Tuesday, December 30, 2008

View from the Cheap Seats: Attending a Transition Health Care Conversation

These meetings are happening everywhere.  Sunday, I moderated one of these. Today I participate. The meeting is at the home of one of our faculty, out in the woods. It was hard to find and I was late.  The following notes would have been "live-blogged", except I couldn't get an internet connection:
Democracy in action is a wonderful thing to watch. This is a big meeting, of folks who work in a wide array of the kinds of programs that are linked through the vast enterprise that is UMass Memorial Healthcare and UMass Medical School.  A number of high level leaders in the clinical and academic systems are present.  There are nurses and doctors, professors and clinicians, an exercise physiologist and educators (and a lawyer, friend of someone, I guess). I got here 35 minutes late, walking in the middle of the introductions, and taking a chair on the edge of the mob that spilled out of dining room into the hall.   I have already heard people talk about prevention and community and nurses and educating patients and parity and disparities; all of the issues on which we have pondered over the past decade. I am sitting next to a researcher who has won awards for his groundbreaking research, and who is concerned about how the health care system is about to split between the haves and the have-nots. (I might argue that it already has split)  His observation, that this is not going to be easy, resonated with everyone. We have done a lot to improve the practice of medicine over the years- the people around this table have testified to the things that they seen, but at the end of the introductions, it was clear that we still have a lot of work to do to bring our growing understanding of disease and the social factors that make disease happen into new systems of care.  
This was a very large group, with a lot of different agendas and many perspectives, working to find some way to make their voice heard in the transition process. 
Our moderator tried to pull key words out of the process: cost, quality, access, equity, coordination, prevention. After listening to all of us, she thought that cost is what bothers us the most; but that prevention is what we want.
Do I agree with that?  I guess so, although I heard a bit more about access and equity in the comments of my colleagues.  It was a bit hard to follow the argument- it kept whizzing back and forth. 
Key question: what drives up cost? After a bit of hemming and hawing, we finally realized that the cost of health care reflects by the way in which we are paid; fee for service will always drive the cost upwards. What is the incentive in such as positive feedback loop to put a lid on costs?  If nothing else, over the last 30 years, we have shown that we can build technology and then find a way to make money off of it. We have a hard time containing cost because we have a hard time estimating the marginal value of the next dollar.  Exactly how much bang are we going ot get for that buck?  One doesn't know, because we don't know how to put a value on health care.
Key question: what is value? Can we measure it? Some said yes, some said no. Some said that capitation is the way, some though that we needed to reward good behaviors.  Some said that the whole idea of pulling profit out of the system is simply wrong, that one cannot build a system predicated on profit that will care for the people on the margins.  Out of all this came a call to study the system: What works in systems as we build them in real-time? Can we set up a system that allows us to test systems in the practice?
Cost and value were the major things pulled out of the introduction by the moderator, interesting areas to focus our discussions.  But were these the issues that we wanted to discuss?
A deep breath: Reality check: What is doable in an incremental way?  Mr Obama is a pragmatist, one of group said.  We need to give him something to do on the day he takes office.
***Can we commit to a values construct:  All children under the age of 18 should have insurance by 2018.***
***How about the stimulus package: Can we fund the NIH at a 100% level?***
Everyone like this idea, but, as with all great ideas, it comes down to this: can all agree to it.  Not even close, it seems.
Then the discussion moved on: 2013 is when the medicare trust fund will run out of money. It will become a crisis. Some systems are starting to do this; Geisinger is doing this, and we are looking at that as well. Other thoughts crept into the discussion: prevention, at least in adults, doesn’t save money. Insurance won’t solve the problems of healthcare, even if it addresses the issue of payment. Poverty overrides many of the access issues. Can we afford universal coverage? I don’t know. And neither did the rest of the room.
Like ours, this was a free-wheeling conversation, ebbing and flowing. We moved onto systems: where do they find their primary care physician? And then, unlike our meeting, we had a break. Food, conversation, wine: good lubricants for a conversation.
After the break, we talked about population health: what can we do to encourage a healthy lifestyle? What can we do to make people want to stay healthy? Our culture is built on sitting, starting at a young age. What can we do to get young people engaged in the process? What can we do to make cigarettes go away? As people began peering off in the night, it was clear that this group was committed to change, and that they had not yet agreed on the appropriate strategy with which to put Humpty Dumpty back together again.
A friend of mine at the meeting last night wondered how effective these gatherings will be at moving the process of health care reform-  "another empty exercise, full of sound and fury, signifying ....?" was the phrase he used.  I don't believe that.  Change, in retrospect, is the inevitable product of circumstance, of economic pressures, of political forces that, it seems couldn't have gone any other way.  But we aren't part of change in retrospect.  These meetings (and you have read of two of them on this blog, with very different characters) are part of prospective change, which is an act of hope, and faith.  Hope springs from our experience on a small scale, where we have all been part of groups of people that have made something happen- a clinic in Webster,  a more efficient model of care for people living with AIDS, a hospital system rise from the ashes of the collision-merger of two health care cultures, a school for the lost youth of Providence.  We have all seen it work on a small scale;  we have all seen it fail, and we hope that we have the wisdom to scale success on a national scale.  Faith, well, that comes with the hope.  Faith is a core belief that this will be really hard, but this is doable and that we as a society are ready to take the leap.  Faith means the willing suspension of our disbelief that we have done this before, we have failed at this before, that those who failed were as smart or smarter than we are, and that we are doomed to failure.  Faith, in this context, is a belief that this process, inefficient and tedious as it is (newspaper said that there have been 8500 of these meetings around the country this week), is an essential part of the building that must go into making change happen in health care.  I stuck a copy of Rockwell's Freedom of Speech at the start of this post:  town meeting is boring, inefficient, contentious and long, but at it's core it is an act of hope and faith that we are an essential part of the process of our country.  What I find most encouraging about yesterday's meeting, and the one on Sunday is not the insight and expertise that we brought to the process.  I am excited by the fact that we all showed up.  We need to keep showing up to make this happen.

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