Health Care Here. Further thoughts on changes.

“In our last discussion, Julie, we presented some ideas of ways by which health care delivery in the U.S. might be changed.”

“As is customary with us, Curmudge, the ideas were not original.  So shall we continue to share the words of wisdom of others?”

“Of course, but we must keep in mind the two schools of thought on the subject.  Some people believe that excellent health care should be provided to everyone; others believe that excellent health care should be available to everyone.  You and I belong to the second school.  We also feel that patients—with their physicians—should be free to make their own health care decisions, and that they can do it best if they have some ‘skin in the game.’  Recall that in our last discussion the last two examples reflected the second school of thought.”

“There are a lot more good ideas to be shared, Curmudge, but space is limited in our blog.  A really profound document to recommend is the Economic Outlook from Premier Inc. healthcare alliance.  Let’s share some of the high points presented in the Outlook by Harold D. Miller in his paper ‘A National Strategy for More Affordable Healthcare.’   Here are some of his observations:

‘Costs may be reduced by improving disease prevention; diagnosing and treating serious conditions at an earlier stage; avoiding unnecessary and potentially harmful tests, interventions, and medications; eliminating dangerous and expensive infections and medication errors; and educating chronically ill patients on how to manage their conditions to prevent costly hospitalizations.’

‘The country is too diverse for a single national solution.’

‘Providers and payors must remove the veil of secrecy that has shrouded cost, quality, and price information.’

‘The proposed “incentives” are just a new flavor of pay-for-performance based on the same fundamentally flawed fee-for-service system.  Two basic payment reform systems are episode-of-care payment (a single payment for all of the services associated with a single acute episode) and comprehensive care payment (a single risk-adjusted payment to cover all of the services a patient needs for a particular condition or set of conditions over a period of time).  These changes can only be accomplished in mutually accommodating ways involving providers and payors.’

‘We can control health care costs without rationing but only if we do it at the community level.’ “

“One should read the whole paper.  Getting closer to home, in his new book John Toussaint advocates designing care around the patient and not at the convenience of the physician, hospital, or nurse.  He also proposed payment for outcomes (as in keeping people healthy), and providing transparency of treatment quality and cost via the Wisconsin Collaborative for Healthcare Quality.”

“Even closer to home is at home, Curmudge.   Affinity Health System has been practicing Lean for over five years and is making progress in improving efficiency and patient safety and reducing waste.  One can develop a Lean culture locally irrespective of what is occurring at the national level.  So Old Guy, after all of our reading and writing about health care here and elsewhere, what do you foresee occurring in health care in the U.S.?”

“Foresee!  Do you expect me to have a crystal ball in my briefcase?  However, it’s clear that there is no shortage of good ideas about improving our flawed health care system.  What we need are a few philosopher kings to purge their parochial mindsets and reason together.”

Kaizen Curmudgeon

P. S.—An Alternate View

“What’s this P. S. stuff, Curmudge?  What’s up?”

“Well, Julie, no sooner had I typed the last word above when I found something interesting in John Goodman’s latest blog posting.  It is an article in the New England Journal of Medicine titled ‘A Systemic Approach to Health Care Spending.’  I recognized the authors as big guns in ‘big-government’ medicine.  Out of fairness, I felt that I should mention it.”

“I am amazed by the kindness of an opinionated old codger.  So what was in the article?”

“According to Goodman’s summary, the two most important proposals are: (1) market-wide negotiation leading to all-payer fees (every third party pays the same) and (2) a ‘global budget’ cap on the rate at which these fees can increase over time.  I suspect that these signify more stringent regulations for providers and payors.  Goodman says, ‘the proposal virtually guarantees that no provider is going to experiment, innovate, and try to find alternative ways of lowering costs, raising quality, and improving access to care.’ “

“And what do you say, Ancient Oracle?”

“Despite these guys’ prominence and power, I characterize them as faux philosopher kings.”

“And what might become of all this?”

“I shudder.”

K. C.  

Health Care Here. How might it change?

“Last week, Curmudge, we agreed to focus this week’s dissertation to points of view and suggestions.  As I recall, we were going to extend our earlier discussions of health care elsewhere and see if there were ideas worthy of bringing back to the U.S.  But considering health care’s political sensitivity, it would require a king philosopher to make sweeping changes.”

“The term, Julie, is philosopher king.  That’s a guy with the knowledge and judgment to know the right thing to do and the authority to get the right thing done.”

“Surely you’re not going to pretend to be a philosopher king!  The knowledge you once had has petered out, and the only authority you have is over what you select from the salad bar when you eat lunch at the hospital.”

“How about my pretending to be an advisor to a philosopher king?  Years ago my job title was ‘advisor,’ but my boss was no philosopher king.  My job went away when he shot the messenger.”

“And if you had a job, that could happen here.  Shall we begin with some broad, general recommendations based on our recent studies and observations?  Then we’ll get to specifics later.”

“Let’s start with a recommendation for a philosopher king who holds an unshakeable belief in government-sponsored health care.”

“But, Curmudge, that person couldn’t really be a philosopher king.”

“True, but he undoubtedly thinks he is.  He should look carefully at the French Securité Sociale and the British National Health Service.  These programs have desirable features that might be adopted elsewhere.”

“Agreed, but now let’s return to the colonies and consider our general recommendations for health care here:

The patient’s well-being should be the focus of the system of care.  In a highly complex society like the U.S., health care is too complex to be the subject of comprehensive laws and regulations promulgated for individuals on a nationwide basis.

Any government should be able to afford any health care system that it sponsors.

The concept of ‘entitlement’ should be eliminated; it soon becomes enshrined as a ‘right’.  Then ultimately, as in Europe, any attempt to reduce an entitlement will be fiercely opposed by those who have become accustomed to its benefits.

Bureaucrats should not make health care decisions for individuals.  These decisions, in the form of rules, can have tragic unintended consequences.

Health care should be allowed to operate in a free market.  Prices should not be administered; they and outcomes should be transparent.

Innovations in health care practice, devices, or delivery should not be discouraged or inhibited, as discussed earlier.

Payments for non-critical health care encounters should not require third-party involvement.  Health insurance should return to its former ‘major medical’ or ‘hospitalization’ role.

Any health care system—national or local—should include a ‘safety net’ for those who truly need it.  This should be in concert with the Triple Aim of providing the best care for the whole population at the lowest price.”

“Well, Julie, shall we move on to specifics?  We should be careful to cite references.  Fictional characters are a lot like parrots; we can only speak those words that we have learned from someone else.”

“We already provided one specific suggestion in our discussion of Clayton Christensen’s book back on June 3, 2011.  ‘Employers who directly manage their employees’ health care use a combination of high-deductible insurance (to protect against catastrophic illness) and health savings accounts (HSAs). The employer puts before-tax money in the employee’s HSA; the employee can also add (before tax) to the account. The employee pays for health care out of the HSA up to where the high-deductible insurance kicks in. Upon retirement, the employee can keep any funds left in the HSA.’  Christensen also described a variation on this system for the uninsured (unemployed) poor.”

“Here, Julie, is a similar approach that also gives the patient the option of deciding how he will spend his own money.  This was in legislation proposed by Congressman Paul Ryan and was described by John Goodman: ‘Suppose the government offered every individual a uniform, fixed-dollar subsidy (tax credit) for the purchase of health insurance, say $2,500 for every adult and $1,500 for every child.  A two-adult, two-child family, then, would get $8,000.  The credit would be refundable, so that it would be available even to those with no tax liability.  If an individual chooses to be uninsured, the unclaimed tax credit should be sent to a safety net agency in the community where the person lives — in case he generates medical bills he cannot pay from his own resources.’ “

“I think I’ve got it, Curmudge.  If health care is perceived to be free, it will be undervalued and overused.  These approaches give the patient the freedom to make efficient decisions with his own money.  Couple this with price and outcomes transparency and we’ve removed some of the chaos from health care.”

“There are more suggestions to be discussed, Julie, including some pertaining to Lean in hospitals.  If you leave town on vacation, don’t stay away long.”

Kaizen Curmudgeon

Health Care Elsewhere 2

“Hey, Curmudge, in our last posting I learned something about health care in other countries.”

“I did too, Julie.  And now we are going to try to reach some conclusions based on a few facts from a limited sample of the world’s health care systems.”

“That will be difficult.  Remember the old saying, ‘All generalizations are false, including this one.’  The most we can hope for is to find some recurring themes among the very diverse countries that we studied.  Here in a nutshell are two pieces of data for each country; the first number is population in millions, and the second number is physicians per 10,000 population.  Switzerland; 7.6 and 40.  UK: 61 and 21.  France: 64 and 37.  Singapore: 4.7 and 15.  And for comparison, Spain: 40.5 and 38, and U.S.: 314 and 24.3.”

“It appears to me that the doc-to-population ratio in developed countries isn’t too critical.  I wouldn’t hesitate to use the health care system in the UK, in fact Mrs. Curmudgeon and Doc Mack used it with success.”

“Curmudge, let’s look at our findings from the standpoint of our original premise—that health care is a complex system.  And not only is health care complex, the populations using the system may be demographically, linguistically, socially, and geographically complex.  If one overlays a highly complex health care system on a highly complex population, the result is apt to be chaos or at least a lot of unhappy patients and providers.  Fortunately, the people in the countries in Europe that we have studied aren’t as diverse as we are and don’t seem highly displeased with their health care.  It is almost as if the country’s health care system fits its personality.”

“Some of that might be due to their small size and the fact that much of the management of the national programs is done regionally.  Perhaps in those cases, one person might actually be able to grasp everything that is going on.”

“Here’s something that is going on, Curmudge, especially in Southern Europe.  Health care is only one of the countries’ social welfare programs, and because of that, whole countries are in financial trouble.  As Margaret Thatcher once said, ‘The problem with socialism is that eventually you run out of other people’s money.’  Other countries will ignore this lesson at their peril.”

“Staying with our concern about complexity, Julie, the United States might be viewed as the most complex of the democratic developed nations.  We have red states, blue states, northerners, southerners, people who think for themselves, people who think only about themselves, people who think it’s their duty to think for everyone else, and people who don’t seem to think at all.  Any one-size-fits-all solution to the health care problems of such a complex nation simply will not fit.”

“Curmudge!  At your salary grade you can’t make judgments like that.”

“Julie, if I had a salary grade I wouldn’t make judgments like that.  And besides, I’ve read it so often that I wouldn’t know whom to reference.”

“Okay, Senescent Sage, but instead of judgments, it might be safer to take a fling at suggestions.  As we said earlier, no one person can fully comprehend such a complex system; but one can offer a point of view and a suggested solution or two."

“Whatever that future subject is called, it will be our topic for next week.  See you then.”

Kaizen Curmudgeon