Archive for June, 2009

June 30, 2009

(H)ealth…or (W)ealth?

When our health care system is often described as “non-functional” or “unsustainable”, I like to take a step back and consider the perspective that every system is perfectly designed to get the results it achieves.  From that point of view, our health system is doing quite well if its goal is the creation of wealth.   Health care is the nation’s largest industry, employing about 10% of the workforce.  And it is increasingly consuming  a larger and larger share of our GDP (now over 16%).  So our health system has certainly been successful in creating wealth – in fact health care has been called “the beating heart of America’s economy.”

If the goal is creating health, the story is mixed, with some clear areas of improvement in the nation’s health statistics and some areas where the U.S. lags behind.  It seems to me that where we have a nexus of health and wealth, say, for example, in the field of cardiology, the nation’s health statistics  improve.  Where such a nexus doesn’t exist, like in primary care and prevention, our statistics aren’t so good.  Wealth is also generated in “look good/feel good” medicine, which arguably has a minimal impact on overall health status (but certainly has an impact on the well-being of those who can afford it).

Health…or Wealth.  With only one letter difference between the two, they are key players in our economy and health care system. As the health care reform debate moves to the next level, some thought needs to be given to the symbiotic and systematic relationship between wealth and health.  Because many important aspects of needed and necessary health care are not profitable, at least in the short term, we need to reflect on the kind of health care reform that is capable of addressing this critical paradox in the context of the fundamental priorities that should underlie any reform effort.  To paraphrase Ben Franklin, we need to be “health, wealthy, and wise.”

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June 29, 2009

Health workforce: only a slice of the pie in health reform

The nation has suffered from fragmented health workforce policymaking and a weak and dysfunctional infrastructure for workforce planning. Existing federal and state health workforce agencies lack the resources, scope of responsibility and visionary leadership to plan and implement a comprehensive, coordinated nation health workforce policy.

The nation has no capacity to collect and analyze uniform national data necessary to assess health workforce needs, target health workforce resource expenditures, and evaluate the effectiveness of health workforce programs and policies.  What exists is a patchwork of conflicting and competing public and private health workforce laws, standards, and requirements (e.g., relating to licensing, accreditation and scope of practice) that hinders the mobility of health professionals and creates barriers to addressing health needs, particularly of underserved communities.  A host of economic, educational, and other external factors  are limiting dramatically the responses of educational institutions, particularly academic health centers, to the workforce crisis. Economic factors limit access to the health professions; accreditation and credentialing standards drive the allocation of resources; and politics often inappropriately influence the nature and scope of health professions education.

A new permanent national health workforce planning entity would create an unprecedented:

  • Forum for federal, state and private policymakers to identify common health workforce problems and formulate joint solutions that can be implemented in a coordinated and integrated manner;
  • Capacity to quantify local, regional and national health workforce needs, allocate available resources, and measure outcomes;
  • Mechanism for harmonizing regulatory and self-regulatory requirements to facilitate effective responses to the needs of underserved communities;
  • Ability to synchronize public and private health care reimbursement policies with national health workforce policies; and
  • Consistent national approach to the international mobility of health professionals.

Policymakers must act immediately and address the workforce as a top priority in health reform.  The President should immediately appoint a national health workforce coordinator to begin mobilizing current resources more effectively as an interim step.  The Congress should ensure a new permanent national health workforce planning entity is created to articulate and implement a dynamic, comprehensive, coordinated national health workforce agenda.

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June 25, 2009

No accountability for insurers in health reform debate

A friend of mine, an association finance officer, tells me that the insurance premiums for her organization are going up 10% for the coming year.  Such blanket moves by the insurance industry—to raise premiums, deny coverage, change coverage options—reveal the problem at the heart of the health care debate.  Who is monitoring the insurers?  Who is holding the insurers accountable? Who asks the insurance industry about the raises?  Does anyone push back?  Does anyone ask why the money is needed and what it is used for?  The White House and the Congress are intent on cutting physician and hospital payments.  I have some sense about what happens with those payments, especially in the teaching hospitals that must educate the next generation of health professionals and pour money into research to advance science. I can’t say the same for the insurance industry.

I can’t remember in the last 20 years any time when the insurance industry has been called to task on Capitol Hill.  The recent Washington Post article, Lawmakers Reveal Health-Care Investments, provides the answer.  Almost 30 lawmakers helping draft the health care legislation have financial holdings in the industry.  There’s a conflict of interest here.  And the White House—already worried about re-election—is also conflicted.  How can you have a strong public plan if you can’t figure out how to be sure your investment portfolios—and big political backers—don’t suffer?  It’s easier to single out physicians and hospitals who must continue to provide patient care no matter what.  It’s time to address the future of the insurance industry—and their future business model–if we have any hopes of health reform.  It’s time to design a new and different role for the insurers in a new economy.

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June 23, 2009

To change the system, change the psyche

In the ongoing and seemingly chaotic health reform debate, there is remarkably little attention being paid to the underlying philosophy that would underpin a reformed health care system.  What are the substantive goals of a reformed health system?  What are the principles upon which it should be based?  Is it all about cost-effective and affordable health care?  Or improving the nation’s health statistics?  Or providing some form of meaningful universal coverage?

Instead, the focus has largely been on cost with some attention to issues of quality and access.  Health reform has become such an apparently daunting task that we have difficulty taking a step back and asking some fundamental questions.  Part of the problem involves the American ethos.  Nurtured by over 200 years of rugged individualism and ongoing cultural changes, we respond warmly to “rags to riches” stories.  We often reflect the attitude: “I pulled myself up by my bootstraps, why can’t you?”   What we don’t speak up about enough is how we want to treat each other as a society.

The goal of a reformed health care system should be of course improved health both individually and collectively.   But with reform should also come an improved sense of confidence and security.  For this to be achieved, we need to have more dialogue about what we really want as a society when it comes to health care.  Perhaps the answer lies somewhere in the American psyche:  health care reform ultimately depends on how much we care about each other.

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June 22, 2009

Health reform train: academic health center issues falling on train track

I read that some Washington Metro train operators are still opening doors of the long trains before all cars reach the station platform, posing a significant risk of riders falling onto the tracks.  That sounds like the health reform train careening toward the station, with doors wide open.  The President wants to move quickly this summer to pass health reform legislation.

However, a rush to legislate reform without careful consideration of the role of academic health centers will pose significant risk and have threatening consequences for the American people.  The Administration and Congress is not addressing the unique education-research-patient care interface that is essential in health care delivery and occurs in only in academic health centers.  Reimbursement reforms intended to improve the cost effectiveness of care will result in limiting the ability of academic health centers to support the education and research missions—so vital to U.S. health and prosperity. If these revenues are lost, they will need to be replaced by other sources or the advance of education and research—and the future of U.S. economic growth will be at risk.   Academic health centers cannot be an afterthought, falling on the reform track in the rush to the station.  Address all issues and options before opening the doors of the reform train.

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June 16, 2009

Health care reform: Who’s in charge?

With the Administration’s hard push for health care reform, it is reasonable to ask:  who’s in charge?    Ever since Tom Daschle’s nomination was withdrawn, the prospects for a single entry point for health reform coordination has disappeared. Perhaps, given the realities of the legislation-making process, this would have been illusory.  Yet there are so many points of entry that it’s hard to visualize a coherent, consistent message being promoted.  The main players thus far, the Senate Finance Committee, a number of House Committees, and the White House, do not seem to be particularly well coordinated.  Even within the White House, there is the Office of health reform as well as the office of the budget.  And where is HHS in the process?   Recently, Senator Baucus has been talking about the “coalition of the willing” as a possible means of getting health reform legislation passed.

Of course this apparent disarray may simply be democracy in action, but it certainly makes it difficult and challenging to get your ideas heard.  More importantly, with all these cooks stiring the soup, there does not appear to be an overarching framework of principles for health reform.  Perhaps this will emerge, but one wonders if the  Daschle nomination should have been put up earlier when his confirmation might have succeeded.

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