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.

Employee Wellness?

No matter what final result transpires from the health care reform debacle, the process has already cost the health care system the last sliver of a valuable asset that is going to be required to make it all work- trust. Now, I’m not saying that there has ever been much trust in the system we have today. But, the process we have just witnessed drained whatever remaining trust there may have been.

Consider some of the numbers:

Only 40% of us trust hospitals as a source of healthcare information.

Most of us rely on our physicians for trusted health information, but over half look to other sources to make health decisions

Over half of us think since “managed care” was introduced in the 70’s, it is a bad thing that sacrifices quality of care for profits (and I am sure with the Administration’s current tirade against insurance companies this number is going to plummet further. We do not trust insurance companies).

Just 21% of us believe the federal government enjoys the consent/trust of the governed. According to Rasmussen Reports, Congressional job disapproval jumped 10% from just last month to over 71%.

Over 80% believe Congress is more interested in their own careers rather than serving the people.

Only 1/3 of us trust or have confidence in the employers we work for.

And, these are the groups we’re going to rely on to get us “engaged” and “actively participate” in our health and the health care system?

I don’t think it’s going to happen unless something changes dramatically.

When you think about it, if you break down all of the complexities we have created in health care you are dealing with four basic groups: the consumers- who receive the care when needed; the providers- deliver the care and help the population stay healthy; the intermediaries- process the transactions and coordinate the finances; and the government- to oversee the social interests of the system (and in the current cases of Medicare, Medicaid, etc. to act as an intermediary).

Yes, there are also employers, medical devices, pharmaceuticals, and thousands of sub-segments that are all part of the system as well, but they can be placed into one of the four basic categories above. Let’s keep it simple.

In our utopian world, these four segments are equally important and rely on a significant amount of trust between each other to optimize opportunities and maximize results individually and collectively. Consumers are engaged, and providers, intermediaries, and the government work together to support and organize care delivery.

That is not what is happening.

We all know these numbers as well:

80% of the costs are chronic, and well over half of these costs are related to the lifestyles we lead- they could be avoided:

Nearly 40% of us participate in no leisure-time physical activity

Only 12% exercise at least 5 times per week

60% are overweight

Well over half are stressed

Employers and health plans (in the intermediary segment) are offering more wellness-related programs and “wellness” (in a broad governmental sense) is at least being discussed as part of reform legislation. Despite all of this, according to Forrester Research only 11% of employees are engaged in any wellness activity offered through an employer. Some of us are trying to stay healthy on our own, but most of us are not.

Consumers (those creating the costs) do not trust the system we have. We don’t trust the intermediaries and we don’t trust the government. We will trust our providers some of the time but that is about it.

The government can enact all of the legislation that it wants. Employers and health plans can throw all of the new wellness gimmicks they can think of to try to “incent” us to do the right things. But, until the system (intermediaries, providers, and government) starts to regain the trust it has lost, it is just not going to happen. We will be looking elsewhere for health and wellness support, if we look at all. In the meantime, health care continues to get more expensive.

In his book, “The Trust Crisis in Health Care”, Harvard professor David Shore, PhD. states, “Trust, in short, is the bedrock- the very foundation- of healthcare.”

If that is the case, we are on very shaky footing with the foundation we have created today.

Changing the Health Care Paradigm

The health care system lives in its own little world. It has its list of acronyms and if you ever get a group of health care organizations or health care professionals sitting together in a room they start to talk in a language most of us can’t even begin to understand. They talk about HIPAA, HMO, PPO, HRA, comparative effectiveness, medical homes, EMR, PHI, FFS, FEHBP, MedPAC, and the list goes on. Those in the health care industry seem to understand the terms, some in government make it sound like they understand the terms, and the rest of us have no clue.

Therein is the problem.

We have made this patchwork health care system so confusing and so complex that most of us feel helpless to do anything about it. We have delegated the responsibility for fixing the mess we have to those who understand it- those that created the mess in the first place. We’ve created a Paradigm of Paralysis in health care.

We don’t need to be paralyzed. We can do something about it. We simply need to start to change the paradigm.

In late 2008-2009 Towers Watson and the National Business Group on Health completed a survey of 489 large and small companies throughout the country. They were wondering if anybody was having any success in managing health care costs within their companies.

What they found was not surprising. The best performing organizations (those that experienced less than the 6% average health care cost increase experienced by employers) were taking a broad approach, a strategic approach, to invest in programs and tactics to address the challenges facing their employees and their organizations.

These organizations didn’t just throw-out a health risk assessment to their employees and call it a day. These organizations created the culture, the strategies, the tactics, and provided the investment in resources to make a difference. They didn’t buy-in to the paralysis complex- they took action and changed the paradigm.

We all need to break through the Paradigm of Paralysis and realize we can make a difference- and understand that it’s not the government or the health plans that will ultimately solve the problems we have.

In a recent edition of the Employee Benefit News, Contributing Editor Michael Puck, SPHR compared the psychological barriers we have created in health care to the barriers that existed in the 1950’s with regard to running a sub-four-minute mile. Back then, we all knew it just couldn’t be done. Within 3 years of Roger Bannister breaking the sub-four minute barriers, over 30 other runners accomplished the same thing. The barrier wasn’t physiological, it was psychological.

We need to change the psychological paradigm in health care.

Puck outlines 4 basic components we all need to embrace to break through the Paradigm of Paralysis that exists in health care today:

Commitment- we need to define the vision and mission and gather the will-power to make it happen.

Culture- we need to create and support the environment we will need to accomplish our goals.

Structures- we need to organize the fragmented delivery processes we have today into a system we can understand and provide the results we expect

Resources- we need to effectively provide the resources necessary to accomplish the goals in a fiscally responsible manner.

While those in the health care industry and the government can continue to debate and discuss solutions to our health care crisis they are only contributing to the Paradigm of Paralysis we have today. Those innovative providers, consumers, employers, and entrepreneurs that don’t buy-in to it can do something about it, because they have the commitment to make it happen.

The Paradigm of Paralysis in health care is psychological for most but can be changed. Just look at what Roger Bannister started.

President's Proposal- Intro to Reconciliation

I had hoped to get away from the whole health care reform discussion for a little while. Quite frankly, I was growing tired of it. But, we have one more “event” to get through before we know which direction health care may be heading. Even after this so-called “summit meeting” on Thursday, we still may not know. I’ll make another post anyway.

I have to admit, when this process started out over a year ago, I was skeptical but still optimistic that we could come to a bi-partisan solution to the cost crisis we’re facing in this industry. When HR 3200 was introduced I became leery. When the Town Halls hit I became frustrated. When the Christmas Eve vote occurred in the Senate I was ticked-off. Like most Americans, I’m simply tired of the politics, and tired of the “protecting the turf of the self-interests” mentality that exists in health care. I’m not nearly as optimistic of the final outcome today.

After reading and summarizing the 1000+ pages of HR 3200 last July, reading the 11 page “President’s Proposal” was a snap; almost too much of a snap.

For a president who gives himself low marks for not explaining health care reform better to the average citizen- he didn’t raise his grade with this. (You can grab it by clicking here). It took me awhile to figure out what it even said.

Here’s my understanding.

In a nutshell, the President’s Proposal is reconciling some of the numbers between the Senate and House bills, pushing some dates around to accommodate some existing agreements, and adding some of the fraud and abuse initiatives requested by the Republicans to come up with a “bi-partisan” document.

The President’s Proposal eliminates the “Nebraska Absolution” and expands Medicaid Funding to all states and tries to address the need to reform the Medicare payment approach which contributes to the escalating costs. And, to continue with its grandstanding against the insurance industry (which is legitimate to a point), his proposal creates another government agency (the Health Insurance Rate Authority) to deal with health insurance pricing (in response to Anthem California’s recent request for a 30%+ rate increase for individual policyholders).

As I was reading it I was wondering what all of this is going to cost and the size of the bureaucracy that would be required to pull it off. I’ve said all along that the perfect free-market does not work in health care because of the way we’ve evolved. The government has to play a role no matter what we do. I understand that. But, there needs to be a balance. This is just too much government- and too much expense.

As the White House said when it introduced this thing, this is just the “starting point” for the discussion on Thursday. But, I have no idea how any real debate is going to occur since none of the major issues of disagreement were addressed.

A Kaiser Foundation Poll completed a couple of weeks ago found 38% of Americans would be “happy or relieved” if Congress ended up doing nothing on health care reform. About 58% would be “disappointed or angry”.

I still believe too much good work from both sides was accomplished over the past year to walk away and do nothing. All of the proposals (Republican and Democrat/free-market and organized-market) have components that could be put together to make a dramatic impact on the trajectory we find ourselves on today. Unfortunately, the legislative make-up we have in place doesn’t see it that way.

I see “reconciliation” on the horizon. And, I’ll be one of the 58% disappointed or angry citizens if that happens- even it means something was accomplished.

Medicare Advantage- A Free Market Example?

A lot of the debate that has been raging about health care reform can be boiled down to a basic principle: how much of our health care system should be guided by the principles of a free-market; and how much should be guided by a more organized and controlled method? Some call the “organized and controlled” socialized medicine, I wouldn’t go that far.

The evolution of our Medicare Advantage program for seniors may provide some insight into which approach may work the best.

Trying to address and manage the costs of our Medicare program has been on the table for quite awhile. In 1997 the Medicare Choice program was put in place as a mechanism to wrap “managed care” into the benefits received by Medicare beneficiaries. This was largely funded by the government and used individual health plan contracts to deliver the health care services to the population. So, this was a combination of a free-market/government approach.

As funding for services from the government deteriorated over the next five years, nearly half of the Medicare Choice programs cancelled their contracts leaving over 1.5 Medicare beneficiaries scrambling to find replacement coverage. The free-market delivery combined and government funding combination wasn’t working very well.

In 2003, Medicare Choice was changed to Medicare Advantage and included increased funding from the federal government and a slightly different structure to deliver services to the Medicare population. These programs increased participation significantly as health plans and private market players jumped at the opportunity to grab some of this new revenue. These private market players did very well. But, it came with a cost.

Some organizations utilized aggressive marketing and compensation arrangements to take advantage of Medicare beneficiaries to gain enrollment. The free-market crossed the line. In 2008, new marketing and compensation rules were put in place to protect the individual consumer.

Today, there are over 2,300 Medicare Advantage plans available to Medicare beneficiaries. More than 10 million people (1 in 4 on Medicare) are enrolled in a Medicare Advantage Plan. On average, individuals are able to select from 30 different plans in addition to Medicare- and some have an option of over 70 plans.

These programs all offer different benefits, out-of-pocket limits, copayments, deductibles, and premium costs creating a monumental task for the individual consumer to figure out which program is best for them. And the costs of these programs continued to increase (opposite of what should happen in a free-market). In 2010, enrollees of the Medicare Advantage Prescription Drug Program will face, on average, a 32% increase in their premiums.

So, while a true free-market is the desire of our country, we have already proven a true free-market simply does not exist in health care. There are too many external factors at play. And while a variety of options may look nice, too many options only confuse the consumer and disrupt the operation of the market.

University of California-Berkley Nobel Prize winning economist Daniel McFadden puts it this way, “If consumers are up to this task, then their choices will ensure that the plans, and insurers, that succeed in the market are the ones that meet their needs. However, if many are confused or confounded, the market will not get the signals it needs to work satisfactorily.”

Too many consumers are confused and confounded today. The market is getting the wrong signals.

Click Here to grab Kaiser Foundation’s Write-up on the Medicare Advantage benefits structure for 2010

So- Which Way Do We Want It?

The February 9, 2010 Wall Street Journal reported that United HealthGroup recently began sending doctors individualized assessments for their treatment of breast, lung, and colorectal cancer patients. The reports seemed to indicate that while breast cancer patients received care that met with most professional protocols, patients with lung and colorectal cancer did not.

Treating cancer patients is one of the largest cost-drivers in our health care system today. Employers will confirm that one or two cancer patient in their entire population can result in significant increases to the health insurance rates for everyone. That’s the problem with the system we have today.

The United HealthGroup initiative confirmed what many of us had already surmised- a lot of the prescriptions and processes used in cancer treatment may or may not be of benefit to the patient, and they cost a lot of money.

Health plans and health systems are spending a lot of time and resources to determine what works best for treating particular conditions. They’ve been doing it for years. Most health plans are including “pay-for-performance” components to try to incent the delivery system to follow protocols, engage in electronic technologies, and improve the care delivery of the patient. Comparative effectiveness is alive and well in the health plan system. Those that deliver the care don’t like it- but it’s the way they get paid today.

A few months ago the U.S. Preventive Service Task Force produced their own results concerning the use of mammograms for breast cancer detection in females. This body was established in 1984 of independent private sector experts in prevention and primary care delivery. When they produced their results indicating it is really statistically necessary for an annual mammogram beginning at the age of 50 instead of 40 a huge hue and cry was raised from the masses as an example of government’s intrusion into our health, our health care, and our way of life. This was the perfect example of “Death Panel Health Care” with the politicians.

In order to get a handle on the costs of this uncontrolled system we have today we need to know what works, what doesn’t work, and what works sometimes. We also need to know what it costs. Call it comparative effectiveness, protocols, evidence-based, or whatever you want there are simply too many options, technologies, and pharmaceuticals, to continue the path we’re on today. The system needs some guidance and direction.

The health plans are already providing most of the direction. The system as a whole needs to decide whether it needs some other options to consider as well. And we need to quit complaining when results are published that don’t necessarily agree with the way things have always been.

The way things have been is what got us into this mess in the first place

A Letter to President Obama and Congress

January 29, 2010

Dear President Obama and Congress,

I watched your State of the Union address last Wednesday evening. It may have been one of your best performances. As one of the many pundits commented afterward, it was a “smart speech”.

You are correct in your assumption that a “deficit of trust” exists with the American people. Your approval ratings should give you a pretty clear indication of what we think. The responses and continued partisanship we heard from both sides of the aisle after the speech are pretty good indications that while the message you delivered may have been appropriate, passionate, and delivered with eloquence, the way our legislative interaction occurs is going to remain the same. The deficit of trust is not going to go away any time soon. I was disappointed in that.

Over three years ago we became a military family. This wasn’t by our choice, but like so many others, by the decision of our son to serve our country in the United States Marines. We are preparing for our third deployment- this time to Afghanistan (after Iraq).

While this wasn’t our choice, we accepted the role we have to play as a family and as a country to support both him and all who are serving to protect our country and our freedoms. We are grateful and appreciative every time our citizens come together to show their appreciation for their service and sacrifice; and they do it a lot. America is a great country. It is a passionate country. And, it can come together to support and defend the ideas and the people it believes in.

We’ve learned a great deal over our three-plus years of deployments, sacrifice, and anxiousness. We’ve learned that while we are confronting a very dangerous enemy on the field of battle they are also working diligently behind-the-scenes to destroy the structure and spirit of the American way of life. The attempted bombing on Christmas Eve was another wake-up call for the American people; the enemy is still there. We need to remember that Al Qaeda never said that the way they will defeat us is through military efforts. They intend to do it by destroying the soul of the American spirit in whatever manner they can. And, they are very creative.

I certainly agree that your speech addressed the topics most concerning our citizens today; the economy and jobs. This was smart. While you may not agree on the approach to address them, I believe there is agreement on both sides that something must be done to put people back to work and get the economy moving again.

I would only also ask you to remember that all of the arguments, disagreements, and partisanship you continue to exhibit only contribute to the efforts of our common enemy. Terrorism doesn’t only exist on the battlefields of Iraq or Afghanistan. Terrorism doesn’t only exist with the bombings and spectacular events created by this enemy. Terrorism also exists by destroying the common vision and soul of our country. Jobs, health care reform, the economy, energy policies, and all the rest don’t mean a thing if our enemy succeeds in accomplishing its goal of destroying the unity of the American spirit.

Please work together. Don’t let them win.

Sincerely,

A Military Father