Health Care and the 2012 Election

In this week’s New England Journal of Medicine, PresidentObama and Governor Romney shared their positions in the debate over healthcare.  I will not comment on the two candidates positions but will rather use this post to talk about the realities of health care costs as related to this national policy discussion.  The NEJM articles are linked and I do encourage all to read it. 

On a government and legislative level, when we talk about health care we are really talking about the financing of health care.  We need to take all that debate and political language and break it down into the costs to each individual and then try to see how the differing positions impact the costs to each of you as both taxpayers and as users of health care (which is a really convoluted way of saying patients).  This is most easily done with equations.  The first of which is:

An Individual’s total health care cost =

1. Taxes paid that go to health care (which includes the interest on the debt that is due to health care) +
2. Health insurance premiums paid +
3. Co-pays and deductibles paid +
4. Out of pocket expenses that are not part of a benefits plan (such as that aspirin you buy over the counter at the supermarket) +
5. Wages lost due to employers paying for part of your health insurance premium instead of giving you that money in wages (you didn't really think that the 80% the employer pays is due to lower profits for the corporation did you?). 

How does that relate to the debate over health care costs?    In this national dialogue that the candidates are having with us, we are really talking about the amount the federal government spends on health care, the amount that is spent on premiums for health employers and employees and the part that people pay in co-pays and deductibles.  Thus in my equation, it includes lines 1, 2, and 3.  While some people do bring up the issue of lost wages which are reflected in line 5 of my equation, for the most part that is not really discussed.   We need another equation to really understand how those individual expenses relate to the total health care costs for our country (watch carefully because we are using both addition and multiplication):

Total Health Care Costs for our country (as opposed to the individual) =

1. Number of people covered under insurance plans, either government or private X
2. The average number of services rendered per person X
3. The average cost per service per person +
4. Administrative expenses per person.

The individual’s health care cost will go up if the total societal costs go up either by higher taxes, higher premiums, higher co-pays or deductibles or all of those factors.  So your costs as an individual will reflect in taxes the total health care costs of the country.  In addition, many aspects of the Affordable Care Act (ACA) impact on all four of these national factors.  So now we can look at the likely costs under the Affordable Care Act (ACA) or another act that is passed instead of the Affordable Care Act (which represents the two positions of the two candidates.  Just to be clear, neither candidate is suggesting that we do nothing.)     How do these positions lower costs in this country in order to make health care more affordable and cover more people?  We need to look at each component of the equation:

1. Number of people covered under insurance plans, either government or private:  The success of the Affordable Care Act is in covering many people who are not now covered.  In other words, the act increases this number significantly.  The law calls for private health insurance companies to cover far more people than they have previously by mandating coverage for children up to age 26, and by removing pre-existing condition clauses that had kept certain people off of the private insurance rolls.  In addition, the movement of more people into Medicaid (which is still murky due to the Supreme Court decision) also will tend to increase those in government programs which will also increase this number dramatically.  The controversial individual mandate which survived Supreme Court review is specifically designed to increase the number of people having health insurance.  I personally believe that it is good to cover more people however to say that covering more people will contribute to lower costs is just not factual.  It must lead to higher costs by the above equation.  However there may be other parts of the equation that can lower costs in order to make up for this obvious factor in increasing costs. 
2. The average number of services rendered per person:  In many ways, this is an area that has a tremendous potential to power costs.  Many studies have shown that about one third of health care services do not contribute to improvement in health or better medical care.  The challenge is that these studies are always done in hindsight and it is often difficult at best, while you are in the midst of an illness, to figure out what is necessary and what is not necessary.  One of the secrets of medicine is that it is often hard for your doctor to figure that out as well when he or she is in the middle of evaluating and treating an illness.  For example, there is much discussion about the high costs incurred during the last six months of life.  While that is true, when you are at the beginning of those last six months, you rarely if ever really know that you are entering into your last six months of life.  There is a measure of magical thinking in believing that we have the power to predict the future, even the relatively immediate future, in that manner.  In ACA, more services are mandated.  Many of the provisions that mandate full coverage for prevention and wellness require that more services per person be done.  It is good to have this coverage however it is hard to say that this will save money even though some make the argument that more prevention will save money in the long run.  While that may be partly true, it is extremely unlikely to offset financially the increased services that are required.  ACA does attempt to create incentives for physicians and hospitals to provide fewer unnecessary services through a variety of indirect means such as moving towards what are called Accountable Care Organizations and it does mandate more review of new technologies and more education and assessment of the comparative value of new drugs, techniques and approaches.  The details of this are for a different blog which will include a part on how doctors and other health professionals are paid but for the purpose of this discussion we will end this section by pointing out that the ways in which the number of services are increased by the ACA are very direct while the techniques to decrease services are unproven and may not be entirely or even partially successful. 
3. The average cost per service per person:  What this really means is lowering the amount of money paid to doctors, hospitals, laboratories, medical device manufacturers, pharmaceutical companies, and others for the products and services they provide.  While that may sound great to many who feel that the people in these pieces of the puzzle make too much money, this actually does give me pause.  I, for one, would like to see my primary care doctors make more money.  I would like to continue to see the innovations in pharmacy and medical devices keep going forward due at least partly to the financial incentive to produce new lifesaving tools for health care.  So this does make me nervous.  The ACA sets up a board that will look closely at services covered and their prices and make changes.  We don’t know the unintended consequences of these changes; however they may include changing the type of people in medicine and driving many physicians who are in their fifties, towards early retirement thus decreasing the availability of physicians.  This is also an unknown area and it is unclear how the current law will impact this piece of the puzzle.  It is clear however that decreasing the profits in certain areas while the development costs still remain high, be that the development of a new technology, a new drug or the development costs of producing a new physician (medical school tuition, etc.) may make it difficult to maintain the United States as a center for health care and health innovation.
4. Administrative expenses per person: In many ways this may seem like the area easiest to attack.  It is not that straightforward.  Administrative costs do vary and opinions also vary on how they are measured.  Medicare and private insurance currently pay about $500 per person per year on administrative costs.  I have seen estimates that Medicare only spends 2% on administrative costs and that private for profit insurers can spend as much as 30% on administrative costs.  I tend not to believe either of those numbers as they are biased on both the left and the right sides o fthe political equation.  On average, these expenses, in the private sector and in government, have varied from a low of about 6 or 7% to a high of about 25% and usually are about 15 – 18%.  No matter how you look at it, more than 80% of each dollar in health care currently goes towards care and not administration which means it goes towards the number of services multiplied by the cost per service multiplied by the number of people.  Those who think we can lower total costs by lowering the 20% rather than the 80% are likely kidding themselves.  The ACA mandates that administrative expenses remain under 20%.  What do we get for that 20%?  We can get lower costs per service because a big part of what is done administratively is negotiating contracts with doctors, hospitals, other health professionals and other providers of goods and services in health care.  The government, with Medicare and Medicaid does not negotiate but rather just publishes their payment schedules, which for many providers is too low to be realistic, which is part of the reason their administrative costs are lower and also why many doctors and other providers choose not to participate in those government programs.   While ACA will lower administrative expenses somewhat through the 20% mandate and the competition between health insurers in exchanges, the complexity of the law with the need to form exchanges in each state (which may be very good on other grounds) may actually increase some aspects of administration, especially for the government and thus impact the portion of taxes that go to these efforts.  If it is totally successful in lowering administrative costs, it will still need to address the ballooning costs of the other 80%

I believe that ACA has wonderful aspects that really do improve access to care for many Americans and may even create a structure to improve care, however it is unlikely in my opinion to lower costs and instead will likely increase costs.  Until the alternative to ACA is more clearly defined, the sound bites that either call for repeal or call for keeping all aspects of the law will move forward with little true discussion of what we need to do to achieve the ends of lowering unnecessary services, keeping health care affordable and maintaining an innovative healthcare environment in which the United States stays at the forefront of care.  I choose not to pick a side here and I hope that whoever wins the presidency, will speak honestly with the American people about these health care financial realities and how we, as a people may solve them.  We do have to find a cost point that fits our culture and values as a country and most of all protects individuals who are sick and allows them to get well while holding onto their own dignity.  

Medical Errors and the Risk of Dying from Health Care

In an excellent article in the Wall Street Journal by Dr. Marty Makary, entitled “How to Stop Hospitals from Killing Us” he describes the epidemic of errors that occur in hospitals that can even cause death.  As he puts it, “Medical mistakes kill enough people each week to fill four jumbo jets. But these mistakes go largely unnoticed by the world at large, and the medical community rarely learns from them.”    But he is being far too kind and diplomatic.  For in his title he only addresses the problem of hospitals killing us while most people who have health care needs will never see the inside of a hospital.  Instead the title should be “How to Stop Doctors, Hospitals and all of the Health Care System and all Health Care Professionals from Killing Us”.  Admittedly for any article, that kind of complete truth can be overwhelming and does not lead to solutions in the way that he suggests and of the type that we need.

The fact is that all of medicine is plagued by errors of overuse, underuse and misuse.  You can get into trouble as a patient if doctors and other health professionals do too much, do too little or do the wrong things.   And all of these errors can lead to more problems and even eventually to death. 

And medicine and health care do not lack oversight.  Government agencies and the infrastructure that forces you to sign forms as you enter a physician’s office and the many agencies of both government and private review organizations that inspect and review hospitals and other health care facilities and organizations offer oversight so overwhelming that even physician practices often have to hire people just to keep track of the requirements.  And all of that oversight often does not address what happens to you, the individual person who is suddenly faced with becoming a patient.  For all these review agencies and the processes they put in place are more about the reporting of hospital and office data and not about what really happens in those hospitals and offices. 

An article in the blog Fierce Healthcare notes that under the ACA requirements, certain errors by hospitals must be reported and points out that for the state of Utah, in more than one year’s time since the law took effect, 17 avoidable errors have been reported.  Dr. Edmund Kwok who blogs at “Front Door to Healthcare” wisely states, “There is absolutely no way that there were only 17 avoidable medical errors in the whole state of Utah over the course of a year” and any physician, me included, will strongly agree with his statement.

Dr. Craig Hersh who works with me at Accolade and previously worked as a hospital Medical Director explains this phenomena of underreporting of errors in this way: “But statistics can be misleading.  At my hospital we didn’t initially pay much attention to the data capture of quality metrics, as there wasn’t any incentive to do so.  Then one day the results of all local hospitals appeared in the paper in a small article.  We were at the bottom of the pack.  We then committed resources to documentation.  Within one year we went from worst to first in quality (that year hospital quality results were the lead story, so our timing was good).  Frankly, we didn’t change much in the way we did things- we just became better than all the others at documenting.  We also knew that  observed/expected mortality rates (which is often one of the calculated benchmark for quality in the hospital) are highly linked to coding.  As we strengthened our coding, and patients looked sicker by their codes, all of a sudden our observed/expected mortality dropped.  Our actual mortality didn’t change, or if it did it wasn’t a result of any real changes to the care we provided.”

And so the issue of avoiding errors, for many hospitals and medical offices, ends up being more of an issue of capturing the right data and reporting with the correct forms rather than really avoiding errors!  However Dr. Makary has some excellent suggestions in his article that can truly get at helping individuals avoid errors and potentially avoid death in the hands of our medical system.  Transparency is part of the solution however the way that we capture information for true transparency remains very difficult and problematic as the data from Utah suggest.  Two of his other suggestions involve the use of cameras and open notes.  He suggests using cameras to capture procedures specifically so that the videotaped procedure can be graded for quality and suggests an open notes system in which the patient can see the notes that the doctor writes or dictates and offer corrections or additional information based on those notes. 

Allow me to add another suggestion that everyone have a “bodyguard”, a protector against medical errors.  At Accolade that person is an Accolade Health Assistant whose job is to help the person who needs the health care system, whether he or she needs a doctor, hospital, nurse, therapist or any other part of the system, avoid those errors which can lead to injury, costs, and potentially even death as Dr. Makary highlights.   Being a patient armed with the proper information at the time you need it whether you are in a hospital or an office setting, and the proper support of a knowledgeable professional  Health Assistant can be the key to avoiding the health risks and potentially even the unnecessary deaths associated with the errors that now plague health care and thus on a societal basis, contribute to the cure of this epidemic.   

Medical Care, Sick Care, Health Care....Who Cares?!

At the risk of sounding cynical or just plain difficult, I have to say that I am tired and bored by articles and books that tell us that we have a medical care system or a sick care system and not a health care system.  Dr. Steven Schimpff is one of the great thinkers in medicine and I apologize beforehand that his post on Medical Megatrends and the Future of Medicine is the initiating factor in this rant.  Dr. Schimpff outlines all the reasons that we have to focus more on prevention and also more on coordination of care and I agree with all of his points.  His argument cogently shares the statistics on causes of death which show that the preponderance of disease is due to lifestyle choices.  He nicely puts together what is said in many articles, blog postings, television medical shows, newspapers and everywhere else that we are killing ourselves by smoking, alcohol, drugs, poor eating habits, driving dangerously  and lack of exercise.    This all leads to the idea that we must foster a healthier lifestyle.  I get it and I suspect that by now if you don’t get it, you must be living in a cave somewhere (although if you are I suspect you are eating healthier and getting more exercise). 

However, taking medicine and our health care system to task for not fostering an emphasis on prevention is misguided.  Dr. Schimpff alludes to this in one of his historical points about the war against infectious diseases.  The tide in that war was turned before the advent of antibiotics by proper sanitation, hygiene and water systems, not by a health care system.  Many years ago I taught a course in preventive medicine to second year medical students.  I would always start the class by asking them who the most important professional was for preventive health.  They all said the primary care physician.  I told them my answer was the professional garbage collector as the collection of garbage prevented more illness than any primary care physician.  We have a societal and cultural problem that will only be addressed with societal and cultural answers not with medicines and with our health care system.  In other words:

                Our medical or health system (I don’t really care what you call it) should not be charged with changing our culture.

Those who change our society and our culture to foster a healthier lifestyle will likely be in disciplines other than medicine.  That battle will be led by those who put bike paths throughout our cities and countryside.  They will be employers who provide eating areas for their employees with healthy good tasting food.  They will be people like my son who worked on an organic farm and then wrote about his experience and another son who is dramatically changing the way people get their food by starting a company, Good Eggs, to foster a more direct farm to table eating experience (I can’t help it…I am proud of my children). 

                If you successfully create a healthy culture, people will still get sick and even die

Life really is a fatal illness and not all disease is “your own fault” as may be implied by the current emphasis on changing our health care system to focus more on prevention.  Dr. Schempff wisely calls for better coordination of care for those with chronic illness and this must be supported with new approaches being developed such as the approach at Accolade.  However all patients, not only those with chronic illness need that level of coordination in this era of fragmented confusing care.  I am not upset by our emphasis on healing the sick and on finding diagnoses and cures.  If I am sick then I want my doctor and other health professionals to focus on getting me well, not on blaming me for the lifestyle choices that led me to illness. 

So I am dedicated to changing our culture and society to be healthier and in the meantime, I am even more dedicated to finding ways to better treat people and families who are sick and in need.  At all times, the charge of all health professionals should be to see each person we treat as a loved family member and help them with energy, intellect and empathy no matter what choices led them to us.  

Defining a Doctor’s Role

What is the future of medical practice and of clinical care?  What is the future role of doctors?  There is an old joke about the airplane cockpit of the future.  It goes that the flight crew manning that cockpit will consist of a pilot and a dog.  The pilot’s job will be to feed the dog.  The dog’s job will be to bite the pilot if he tries to touch anything. 

In the same vein, this linked blog by Dr. Davis Liu reports the observations of a primary care doctor who attended the   HealthInnovation Summit hosted by Rock Health in San Francisco.  In a report that seems sometimes like that of an alien being plucked down in the middle of a football game, trying to understand the culture and values of earth,  this intelligent physician seems to be both a bit confused and also enlightened by what he heard.  For me, the comments by the keynote speaker that he reports on reflect the changing definitions of medical care and the changing role of the physician. 

That keynote speaker was Vinod Khosla, co-founder of Sun Microsystems.  He is quoted in this blog as saying: “Health care is like witchcraft and just based on tradition” and that technology had to stop doctors from practicing like “voodoo doctors” and be more like scientists.   It sounds to me like someone needs to add a dog and a doctor to this vision of technology's role in the health care office of the future.

Mr. Khosla went on to say, according to Dr. Liu, that the “machines”  should do “80%” of what doctors currently do and that the machines should be developed by people who are not in health care as the knowledge of health care is a disadvantage in developing these new technologies.  I have actually heard this argument from many entrepreneurs in the past.  The argument that being steeped in a discipline, while giving one in depth knowledge, also give one certain paradigms  which impede the ability to think creatively about problems.  And in some ways I have come to agree with the argument as having a set of fresh eyes working with experts often can be the proper shock to challenge the “petrified opinions” that Mark Twain talks about that invariably develop as part of professionalism.  (Twain’s full quote is “Loyalty to petrified opinion never broke a chain or freed a human soul.”)

But the central core of Mr. Khosla’s argument may fundamentally misunderstand the role of the physician.  Or it may be that I am romanticizing the role of the physician in a way that reflects a world that no longer exists.    If the definition of a doctor’s role in medical care is to diagnose and prescribe treatment for illness based only on the pathophysiology of the disease, then I agree that 80% of that can be done by a machine.  Perhaps more!  If a doctor’s role is to understand the person who has the disease, as William Osler said (“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”) then I question whether a technology can sort through the personal beliefs, the feelings, the social aspects, the finances, and the spiritual beliefs that go into any medical decision, however big or small.  Even if that is possible, I doubt it possible for a technology to form a “human” relationship akin to the strong person/health professional relationship that can help in overcoming the barriers that we all have due to our own personal characteristics and situations that impact our own ability to swim through the rapid currents of health care. 

But doctors are now being trained to be more scientific.  They are paid by a system that encourages them to practice strictly according to “evidence” which means scientific evidence based on pathophysiology alone and are also paid to spend precious little time actually listening to people and learning who they are as people all in the name of efficiency and science. 

Without that perhaps “soft” role of physicians, then I find myself agreeing with Mr. Khosla.  Perhaps it is time to just accept that physicians are no more than diagnosis and treatment machines and that they are no longer the confidantes, supporters, and even at times friends that the profession used to be.  Perhaps this priestly function of medicine is gone. 

While that may be the case, let us not forget that good care requires that we understand people with all their irrationality and with all of their own reasons for following or not following “science”. 

Perhaps in the area of science that involves technology, Mr. Khosla is right in assuming that good entrepreneurs and good programmers are the answer even perhaps the complete answer.  In the areas of science that involve human behavior (and medicine is more about human behavior than it is about the pathophysiology of disease) the answers are not often found in binary code or proper investments.  The answer may be a new professional.  The answer may be to relegate physicians to being diagnosticians and prescribers of therapy rather than to be the Doctor that I grew up aspiring to be.  Or the answer may include changing incentives and standards to include that human role for physicians. 

I don’t know the right answer.  I only know that Mr. Khosla’s vision is an important one but it is fundamentally wrong if it ignores the human aspects of caring, listening, understanding and human problem-solving that is so necessary in medicine.

Life, Death and Decisions

We at Accolade help people make decisions.  We do not make decisions for them and we do not judge the quality of their decisions, rather we help them put voice to their own values, their own beliefs and help them understand their options as they enter and travel through the maze that is health care.  When one reads the scholarly articles about “decision analysis” (and there is an entire body of study, even an organization and journal dedicated to the science of medical decision making) there are critical truths that Accolade Health Assistants deal with every day that are only rarely addressed in the scholarly literature. 

In a wonderful article in the New England Journal of Medicine, entitled, “There is More to Life than Death”, the husband wife team of Jerry Groopman and Pamela Hartzband point out that while the emperor may have clothes those clothes are rather tattered rather than being the sweeping robes of royalty.  They point out the central focus in decision research is on death as the main, and often only factor to be considered while the truth is that people are complex beings who make decisions that are based on factors in which the risk of death is but one of many.  How will my decision affect my family, my ability to work, my ability to be independent, my need for money, my relationship with God if I am religious?  These are just some of the factors that go into every decision that involves the state of one’s own body and well-being. 

Groopman and Hartzband further point out that while decision support may encourage decisions be made before the issue is possibly present, hence the push towards advance directives and the public discussions of PSA screening and mammography testing, it is virtually impossible to anticipate how one will look at a situation until one is in that situation.  They state: “”But these calculations are flawed.  They require people to imagine themselves in a health state that they haven’t experienced.”  This brings to mind a quote from Freud who said, “We cannot, indeed, imagine our own death; whenever we try to do so we find that we survive ourselves as spectators.”  Freud’s statement is not only true for death but also holds true for all health issues.  We cannot really imagine our own illness and our own individual decisions that we have to make when moving through the progressive nature (progressing towards resolution, chronicity or death) of any illness.  Hartzband and Groopman point out that this is due to what cognitive psychologists call “focusing illusion”.  That is the illusion that occurs when one tries to anticipate the global impact of any future change especially a health change.  People tend to focus on one aspect of the change and disproportionately weigh its effect on their lives.   Thus their decision when nothing is really at stake is different than when they are actually in the situation. 

This type of “focusing illusion” occurs in a sense with medical decision researchers.   The fact that they put numbers against these often faulty assumptions based on their own focusing illusions make their conclusions appear to be precise when in reality that is false precision.  They tend to focus on death as an outcome and also tend to put their own values and their own numbers, on quality of life, rather than take the much more difficult step, and the step that may be virtually impossible to quantify, of trying to understand the individual process of decisions making based on the global impact to different people with different beliefs, values, family issues, economic issues, and psychological issues. 

At Accolade, we help each individual with their own decisions as they work through their personal health decisions, best done with their doctors, at the time they need to make those decisions.  We use those numbers that our brilliant colleagues in medical decision research develop but help people understand their limitations and the assumptions that lie beneath the surface of the numbers.  We focus on their values, their needs and their family support as they go through their decision making process. 

Drs. Groopman and Hartzband end their article with the following paragraph which sums out the issue quite well so I will also end this commentary with their words.

“Basing decision on the outcome of death ignores vital dimensions of life that are not easily quantified.  There are real complexities and uncertainties that we all, patients and physicians alike, confront in weighing risk and benefit.  Wrestling with these uncertainties requires nuanced and individualized judgment.  It is neither ignorant nor irrational to question the wisdom of expert recommendations that are sweeping and generic.  There is more to life than death.”

Screening Dilemmas

A recent blog by Melinda Beck in the Wall Street Journal discusses the issue of whether there is "Too Much Breast Cancer Treatment?".  The blog is partially based on a study from the Annals of Internal Medicine in April , about the over diagnosis of breast cancer.  It brings up a difficult problem for all of medicine and for all health professionals.  What do you do if there is population data that suggests, as that article does, that many people who undergo treatment are not going to benefit and may actually suffer due to the risk and side effects of the treatment, yet for any specific individual, it is virtually impossible to tell who fits into the group of those people who truly need and benefit from the treatment versus who is in the group who will not benefit from the treatment?  And how do you truly understand the choice involved when the risk of not treating is catastrophic? 

In some ways, we are talking about the basics of screening tests.  A good screening test tends to be highly sensitive.  Unfortunately, this can mean, and often does mean that is it not very specific.  In other words, it is designed to have very few false negatives even at the risk of having a lot of false positives so this article on screening for Breast Cancer may be accused of belaboring the obvious (although it tends to not be obvious to many in the population and in our legislative bodies who think you can always have high sensitivity and high specificity in screening tests).  We often tend to make a societal decision to avoid the risk of individual catastrophe by putting up with the higher costs and the relative risks of pursuing all of those false positives with more tests and treatments that have their own risks.  In the past year, the debate over the recommendation on the age of initiating mammography for breast cancer screening has remained in the public awareness as that societal decision on the avoidance of risk was made differently by the US Preventive Services Task Force which recommended starting screening at age 50 while the American Cancer Society suggested remaining at a screening start age of 40. 

The real challenge to health professionals is to inform people without panicking them and without biasing them one way or another.  The judgement of the relative risks and benefits should properly be made by an individual and not by the society as a whole however it should be made with full knowledge.  People need to know that a screening test may leave them with a “positive” result that is ultimately false that leads them down a path that can create other problems.  At the same time, they also have to know that missing early stage disease, such as breast cancer, can make treatment more difficult and less likely to be ultimately successful.  These are not easy messages to give as they are more nuanced than just saying, “have the test” or “don’t have the test”.  Health professionals should be present to help people make their own decisions after they have all the facts and are as calm as possible when they make those decisions not to force their own values or even society's values on those individuals.   

"Patient Engagement is the Blockbuster Drug of the Century"

A blog written by Leonard Kish which is then highlighted in a Forbes blog by David Chase deserves comment.  At Accolade, we have believed and have put into practice just that philosophy that "an engaged patient is the blockbuster drug of the  century."  We take it one step further as none of us ever know when we will make that transition from being a person to a patient.  We have therefore found that part of the challenge is to engage people who are about to become patients, before they take that fateful step or very soon after.  For over 60% of the people we engage and help, we become their trusted assistant before they actually access care.  They engage with their Health Assistant who makes them smarter, calmer, more confident  and better patients and they end up using the health care system in such a way as to get outcomes that are better for themselves and lower costs for the system as a whole.  For us, this "blockbuster drug" has become reality as our people, processes and systems combine to create a new profession  in health care that can focus in a laser like fashion on engagement and decisions support.  The profession of Accolade Health Assistant assists with every decision including those decisions which are financial, logistical, social and insurance driven as well as clinical.  by first engaging and creating a trusted relationship with a trained professional.  It works and our results show that it is proven to be the blockbuster that these authors write about.

The Institute of Medicine Report “Best Care at Lower Cost”

As we listen to the political debates about health care, and the childish accusations of who is lying about what, it is nice to see adults really studying the problem and developing a thoughtful approach to the analysis and to possible solutions. The Institute of Medicine is famous for doing such careful studies and this one is no different.  I spent much of this weekend reading the report itself, as well as the news reports of the study, and came to two major conclusions of my own:

The press reports of the study suggest that most journalists have not actually read it, or if they have they have missed the major conclusion.

The challenges faced by the high costs in medical care require a rethinking of health care in our country and not just a debate over who is going to destroy or save Medicare. 

If you read the media reports about the study, one would think that the purpose was to determine the excess costs of health care in the United States.  That, of course, is at best incomplete, and at worst incorrect as suggested by the title.  The study is an attempt at analysis and solutions, not at just defining the size of the problem.  Thus the study starts with a quote. 

            “Knowing is not enough, we must apply.

            Willing is not enough, we must do.”

-          Goethe

This IOM study is about what we must do to optimize health care for all in this country and not just about the excess costs.  The number of more than $750 billion dollars of waste in the system is what caught the eye of the media however even more interesting is what the authors saw as the source of the excess costs.  That was reflected in this table.

TABLE S-1 Estimated Sources of Excess Costs in Health Care (2009)

Category	Sources	Estimate of Excess Costs
Unnecessary Services	· Overuse—beyond evidence-established levels · Discretionary use beyond benchmarks · Unnecessary choice of higher-cost services	$210 billion
Inefficiently Delivered Services	· Mistakes—errors, preventable complications · Care fragmentation · Unnecessary use of higher-cost providers · Operational inefficiencies at care delivery sites	$130 billion
Excess Administrative Costs	· Insurance paperwork costs beyond benchmarks · Insurers’ administrative inefficiencies · Inefficiencies due to care documentation requirements	$190 billion
Prices That Are Too High	· Service prices beyond competitive benchmarks · Product prices beyond competitive benchmarks	$105 billion
Missed Prevention Opportunities	· Primary prevention · Secondary prevention · Tertiary prevention	$55 billion
Fraud	· All sources—payers, clinicians, patients	$75 billion

                                                                                                Source: IOM 2010

So this is not a simple problem and it is also not a problem for payers that will be solved by a total focus on prevention or a total focus on excess administrative costs.  One must also address unnecessary and inefficient services in order to truly address the health care cost crisis in our country.  With this starting point, the study methodically makes the case for a “continuously learning health care system” with the following characteristics.

TABLE S-2 Characteristics of a Continuously Learning Health Care System

Science and Informatics

·         Real-time access to knowledge—A learning health care system continuously and reliably captures, curates, and delivers the best available evidence to guide, support, tailor, and improve clinical decision making and care safety and quality.

·         Digital capture of the care experience—A learning health care system captures the care experience on digital platforms for real-time generation and application of knowledge for care improvement.

Patient-Clinician Partnerships

·         Engaged, empowered patients—A learning health care system is anchored on patient needs and perspectives and promotes the inclusion of patients, families, and other caregivers as vital members of the continuously learning care team.

Incentives

·         Incentives aligned for value—In a learning health care system, incentives are actively aligned to encourage continuous improvement, identify and reduce waste, and reward high-value care.

·         Full transparency—A learning health care system systematically monitors the safety, quality, processes, prices, costs, and outcomes of care, and makes information available for care improvement and informed choices and decision making by clinicians, patients and their families.

Culture

·         Leadership-instilled culture of learning—A learning health care system is stewarded by leadership committed to a culture of teamwork, collaboration, and adaptability in support of continuous learning as a core aim.

·         Supportive system competencies—In a learning health care system, complex care operations and processes are constantly refined through ongoing team training and skill building, systems analysis and information development, and creation of the feedback loops for continuous learning and system improvement.

The report starts and does not end with this definition of the scope of the problem and this vision for a continuously learning health care system.  It then goes on to build recommendations and strategies for achieving these characteristics in order to reach that new health care system model.  The recommendations that they put forth fall into these categories as defined in the report.    

Categories of the Committee’s Recommendations

Foundational Elements

Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.

Recommendation 2: The data utility. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.

Care Improvement Targets

Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.

Recommendation 4: Patient-centered care. Involve patients and families in decisions regarding health and health care, tailored to fit their preferences.

Recommendation 5: Community links. Promote community-clinical partnerships and services aimed at managing and improving health at the community level.

Recommendation 6: Care continuity. Improve coordination and communication within and across organizations.

Recommendation 7: Optimized operations. Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.

Supportive Policy Environment

Recommendation 8: Financial incentives. Structure payment to reward continuous learning and improvement in the provision of best care at lower cost.

Recommendation 9: Performance transparency. Increase transparency on health care system performance.

Recommendation 10: Broad leadership. Expand commitment to the goals of a continuously learning

While I praise these elements, I also know that the strategies suggested in the report will by necessity be incomplete, as many minds in every field will develop new ways of looking at these problems and new solutions.  Often, many of the best tactics and strategies come from the private sector which includes for profit and not-for-profit organizations.  We, at Accolade have found our own solutions to some of these issues and have been able to prove their efficacy at meeting the challenge of “best care at lower cost” that the authors have defined. 

In our case we have focused on the care improvement targets and those foundational elements and policies which support those elements.  We also know that solutions tend to build upon a foundation of other solutions.   Thus, we are just at the beginning of finding new approaches and new technologies to solve our health care dilemmas.  We are only limited by our commitment and our creativity so I remain optimistic about our health care future.   

Unintended Consequences

The article by Paul Gionfriddo entitled "How I Helped Create a Flawed Mental Health System That's Failed Millions -- and My Son" tears at one's heart and points out the need to address the needs of those with mental illness in a holistic way.  It is clear that earlier recognition of these issues by schools, the courts and society in general is desperately needed.  It is equally clear that a tendency to blame bad parenting and to call everything "attention deficit disorder" also contributes to this societal and personal (for Mr. Gionfriddo and others in the same situation) disaster that is all too common.  I only wish that I believed that the solutions he outlines would be effective.  In the same way the system he helped dismantle through legislative action and the system that he attempted to build in its place contributed to some of the problems he  has lived through, the solutions that he has outlined may have other unintended consequences as well.

Something must be done and I wish I knew the right answers and was as certain that this author is about the need for certain specific actions.  Here are some of my thoughts about his suggestions as to what he would do if he were a legislator today, taken with the understanding that I have not had to live through his experiences with his son.

• "I'd mandate - and provide funding to ensure - that every teacher receive training in recognizing symptoms of mental illness in students and how to handle students with a mental illness effectively."    I strongly agree that schools must have people who have more knowledge of mental illness.  The challenge is that training every teacher and then having those teachers only use those skills infrequently almost guarantees that those taught skills will become rusty and below that which is needed.  While our answers are often to train, we have to understand that training only works if the skills that we train on are reinforced and used in an ongoing way.  
• "I'd implement the Affordable Care Act's Medicaid expansion for single adult without delay in 2014 and put much more money into community mental health services."  As a physician who has watched the Medicaid payments get squeezed to a point where few physicians and therapists will see patients, I do have a hard time understanding how sub-optimal therapy that is expanded to more people will create better care when the resources of talented people with time to spend on each patient is still far too limited.  I too believe strongly in the promise of better community mental health services and only wish that they could be put into place with their effectiveness being measured directly by the families of those mental health patients affected.  
• "I'd integrate how services are delivered by funding collaborative community mental health  programs and have them run by mental health professionals."  Here again I worry more about how this will be done to ensure that the services are those that actually help the people involved.  Translating a good intent into effective regulations and policies is often where those pesky unintended consequences occur.  
• "Finally, I'd insist that the spirit and mandates of the federal Mental Health Parity Act of 2008 be enforced uniformly across the states."  I agree with the emotion that the intent of that law passed in 2008 should be followed everywhere but with culture and resources varying so much from state to state and from locale to locale it is hard for me to agree that all the mandates should be followed in the same way.  Rather I would like to see an understanding that people with mental illness must be treated with dignity and care so matter where they are treated and that they and their families be the people to decide if that treatment fits their need.  

Let us all share Mr. Gionfriddo's outrage and pain and do all we can to improve the total life care of those who suffer as his son suffers and to work to create a different improved path for those children who are starting to show signs of significant mental illness.  

Whose Values?

Our society has wonderful well-meaning people across the political spectrum who are concerned about health care.  As part of our political discourse and our societal culture, we have to continuously make difficult decisions about resources for health care and about how to be caring and fair to the broadest swath of our society.  For a health professional working with and caring for individuals in need, the challenge is a bit different.   It is to uphold that person’s needs and their values while caring for them through the challenge and sometimes the tragedy of illness, either for themselves or their family. 

Our societal and political discussions may miss the individual nature of medical decisions and miss the fact that many decisions are less about the scientific evidence and more about the personal situations and beliefs of those people who are directly affected; namely the patient and their family.   The evidence is important as a starting point however the science will never be able to totally take the person’s unique situation and point of view into account.   

Sometimes what seems like a clear cut choice and decision to one person is equally clear cut to another person in a totally different direction.  So our societal decisions have to be sensitive to the individual point of view and need to have the flexibility to allow individual decisions to be made by that person and their family working with a doctor, a therapist, a nurse, a social worker or another health professional.  A recent article in the journal “Medical Decision Making” makes this point in an interesting way.  The article entitled “How Long and How Well: Oncologists’ Attitudes Toward the Relative Value of Life-Prolonging versus Quality of Life-Enhancing Treatments” points out that the values of those who make the decisions strongly influences what those decisions are. 

In that article, oncologists were surveyed and were asked to respond to two scenarios involving the use of a hypothetical new chemotherapy drug.  In each scenario, the authors were able to calculate the cost effectiveness of each of the decisions.  In one scenario, the oncologists were asked about the impact of the chemotherapy on the lengthening of life and in the other scenario they were asked about the quality of life impact of the chemotherapy.  The findings showed that the oncologists valued the length of survival more highly than the quality of life when making the decision about the use of the chemotherapy.  What if the law were only based on those oncologists value?  Would we design payment to be only related to the “outcome” of longevity rather than the outcome of quality of life?  The question to ask (which the article did not directly address) is whether or not that is the same value for an individual person and whether a cohort of patients given those same scenarios would decide the same way.

I do not know the answer for that cohort of patients and I can never know the answer for an individual at any point in time.  That is because the answer will never be in the purview of a physician or a legislator or a health policy expert (or me for that matter!) but always in the purview of the patient and their family.  In a classic article in Health Affairs in 2009, Don Berwick, who was recently head of the Center for Medicare and Medicaid Services, addressed this in “What ‘Patient-Centered’ Should Mean: Confessions Of An Extremist”.  In this article, he offered three maxims for true patient centeredness.  They are:

1.      “The needs of the patient come first.”

2.      “Nothing about me without me.”

3.      “Every patient is the only patient.”

He goes on to say, in his conclusion to the article that “I fear to become a patient”.  He eloquently explains this fear:

“What chills my bones is indignity.  It is the loss of influence on what happens to me.  It is the image of me in a hospital gown, homogenized, anonymous, powerless, no longer myself.  It is the sound of a young nurse calling me “Donald”, which is the name I never use – it’s “Don”, or, for him or her, “Dr. Berwick”.  It is the voice of the doctor saying, “We think….,” instead of, “I think…,” and thereby placing that small verbal wedge between himself as a person and myself as a person.  It is the clerk who tells my wife to leave my room, or me to leave hers, without asking if we want to be apart.  Last month a close friend called a clinic for her mammogram report and was told, “You have to come here; we don’t give that information out on the telephone.”  She said, “It’s OK, you can tell me.”  They said, “No we can’t do that.”  Of course they “can” do that.  They choose not to, and their choice trumps hers: period.  That’s what scares me: to be made helpless before my time, to be made ignorant when I want to know, to be made to sit when I wish to stand, to be alone when I need to hold my wife’s hand, to eat what I do not wish to eat, to be named what I do not wish to be named, to be told when I wish to be asked, to be awoken when I wish to sleep. 

                Call it patient centeredness, but I suggest, this is the core: it is that property of care that welcomes me to assert my humanity and my individuality.  If we be healers, then I suggest that that is not a route to the point; it is the point.”

The point is that each person is unique and health decisions have to be made from that person’s point of view.  Not from the point of view of a doctor, or a congressman, or a bureaucrat, or a health care manager.  With health policy and health law decisions now being made by legislators based on expert advice from health policy experts, I do worry that our laws will not reflect the autonomy and flexibility that good health care requires. 

The secret that we at Accolade have come to learn is that when the autonomy of each person is encouraged and supported, better care decisions are made and costs end up being lower.  The fear on the part of our governing bodies and of other representatives of payer organizations are that the opposite will happen: that individualized patient decision-making will lead to unnecessary care and higher costs.  Accolade has taught me that my belief in the individual making their own decisions being best for society as a whole is now supported by hard evidence and there is nothing that portends better for our health care system.