I remember reading President John F. Kennedy’s Profiles in Courage when I was a girl and being inspired by the recounting of Senators standing up to colleagues and constituents alike to speak out and vote on principle for what they thought was in the highest interest of the nation. Courage was the word that has most frequently come to mind with the passage of the Patient Protection and Affordable Care Act, better known and the Health Reform Bill, Sunday night in the House of Representatives. Despite levels of vitriol not seen since the Civil Rights Movement of the 1960s, complete with shouting, spitting, and name-calling outside and inside the Chamber, Democratic members of Congress came together to lead. With this bill the administration made a statement about who we are as a nation, as a people, a nation that cares and supports all its citizens, a nation that understands that a foundation of health is necessary for enjoyment of all our constitutional rights and the many privileges of living and working in this great country, a nation that can find money for peace as well as war.

Some say that this is a government take-over of healthcare. It is not. Insurance companies, drug manufacturers, and hospitals are still standing and benefit from more insured. Small businesses are key beneficiaries and there will greater opportunities for job mobility without fear of losing and never regaining insurance coverage one can afford. Patients benefit. Almost all of us will have a “pre-existing condition” if we live long enough.

Some say it costs too much. How much is too much for health? Ralph Waldo Emerson once said that “The first wealth is health”. We would do well to remember that. Do we need to do more to reduce (not just shift) costs of healthcare while maintaining/improving quality? Yes. However, one bill is not required to do all things.
If the purpose of government in a capitalistic, constitutional democracy is to do collectively what we cannot do individually to ensure a strong, stable and prosperous country then this Democratic Congress has done its job. They have my vote not only in the next election, but for the next edition of Profiles in Courage.

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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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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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Before you think I’ve reverted to writing fiction with the title “Patient-Owned Health Delivery System in Alaska” let me share with you things I learned at a presentation last night at the National Library of Medicine, the originators of Medline Plus and PubMed among other activities. http://www.nlm.nih.gov/

Katherine Gottlieb, MBA, Native Alaskan, and CEO of the Southcentral Foundation described the creation and operation of the Alaskan Native and American Indian owned $160 million corporation which runs healthcare in Anchorage and its surrounds.  This is no casino-fueled initiative, but the result of a decision by the native peoples to take control of the monies previously spent on their behalf by the Indian Health Service and other government entities.  Under  their self-trained and determined native leadership the SouthCentral Foundation reports 50% reductions in urgent care use and hospital admissions than under IHS, 66% fewer C-sections than the national average, 95% childhood immunization rates and 91% customer satisfaction.

Their operating principles are based on considerations for the whole person and the whole community. Their vision is for A Native Community that enjoys physical, mental, emotional and spiritual wellness and they underscore key points of shared responsibility, commitment to quality, and family wellness.

http://www.southcentralfoundation.com/

When will patients in the Lower 48 decide that we can direct and drive healthcare here too?

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If we truly wanted to create a patient-centric healthcare system – not insurer-centric, employer-centric, or even physician-centric – I believe that we need to do the following:
1. Redefine healthcare to include a holistic, 360 degree view of health from wellness, to prevention, diagnosis, treatment, rehabilitation, and hopefully back to wellness.
2. Align a payment system, not necessarily, but possibly an insurance system, to support those elements along this 360 degree paradigm that provide actual value, i.e. improve patient outcomes.
3. Provide transparency in pricing. Costs, potential cost-savings, and how those costs were calculated should all be included. Cost and price can be two different things. The government declaring that they need to cut physician payments in Medicare, for example, does not lower the costs of physicians delivering care.
4. Widely disseminate consumer education and patient decision support tools to facilitate informed evaluation of health and medical options.
5. Universal mandatory participation in some type of health insurance or financing mechanism coupled with guaranteed issue. The system should put individual coverage on an even playing field with employer coverage and drop barriers to multi-state or other groupings.
I believe in a system that is consumer-directed, where patients are able to accurately estimate the amount of financial risk they can tolerate for health expenses and can buy reasonably priced coverage for services above that personal level of risk. I believe that patients should have their choice of physicians and be supported and empowered to engage in appropriate self-management by members of their healthcare team. I believe that the most important decisions we make in healthcare involve what we eat, how much we move, choosing not to smoke, and other lifestyle choices, but when our genes, fate, or attempt to stay forever young fail us, the availability of quality medical care that does not bankrupt us in the best interest of all.

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