The unexpected happened and Massachusetts elected a Republican to the Senate seat long held by Democratic lion, Ted Kennedy.  Beyond the far-reaching implications for BOTH parties as to how this instructs them to respond the electorate, Scott Brown’s election breaks the fragile 60 vote Democratic Caucus in the Senate, putting healthcare reform as we have come to know it in dire peril.

Many, including myself, do not think that this is a bad thing necessarily. What if we had to start from scratch?  What if we unraveled all the convoluted provisions and the waivers and side deals connected to them and created a bill that truly reflected the needs of patients and healthcare practitioners?  What would this look like?  We’ve come so far away from first principles that it may be hard to recall or recapture, but here’s my short list.

1. Real cost savings – Few things actually reduce overall costs in healthcare rather than just shift them.  A new healthcare bill should include a) Medical malpractice reform, and b) Payment based on a coordinated care model.
2. Expanded coverage – We will never get to 100% without automatic universal coverage so stop using that as a goal if we don’t plan to go that far.  We would be able to get closer, more easily by raising the income and category limits on Medicaid and lower age limits to buy into Medicare.  Incentives for small businesses, tax deduction for individual coverage, and allowing children to stay on their parents policies until age 26 would make a significant difference.
3. Meaningful coverage – accept the insurance company proffer to eliminate pre-existing conditions, guarantee issue, remove lifetime caps, etc.
4. Improved quality – See 1 and add supporting practices of all sizes to adopt and use electronic medical records (with patient access to their data) and accelerated translation (uptake and adoption) of evidence-based medicine.

Then walk away. Put the pen down. Leave the exchanges, mandates, Louisiana Purchase, state opt-outs in the dust bin of history and bask in the feeling of getting something done.

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It has been interesting for me to watch the transformation of the term health insurer to health plan.  Having been insured since in my mother’s womb, I have never been notified that any of my health insurance companies has a plan for my health.  For a health insurance company to be termed a PLAN, in my mind, I would like to see:

1. Prompting and  reimbursing me and my physicians to establish my baseline health metrics and specific health goal(s)

Enrolling in a plan as a new subscriber, a milestone birthday, or just the turn of the calendar could provide the incentive to create a personal plan for my health.  Am I hypertensive? Am I diabetic?  Do I want to lose weight this year, train for a marathon or have a baby?

2. Providing quality and cost assessment information so that I could select the best physicians for my circumstances

See post  A Patient’s Quest for Quality in Healthcare.

3. Facilitating information exchange between my team of physicians

I have a primary care physician, gastroenterologist, transplant hepatologist, gynecologist, reproductive endocrinologist, dermatologist, and from time to time an oncologist, across 4 different practices and medical centers. I would pay anything to have them talk to each other.  Even to have them reliably and regularly share data and view one unified chart and come to a common assessment and plan for my treatment would relieve me of the huge burden of coordination, and no doubt reduce cost, waste, and error.

4. Suggesting, creating networks and reimbursing or providing discounts to complementary services to augment my health such as acupuncture, nutrition counseling, gym membership

90% of what I do to maintain and improve my health happens outside of a doctor’s office.  Health insurer’s buying power and breadth can support my access and use of complementary wellness services to optimize medical treatments and prevent others.

5. Proactively sending me lab results, medication refill and appointment scheduling reminders

Health insurers could add real value by leveraging technology to facilitate my adherence to my treatment plan in the midst of a busy life.

6. Helping me track my progress against an integrated care plan that I create with my team of physicians and complementary providers

Whether building on success or highlighting areas for early intervention, an integrated health plan dashboard with alerts could encourage my focus and active pursuit of health.

Under increased scrutiny in this era of healthcare reform, health insurance companies need to decide and describe how they add value to the healthcare system.   Their access to aggregate data on their members can fuel the integration of care across physicians, hospitals, and pharmacies for patients and support empowered consumer behavior.

Further reading:

The Patient-Centered Care Collaborative

Optum Health, subsidiary of United Health Group

Mayo Clinic Health Policy Center

Google Health

Microsoft HealthVault

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As part of an otherwise excellent presentation on the key drivers of rising healthcare costs, two slides purported to demonstrate that overbuilding of healthcare facilities was the result of inappropriate emphasis by patients on facilities’ cleanliness and convenience as measurements of quality.  The presenter’s point was that patients could not be trusted to assess healthcare quality since they chose such obviously silly metrics instead of judging and selecting hospitals or physician practices on the basis of cost, outcomes, or adherence to guidelines.

I had several thoughts in reaction, a few of which I can print – (1) With upwards of 2 million nosocomial (my favorite word) infections a year causing more that 100,000 deaths and complications, cleanliness is nothing to sneeze at; (2) in a past life I was taken to task by the HRSA administrator for making the point that there might be value in having the choice of  a transplant center close enough that families could support their loved one through a traumatic life event so I won’t comment here on the issue of proximity; but most importantly (3) patients judge what they can see.  If we make quality metrics such as cost, outcomes, and adherence to guidelines more accessible to patients then they will include those metrics in their decisionmaking.

And so I embarked on my own journey to see how readily available patient-friendly quality data is for patients.  First I looked for information on hospital information.  Hospital Compare http://www.hospitalcompare.hhs.gov/, an HHS website powered by Medicare data, allowed me to compare hospitals within a radius of my chosen zipcode on process of care (basically guidelines/evidence) adherence, outcomes like death, and patient satisfaction elements like physician communication or nurse responsiveness.  Interestingly, among the subset of local hospitals I chose, quality was similar but median Medicare payment ranged from a two to four fold difference.  Still a limited set of procedures and conditions are included, I have no idea how patients with my demographics and characteristics fared, and the Medicare cost data may bear little relation to what I might actually pay under my insurance let alone self-pay.

Physician information is available in a variety of formats for various fees, typically $9.95 to $24.95 on websites such as HealthGrades http://www.healthgrades.com and Physician Reports http://www.physicianreports.com or compiled in the Consumer’s Checkbook Guide to Top Doctors or Castle Connolly’s various city-specific  Top Doctors.  Plugging in one of my specialist’s name I was able to get disciplinary actions (luckily none), board certifications, years of education, hospital affiliations and even ease of scheduling, however I had no idea from the information provided if my doctor was any good.

Lastly my health insurer has a premium designation that awards stars for quality and cost-efficiency.  I could not find the basis for those designations and having been ill-served by one of their “centers of excellence” in a particular specialty, you can color me skeptical.

My takeaway is that even for a highly motivated, insured, internet savvy patient, with fair familiarity with health care and health care jargon, comprehensive actionable physician and facility information is limited, hard to find or non-existent.

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As members of Congress continue the arduous work of cobbling together healthcare reform legislation patients and consumers should hope that they are listening to the likes of Dr. Robert Galvin, Chief Medical Officer at General Electric.  I have to admit that after speaking with Dr. Galvin for some time last week about his career in clinical practice and his 15 years in the corporate setting researching, piloting, and sharing best practices in healthcare delivery and financing, I am now a huge fan. http://www.health.mil/dhb/members/20080812/Galvin_final_bio.pdf

I am a fan of:

• A physician designing a health plan http://bit.ly/3guTXM
• Emphasis on incentives for patients to choose high-quality low-cost care without unduly limiting choice
• Creating a transparent marketplace so patients have a basis for choice http://www.centerforpaymentreform.org/
• Payments to providers based on achieving quality goals, eliminating waste, and controlling costs in collaboration with other healthcare providers http://www.bridgestoexcellence.org/
• Leveraging the power of purchasers to  compel improvements in patient safety http://www.leapfroggroup.org/

Large employers, like GE, have served as a testing ground for many of the major elements of health reform.  Let’s use their lessons as a platform to accelerate meaningful changes in the healthcare system that  benefit us all.

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