Commentary by David F. Durenberger
As healthcare costs dominate our local, state, and national
agendas, there can
be no doubt we are approaching another crisis in health care. Health
care is a $1.57a trillion industry today, with the potential to double
that amount every
five years.
In earlier healthcare crises, we attempted to apply magic bullets
to contain
rising costs. In the 1970s the government enacted supply regulations
such as
limiting the number of new hospital beds and new technologies. That
effort
failed. In the 1980s the government tried again by setting Medicare
prices
prospectively for both hospitals and physicians. That effort had an
impact on
hospitals but not on cost escalation.
The volume of healthcare services provided continued to rise, and,
in the 1990s,
the industry embraced managed care. Because of patient and professional
reactions to perceptions of a third party "managing" the
physician-patient
relationship, managed care has now substantially changed. This last
magic bullet
of health policy also seems to have failed us.
Provider Role in Healthcare Reform
People who are talking about lowering
costs
are missing the point. Short-term measures such as reducing benefits
or limiting
access to services are not going to successfully restrain costs over
the long
term. We must confront the root cause of healthcare cost increases:
the systemic
dysfunction of our health system. And we must do so from the inside
out and from
the bottom up.
Top-down, outside-in reform doesn't work. If the government, large
employers, or
big national for-profit companies try to change the system once again,
will
reform be any more successful than it has been in the past? Our health
system
was built from the inside out, and so it must be changed by those who
function
at its core: the providers.
Clinical breakthroughs and technological innovation sprang from a
rich tradition
of physician-led healthcare enterprises, and the provider-patient relationshiphas
long been the bedrock of our world-renowned U.S. healthcare system.
Today,
however, insurmountable pressure from outside forces is undermining
that
leadership and the relationship between the provider and the patient.
Physicians
as entrepreneurs, hospital owners and managers, medical technology
companies,
and private investors have brought us supply-and-demand policies that
have so
distorted the normal producer-consumer relationship as to create cost-driving,
resource-dependent systems without evidence of real value for the money
being
spent. Quality is presumed from licensure, and third-party payers cover
the
costs. The health system is so fragmented by special interests as to
be rendered
untenable.
We need to restore the provider-patient relationship to its original
stature--the heart of the system. This relationship must include partnership,
empathy, and accountability between patients and providers, and mutual
trust
must be at its core. If we are to successfully reform our health system,
trust
also needs to be at the center of all interactions within the health
system:
physicians have to trust hospitals; hospitals have to trust health
plans; nurses
have to trust allied health professionals; and purveyors of invaluable
technology and service must trust the fundamentally altruistic origins
of
healthcare delivery.
To achieve this kind of transformation, we have to sit across the
table from
each other at the community level--in hospital board rooms, city council
meetings, educational institutions, neighborhoods, and state government--to
find
ways to take down barriers created by licensure issues, special-interest
groups,
and payment policies. We need to dismantle the cottage industry that
has
fragmented our healthcare system. Stakeholders must be willing to abandon
their
strongholds in favor of collaborative change. We know each other; we
can count
on each other. Together, we can build the foundation for systemic reform.
Inside-out reform must also come from example. If we could all agree
today on
what an ideal system is, you'd be surprised to find organizations of
caregivers
that are already halfway there. Dartmouth-Hitchcock in New England,
Mayo in
Minnesota, Marshfield in Wisconsin, and Intermountain in Utah come
to mind.
It is critical that any reform effort reflects the multifaceted pressure
that we
confront--the costs, volume, and delivery of goods and services. Focusing
on any
one of these factors without considering the impact of the others cannot
lead to
sustainable change. And at the heart or any reform effort must be the
provider-patient relationship. If we lose our focus on that, we lose
our handle
on what makes good medicine work.
A Framework for Healthcare Reform
The National Institute of Health Policy (NIHP) has developed a framework
for
healthcare reform that offers an achievable vision for change while
significantly curbing the rise in costs.
The greater use of evidence-based medicine. If all physicians in the
United
States practiced as effectively as the top 10 percent, we would save
enough
money to add a drug benefit to Medicare and have funds to spare. Few
high-quality clinical decisions come from "gold-standard" evidence.
They come
from education, training, practice, and organizational guidelines built
on a
culture of quality. It's this culture we need to create. We know where
it exists
in the United States and where it does not by looking at geographic
practice
variation and the consequent evidence of overuse, underuse, and misuse.
We need
a state and national political consensus to pay only for high-quality
services
and to look for value for our dollar. And we must start with those
who already
are involved in total quality improvement.
The application of evidence-based operations. Our health system's
operations are
inefficient. The healthcare industry's rate of productivity increase
hovers
around 0.8 to 0.9 percent per year compared with 3 to 4 percent in
other
industries. We have a cottage industry in which each organization operates
in an
idiosyncratic manner based on its history, leadership, and providers.
We need a
new paradigm that combines the art and science of medicine with the
best
operating practices of our nation's most efficient industries.
New methods to lower financing and transaction costs. Healthcare administrative
costs account for 4 percent of our GDP. The exchange of information
and funds
between payers and providers is wrought with burdensome and complex
systems. In
some cases, the process is partially automated, but, in many cases,
paper is
still needed. We need to find ways to reduce the cost and volume of
paper
exchange. Shared records among multiple providers who treat the same
patient
would be one way to start. A reduction in regulated reporting, which
creates an
undue burden on clinical and administrative staffs, could be another.
This
overburdensome demand for accountability and duplication of efforts
producing
the same information are ripe for reform.
A more active role for the consumer. We know that many consumers overuse
the
system, are uninformed about the costs of health care, and make poor
lifestyle
choices that lead to costly illnesses that are costly to treat. But
we also know
that consumers will make good choices when they are motivated to do
so. We need
to create incentives that will encourage us to care about our health,
live
healthier lives, and to use the healthcare system more judiciously.
Trust in
providers has been eroded and must be reestablished to make the most
of the
provider-patient relationship. Combined with evidence-based practice,
a healthy
provider-patient relationship can ensure more appropriate use of medical
resources and lower reduction in costs associated with defensive medicine
and
frivolous litigation.
We also need to create a source of accurate and usable information
for
consumers. Information about price, provider and payer quality, and
illness and
wellness can contribute to a more active and effective role for us
all,
Our healthcare system is broken. Business as usual is compromising
the best of
what makes the U.S. healthcare system a model of innovation and progress.
It is
eroding an industry that is critical to the health of our economy,
and it
prevents us from providing access to high-quality health care for all
Americans.
Each stakeholder has something to add to this debate, and each has
a special
interest to protect. Those special interests must be subjugated, for
the time
being at least, to the common need for systemic reform. All politics
is local,
all health care is local, and thus all health system reform must begin
at the
local level.
I believe that many of the best solutions to today's health policy
challenges
already exist in progressive healthcare organizations. We can't wait
for the
government to "fix" our healthcare system. The solutions
will need to come from
you.
David F. Durenberger, JD, is chairman of the National Institute of
Health
Policy, a program of the University of St. Thomas in Minneapolis/St.
Paul, Minn.
He served in the U.S. Senate from 1978 to 1995. Currently, he is a
member of
MedPAC and the Kaiser Foundation Commission on the Future of Medicaid
and the
Uninsured.
Senator Durenberger was recently named by Governor Tim Pawlenty to
lead the
Minnesota Citizens Forum on Health Care Costs, an inside-out, bottom-up
approach
to healthcare reform in Minnesota. He also is chairman of Citizens
for Long Term
Care, president of the Medical Technology Leadership Forum, and cochairman
of
America's Health Together. He is author of Prescription for Change
and Neither
Madmen nor Messiahs.
