosis, your life expectancy can be diminished by a decade if you choose one of the lower success care programs for that disease.
But people don’t know where to go for best care for almost any level or category of care. That is the missing link in our healthcare delivery infrastructure. The least successful cancer centers will not get better if neither they nor the world knows how relatively low their success levels are. The world needs a scorecard for care performance that is mathematically sound and scientifically valid. It should only measure and report outcomes where outcomes vary and matter.
Enough of those areas exist now, but others still need to be created. The survival rates for each stage of each major cancer should be in a publicly accessible database, and patients with cancer should be able to consult that database to see where to go for best care. The database should also show clearly what the survival rates are for each major type of treatment for each stage of cancer. For example, surgery survival rates, hospital infection rates and cancer treatment survival rates would be a nice starter set for improving patient choices about care.
Such a database is entirely feasible, but we need people with authority and purchasing power to demand it. Employers, care purchasers, governmental care buyers and the new health insurance exchanges created under the new American health care reform act should all be insisting on these data sets.