8 March 2019
Dear Interested Readers,
What Medicare-For-All Can’t Fix
Let me remind you of Dr. Robert Ebert’s 1965 formula for the future of healthcare in America. He lived for thirty years after this observation and did much to test his own formula, but we are still failing to take advantage of its total wisdom. Frequent readers probably can say it from memory, but just in case you do not know what I am talking about, here it is for the umpteenth time:
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Dr. Robert Ebert, Dean of Harvard Medical School, 1965
Earlier this week I returned to the discussion of Medicare-for-all for several reasons.
- Bernie Sanders has sold the idea to most of the Democratic candidates for president.
- Democrats will be running on healthcare as an essential issue, and the Republicans will be trying to connect it to “socialism,” and will assert that socialism will surely diminish “freedom” if the Democrats add a majority in the Senate and the presidency to their gain of the House in 2018.
- The next two years will be a critical period for the further education of the public. They now seem to understand the value of guaranteed insurability despite preexisting conditions. Can they be convinced that anything less than affordable universal access is not good for the nation? The ultimate challenge is to convince voters that healthcare, like clean air, and drinkable water should be an entitlement that equally benefits all Americans.
- Representative Pramila Jayapal has introduced a bill in the House that outlines a much faster migration to Medicare-for-all than the Sanders bill in the Senate, and Speaker Pelosi has granted public hearings for the bill which will surely draw substantial public interest because extensive testimony will be taken regarding the deficiencies in our current system of care that make it the most expensive and least effective delivery system found in the world’s developed countries.
- It is time to start working on legislation now so that it can be ready for discussion and passage in 2021. Even if Democrats gain substantial majorities in both Houses of Congress and make healthcare their number one priority as they did in 2009, implementing Medicare-for-all will be a much more significant transition than establishing the exchanges of the ACA. That means it would be at least 2023 or 2024 before the public would experience the benefit of any new bill to expand coverage. That’s a long time to wait for someone who is among the 30 million uninsured Americans or one of the tens of millions more who are financially prevented from experiencing the benefit of the coverage that they theoretically have. It is also a long time for employers, large and small, to be in a state of rising costs and operational uncertainty.
Representative Jayapal’s Medicare-for-all bill is a terrific idea and the discussions that will occur in hearings and as the 2020 presidential campaign gains momentum are important opportunities for us to consider because our lack of universal access to care is a national disgrace, but Medicare-for-all is not sufficient alone to give us either the health or the healthcare we desperately need and desire. The tension is between finance and coverage has been at the heart of an important debate among healthcare policy wonks for decades. You might remember that it came up during the run up to passage to the ACA. Do we cover everyone first and then figure out how to pay for it, or do we figure out how to finance healthcare and what coverage is being offered, and then figure out how to roll it out to everyone? The ACA was bold and the decision came down as a compromise that produced a flawed finance system and did not cover everyone, but we have learned a lot.
In her interview with Sarah Kliff that I referenced, Representative Jayapal was clear on where she stood. She is for implementation first, and thinks working out finance is secondary priority. Her feeling is that coverage is a life threatening emergency for too many people and the money that is lost because of delays in care and the inefficiencies and waste in the system offer many options for finance that will result in savings. It is good that Medicare-for-all is more politically plausible now than ever before, but the opportunity makes it necessary for us to seriously think about much more than getting to universal coverage. Universal coverage is such an exciting idea that is hard for its proponents to understand that it is a ticket to ride toward the Triple Aim, but it is no guarantee that we will arrive at the destination. It is a necessary part of an overall answer, but far from sufficient by itself to produce the solution to the question that is explicit in Dr. Ebert’s declaration. Fifty plus years ago he was giving us the answer to a question that not everybody was asking, “How do we optimally provide for the health needs of the nation?” The answer is much longer than, “Give everybody coverage.”
Robert Pearl, the former CEO of the Permanente part of Kaiser Permanente, has offered an answer to the question that nicely fits Dr. Ebert’s formula. You may remember that two years ago he wrote a very readable book for the public that also has a lot to say to healthcare professionals, Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong. I read the book as soon as it came out and used Pearl’s analysis in the book to write about the positive aspects of the ACA when it was under attack in May 2017. Pearl writes a regular column for Forbes magazine, and in 2017 he wrote a review of his own book that is worth your attention. Pearl’s description of the problems with our system of care in 2017 were not overstated. The issues have not changed, and they are worse now because the cost of care continues to rise and the Trump administration has had two years to undermine many of the advancements of the ACA.
Serendipity is a recurrent joy in my life. While I was thinking about the issues that Medicare for all does not fix, I happened across a podcast interview with Robert Pearl from last September that was presented by my former colleague Dr. Zeev Neuwirth who is now an executive at Atrium Health in Charlotte, North Carolina, formerly Carolinas Healthcare. Over the last couple of years Zeev has posted more than 60 in depth conversations with leaders, thinkers, and innovators on his podcast that he calls “Creating a New Healthcare.” As I listened to the interview I realized that Dr. Pearl was giving us a pretty good answer to Dr. Ebert’s implied question “How do we optimally provide for the health needs of the nation?” Listening to his answer also connects to the realization that harvesting the benefits of Medicare-for-all will require a finance mechanism for the delivery of resources to providers and that the finance mechanism will be the driving force that determines whether or not the operating systems of healthcare will change enough to deliver Triple Aim results. Universal access to what exists now would not deliver on our most hopeful expectations.
Pearl is a great storyteller and I suggest that hearing him is worth your time. He uses stories to provide understanding to his formula describing how to “fix healthcare.” His answer meets Dr. Ebert’s requirements and more. Pearl describes an operating system, and a finance mechanism, as well as the professional behaviors necessary to make healthcare work. After hearing the podcast I returned to his book and reread chapter seven entitled “The Four Pillars of Transformation.” Then I realized that Pearl had reduced the essence of the chapter to the last paragraph of his Forbes review of his own book.
As such, the concluding chapters of the book provide a prescription… Integrate the care provided so that it is coordinated and collaborative. Require all of the information and data in the health record of patients to be compiled into a single record to prevent errors of omission. Align incentives for doctors and patients through pay for value, not pay for volume or fee-for-service. And invest in physician leadership so that the doctor-patient relationship can be restored as the foundation for medical care. Change can happen, but it won’t until all of us–doctors and patients alike–demand it.
If that is too condensed let me expand the four points, or as he calls them, “pillars,” of the new healthcare.
1.Integrate the care. The best example is Kaiser’s integrated delivery system. The benefit will be efficiency and an improvement in safety. Care should be delivered to populations. Integration will result in a reduction in the number of hospitals and a more efficient deployment of specialty resources. Capitation payment for populations can drive beneficial consolidation, a search for efficiency, and the elimination of waste. That is good because there will be a need for fewer beds when we begin to focus resources to meet a budget while providing quality, safety and service. Many systems have proven that you reduce the need for hospitalization by delivering better care for chronic disease.
2. It’s Better and Cheaper Not to Get Sick in the First Place. Health care will need to be prepaid, moving away from pay-for-volume toward paying for value and superior outcomes. Pearl effectively argues that in a system that is financed by capitated revenue beneficial program development can lower costs, improve quality and safety, and provide a sustainable professional experience. These gains can not be realized in a volume driven system. He is unapologetic in his use of the word “capitation.” I know that word conjures up visions of a dysfunctional world of HMO care that denies treatments that are needed, and that behavior did occur in some places in the eighties and nineties when HMO became a four letter word. Now we are able to measure patient satisfaction and outcomes to help prevent abuses. Now grater abuses occur from fragmented and excessive care driven by the need to increase volume with FFS practice. Those abuses are much harder to manage.
3. What Your Doctor Doesn’t Know Can Hurt You. Health care will need to be technologically enabled, with comprehensive electronic health-record systems, patient access to medical information, and the ability to obtain care using mobile and video technologies. As much as we complain bitterly about EMRs, we need them, and we need them to allow any patient’s data to be readily available wherever the patient goes for care. We also need the ability of technology to “multiply” our efforts and to reduce the barriers of time and distance.
4. Who Will You Trust? Health care will need to be physician led, which will require greater leadership training and development. Doctors can’t do it alone, but we can’t improve the care that is available without the cooperation and leadership of physicians. Pearl believes in the professionalism of his colleagues. He believes that many physicians worry that they will be asked to do the impossible in the future. They will need leadership and support. We must have more effective conversations about “why” change is necessary. A new generation of leaders must be trained.
Pearl’s formula sounds simple. In the podcast he admits that strategy is easy and change is an exercise in implementation. Dr. Ebert would have agreed with Pearl. Harvard Community Health Plan was an attempt to pilot exactly the same formula that Pearl advocates. Kaiser is proof that the method can be scaled to cover many millions of people in a system that communicates effectively from coast to coast at a level of price and quality that competitors can’t touch.
Pearl’s recommendations describe a “systemness” that does not exist in many places. We have begin to talk about failures in care delivery as systems issues rather than manifestations of individual failure. Many have come to believe that the answer to why American healthcare is so expensive, yet yields such disappointing results is a systems issue. Our system of care and care distribution has not evolved to match our technology or the growing need of a larger population. Ironically, people want the feel of the care they related to an earlier day when practice was a “cottage” industry, but they also want the results, convenience, and efficiencies, of a highly integrated system. Pearl believes that all are possible, and tells a story in the book, and also on the podcast, that beautifully describes how a system of care provides advantages for both providers and patients.
The main characters in the story are Christy, a medical assistant in ophthalmology, and Sarah, a patient with concerns about glaucoma who needs frequent measurement of the pressure in her eyes. Christy’s responsibility is to greet the patient, do some tests, and prepare the data in the medical record that enables the visit. She has been trained to also check to see if there are any routine health screening events that are overdue. She notes that Sarah has never had a mammogram, and tells her that after her eye appointment she should walk down to mammography where they will do her mammogram on a walk-in basis.
At the next visit Christy notes that Sarah has still not had her mammogram. She surmises that Sarah is avoiding the test perhaps because of fear. After the eye appointment she offers to walk with her down to mammography to get the test. Sarah agrees. A malignancy is discovered. It is early and small. The surgery reveals no spread to nodes. Perhaps Sarah’s life has been saved.
The story reinforces Pearl’s four pillars. The care is integrated. Ophthalmology and Mammography are co located and the same information is readily available to all providers who serve the patient. In a capitated system all of the providers are motivated to work together across specialty boundaries and geographical barriers to improve care. The system is organized and led by professionals that define success in terms of outcomes and patient satisfaction. Christy was rewarded with a sense of satisfaction for having helped Sarah, and she was recognized and honored for her efforts. It is a very good story that begins with Sarah having access to a good system, and access to just any system would not have had the same results.
When we do expand coverage to everyone because we realize and accept that we can no longer justify or afford not do it, we will be well advised to write the legislation with Dr. Ebert’s concept of the necessity of optimizing the method and finance of care. I hope that when the safety, quality, and affordability of care finally become a bipartisan concern that merits real change policy makers will carefully assess the success of the systems that have always provided safe, efficient care, and ask how that care can be scaled up to meet the needs of the nation. I hope that Representative Jayapal prepares us for that moment by calling for the testimony of experts like Dr. Pearl who have done it before.
Will Winter Overstay Its Visit?
Many of my neighbors have four legs. They notice me when I am out for my walks and will often try to get close enough to have a meaningful interaction. Even though our interaction is limited to salutations associated with a few pats on the nose, or scratches behind an ear followed by responsive head shaking, pleasant snorts, and thwarted attempts to nuzzle up to me over a fence or wall to see if there might be an apple in my pocket, we do have meaningful communication. I can sense that my four legged friends share my eager anticipation of seasonal change.
Mother nature is giving us some mixed signals. On the one hand, we have had some very clear bright days, and the sun is at a much higher angle and lingers longer into the early evening hours. It is great to anticipate sunsets closer to seven PM after daylight savings returns this weekend. On the other hand, when this picture was taken the temperature was in the high single digits and the wind chill factor up on Burpee Hill where these friends live was probably below zero. All three of us were undaunted by the thermometer and the breeze and were outside because we wanted to enjoy the fresh air and sunshine.
The picture was taken the day after Boston got about a foot of snow. We did not get that much, but for most of the winter we have gotten regular “small deposits.” The result of our frequent small storms is that we have had a couple of feet of snow on the ground for most of the winter, so I was happy to have the new four or five inches that we got just to add a fresh cover to the tired, dirty appearance that emerges between deposits. The fellow who plows our drive and the parking area in front of our garage has created a tunnel with high walls on either side down the drive, and there is a mountain of snow in the front yard that is ten feet high.
At this time of year I always begin to wonder when the mountain of snow will melt. Experience tells me that it will happen, but in the moment I still wonder. It seems impossible that it could all go away before the Fourth of July. I look around in amazement and confusion and say, “I can’t believe Spring officially begins in less than two weeks, and Opening Day of the 2019 baseball season is less than three weeks away! How can that be true?” But every year the snow is suddenly gone, the ice on the lake disappears, and winter is followed by the agony of “mud season,” and then a month later than the calendar predicts, spring finally arrives. I am beginning to tingle with anticipation! If winter is still around where you live, get out and enjoy what is left this weekend because it will not last forever.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
