What Is Our Definition of our Health Care System?

Carl Bialik posted an interesting article in the Wall Street Journal a few weeks ago. Grab it Here If You Want. The article, “Ill- Conceived Ranking Makes for Unhealthy Debate” discussed the flaws in the data used by the World Health Organization nearly a decade ago to come up with the infamous “37th in the world” ranking we’re all familiar with. I actually think he got his title backward, it should read “Ill-Conceived Ranking Makes for Healthy Debate.”

One of the primary objectives of the World Health Organization when they released the study was to “stimulate debate and focus on health systems” as opposed to just focus on individual components. The data and methodologies weren’t perfect, but it provided a benchmark. We all knew we could do better particularly when the cost is added to the formula. No matter what the final ranking actually may be we all know we can do better than we’re doing today. And, we’re talking about it so it achieved its original purpose.

But, that wasn’t the issue that caught my attention.

When explaining the decline in the country’s ranking in child mortality and life expectancy since 2000 the article stated, “But some researchers say that factors beyond the control of the health-care system are to blame, such as dietary habits.”

And, Alan Garber, an economist and professor of medicine at Stanford University closes the article by saying, “We might get more bang for the buck by setting aside some of our health-care money to support novel approaches to improve nutrition, education, exercise, or public safety.”

Until we all get on the same in our definitions the health care system will continue to struggle. In our view, nutrition, education, and exercise (and many others) are not “novel approaches”, but fundamental participants in the health care system that is evolving. And, dietary habits should be included in any research as they are critical in evaluating the whole-person and determining the approaches or strategies to improve the health of an individual.

We obviously define “health-care” different than others.

As long the majority continues to define health care as the “diagnosis-focused insurance financed” system we have today (as indicated in this article) instead of including health, wellness, and lifestyle as critical components; we might end up even lower than 37th- no matter what flaws may be in the data.

Independent Voters Will Make The Difference in Health Care Reform- And Everything Else

Independent voters (those independent of political affiliation of the two major parties) have always been a part of our political landscape. Both political parties target the “independents” during election cycles as the only way to assure victory because neither one can seem to acquire the numbers they need on their own.

From all of the talk in Washington, you would think health care reform is all about Republicans or Democrats- it’s not. It’s what the independents want that will make the real difference. For the first time in a long time, independent voters outnumber those affiliated with either major political party.

The Pew Research Center provides an interesting visual of the history of individual affiliation with our political parties over the past 70 years. You can link to it by clicking here.

Starting back with Franklin Roosevelt in 1939, independent voters made up 18% of the electorate. At that time, Democrats made up 41% while Republicans were at 35%.

As we all know, party affiliations change with the times. Democratic affiliation peaked at 51% in 1964 after the Kennedy assassination and Republicans dropped pretty substantially to 25%. Independent voters increased to 23%.

Since that time, the affiliations of both major political parties have continued to erode. With the exception of a brief spurt during the Reagan years, the Republican Party has had a tough time solidifying a base. Democrats have not had much more success.

Beginning in 1991, under Bush I, the Republicans, Democrats, and independents have all been competing as equals in addressing the needs of the American people. And, in 2009, independent voters now make up 36% of the electorate, Democrats have 35%, and Republicans 23%.

So as we continue on with all of the partisan politics that’s taking place in Washington regarding reforming our health care system, both parties better realize it’s not those that are affiliated with them that will be their staunchest advocates or most vocal critics. It will not be a Democratic or Republican agenda that will make a difference. It’s the independent voter that will have the biggest impact. Congress (both sides) had better listen.

And, from what we’re seeing, we can expect the independent ranks to grow even larger in the future. Because we don't think that they really are.

Consumers Value Health Care Different Than Health Care Values Health Care

I had the opportunity to speak at Life University’s homecoming over the weekend. Many thanks go out to the folks at Life, and particularly Dr. Stephen Bolles for making it a really enjoyable experience.

My topic was centered on “delivering value” in health care, not from a clinical standpoint or a health plan standpoint, but from a consumer perspective. We haven’t heard much about the consumer’s perspective of what they are searching for in the health care debate (except through the emotional interaction of the Town Hall meetings over the past few months). I'ts about time we started to listen.

I felt it was important for the audience at Life University (clinicians) understood the brutal realities of the health care market they are part of. We all know the numbers, we spend too much, our results aren’t what they need to be, and there is a very real possibility that the whole financial model could crash if we don’t do something about it. Consumers don’t trust the health plans, they don’t trust their employers, and they certainly don’t trust those in Washington making the decisions to “reform” the system we have today (I’ve written enough on my views on what’s going on with the whole reform fiasco). Due to the lack of trust, consumers get a lot of their information today via the internet. Eighty-eight percent of them validate the information they receive on the internet with their health care providers. Eighty-eight percent of those people then validate the validation they received from their health care provider with family and friends. Health care information is a social phenomenon.

The definition of “value” in health care from a consumer perspective (from the outside) has a very unique context around it. Value from a consumer’s perspective is something they can trust, is personally relevant to them, delivers the results they expect, and can help them navigate through the mess we have today when they need to navigate through the mess. Value is very personal when looking at it from the consumer’s eyes.

The definition of value for those inside health care is totally different. Value is based on outcomes and cost. Value is about following the right protocol or the right formula in delivering care. The value of health care is transactional- not personal. And, as we all know, our health care system has become a system based on a series of transactions- not relationships.

My argument has been that until we start to recognize and appreciate the definition of value from a consumer perspective, we’re never going to get them involved. They will continue to be merely participants aimlessly following the confusing rules and processes we have laid out for them. Yes, they might be “nudged” along by incentives (another transaction) to get them to do the right thing- but they are not going to engage and do the things we will need them to do to be truly engaged and active participants in their health and in the health care system itself until a relationship is established. We have a long ways to go.

Our health care system has become a fragmented array of individual self-interests focused very narrowly on individual points of view. To really reform our system will require a change in perspective for many of the individual self-interests to work in a more focused and integrated manner than they ever have before. And, while not discarding the health care system’s definition of value, they will need to focus much more on the definition of value from the perspective of those receiving care. Patients are not a transaction- they are a person.

Did anyone really hear my message at Life? I don’t know, but it felt good getting it out there for others to think about.

State Health System Performance- Confirming What We Already Know

The Commonwealth Fund just released its state scorecard on health system performance. We posted it on our site under the “Health Systems” section in our library at http://www.collaborationhealthcare.com/ or you can grab it by clicking here.

The study looked at a number of indicators to determine its rankings of the states. In 2009, Vermont, Hawaii, Iowa, Minnesota, and Maine/New Hampshire came out on the top and Florida, Louisiana, Nevada, Texas, Arkansas, Oklahoma, and Mississippi came out on the bottom.

The main message once again pointed to the significant variation between the states that continues to exist in access to care, quality, costs, and outcomes for individuals. Even those states at the top of the list had some room for improvement.

Perhaps most striking is the amount of dollars that could be saved in the system we have today simply by organizing care more effectively and dealing the costs associated with the unhealthy lifestyles of our population:

$5 billion for unnecessary re-admission to hospitals or nursing homes

$37 billion “outlier” Medicare costs

$193 billion for tobacco-related health care costs

$147 billion for obesity

So as we continue to move through the health care reform debate, we’ll continue to argue that the issue is not whether we have a public option, or co-ops, or whatever else we want to throw in there. The issue is not making the health plans, the doctors, or the hospitals the “bad guys”. The issue is how this system is organized and how care is delivered and paid-for in the system we have today. Until we deal with the fundamentals, the rest is simply irrelevant.

The Commonwealth Study only reinforced what we already know. I just hope we do something about it.

A Local Conversation for Integrative Health

We were pleased to take part in an event the other day hosted by Northwestern Health Sciences University and co-sponsored by the University of Minnesota's Center for Spirituality and Healing, School of Nursing, and LifeScience Alley. The theme; Integrative Health: Implications for Patients and Purchasers was designed to be a "local conversation about healthcare reform".

The event was well represented by many of the key health care stakeholders throughout the Twin Cities area and was indicative of the interest the market (or at least some key stakeholders) is beginning to show for integrative health care approaches and the role it can and should play in the new system that is evolving. The attendance was also indicative of the need for more of these types of discussions to share ideas, collaborate, and simply provide a venue to let everyone know what is going on in a changing world.

Mary Jo Kreitzer, PhD, RN (Director, Center of Spirituality and Healing) summarized the evolution of integrative health care from the beginning to where it is today. She pointed out that integrative health care has moved from "alternative" to a position to where it can and should play a much more integral role in health care delivery.

Charles Sawyer, DC (Sr. VP, Northwestern Health Sciences University) reviewed the escalating health care cost statistics we are all so familiar with today.

Patrick Geraghty (President and CEO of Blue Cross and Blue Shield of Minnesota) discussed the changing culture of his health plan from being a "health insurer" to a "health company" in response to the changing market expectations and demands.

Carolyn Pare (CEO of the Buyers Health Care Action Group) outlined the expectations of the employers in the new health care market and their interest in "value" not just new gimmicks or "stuff".

Frank Cerra, MD, (Dean of the Medical School at the University of Minnesota) discussed the changing roles of the providers, and emphasized that real health care reform needs to come from the providers and those delivering care.

When you reflect on the total context of these individual discussions it is very clear that the health care market is already changing. Relationships are changing and many of the delivery models that exist today won't be around a few years from now. Integrative health care with a "whole person focus" has a wonderful opportunity to play a much, much, larger role in health care delivery than it does today. We just need to develop the innovative approaches and the business models to make sure it happens.

The time is right.

Do We Need to Reform The Cost of Health Care? You Do The Math

The Kaiser Family Foundation and the Health Research and Educational Trust published its 2009 Employer Health Benefits Survey. We posted it on our site you can get it by clicking here.

For those who are questioning any need for reforming the cost structure of our health care system- let’s just do a little math exercise:

In 2009, the average cost for family coverage increased to $13,375 for family and $4,824 for single coverage. As a reference the average cost for family coverage was $5,700 in 1999. The cost increase from 2008 to 2009 was relatively stable for single coverage, and family coverage increased a modest 5%. But, keep in mind these pricing changes are likely softened by the increased cost-shifting to individuals through higher co-pays and deductibles- we pay more, the health plan pays less.

Employers continue to pick up most of the tab by contributing 74% of the cost for family coverage- we pay $3,477.50 and the employer pays $9,897.50.

The study then provided some other background information comparing 2008 to 2009:

Individuals with deductibles over $1000 increased from 18% to 22%

21% of the employers increased co-pays or reduced benefits

15% of the employers increased the contribution requirements of employees

60% offered benefits in 2009 (compared to 66% in 1999). Only 46% of small businesses offered benefits in 2009 compared to 56% in 1999.

I believe we can safely assume that if things don’t change more of the costs of health care will continue to be shifted to the individual (through high-deductibles, copays, benefit cuts, or increased contributions) or the benefits will simply be dropped because they are too expensive.

The study then projects that if things don’t change and the cost of family coverage increases 8.7% over the next decade (as it has in the past), the cost of family coverage will exceed $30,000 per year. Assuming the same contribution levels between employee and employer, this means individual families will need to double-down what they are paying today for their health care benefits (to $7,800 per year) and employers will need to kick-in over $22,000 per family.

Eighty-percent may be satisfied with the health care coverage they have today. But, we wonder if the same people will be as satisfied when all these projections become a reality.

You do the math.

Opportunities for Complementary and Alternative Medicine (CAM)

In the 1990s, Dr. David Eisenberg and collegues at Harvard created a little stir in the health care discussion when they published the results of several studies regarding the use of (and estimations of the dollars spent on) “Complementary and Alternative Medicine” (CAM) by consumers. The definitions of the services included in “CAM” for the study were a little loose- (not taught in traditional medical schools) and some of the categorization may have been a little confusing but the bottom-line was very real: Over $27 billion was estimated to have been spent on CAM services, most of it was cash, and most medical doctors were unaware of the use of these services.

The $27 billion number caught the attention of the insurance industry. Since most of these CAM services were outside the traditional benefit structure of a health plan, the insurance providers began to try to figure out ways to capture some of the dollars. Affinity networks were all the rage for awhile as insurance payers simply developed networks as a “value-add” to a health plan member. They would provide access to CAM providers to members at a discount from normal charges and collect an administrative fee for coordinating the efforts and providing the access to their members. Very little was done to actually integrate these services further into any health care plan for an individual patient. In the 90s, creating a “health and wellness culture” in health care was still an altruistic vision to most insurance payers (still is to some); they remained focused on managing illness and paying claims. Offering CAM networks was a product decision by the marketers, not a clinical one.

No doubt, some progress has been made since 1997 but the health care system we have today still has a long way to go to integrate the services included in the CAM definition, into a clinical delivery structure that focuses not only on improving the physical health, but the quality of life of each individual.

The Department of Health and Human Services, Centers for Disease Control and Prevention recently published some updated numbers which shows there continues to be a strong demand for CAM services.

The study, “Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007” estimates that nearly $34 billion was spent out-of-pocket by consumers for a variety of CAM products and services in 2007. The vast majority of this cost ($22b) was for “self-care purchases i.e. products, classes, and materials; and nearly $12 billion was spent on practitioner visits.

The methodologies between Eisenberg’s approach in the 90s and the approach used in this updated study are so drastically different you have to take some of the comparative conclusions made with a tad of skeptisicsm. We all know that developing consistent definitions and comparisons in health care has not been one of the industry’s strengths.



Nonetheless, this updated study projects an even larger expenditure for CAM services than Eisenberg estimated in 1997. This continued growth creates opportunities for CAM products and services to play a more visible role in the health care system that is evolving.

This study shows that individuals continue to seek more holistically focused (and yet safe) methods to address health issues, and more important, look to these services to maintain their health and quality of life.

As the health care system gravitates toward health, wellness, and quality of life even more, we hope the clinicians (and not the marketers) take the steps necessary to integrate appropriate access to CAM services and make them an even more important component of health care delivery in the future.