Atul Gawande- Remembering What We're Fighting About

When you are in the middle of a fight, very seldom to you ever stop, assess, and confirm that you remember why you are fighting in the first place. Most of the time we just keep on fighting.

That’s what we’re doing with health care. Even though legislation has been passed to change the way things work, we’re just continuing to fight because many adamantly disagree with the approach that is being used to make the changes and most don’t really understand what is going on. If you didn’t understand the health care system before- you really don’t understand it now. If we don’t change, it is very likely the end-result will cost a lot more and create more damage before we are through. The health care debate has become a part of a much deeper discussion our country is having with itself and still hasn’t quite figured out the right answer.

Atul Gawande’s June 1, 2009 New Yorker article had quite an influence on getting us where we are today. (It’s a good article- You can link to it Here) Sometimes it’s important to step back and reflect on why this fight started in the first place.

The health care system Gawande describes is influenced by many different incentives both internally created and externally driven. The influence of the incentives and the personal make-up of the health care stakeholders determine the type of health care system that is developed in a local community. The health care system then determines the economics (how much it costs and how it is delivered). Gawande believed the health and age of a population have little to do with significant variations in the cost of health care we are experiencing today; it’s the system used to deliver health care that really matters.

Yes, critics have challenged some of the facts but the challenges don’t erase the picture of health care the article constructs. The challenges don't negate the reality.

Even as we continue to fight about it, we should also take some time to step back and reflect on the health care system described by Gawande almost 3 years ago. We need to take a moment and remember what we’re fighting for- and hope we are making some progress to come to a solution as we fight.

At this point, the progress seems questionable.

Iowa Caucuses- Health Care IS an Economic and Debt Issue

The Iowa caucuses are over and it’s on to New Hampshire. To nobody’s surprise, it was a close contest, a lot of money was spent, and a lot of negative advertising was used in the strategies. Republicans still aren’t united behind any single contestant- but the field will narrow over the next few weeks.

Iowa gave us the first look at the results of the Citizens United decision made by the Supreme Court last year. There is going to be even more money spent, with candidates hiding behind the covers of the “super PACs” created on their behalf. Free speech? We’ll see.

Iowan’s are a rational bunch. They look at things from a different perspective than those in Washington D.C., New York, California or the other highly populated areas. They care about community, about agriculture, and about things that are relevant to themselves. They don’t usually like the negativity associated with politics- but the Iowa caucuses proved the negative ads work. We’ll see a lot more of them.

Interestingly, Iowa Republican’s participating in the caucuses listed the economy and the debt as their primary issues of concern. Health care and abortion listed in the distance.

The Iowa caucuses proved that we continue to keep health care as a separate and distinct political issue even though fixing our health care mess is directly related to both the economy and the debt. A Pew Research Foundation study in April, 2011 determined the unfunded liabilities associated with pensions and health care for state governments increased 26% (to $1.6 trillion) in one year alone. Health care IS an economic and debt issue.

Iowa has always been the starting point of the presidential election process and used to either gather momentum or begin the elimination of candidates. Iowa also provides lessons as to what works and what doesn’t work in the campaign process.

The Iowa caucuses taught us: The Republicans are still not sure who to get behind to run against Obama in 2012, Super PAC negativity works (unfortunately)- and we’ll see a lot more, "retail/door-to-door" politics is still effective, and we still don’t believe reforming health care has much to do with jobs, the economy, or our debt.

We’ll see what we learn in New Hamphshire.

2011 Government Financial Report- Unacceptable

Right before Christmas (December 23) the Government Accountability Office (GAO) released its “2011 Financial Report of the United States Government.” The GAO works for Congress and operates as a bi-partisan watchdog to monitor how taxpayer dollars are being spent.

The press release associated with the release of the report stated, “The U.S. Government Accountability Office (GAO) cannot render an opinion on the 2011 consolidated financial statements of the federal government, because of widespread material internal control weaknesses, significant uncertainties, and other limitations.

Specifically, the press release cited; 1. Serious financial management problems at the Department of Defense (DOD) that make its financial statements unauditable, 2. The federal government’s inability to adequately account for and reconcile intragovernmental activity and balances between federal agencies, and 3. The federal government’s ineffective process for preparing the consolidated financial statements.

The report identified a material weakness of $115.3 billion in improper payments, information security issues across government, and tax collection activities.

I’ve posted the study in the Library of our site. It discusses some of the basic numbers ($1.3 trillion deficit compared to $2.1` trillion in 2010; 1.9 million new jobs compared to 350,000 in 2010) and an overview of some of the actions taken to try to get the country on the right track. You can look at the numbers and decide how well they are working for yourself. The numbers indicate some progress was made- just not nearly enough.

From a health care perspective- the report makes two significant points- Medicare, Medicaid, and Social Security are big parts of the problem (representing 45% of all spending), and the Medicare Trust Fund will run out of funding in 2024- five years earlier than was projected in 2010.

While many are calling for “cuts” that usually impact the “boots on the ground” citizen, this report shows we would likely find huge opportunities to reduce spending simply by putting accountable accounting systems in place to track where money is going and how well it is being invested.

In a nutshell, the accounting controls and books used to measure how well we’re doing financially as a country are a mess. In all honesty, we probably don’t have a real clue how big our debt really is- and its inexcusable. The financial managers associated with such a report in the private market would likely be fired.

We should expect no less from those responsible for the allocation of our taxpayer dollars- including the Congress (both Republican and Democrat alike). They need to be held accountable for the results of their efforts. This effort is unacceptable.

Too Confused to Use?

A study by GfK Custom Research of 502 private-sector employers painted a picture of where employers stand today regarding the Affordable Care Act and offering health insurance benefits to employees. Not surprisingly, most still don’t believe the Affordable Care Act will have much impact on the future costs of health care, and many believe it will actually increase the costs in the future. However, the majority of employers still don’t understand what is in the law and how it is supposed to work- so, the comments are based more on perception than fact.

Over 55% of the employers indicated they would continue to offer health insurance to their employees even after the major components of the “insurance reforms” of the Affordable Care Act are put in place. However, the responses were dependent on the size of the company. Most large companies plan to continue to provide health insurance- while smaller companies aren’t so sure. Over 30% of the companies (both large and small) are unsure whether they will continue to offer health insurance as a benefit to the employees in the future. Not surprisingly, the majority not offering health insurance now base their decision on cost (not on the Affordable Care Act).

In 2004, about 68% of the employers offered health insurance to their employees. The number stands at 60% today. By 2014 (when the theoretical “health insurance exchanges” are supposed to be operational) the number will likely be somewhere between 50-60%.

If the numbers hold, consumers are going to need to purchase health insurance different than they have in the past. They are going to need more education, more guidance, and more “transparency” than ever before. Transparency has never been a core competency of Health Care.

So, while Health Care focuses on all of the other transactional details to establish exchanges, develop new delivery models (Accountable Care Organizations), collect data, and all the rest let’s hope it doesn’t forget about the needs of those who can really have an impact on changing the trajectory we are on today- the individual/the patient.

All the new ideas won’t make much of a difference if the individual doesn’t understand how they work- or are too confused to be engaged to use them.

Transparency- Getting People To Use Information Is The Real Key

The November, 2011 publication of the American Journal of Medical Quality found 80% of the “highly findable” health care rating sites (rating doctors and hospitals) draw on anecdotal patient reports (the patient opinion and experience) more than anything else. According to the article, the sites many are using to research care providers and show highly ranked in the search engines don’t use some of the measurements Health Care would like them to use to help make informed health care decision. Only half of the highly findable sites include quality information and a third feature cost data. Forty-four percent featured performance results based on claims data or board-certification information.

Despite the effort Health Care is making to increase the amount of data and information available to the general population, a large segment remains frustrated with their inability to find what they need when they need it. Their frustration lies in three key areas: A lack of awareness of what is available, not knowing what questions they need to ask, and then finding the information once they know what they need. Individuals will likely continue to rely on family, friends, and their social networks as a more reliable source until Health Care packages and markets the information in a way that is relevant to the individual.

As Health Care continues to improve the "transparency" of how with works with the general public it will need to continue to acknowledge the “trust barrier” that exists with many individuals. Individuals will gravitate to the sources they feel they trust and provides information that is relevant to them. Collecting information is the first step, analyzing the information is the second step, packaging and communicating the information is the third step. And, it seems as if “experiential rating sites” have done a better job packaging and communicating their relevance to the general population than those that use the metrics Health Care prefers.

Maybe Health Care can learn from them.

Down to the Thanksgiving Wire

The Joint Select Committee on Deficit Reduction has until November 23 to come up with a plan to cut $1.2 trillion from the deficit. Then, Congress needs to have an up or down vote on the plan by December 23. We’re in for an interesting few more months watching the congressional version of “Survivor.”

Here’s a prediction: The plan will arrive at the very last minute and it still won’t deal with the fundamental systemic dysfunction our economy is facing today. The numbers may add up to $1.2-$1.5 trillion- but the way getting there will likely hurt a lot of people unnecessarily. The politics continues to avoid addressing the “causes” for the dysfunction instead of addressing them head-on.

The costs associated with Medicare and Medicaid need to be on the table. They are a large part of the problem and can’t be ignored. Unfortunately, the “super committee” will likely focus on the level benefits provided to beneficiaries and the costs paid to providers (“end result items”) as opposed to creating the environment to help the health care system eliminate the waste, inefficiency, and fraud (“the cause items”) that create the costs in the first place.

Eligibility will change for both Medicare and Medicaid, contributions will increase, current benefits will be scrutinized or reduced, and the amount paid to those delivering the care will be reduced as well. The “end results” will be covered.

Nothing will likely be mentioned about changing the current pay-as-you-go reimbursement methods, very little mentioned about improving consumer education and understanding to help them make better decisions, not much will be discussed about improving the coordination and communication of care decisions when inside the health care system or creating systems where health care providers in general agree with what works and what doesn’t.

I suppose the super committee will assume that the private market will simply need to adjust to the new reality- there were no other options. Many of these items are somewhat addessed in the Affordable Care Act but consumers aren’t so sure of that one either. But, there are other options. If the super committee really focused on “the cause items,” Medicare and Medicaid could contribute significantly toward the deficit reduction goal without cutting benefits or payments nearly as significantly as they are likely to propose.

I guess we’ll just have to wait and see what happens. It will be another down-to-the-wire episode.

Steve Jobs- A Role Model of What Our Country Needs Today

Our country lost one of the great innovators of our time- perhaps of all time. Steve Jobs was only 56 when he died but fundamentally changed the way we live during the short time he was with us.

Most of us never met Steve Jobs- but we all felt his creativity and passion for excellence every day. We saw the results of what can be accomplished when you dream, you believe, and you persevere. Our lives have been changed by his commitment to dream. Our world was changed by his example of believing and passionately working as a team for the accomplishment of a common good.

Perhaps health care, politics, and our country as a whole should take a break from acting the way it is today to reflect on the legacy of a true innovator and creator. We need more passionate and innovative creators to dig us out of the hole we are in. I’m sure Steve Jobs wouldn’t see the hole- but the opportunities available to dig us out.

We may have lost the dynamic presence of Steve Jobs in the world but we will forever live on with his legacy.

As Facebook creator Mark Zuckerberg wrote in a brief eulogy to Steve Jobs, “Thanks for showing that what you build can change the world.”

We need to continue to dream, create, and work together toward a common goal. It will be the best tribute to one of the most creative innovators of all time.