Health Care In 2011: Defining Ourselves as a Country

2010 was another memorable year. We had the Gulf Oil spill, the passage of health care reform, the rise of the Tea Party, and an attempt to rebuild an economy devastated by the Recession of 2008. The November elections pointed out that Americans were tired and wanted change. The election results will change the course of politics in 2011. And, the wars in Iraq and Afghanistan (except for little spurts of topics) remained a side-issue for most Americans (2010 was the deadliest year of the 9-year Afghanistan War and less than 1% of the American population was asked to sacrifice in ways we can’t even begin to comprehend.)

All of these events are related. Slowly but surely they are defining the character of our country. Will we be able to come together as a nation to solve the many challenges we face, or will we remain partisan and divided and only expect others to sacrifice instead of ourselves. All Americans are going to need to sacrifice in some way if we’re going to pull ourselves out. It’s a new mindset for most. Time will tell whether we will.

Kaiser Foundation determined the uninsured in America grew by nearly 4 million people in 2009. Now, over 50 million Americans are without health insurance to finance the health care they may need. The number of Americans without access to some type of health care financing/insurance support now exceeds the population of Spain. This number will likely increase when the study is repeated for 2010.

Uncompensated care for the uninsured reached $57 billion in 2008 with the state and federal governments footing three-fourths of the tab. This number will continue to add to the strains of federal and state budgets as the number without health insurance increases.

The Employee Benefits Research Institute concluded that a couple will require $170,000 in savings for a 50% chance of covering their health care expenses during their retirement- including what would be paid through Medicare. Considering the average savings is only around $50,000 today, it doesn’t take a math wizard to conclude there are challenges ahead. Twenty-seven percent of those uninsured already used all of their savings to pay for the health care they need and many are delaying treatment simply due to cost. Sixty-percent of all bankruptcies are now related to health care expenses.

Only 20% of the Baby Boomers now beginning to flood the Medicare system believe it is financially stable and nearly half believe they will live longer than Medicare itself. The influx of Baby Boomers is going to put a strain on a system that is already strained and adding daily to our national debt.

Something has got to give.

As we enter 2011 and begin to argue again about reforming our health care system let’s not delude ourselves into thinking everything is ok. These numbers are only going to grow if we do nothing or just continue to tinker around the edges. We’ve tinkered around the edges for long enough.

And, yes, it will require sacrifice; sacrifice from everyone this time. Whether you are Republican, Democrat, Tea Party or any of the other variations, and no matter what demographic or economic class you are in, it is how we accept and address these challenges will define us in 2011 and beyond.

“For unto whomsoever much is given, of him shall much be required: and to whom men have committed much, of him they will ask the more.”

A good verse to keep in mind for 2011.

Happy New Year

Just Continuing To Kick the Can Down The Road

It's almost Christmas.

Last year, Congress was frantically putting the pieces together on the health care legislation- which wasn't pretty. This year they are frantically trying to put together the pieces for the omnibus spending and tax bills- even less pretty. At a cost of over $850 billion and loaded with over 6,000 earmarks, this legislation is once again an example of cramming together what is politically viable instead of what is needed for the country. Before signing the omnibus spending bill in 2009, President Obama stated, "This piece of legislation must mark the end of the old way of doing business and the beginning of a new era of responsibility and accountability that the American people have every right to expect and demand." I guess he feels one more time won't matter. We'll really, really make this one the last time. I doubt it.

Last week the House passed the Medicare and Medicaid Extenders Act of 2010 avoiding the 25% cut in Medicare physician payments and freezing provider reimbursement at the current levels until the end of 2011. Physicians breathed a sigh of relief- the Medicare budget was blown to hell. This marks the fifth time we have set aside the sustainable growth rate (SGR) model this year and the fifteenth time it has been set aside since 2001 accruing a liability of another $300 billion. Do you think the SGR model might need to be changed instead of continuing to simply push dealing with Medicare cost increases off in the future?

A few days ago the first judge ruled against the individual mandate included in the health reform legislation signed earlier this year. Republicans celebrated as they felt this supported their calls for repeal. Democrats simply ran (or continued running- they have been running from this for a long time). In the meantime, the $2 trillion spent on health care costs continues to climb and our life expectancy compared to the rest of the world (one measure of how effective our system is) declined.

The Debt Commission report released a few weeks ago stressed we are nearing the edge of the cliff. We heard it, we know it, but we simply continue to put our hands over our ears and yell, "I'm not listening, I'm not listening, I'm not listening," hoping it will all just magically go away and we can return to the way things were. Ain't going to happen.

While stabilizing the economy in the short-term is important, considering the long-term impact of all of this on our debt is more important than ever. We all know we're in a very precarious situation as a nation; we just don't like to sacrifice anything if we don't have to. We're big into "screw-avoidance." Whenever sacrifice is mentioned, we think we're getting screwed. A hint; fixing our financial and health care structure is going to require some shared sacrifice from everyone whether we like it or not.

Or, we can just continue to kick the can down the road as we've always done and enjoy the scenery as we're falling off the cliff. We don't have very far to reach the edge.

Happy Holidays.

Health Care Consumers- An Enigma For Health Care

Last week I sat in on one of the webinars hosted by the Institute for Health Improvement (http://www.ihi.org/). The topic was "bending the Cost Curve" and was intended to continue the never-ending discussion of how to address the health care cost crisis in this country (if you get a chance, sit in one one of these- some of the topics are pretty decent). There were over 600 health care professionals listening in to this one.

We heard all the usual numbers. We heard the usual descriptors; crisis, unsustainable, breaking-point. We listened as one of the speakers discussed the methods used to contain hospital costs in Maryland with propspective payment and bundling approaches. Then, there was one slide that seemed to create a stir with most of the audience (I've posted it here).

When discussing how to get consumers involved- the group was at a loss. When discussing the creation of "discernable health care consumers," changing consumer behaviors, and changing the expectations of individuals, the group honestly did not know what to do. Most in the audience are used to controlling, incentivizing, and directing. When realizing they may need to begin a real dialogue with the general population, this audience simply didn't know how to go about it.

Health care needs to change its image. It needs to realize that consumers are not simply a herd of cattle that needs to be driven in the right direction. With the right relationships and context, consumers (for the most part), know what they need to do. They just need some trust and guidance sometimes. Health care needs to realize that the individual consumer is not simply a component that needs a clinical fix that can be directed by free gifts an money- but an important part of the solution that needs to be part of the dialogue, discussion, and relationship.

If we're ever going to fix the problem we have, health care is going to need to communicate better with the general population. It is going to need to break down the clinical and technical communication approaches it has relied on in the past and begin a dialogue and discussion with the "Joe the Plumbers" of the world. It needs to regain some semblance of trust, relevance, and context for the average individual before they are ever going to get engaged and participate.

Only then will we be able to begin to address the issues with "Bending the Cost Curve." And, hopefully, we won't have 600 health care professionals wondering how to get consumers involved.

We'll have solutions to discuss already making it happen.

Health Isn't Just About ROI

A familiar Einstein quote: "Not everything that counts can be measured. Not everything that can be measured counts."

W'ere trying to measure everything today in health care. We don't make a move unless the data is there to justify a positive "return on investment" (ROI) before we even start. We've reverted to use clinical and academic approaches to making decisions because we've been screwed so many times in the past. Data is safe. ROI is measurable. The way we make decisions today is justifiable in some cases and only holds us back in others.

Improving the health of our population is logical. When considering the costs of preventable chronic illnesses it only makes sense to help others change behaviors to prevent or minimize their effect- for the quality of life of the individual, and the costs associated with them. Yet, for any number of reasons, the health care system (employers, health plans, providers) continue to debate within itself with where the responsibility for "health and wellness" fits in the curative/sickness-focused model we have today. Who should pay for it? Will I get paid for doing this? Why should i keep someone healthy when they will only go to another employer or health plan when I'm done? What is the evidence and clinical model? With the costs of diabetes, obesity, hypertension, and other lifestyle-related chronic illnesses skyrocketing, a focus on creating a healthy population simply makes sense, we need to quit the debating, and begin to do something about it collectively.

An article in the December issue of the Harvard Business Review ("What's the Hard Return on Employee Wellness Programs?") further supports the value of wellness programs in the workplace. In typical academic fashion, the article identifies six "pillars" organizations included in the research used to create successful wellness programs in their organizations; Pillar 1: Multi-Level Leadership; Pillar 2: Alignment with organizational identities/aspirations; Pillar 3: Scope, Relevance, Quality; Pillar 4: Accessibility; Pillar 5: Partnerships; Pillar 6: Communication.

This isn't rocket-science.

I would argue these Pillars can and should be included underneath a more general platform of the need to create a "culture of health" that is trusted and embraced by the individual. The organizations included in the HBR article all had high "participation," positive ROIs, and focused approaches. But, all had also created a culture of health within their organizations that was a natural part of the organizational DNA. The health and wellness component was only an extension of the relationship these employers had created with their employees. It took time, and they all earned the trust of those participating with them.

Before relying on the 6 Pillars as the saving grace of what is required to create a healthy population of individuals we also need to focus on creating the culture of health throughout the landscape. This may take time and may not show a positive ROI for some time. Most individuals understandably do not trust the health care system we have today, some don't trust their employer relationship, and most certainly don't trust the health plans. Health care (providers, employers, health plans) need to build the trust and not simply rely on metrics or pillars to determine their success. They need to help individuals understand the relationships and provide the context they need to recognize they are part of the solution- and not simply a cog that is part of an external process. They need to be engaged.

To paraphrase Ghandi- "a (health care system's) culture resides in the hearts and soul of its people."

The culture is not determined just by the short-term ROI or other metrics that may or may not be important right now.

Fixing Health Care- Making It A Patriotic Duty Instead of a Political One

Last week we lost 18 soldiers and Marines in Iraq and Afghanistan. Unless you are family, friend, or part of a community hit by the reality of these wars (yes, they are wars) you don’t hear much about it. The country has too many other things to worry and argue about.

As we enter the Holiday Season this year, take a minute and say a prayer for the men and women half-way across the world and living in horrific conditions to protect the freedoms we enjoy today. Say a little prayer of thanks and appreciation for those who have made the ultimate sacrifice. While you’re at it, say a prayer for their families as well. These folks know what real sacrifice is all about. It’s not easy but they know their role, accept it, and make the best of a really rotten situation.

Instead of making health care a political football why don’t we think about pulling together a little to achieve a common mission in the best interest of our country. Let’s make it our patriotic duty to work together to solve one of the biggest economic challenges facing our country. We may not all necessarily agree with the rules and we may not even like those we need to work with. Mark my word, those serving in Afghanistan and Iraq face the same challenges. But, they adjust and look beyond themselves to achieve a common objective. They make things happen.

They are Americans before they are anything else. We can learn a lot from them.

Have a Safe and Happy Thanksgiving

The Brutal Reality: Health Care Today = Increased National Debt

In their book "Confronting Reality; Doing What Matters to Get Things Right," Larry Bossidy and Ram Charan put forward a statement that has implications for everyone in our country today. They state, "To confront reality is to recognize the world as it is, not as you wish it to be, and have the courage to do what must be done, not what you'd like to do." Very appropriate to describe the reality of the financial situation in our country.

Last week, Erskine Bowles and Alan Simpson, Co-Chair of the National Commission on Fiscal Responsibility and Reform submitted their "Co-Chairmen Proposal" for tackling the $13.7 trillion dollar debt facing our country. This debt is the result of the policies and entitlement expectations we have accumulated over the years (not just over the past two years) and was exacerbated by the Great Recession of 2008 experienced in the global economy. We are now facing a level of debt that jeopardizes the economic foundation of the country.

We have posted their proposal on our website at http://www.collaborationhealthcare.com/ and you can also look at it by clicking HERE.

We encourage everyone to take a look at it. It's only 50 pages and is mainly a "powerpoint on paper" highlighting the key messages. It has already been blasted for its lack of specifics. I look at it more as a starting point, not the final solution.

Those on the right have been critical because it includes tax and revenue increases. They believe there is already plenty of revenue- just not enough spending discipline.

Those on the left have been critical because it takes on some of the entitlements that have historically been off-limits; Medicare and Social Security.

The brutal reality is that we need some combination of addressing both.

Why is this topic included in my health care blog? Because health care (Medicare/Medicaid) is a major contributor to our debt and our lack of action in the past is impacting our businesses in the private sector and ultimately negatively impacting our economy. It's only going to get worse and it's time to quit arguing about the way to fix what we know needs to be fixed - and just do it. The impact of our debt is going to impact every American sooner or later. To fix our debt problem and our economy we must begin to change the way health care works whether we have laws that require it or not.

Some are still in total denial that the problem is as bad as others are making it out to be (AARP and the Natinal Committee to Perserve Social Security). On the other hand, David Cote, Chairman and CEO of Honeywell International and one of the committee members, was shocked to find out how bad our situation actually is.

The first founding principal of the Debt Reform document states, "We have a patriotic duty to come together on a plan that will make America better off tomorrow than it is today." America can come together when it wants to. Unfortunately it usually some type of crisis or catastrophe to make it happen.

The country has an opportunity to address a real issue before it is too late and becomes a catastrophe. This is beyond politics or ideology. It's time we confront the reality, become informed, and recognize it's going to take some sacrifice from everyone.

We have said before that fixing health care is critical to fixing our economy. Let's quit putting the ideology in front of the actions- as stated by Bossidy and Charan- "we need to have the courage to do what must be done, not what we'd like to do."

Republicans- It's Time For Specifics and Not Just Campaign Rhetoric

The $4 billion the country spent on this last election should be looked at as a little boom for the economy. Political consultants, media buyers, the hospitality industry, and others tied to the various campaigns got a little boost in revenue. So, that's good. You see, we can find money to spend when we want to.

While we had to suffer through the nauseating attack ads that are now part of the norm, we watched a country tell its government it wanted a change in direction. This was by no means an embracing of the Republican Party as the devout Republicans would like to think. It was the independent citizens telling the government they didn't like the direction the country was heading and wanted change. The level of trust in government is at an all-time low- for both major parties. In two years if we're in the same place, the same thing will happen- we'll have another change.

Now that the Republicans are driving the bus (or at least near the front) they now have an opportunity to step up to the plate with specifics on what they intend to do. They have been exceptional in the complaining department (and have brought up justifiable concerns). It's just they have been woefully short on the specifics of their alternatives. They now have the chance to show what they can do.

Repealing the health care reform legislation is becoming a central battle-cry for the "new government." Minnesota Governor Tim Pawlenty is leading the charge as he explores his presidential run for 2012. On CNN he once again denounced the "takeover of health care by the federal government" and instead wants to rely on the "free market" to do its magic- but there are not a lot of specifics beyond that. Michelle Bachmann (R MN) has jumped on the bus as part of the Tea Party movement commenting during her debates that she believes allowing consumers to purchase health care across state lines will solve the problems we have in health care. This is all great political-speak for the free-market purists, but, exactly what are you going to do and exactly how will it work? I guess they haven't got that far yet.

Solving our health care crisis is an economic issue, it is a debt issue. It is no longer simply a campaign debate. Health care (even before the reform legislation) was dragging our economy down. We seem to have lost this fact in all the political talking points we've heard over the past year. Medicare/Medicaid spending are the two biggest components of our growing national debt (along with Social Security) and is only going to get worse as the Baby Boomers create a tsunami within the Medicare system. The same is true for Medicaid as the rolls of recipients expand as a result of our depressed economy.

Regardless of what one thinks about the legislation that was passed earlier in the year (Pawlenty called it "the worse piece of legislation passed in modern times") it brought the issue of health care near the top of the national agenda- where it should be. Our health care system is (and has) impacted the competitive positioning of employers and thus impacts jobs- this is nothing new. It has economically wiped out average citizens and created hardships for many others with the fragmented and costly inefficiencies that are part of it today. Everyone agrees the health care system we have today is unsustainable for the future.

As Republicans assume their new role it's time they move beyond the broad generalities outlined in the Pledge to America and through the campaign rhetoric. They will likely find once again (as Democrats found in 2010 and as Republicans should have learned in 2008) that campaigning and governing are two totally different animals.

Americans are open to new ideas. Instead of focusing on the campaign message of "Repealing Obamacare" let's hear what your specific alternatives might be. The health care crisis is not going away.

Americans are listening and waiting to hear what you have to say. You've got two years.

Another Election- Colbert and Stewart To The Rescue?

I wonder if all the ghosts and spirits of Halloween can stir up some miracle for many of the Democrats on Tuesday. I doubt it.

It looks like the balance of the legislative process is going to shift back to the right- the House and many Governors will likely be Republican when all of this is over. There is still a chance (an outside chance) the Senate may move that way as well. Many of the pundits have speculated that this shift will simply result in a partisan stalemate in Congress we have never experienced before. I suppose you can just add it to the list. We haven’t experienced a lot of this before.

George Will (Conservative columnist from the Washington Post) argues this is the way the Founding Fathers intended things to work; partisanship is natural and the different bodies making up our structure of government were never intended to be bosom buddies. They were intended to provide the checks and balances required to protect our freedoms and the rights and responsibilities outlined in the Constitution. Disagreement is good. Partisanship is simply the result of having political parties with different ideas. He thinks the process is working.

But, I wonder.

I wonder if the Founding Fathers envisioned a legislative process paralyzed by politics when the country needs it most.

There’s enough blame for this to go around to everyone. It's time to fix it.

Yes, the Democratic leadership went too far when developing some of the policies important to its agenda. They didn’t have a choice in some areas- in others they did.

In health care they went too far given the circumstances we were dealing with as a country. They very likely figured they had only one shot at reforming the mess we have today and had to go for all the marbles- and that assumption cost them. The process was ugly and the final product was so complex and undefined almost everyone remains confused about what it is. The responsibility for communicating the “messaging” about the big picture has been assumed by cable news since everyone else has done such a poor job. And, most of the population does not like the content of the messages we’ve been hearing. As expected, the focus on reforming the insurance market and getting everyone covered under some type of coverage has overshadowed the real reform that could save billions of dollars and many lives over time.

While the effort may have been too ambitious for the country at the moment there are still many things included the legislation that make a lot of sense. Unfortunately, we remain focused on all the bad stuff and very few even hear about some of the other positive steps.

Payment reform that rewards value as opposed to volume when setting reimbursement approaches for care delivery is a huge step forward. Coordinating care more effectively between care-givers, improving technology use, enhancing the focus on wellness and prevention as opposed to sickness, and expanding community health initiatives are all critical areas needed to fix what we have. They don’t get much play in the world of politics today but should remain a focus whether in a law or not.

The elections on Tuesday will (once again) shake-up the political make-up of our democracy at all levels. These elections may very well impact whether we can, in fact, be successful in reforming our health care system to protect our economic foundation down the road. I hope and pray that after these elections the two sides can work together toward a common goal of creating the health care system that is accessible and affordable for all citizens whether it’s included in actual law or not. It’s just the right thing to do.

After we digest the results on Tuesday maybe we need to look for an alternative approach. If they can’t do it in Congress, maybe we should ask Jon Stewart and Stephen Colbert to help out.

It seems like they make more sense than anybody these days.

Health Reform- To Repeal or Not To Repeal

The emotions created by the election rhetoric are moving full-steam ahead. One of the mantras of the Republicans is to “Repeal Obamacare.” The Democrats are scared stiff and refuse to discuss anything that hints toward “bigger government”- thus, they aren’t even bringing up health care reform. Word has it that consumers/citizens are fed up with it anyway and have shut down. Big mistake if that’s what happened. Consumers/citizens need to get involved and need to be informed now more than ever. Not fixing health care (with PPACA or not) will only lead to an economic calamity even worse than the housing/mortgage crisis we’re trying to dig out of today.

So, what do American health care consumers want?

We know we need to fix what we have. The costs are unsustainable, the quality is irregular, the access is spotty, and, quite simply, too many Americans are being hurt (financially and otherwise) by the system we have today.

By all measures, we’re divided in our support of what was produced by Congress earlier in the year (PPACA). It’s safe to say most are not really familiar with the “big picture” with what was produced in the first place. The strategy and purpose of what our country needed to fix was overrun by politics and emotions. The fear of “big government” has become the prominent message as opposed to the proper message of fixing one of the major issues facing us as a nation and protecting the economic foundation of this country.

Most Americans are not familiar with the details of the legislation and have been influenced by the loudest talking points (I would argue that most of our legislators are not all that familiar either). And yet, we hear the message to “repeal Obamacare because that is what the public wants". Is it really what the public wants or is it that the Republicans simply want to stick-it to the Democrats?

Kaiser Family Foundation recently completed an informal analysis of eight major polls completed over the past month asking Americans whether they favored repealing the legislation we have today. They found the results were all over the board ranging from a high of 51% in an NBC News/Wall Street Journal poll, to a low of 26% in the September, 2010 Kaiser Tracking Poll. They determined the results were dependent upon how the questions were worded and where the questions were placed (as we all learned in Marketing Research 101).

A Bloomberg Poll completed in early October found consumers support (>70%) protection for high-risk individuals, eliminating pre-existing condition restrictions of insurance companies, and eliminating the Medicare prescription drug doughnut-hole as part of any reform initiative. They would like to get rid of the tax on employers for “generous” benefit plans and are uncertain of the individual mandate requirement.

There is no doubt that the PPACA is cumbersome, complex, and has been communicated extremely poorly. Many, many items in the law could be improved. We would have hoped the legislative process could fix what doesn’t make sense and keep what does. Unfortunately, with the way we are polarized today that’s not going to happen. This is a war between Republican and Democrat, nothing else.

If the Republicans are going to continue to call for a full repeal of the law (Michelle Bachmann) they had better have an alternative to replace it. They are only contributing to the confusion of the individual consumer by promoting their position today- and we need the consumer/public to be on board of anything is going to work.

One alternative is Republican Representative Paul Ryan’s, “A Roadmap for America’s Future; Version 2.0.” Ironically it includes many of the items already included in the Patient Protection and Affordable Care Act as part of his health care solution- there are parts of the legislation where both sides agree.

I guess even if you agree with it, it just depends from which side of the aisle you are on to determine if “Repeal Obamacare” is part of your mantra or not.

And, it’s a sorry state of affairs for the American people and no wonder we’re confused

A New Report Card For Our Government- Stay After School

If my kids would have brought home a report card like that reported in a recent Washington Post/Kaiser Foundation/Harvard University Poll evaluating the consumer perspective of the federal government we would have had a nice long chat. Not surprisingly, we don’t think our government is working very well- and the report card reflects it. This poll was conducted between September 22 and October 3, 2010 and included a representative sample of 2,054 adults over the age of 18. We’ve posted the survey results in our library if you want to dig into the numbers further.

Here’s how we graded our government:

The Military= B+

Our Own Representatives in Congress= C

The Federal Court System= C

President Obama= C

Democrats in Congress= C-

Federal Government in General= D+

Republicans in Congress= D+

Not a report card to be proud of (except the Military where I am extremely proud)

This is no surprise. Our economy remains very fragile and the unemployment created as a result of the Recession of 2008 remains too high. This recession hit hard at a very personal level to millions of Americans. The basic question we are struggling with is how much can or should the government be involved to fix the systemic problem we have created.

While we are stuck in polarizing politics (which will get even worse with the upcoming mid-term elections), nearly 80% of Americans feel our government can be run well. However, most feel it is currently dominated by special interests with a lot of money looking out only for themselves as opposed to the good of society in general.

Economists and citizens are statistically split between increasing government spending (50%) and avoiding deficits (46%) as components of the economic strategies necessary to dig out of the mess we are in. This will continue to be debated and studied for years in the future.

Almost all agree we are not getting the value out of the tax dollars we contribute to make our government work.

When asked whether the government actions threaten our personal rights and freedoms we are surprisingly at the same level we were at in 2000- before 9/11. Fifty-two percent of Americans feel the federal government interventions are not a threat to liberty and personal freedoms both in 2000 and in 2010. But, Rush Limbaugh, Sean Hannity, Glenn Beck and others are making inroads arguing otherwise.

Health care continues to be a primary item of uncertainty for most Americans. While they are skittish about the impact health care reform most remain uncertain and confused by the impact the PPACA will have on their lives.

These results are another indication that we have a long ways to go as a country. However, most Americans still believe that by working together and eliminating the self-interests dominating our political processes today we can make it work. Congress has a long road to climb to get Americans on board. It may take a change in the seating arrangement after the November election as part of the process. Either way, they are going to have to stay after school for quite awhile to improve on the grades they have today.

A Pledge to America- Good Political Move; Not the Solution We Need for Health Care

I can’t remember when politics in this country has been so polarizing. It seems like we’re all pulling in different directions. Thomas Friedman hit it on the head last week when he wrote, “For democracy to be effective and deliver the policies and infrastructure our societies need requires the political center to be focused, united, and energized. That means electing candidates who will do what is right for the country not just for their ideological wing or whoever comes with the biggest bag of money. For democracies to address big problems- and that’s all we have these days- requires a lot of people pulling in the same direction, and that is precisely what we’re lacking.”

All of the name calling, finger pointing, and blaming is not going to solve the big issues we face today. It’s time to pull together and figure out how to pull ourselves out of this mess.

The Republican side came out with their Pledge to America last week. Obviously trying to replicate the success of the Contract with America that was launched by Newt Gingrich in the 90s, the Pledge basically continued the name calling, finger pointing, and blaming that is the standard operating procedure of politics today.

You can't disagree with some of the facts presented in The Pledge. Our government has grown too much and is involved in too many things. The deficit is a huge concern and needs to be addressed. However, the free market (however you want to define it) has also proven that it runs into problems when left on its own. There needs to be a balance. Health care is a prime example.

The Pledge calls for repealing the legislation that is in place today. We do not disagree that the PPACA is confusing, complex, and went too far in some areas. But, that’s what you get when you can’t work together and operate in a partisan manner. That’s how our government operates today. The most recent Kaiser Tracking Poll found over half of the population is confused by the law. Most have not read it and can’t begin to put it into context. Most Americans can only determine their perception of the law by personal experience and by emotions. And remember, most Americans receive the majority of their information about health care reform through cable news- not the most unbiased source in the world.

The Pledge believes PPACA should be repealed and replaced with enacting malpractice reform, allowing consumers to purchase health insurance across state lines, and emphasizing the use of Health Savings Accounts. We’ve heard all of these before. We’re sorry, these will not solve the mess we have with a shortage of primary care physicians, increasing medical technology and pharmaceutical costs, and the tremendous inefficiency in health care delivery we have today. The Pledge does not even address what it would do with Medicare and Social Security- the largest components of the budget and the deficit challenge we are facing.

Repealing PPACA is a nice political talking point as long as American’s remain confused with the broader problems we face in health care. Both sides have done a terrible job of objectively communicating a complex issue to the American people.

If PPACA does end up getting repealed (which it won’t) I hope those who wrote The Pledge can come up with better and appropriate ideas than they have included in this draft. A better idea is to take what we have and work together to make it better- but that ain’t going to happen with the political culture we have today; and that is sad for America.

Our Governor Is Not Going To Play Nice With Health Care

On August 31, 2010 our Minnesota Governor, Tim Pawlenty signed Health Care Executive Order 10-12; Directing State Departments and Agencies Regarding Discretionary participation in the Federal Health Care Law. This was our governor’s attempt to essentially tell the Patient Protection and Affordable Care Act to take a hike.

Now, our governor is probably running for President and he’s made his views very clear concerning any government involvement in health care- and anything else for that matter. This Executive Order was a political statement more than anything else. You can’t object to legally directing those in our government to use some discretion in requesting and using federal funds- if we don’t need it, don’t take it. That’s not the way government works. The only way to filter spending is to hold someone accountable- Pawlenty is assuming that role and I can’t object to that.

It’s the way he did it that bothers me. Instead of a directive focusing on federal and state fiscal responsibility- he used it as a political statement. Here’s a “fact-check” of the reasons supporting his Executive Order:

1. PPACA was signed on March 23, 2010:

True

2. PPACA is a dramatic attempt to assert federal command and control over this country’s health care system and reduces individual freedom for health care decisions.

PPACA establishes the framework at the federal level, and allows the states to implement as they see fit. Pawlenty is free to participate or not. However, the reason the government set some framework is because the private sector could not or would not do it on its own. Somebody needs to take control of health care spending before it breaks the bank.

3. PPACA is unprecedented federal intrusion into the individual liberty including the mandate to purchase health insurance.

This one would be easy to fix- have the health insurance companies eliminate pre-existing conditions for those who can’t receive coverage today and not require everyone to participate. They won’t do it- and we can’t have it both ways.

4. PPACA is funded by taxes and fees coupled with unrealistic assumptions purported for future cost savings.

This is true, to an extent. The only reason the cost assumptions are "unrealistic" to some is because nobody is willing to give. Hospitals, health plans, consumers, and employers will need to realize the old way is not sustainable. The days of $0 co pays are over, fee schedules will be determined by value, and the technology will be dispersed efficiently instead of on every street corner. If everyone embraces the broader need and sucks it up a little the assumptions may not be all that far off.

5. PPACA increases federal spending at a time when the government debt threatens private sector economic growth.

Yes it does- but if we don’t do something, the unfunded liability of our health care debt could bring our entire economic picture down in the not so distant future. Just advocating for more HSAs, competition across state lines, and malpractice reform is not going to cut it. The problems we have created are much deeper.

6. PPACA includes many demonstration projects intended to speed the transition to federally-controlled health care.

This is just silly. The intent of all of this is to organize care better than it is organized today. Once again, if the private market wanted to do it- it should have by now.

Pawlenty’s Executive order would have been much more palatable if he had just stated that since health care represents over 1/6 of our national economy- and since fiscal responsibility is of paramount importance- all requests for funds will need to be directed and approved by his office.

But, he’s running for President, so I guess he felt he needed to create a buzz. That’s the way we do it nowadays.

Medical Errors and Readmission- We Shouldn't Need A Law To Fix What Shouldn't Be An Issue In The First Place

We took a little break for awhile. We wanted to regroup as the health care reform shakeout unfolded and to make sure we continued to provide relevant ideas, information, and thoughts through our blog. We’re going to resume our previous direction. We simply want to provide interesting information, resources, and thoughts concerning the broader context of our health care system. We’ll obviously need to include some of the activities, fallout, and progress associated with health care reform- and we want to provide our views from a consumer/patient perspective. Our goal is simple- to improve the dialogue and context of health care between all stakeholders; consumers, providers, employers, health plans, government. We believe an informed health care market can and will make better decisions than one relying heavily on emotions, siloed perspectives, or legislation.

The dollars and costs of our health care system are simply staggering. We all know we spend over $2 trillion in health care. We talk about this number so frequently that the number has, itself, become abstract. To put context of how big a trillion dollars is consider this fact; 1 million seconds is about 11.5 days. 1 billion seconds is about 32 years. 1 trillion seconds is equal to 32,000 years. These are big numbers- our current health care expenses equate to over 64,000 years from this perspective.

So, when we talk about an area that costs our system less than 1% of our annual health care expenses it doesn’t get a whole lot of attention. However, it’s when we start to make a difference in these “smaller” areas that we can start to make a difference on the bigger number. In addition, addressing some of these areas is simply the right thing to do.

The Society of Actuaries recently released a commissioned study completed by Milliman, Inc. concerning the costs of medical errors in our health care system today. (We posted the study in our Library and you can get it by Clicking Here). This study quantified the cost of documentable medical errors using claims data and some pretty conservative methodologies. In 2008, medical errors cost our health care system an estimated $19.5 billion dollars. Over $17.5 billion were direct costs of inpatient, outpatient, and prescriptions. Another $1.1 billion was related to lost productivity (10 million excess days missed from work), and over $1.4 billion to increased death rates (2,500 deaths due to medical errors).

An estimated $15 billion is spent in Medicare for readmissions to hospitals for preventable medical events. In California, over 1/3 of the patients are readmitted to the hospital within a year.

These are very real costs. These are preventable costs. In addition to the financial costs, these events impact the quality of life of every individual accessing our health care system. The Patient Protection and Affordable Care Act (PPACA) included a significant segment of its massive rules to addressing the issue of “readmissions.” In our view, this is an example of where the private market (hospitals, doctors, health plans) should have and could have picked up the ball and addressed the issue on its own. In “the best health care system in the world” you shouldn’t need a law to dictate the rules to fix an issue that shouldn’t be an issue in the first place. Unfortunately, the private market fumbled on this one. Now, we’ve got rules and laws to follow.

Live and learn.

"Reframing" Health Care

The May/June, 2010 edition of “interactions” includes an interesting article about the way we think about health care. We’ve posted it in our Library at http://www.collaborationhealthcare.com/ and you can grab it here if you want to take a look at it.

The health care industry lives in its own little world. In some ways it is not dissimilar from other industries as it develops its own “culture” and language. Retail, financial services, technology, and many other industries have their own insider cultures, buzzwords, and terminology as well and most of the time they are irrelevant to the individual consumer. But, health care is different. Health care is very personal, very emotional (as we’ve seen), and ultimately touches every individual in one way or another. What is different from most other industries is that every individual interacts with our health care system at some point in their life, sometimes regularly, and many times emotionally.

The recently enacted health care reform legislation sets the framework to try to change the health care culture that has been established over the years. Many health care stakeholders are going to have to look at the system and their role in it very different if they are going to participate in the future. Health care is going to change.

We’re asking consumers to take a different role. We want them to be active participants but the system is really not set up to allow them to do so. The “frames” that exist with the way our health care system is structured today sometimes even prohibits their participation.

In the article “Reframing Health to Embrace Design of Our Own Well-Being,” the authors argue for a need to change the design principles, or frames, that exist in health care today. As we’ve stated repeatedly over the past several years- we need to change the way we look at it.

If we want to really get consumers involved, we need to change the frames that exist today. The authors state, “We debate how to be more efficient and reduce cost rather than radically increase effectiveness and eliminate causes.” A radical change in thinking is going to be required.

Our current system has evolved over the years resulting in what we have today. In the 1900’s the system was focused on monitoring and preventing transferable diseases through immunizations. This part was very successful. Later, the system evolved to focus on eliminating or minimizing acute diseases. It’s been expensive, but it has worked well overall as well.

Now, we’re addressing a population abundant with chronic disease significantly influenced by the culture and lifestyles we lead. The health care focus is now on prevention and wellness. The frame needs to change again. The authors believe well-being and self-management require their own frames. The acute care frame, while still important, cannot address prevention, well-being, and consumer engagement as will be required in the new health care world.

The acute care frame that exists today is trying to accommodate, but it just won’t get there. The article quotes social epidemiologist Leonard Syme who states, “We need to pay attention to the things that people care about, and stop being such experts about our risk factors.” (the acute care frame). We need to get consumers more engaged in a collaborative role in their health and well-being and actively participate when they are healthy as well as when they are sick and need access to the acute care frame. The authors contend, “Health is a means to a goal- one of the things that supports the quality of our everyday life.”

In the self-management and well-being frame health care professionals become coaches and mentors, consumers become the decision-makers and collaborators. Data and information is abundant for the individual to track their progress when setting goals both when they are sick and when they are healthy. And, consumers have simple ways to navigate their options and use health care professionals for advice and insight as well as receiving directions and treatment plans when they are required.

Creating a new well-being/self-management frame will require a total change of the financial structure and payment methods for health professionals. Instead of being paid for services, they are paid for keeping the population healthy.

The traditional “healthcare frame” as we know it today does need to change. We just wonder of the system itself can make the radical changes that will be required to introduce a new frame; one that focuses on the well-being and self-management of the individual consumer.

Health Care Reform- Cable News Has A Role

The Kaiser Family Foundation's May Tracking Poll results of consumers might be an indication that emotions are starting to stabilize a little since the health care legislation was enacted a few months ago. The public may be a little less confused, but a solid minority (44%)still remains uncertain with how the legislation is going to impact them personally.

While the general framework of a system redesign may be in place, the health care system is now waiting for the rules to be written to define exactly how all of this is going to work. The country has moved on to other things for now. It’s now up to the health care system to execute whatever rules are written- and hope it all works. Business strategies for all stakeholders are already changing as a result.

While the intense emotions that we witnessed over the past year may not be visible, you can bet they are still there. Health care reform remains a very partisan social issue. Those that supported the reform structure ultimately enacted still do- just not as intense as in the past. Those who have been against the approach still are- and are just as intense in their disapproval as before. This divide will become visible again if any surprises occur. And, you can be sure there will be some surprises along the way.

The rumors and myths of the legislation continue to fly around to further confuse the general public. Recently, a mass e-mail was sent stating that the new legislation required employers to start including the health care contributions they make on the W-2 of each employee- and this contribution would be included as taxable income thus, increasing the taxes for all who receive employer contributions for their health care benefits. The e-mail called for a “call to arms” to all recipients to reject this tax increase and pass it on. The first part of the author’s contention is true- the second part is not. However, the message created quite the stir in the internet world. Such is the world of instant communication with the internet- whether the information is accurate or not.

Kaiser’s May Poll shows most consumers access family and friends, cable TV (Fox, CNN, MSNBC), and the broadcast networks most frequently to obtain their information about health care reform. Cable TV received the highest weighting when determining the “primary” source of health reform information. The slant used by these venues has a significant impact on the consumer’s perceptions of health care reform and ultimately on their desire to engage in the system. Cable news could be a tremendous asset to help consumers become more engaged by sharing fair and accurate information and helping consumers understand, or they could be a tremendous obstacle. Only time will tell what the result will be.

The country has moved on to some of the many other pressing problems we face. Even though the emotions of health care reform may have subsided for the moment, we can’t forget that fixing our health care mess is a very key component to fixing our economy. Engaged consumers are a critical part of the solution. We need to provide them with the tools and information they need to make the informed decisions and become a part of the solution, not drive them further apart.

Prometheus- A Titan In Payment Reform?

One of the basic lessons you learn in Economics 101 is the fact that price is always a function of supply and demand. At least it should be. But, as we’ve seen, that doesn’t always apply to health care. Health care pricing has turned into a convoluted mess of cost shifting and political negotiations with little relationship to supply and demand. The ultimate result- those that deliver the care usually receive less “per unit” and total costs to the system continue to go up.

The Patient Protection and Affordability Act sets minimum standards for what health plans (or other payers) are required to pay in “medical costs” and what they may retain in “administrative costs.” This will ultimately drive the setting of prices set with employers and consumers. A study of literature by the Deloitte Center for Health Solutions found health plan administrative costs ranged from 9% to 41%. Obviously, there is no set definition of what is included as an administrative cost from a health plan perspective. You can expect the pricing manipulations to continue as the PPAA rolls out.

One thing is clear- how our health care system reimburses care providers needs to change if we’re going to get a handle on the costs. Until it changes, those responsible for the financing of health care (the health plans, the government, and payers) are going to continue to focus on obtaining lower per unit costs for services or eliminating them altogether if there is no evidence that the service works. This process will ultimately impact the quality of care received from the patient.

We’re starting to see some movement to changing the fee-for-service/volume-driven payment system we have today. The American Board of Internal Medicine (ABIM) Foundation recently put forward some guiding principles designed to “produce a health care system that reflects societal values more accurately than do those inherent in existing payment methodologies.” Almost everyone agrees on the need to change the financing and payment for health care services.

We’re seeing pay-for-performance methods, episode-based payment models, accountable care organizations, and medical homes as the new financing ideas for health care delivery. There are already many derivations off of the main ideas (baskets of care, etc.) Each idea has strengths and weaknesses but none have proven to be the “silver bullet” that will encompass all aspects of care delivery, reasonably reimburse providers, and assure quality care and manage the costs of delivery.

The Robert Wood Johnson Foundation has put a lot of money into the Prometheus Payment System to explore new payment models in care delivery (go to www.prometheuspayment.org). Prometheus (Provider Payment Reform for Outcomes, Margins, Evidence, Transparency, Hassle-reduction, Excellence, Understanding, and Sustainability) is an episode-based payment structure. The idea is to determine a total budget for all providers involved in treating a particular episode of care. Prometheus has developed 21 Evidence-Informed Case Rates (ECR) that establishes a comprehensive budget within which a payer or multiple providers negotiate their price to provide all of the care for a specific patient for a specific condition.

In its payment algorithms, Prometheus also establishes a budget amount for Potentially Avoidable Complications (PAC) that have been identified in specific cases as the “deficiencies in care that cause harm to the patient yet might have been avoided with more proactive care.” The Prometheus data indicate up to 40% of every dollar spent on chronic conditions are a result of PAC. If PACs are avoided, the providers keep the money.

We've included a study on our web site providing more details of the Prometheus model as it applies to primary care and medical homes.

The Prometheus model is currently being tested in four markets with expansion planned in the future.

Prometheus obviously had to stretch quite a bit to make an acronym for what it intends to do. However, the definition of Prometheus (defiantly creative) seems to define the intentions best.

We need more defiantly creative ideas introduced that can change the way health care thinks and begin to fix the mess we continue to face today.

Be Well

Social Determinents of Health- How We Live Influences Our Health

Several months ago a doctor and I were discussing the challenges facing us in health care today. I have always been a big believer in the concept of “integrative healthcare” and the need to expand our definition of health as a society to fix the mess we’ve created. From a purely business and consumer perspective I had always wondered how we can expect to change the trajectory of increasing costs when all we are talking about is fixing the end-result (the diseases). My arguments didn’t go very far inside the system. The system is still focused on only addressing the end-result.

Yes, the system has created the idea of health coaching and health promotion but it’s all still very clinical from my perspective. Health care has not embraced them as critical elements to the solution. The incentives are in treatment- not in the other stuff. We’re identifying risks, then trying to get people enrolled in specific programs to address the risks. We’ve had moderate success. The new reform legislation includes rules and initiatives focused on prevention, health promotion, and community health but they remain a separate world from the developments in technology, telemedicine, pharmaceuticals, and all the rest that are more part of our “standard” sickness system. We have not yet integrated our culture and social well-being into the equation. We’re talking about it- but we have a long way to go.

The doctor turned me on to the work of Sir Michael Marmot. Professor Marmot is a professor of epidemiology at University College London. His work looks at the social aspects that can have a dramatic influence on the health of any population. His conclusions: the social (cultural) factors we encounter each day can influence how healthy or how “sick” we are. We’ve posted the World Health Organization’s Social Determinants of Health (of which Professor Marmot was a contributor) on our web site. You can get it by clicking here.

This report looked at nine different social influence's that have a dramatic impact on the health of a population. These included:

*Stress- which is largely influenced by the socioeconomic status and self-perception of an individual

*Early Life- which includes how we set the foundation and example for our children early in life.

*Social Exclusion- which evaluates the social connectedness we have in our lives

*Work- looking at the relationships and satisfaction in our work

*Unemployment- evaluating the effects our professional lives have on our health, and especially when a person is out of work

*Social Support- the culture of support and guidance available to a population

*Addiction- the impact drugs, alcohol, and tobacco have on health and well-being

*Food- The nutritional make-up of our lives

*Transport- which essentially equates to getting out of the cars and exercising by walking and looking at other means of transportation.

These factors have a dramatic influence on the health of any population. Employers are making some progress individually but the engagement rate of consumers in the “risk based” models being introduced today remain relatively low. Some of the social factors identified by the WHO report are dealt with indirectly but are certainly not part of the overall platform that is evolving in the health care system we have today.

Our culture is stressed, 71% are not enamored with their work, our unemployment rate is high, we’re overweight and don’t exercise, and the social support available is being reduced simply due to the economy. We are not a healthy population.

It’s time we start building these social factors into what we traditionally define as “health care.” Until we do, all the medical homes, baskets of care, and other new ideas in the world aren’t going to make a difference to the costs we will pay if we just keep getting sicker.

A Broader Definition of Health

Eva Makvoort was 25 when she died. Eva Makvoort created a blog to communicate with her friends and growing community of followers as she struggled with the ravages of cystic fibrosis. It’s a beautiful blog and you can go to it by clicking here. You could tell that despite her physical challenges she loved life, appreciated each moment, and would give anything for a clear and unobstructed breath of fresh air.

We wrote about Randy Pausch in our July, 2008 Newsletter. He was the Carnegie Mellon professor who created a huge following with his talk to students at the university that resulted in his book “The Last Lecture.” Randy Pausch’s message to others was to always, fearlessly, pursue your dreams. He gave this lecture knowing his cancer was terminal and he died in 2007 not long after his book was published. Despite the physical challenges, the other aspects of his life remained strong. He maintained a positive perspective of life to the end.

These two individuals are examples of the idea that “health” is a much broader term than traditionally used in health care today. While we’re used to the diagnosis, prognosis, prescriptions, interventions, and measurement of the physical aspects of health we really don’t dive into all of the other areas of life that have an impact our overall health and well being as a standard part of the health care delivery process. The emotional health, spiritual health, intellectual health, and social health of a person can dramatically influence the way a person maintains when the physical health breaks down. They may also have some influence in determining what ultimately results to the physical health as well. We need to start paying more attention to these aspects in our definition of health as we change the paradigm in health care delivery from sickness to health.

The CDC’s latest report on the U.S. National Health and Nutrition Survey indicates almost half of US adults now have risk factors contributing to heart disease. We all know the obesity statistics. A study to be released in the Archives of Internal Medicine found that the lifestyle habits of a study population in Britain cut longevity by 12 years. We all know the simple lifestyle decisions made each day are contributing to the enormous costs of the care needed today and the care that will be needed tomorrow.

Reed Tuckson, M.D. of the UnitedHealth Foundation put it this way, “Unless there is urgent action across our society, our already burdened care system will be swamped by a tsunami of cost and demands from preventable chronic disease.” Our system simply can’t afford the lifestyles our society has embraced.

While Eva Makvoort’s and Randy Pausch’s physical health failed, the other aspects of their lives remained strong giving them the best quality of life they could achieve given the circumstances. Their physical options were limited.

But, most have a choice and have the opportunity to make the decisions we all know are necessary to improve both health and quality of life. We just need to make the commitment and do it and provide the support and resources along the way to help make it happen. While the physical health may remain the “standard marker” for defining a healthy person we’ll need to consider the emotional, social, spiritual, and intellectual aspects of health as well. They are all related.

One of Eva’s followers wrote, “I felt so selfish when I stumbled across your [LiveJournal] on here, because I’ve been smoking cigarettes for yours, taking my lungs for granted. You’ve helped me quit the worst habit I’ve ever had.”

Sometimes it just may take appreciating what you have to get started.

Checklists and Decision Trees

According to a study by PriceWaterhouse Coopers over $1 trillion of the $2.2 trillion we spend on health care in this country is wasted. While the definitions of waste in the study are pretty broad- defensive medicine, treating for lifestyle conditions, etc.; the point is made. There is a significant amount of waste in the system we have today.

Health care consumers and providers of care have pushed-back significantly when attempting to introduce protocols or decision making tools in the process. The thought being you cannot reduce something as complex as health care to a series of algorithms.

Two books provide some indication that the emphasis on standardized decision making in health care will not go away. The research cited, in-fact, provides credibility that by using simple decision making methodologies outcomes may improve, may cost less, and provides more transparency to varous stakeholders throughout the system.

The Checklist Manifesto, by Harvard surgeon and New Yorker staff writer Atul Gawande, M.D. introduces the simple idea of using “checklists” as part of the care delivery process. His premise is simple- no matter how much of an expert you may be, you can always improve your outcome with well designed checklists to guide you through the key steps of any complex procedure. Click here to go to Gawande's web site- he's got some cool checklists already developed.

While Gawande believes his checklist idea is applicable for many other areas of life, his experience in the health care field lends credibility to his argument for designing simple methods to assist in the decision making process resulting in better outcomes and lower costs over time.


Thomas Goetz, a journalist and Executive Editor of Wired Magazine presents a different approach- but this time for health care consumers.

His book, The Decision Tree: Taking Control of Your Health in the New Era of Personalized Medicine introduces a methodology to assist individuals in making health care decisions. Much like Gawande argues in The Checklist Manifesto, Goetz recognizes the decisions we make today are much more complex than ever before. Health care consumers are usually left to their own devices to acquire the information they need to make decisions concerning their health and are at the mercy of the health care system when confronted with it. The Decision Tree presents a method and device for individuals to formalize health care decisions and externalize the choices made in their health and health care they typically make without thinking. The studies he cites confirm the fact that those individuals who actively participate in the decision making process are more engaged, and achieve better results. Click here to go to the Decision Tree web site. Take a look at the video to get a better idea of the concept.

Our health care system has been fighting the battle of “protocols” and processes for many years. While one side recognizes the possibilities for improved efficiency the other side views them as barriers that obstruct the delivery of care and the relationship with the patient. Consumers are accessing and becoming overwhelmed with a growing body of research and information (both good and bad) from which to base their decisions- and have not always been welcomed when trying to participate in the decision making process.

With such a significant amount of money being wasted in our health care system the need to at least set a framework for making decisions by all stakeholders will only increase. Gawande and Goetz provide some food for thought with some simple ideas to consider with the support behind them to show that outcomes will improve, engagement will increase, and costs will go down.

They are certainly worth a good discussion at the water cooler.

OpenNotes and Medical Record Transparency

If there is one group of stakeholders totally confused by the health care system we have, it’s the individual consumer. The consumers don’t understand the legal jargon included in most health plan Certificates of Coverage (COC), they don’t understand how to navigate around the primary care/specialty care maze we send them through, and they don’t understand how the pricing and financial structure works. I’m not saying consumers are ignorant. They simply have not been provided the information they need to participate effectively. Our health care system has been very good at keeping information in silos. Consumers have had to rely on other sources to try to get the information they require to make the decisions they need to make. We can safely assume this lack of “transparency” impacts efficiency, cost, compliance, and possibly the outcomes associated with particular medical events.

The Journal of General Internal Medicine recently published an article highlighting the fact that consumers want full access to all their records and are willing to make some privacy concessions in the interest of making their medical records completely transparent. Consumers want more information than they are being provided today.

Through a $1.2 million grant from the Robert Wood Johnson Foundation and with the participation of 75-130 primary care physicians connected to Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Danville, Pa, and Harborview Medical Center in Seattle, a project is underway to answer a basic question: Can improving communication with the patient lead to better health care outcomes?

The answer seems obvious.

Through the OpenNotes project http://www.myopennotes.org/, health care providers will be using processes to provide patients with access to their primary care physician’s visit notes through an electronic medical record. While EMRs traditionally include such things as lab results, biometrics, and medication lists the office notes themselves are traditionally not accessible to the patient. This project is designed to determine if the office notes themselves can be repositioned to be “for the patient, instead of about the patient.”

Not all providers are enthralled with the idea. Some believe that providing access to the notes only adds to the possibility for misinterpretation and miscommunication. They believe the office notes are clinical and cannot be useful to the average consumer.

This argument highlights one of the more significant problems in health care- everybody is talking in different languages.

The OpenNotes project hopes to address the following:

1. Create a more transparent and democratic health care environment
2. Enhance patient-doctor communication
3. Improve the accuracy of provider notes- ultimately reducing the possibility for litigation
4. Increase shared decision-making and improve patient satisfaction
5. Help patients and families become more actively involved in follow-up and compliance
6. Improve patient recall after a visit.

The goals are admirable and the intent of the project is certainly heading in the right direction for the consumer and patient. Sometimes I just wonder if we need $1.2 million and a 12-month research project to do what we know is the right thing anyway.

Be Well

Will Wellness Incentives Work In Health Care?

Last year the average incentive paid to participants in an employer-sponsored wellness program was a little over $300 a year. Some employers paid a lot more- one paid $4,000 to employees just to complete an HRA- and some less, but the overall average increased over the previous year.

A lot of dollars are being thrown at employees to get them involved. Why is it that still only 11% of the employees actually are?

Daniel Pink’s new book “Drive; The Surprising Truth About What Motivates Us” provides an interesting perspective.

Pink delivers his argument from a historical perspective and simply comes to the conclusion that the way individuals were motivated in the past no longer applies today. He describes the historical way we have tried to motivate individuals as Motivation 2.0. Motivation 2.0 assumed “the way to improve performance, increase productivity, and encourage excellence is to reward the good and punish the bad.” It was the old carrot and stick model.

The carrot and stick model worked fine when the actions you were trying to change were repetitive and measurable and there was no consideration of external forces influencing an individual. If you produced more widgets, you were paid more. If you didn’t meet your quota, you might not have the job for much longer. The measurements were simple.

Pink argues that our culture no longer works that way. The dynamics of the workplace and the characteristics of our demographics are dramatically changing. He believes that we are moving toward Motivation 3.0. Motivation 3.0 “concerns itself less with the external rewards to which an activity leads and more with the inherent satisfaction of the activity itself.” Individuals don’t always respond to the carrot and the stick approach any more.

Individuals are looking for more in their lives (including their work) than they ever have before. Pink believes motivation to take action at any level is based upon an individual’s desire for three things: 1. Autonomy- the desire to direct our own lives; 2. Mastery- the urge to get better and better at something that matters; and 3. Purpose- the yearning to do what we do in the service of something larger than ourselves

Focusing on material incentives (money and gifts) may sometimes work to achieve short-term results but will probably not work to achieve the real goal of engagement and active participation. Actually, Pink cites examples where the carrot and stick approach worked in reverse. In health care, engagement and participation of the individual consumer is crucial. We can’t get much lower engagement than where we already are.

Getting employees engaged in this new health care world will require more than a carrot and stick approach. It will require creating the culture around the individual that meets their personal requirements of feeling they are in control of their lives (autonomy), continually improving their health because they know it matters (mastery), and participating because they know its not just about themselves (service).

Pink writes, “In our offices and our classrooms we have way too much compliance and way too little engagement. The former gets you through the day, but only the latter will get you through the night.”

If we can move to Motivation 3.0 in health care maybe we’ll have more than 11% of the individuals engaged in sponsored programs and we won’t have to pay $4,000 to get someone to complete an HRA.

Be Well.

Reform- Going Forward

The way health care is delivered and financed in this country is going to change as a result of the legislation passed in the House last Sunday and signed into law today. We now have the opportunity to listen to the analysis of what it all means, the stories behind how it happened, and predictions of the consequences. In reality, no one has a clue.

What we do know is the approach that we are going to use to reform the health care system is very expensive, administratively complex, and has an unknown level of support from the stakeholders who are going to be needed to put it all into place. We know that millions of new customers (“customers” is the buzz-word) will be injected into the system. Health plans – in the private sector- see this as an opportunity. Aetna’s and United HealthGroup’s stock prices are up 80% and 60% respectively over the past twelve months. While health plans were made the “poster-child” of the debate, most are doing just fine, thank-you. We also know that with this influx of new customers there may likely be an increased demand placed on the system itself. Some don’t think this will cause any additional stress on an already strained system (primary care and hospitals)- we think it will.

We have all learned more about the parliamentary rules that are part of our legislative process through this debate than we would care to know. We have learned more about how Congress really works through this debate than we would care to know. And, we are likely to see and learn more new and interesting things as the efforts to stop the legislation continue to unfold.

We agree that more individuals will now be a part of the health care system than ever before and that is good. But, we believe that the ultimate costs are going to be much, much, more than projected (Medicare blew-through its projections in less than two years). While those supporting the legislation are touting the CBO numbers, quite frankly, we think the assumptions are optimistic at-best. And assuming the best is risky for our economy right now.

No matter which side you are on, Sunday’s vote and today’s enactment were historic events for this country. Whether you agree or disagree with the legislation itself we at least have a foundation to use to plan our business approaches for the future. This foundation will certainly change, but at least we have a footprint to follow.

The path we were on was unsustainable. The process we went through was quite ugly. I hope the path we’ve chosen doesn’t break-the-bank before it fixes the problems that need to be fixed. Time will tell.

We're Creating A Herd of Unhappy Elephants

The Institute for Healthcare Improvement (IHI) produces some interesting webinars on some “non-traditional” topics that can be applied to health care. You can listen to their programs by going to www.ihi.org and then going to the WIHI section on the site. Look in the Archive section for past programs.

Yesterday, IHI had Chip Heath, the Stanford professor who, along with his brother Dan, a Harvard MBA, produced the bestselling business book “Made to Stick.” Made to Stick discusses why some ideas seem to create lives of their own, and others die a quick death in both business and in our lives.

Their new book, “Switch- How to Change When Change Is Hard” discusses why it is so hard for us to change even when we know that change is the right thing to do.

Everything in our lives is changing right now whether we like it or not. The fundamental way we interact as a society is changing as technology, globalization, and the foundation of how our economy operates sets the stage for continued change in the future.

Our health care system is changing and is going to change even more when whatever comes out of Congress starts to become reality. While these external forces may dictate the changes we will need to make we don’t always go along willingly even though we know change is necessary.

In Switch, the Health brothers use the metaphor of The Rider, The Elephant, and the Path to visually describe why change is hard and why many good ideas fall to the wayside because we didn’t understand that we need to address both the intellectual and emotional aspects of making changes when they need to occur.

“The Rider” is our intellectual side. The Rider is our rational thoughts and all of the statistics, research, PowerPoint presentations, academics, etc. that knows changing the way our health care system operates is the right thing to do. We all know the way our health care is financed and delivered today is unsustainable for the future. In all of the research we’ve seen 75%-80% of Americans believe we need to reform the system.

“The Elephant” is our emotional side, and, as you visualize the metaphor, the more powerful of the two. The Elephant is more comfortable just plodding along in its comfort-zone but can be motivated and directed by The Rider if handled appropriately. The Elephant in health care can be seen with the reactions in the Town Hall meetings last summer, the Tea Party movement, and the response to what is taking place in Congress today. The Elephant in health care is being directed by the whip instead of following the direction of The Rider by the light tug of the reigns.

“The Path” recognizes the need to create the right environment to create lasting change. Here, the Health boys utilize the ideas of Stanford professor Lee Ross stating “people have a tendency to ignore the situational forces that shape other people”. You need to clear The Path to create real change. The Path for change in health care is being cleared by Congress since the free-market has not been able to get it done. It’s not a pretty path and certainly has many potholes, but it’s the path we have today.

As we look at our healthcare system The Elephant is reluctantly traveling down a bumpy path. The Rider is furiously using the whip to make The Elephant obey. When Congress passes the reform legislation that is on the table we don’t know if more obstacles will be thrown on the path or if obstacles will be cleared. We don’t know if The Elephant will finally follow the direction of The Rider or will rear on its hind legs, throw The Rider off and run back into the jungle.

But, we do know that lasting change using the approaches in place today will be difficult and ugly. Using the whip as the way to implement health care reform is going to create a herd of unhappy Elephants.