Tuesday, January 6, 2009

Another Point of View: A Health Care Discussion in Westborough, MA

I was invited to participate in another Health Care discussion last week; the convener, Silvia Corvera MD said that I could post her summary.  I posted my reflection on it last week here:

December 30th, 2008
Westborough, MA

All participants (listed omitted) agreed on an ultimate goal of achieving universal high quality health care at a cost commensurate with the health value provided to the individual and to society.

Two key challenges were identified: Excessive costs inherent to the current system and uneven access to health care. Universal health care will remain unfeasible unless costs are contained, and unless access both to insurance and health care provision are improved.

The Obama administration has a tremendous opportunity to demonstrate its commitment to solving the difficult problem of health care reform by agreeing to an ethical value-driven construct. We suggest announcing in the Inaugural Address a commitment to universal health care for children 0-18 years of age by the year 2010. Moreover, as a non-earmarked economic stimulus, it should immediately provide the NIH with the funds to support the research proposals that already exist and have been deemed meritorious through peer review.

The main problems identified and discussed were that of COST and ACCESS.
A. PROBLEM OF COST:  On the issue of cost the key question identified was, what drives increasing medical costs?  Two factors were identified:
1. Medical care is reimbursed for procedures done and tests conducted, not for health outcomes achieved. This leads to a technology supply-driven demand with no accountability for value.
2. Medical care is being increasingly provided for diseases that arise from societal behaviors that can and should be prevented.
Recommendations on cost control:
1. Medical care reimbursement should be commensurate with health value achieved, rather than with procedures or tests conducted. However, there are no appropriate metrics for health value. For example, we don’t know how to measure health outcome as a function of disease severity. Thus, the NIH must support research into, and disseminate information about:
a) The definition of value in health care (e.g. how does the physician’s time spent with a patient translate into improved health outcome, versus the prescription of yet another new drug or the request for yet another test? How is health improvement quantified? What makes sense to patients and their families as a positive outcome in a chronic or terminal disease?)
b) The design and integration of coordinated systems of care. Health care is provided by a team of providers not physicians alone. The concept that all health care is provided by or managed by physicians alone is part of the problem. The most effective healthcare is provided by teams of healthcare professionals. In community health centers in rural or inner city areas effective health management teams may not always need to include a physician. The future of healthcare is going to need a broader vision of the healthcare team and a significant amount of workforce development at all levels to create the providers who are most successful in these settings. The federal government should provide direct support for the development and analysis of systems that encourage collaborative multidisciplinary approaches to chronic disease reimbursed as disease management bundles
c) Understanding the relationship between cost and quality of care.
2. The federal government should aggressively intervene to promote lifestyle changes to prevent lifestyle-linked diseases. These include smoking-related diseases, obesity-relate diseases and AIDS. The federal government should immediately:
a) Require all food packages to prominently display calorie count per serving.
b) Provide tax incentives to all restaurants and fast food establishments that prominently display calorie counts per serving.
c) Require all buildings receiving federal funds to prominently display the location of stairwells, and encourage their use.
d) Provide tax incentives for health-promoting workplace designs (e.g. mini treadmills, pacers, etc)
e) Require and fund a minimum number of hours dedicated to physical education and sports in public schools. Exercise is linked to improved scholastic outcome, thus this promotes academic and physical well-being.
f) Implement a counter-marketing strategy against unhealthy food consumption pressures (e.g. “super-sizing”).
g) Ban the incorporation of high fructose corn syrup into products
h) Enact a uniformly high federal tax on cigarettes.
i) Enact routine testing for HIV.
j) Require the public school system to incorporate into the science curriculum the scientific basis of diseases such as diabetes, cancer and AIDS, and their links to lifestyle choices.

On the issue of access, there was agreement on the notion that uneven access leads to health care disparity. Both access to health insurance, as well as access to health services need to be enhanced. Several key issues hampering access to health services were identified:
1. Access to services is hampered by economic, racial and linguistic barriers.
2. Access to services is hampered by a current reimbursement system that does not encourage the development of relationships between primary care physicians and patients.
Recommendations on Access:
1. Support the integration of the public school system into the solution to healthcare. Teachers are often the first to identify health problems in children of diverse backgrounds, but mechanisms should be developed to help teachers direct children and their families into the health care system.
2. Support the creation of community health centers that incorporate into their creation input from patients as well as teams of care providers in the community. This patient-centered approach can help overcome barriers to care.
3. Implement a marketing and public information strategy to enhance recruitment of students into primary care health care team professions.

It is fascinating to me to see how two different groups saw the same problem from two different directions.  I look forward to seeing how the Administration combines them.

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