Stanley Feld M.D.,FACP,MACE
The mechanism the facilitator stakeholders use to slow down improvement, in my opinion, in the healthcare system, is to do pilot studies on innovative ideas and improvements using faulty criteria in the context of the present dysfunctional healthcare system. The results are usually contradictory to the expected result, statistically flawed, and confusing. However, pilot studies generate another funding source for academic institutions which perform the studies.
A recent article in the Archives of Internal Medicine stated that the measurement of quality indicators were no better in clinics with Electronic Medical Records than in those clinics without an Electronic Medical Record. The data was collected between 2003 and 2004. I will review the flaw in this data in the future. However, a big flaw in the data is that quality indicators (frequency of specific testing for specific diseases and screening testing) are not a direct measurement of clinical outcomes or the financial costs to achieve the improved clinical outcomes. I covered this topic in detail in my blog on the Ideal Electronic Health Record.
In 2004, the United Kingdom invested $3.2 billion in a new program to reward general practitioners for the delivery of high-quality care defined as adherence to quality indicators. The authors examine longitudinal data on quality and report that the incentive program may have prompted a modest improvement in the quality of care for two of the three chronic conditions they studied.
It has been clear for many years that an improvement in the measurement of quality indicators does not mean an improvement in quality care. Improving the clinical outcomes by acting on the findings of the quality measurement is the meaning of improving quality of medical care. The execution of the findings is dependent on the patient’s adherence to appropriate therapy recommendations. The only way to improve quality and clinical outcomes in my opinion is to create a competitive environment among physicians driven by patients owning and retaining their healthcare dollars. This will lead to transparent pricing and drive innovation and cost efficiency.
Yet, the entire pay for performance movement is based on grading physicians on the basis of their quality indicator measurements. This is the reason I said P4P is another complicated mistake.
I understand the reason policy maker advocate P4P. It is because they believe they can easily quantitate the quality of medical care. They will discover as the British have that they will be spending more money without improving clinical outcomes. It is the patient/physician relationship that must drive quality care and improve clinical outcomes.
These interim pilot studies take years to complete. They do not help move medical care into the digital age. If anything it slows medical care down.
Consumers must demand legislation to level the playing field. They must make it clear that they are the primary stakeholders and should be the drivers of the system. It is vital for us to create a true consumer driven healthcare system with the patient and the physician being responsible for the execution of medical care. Consumer driven healthcare would permit consumers to drive the system. The government and the insurance industry have failed, as Regina Herzlinger has pointed out in Who Killed the Healthcare System.
Pilot studies of innovative ideas in our dysfunctional system cannot predict the outcome of these ideas in a new system. Our government can not continue to protect old systems that do not work. Health insurance should mean what insurance means after a certain point of risk. Insurance is a form of risk management primarily used to hedge against the risk of a contingent loss. Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for a premium. Only then could we see if these innovative ideas would work.
In the last couple of years the President and Medicare have called for change. Their requests have gone nowhere because facilitator stakeholders to not want to change a system that is to their advantage. The system must be changed to the patients’ advantage.
The changes required have to be enacted simultaneously because single point change will permit secondary adjustments by the facilitator stakeholders. These changes include:
• Pre tax insurance guaranteed for all.
• Community based rating for premium pricing with government oversight.
• Total price transparency of the lowest negotiated prices for all based on cost and not fiction. The hospitals, the physicians and the insurance companies must be required to comply. This is critical. It would generate a competitive marketplace and force stakeholder to be innovative and develop more cost efficient systems.
• There should be guaranteed insurance coverage for all (universal coverage) with government subsidies. The subsidies should be full or partial for the people who can not afford insurance. The Massachusetts model is going to fail because it is built in a non consumer driven system to the advantage of the insurance industry.
• There should be the option for the Ideal Medical Saving Account and not the contaminated Health Savings Accounts built in favor of the insurance industry. Patients must have incentive to control their healthcare dollar. They must be allowed to retained the money they do not spend in a trust account for their retirement. If the patient has a chronic illness and he maintains good clinical and financial outcomes he should receive a financial reward.
A single party payer system would impose a new and inefficient bureaucracy that would be devastating to the incentives and innovations necessary to Repair the Healthcare system. Innovations and incentive in a competitive entrepreneurial environment is what America’s greatness is all about.
• An affordable Electronic Health Record must be available to all as described in the post the Ideal Electronic Health Record.
All of the above must be implemented at the same time for the new healthcare system to work. It will require strong and bold leadership. This bold leadership will only be precipitated by a very vocal demand by an informed public. In our evolving knowledge based economy this People Powercan be accomplished.