On Jan. 20, Barack Obama will become the 44th President of the United States against the backdrop of two foreign wars and one of the worst economic crisis since the Great Depression. U.S. business icons are failing; unemployment is at its highest rate in decades; housing values are plummeting as foreclosures and credit tightening make the American dream of home ownership more of a nightmare than a reality. Personal net worth is shrinking and the financial ability for some to even consider retirement is fading away.
Yet, at the same time there is dire need to structure and re-invent many institutions. Our infrastructure of roads, buildings, and bridges has been neglected and are in disrepair. Our education system is not preparing our young people for a global market, a place where the best and brightest may now be found in India, Japan, Europe, and China, as much as in the U.S.
And healthcare, my oh my healthcare, needs more than just a face lift; it needs an overhaul, a righting of the ship, and a truing up of its direction for the future.
Yet, fixing healthcare is very much intermingled with the rest of our economic woes. With company failures and layoffs comes the loss of health benefits, and, ironically, more time available to seek healthcare. Even those with jobs may find themselves with no insurance or inadequate coverage. It is not unlikely the current 47 million uninsured will soon be joined by another 15 million uninsured or underinsured, made up mostly of middle-class workers who have never before been faced with the prospect of financial ruin if they or their family members take ill. Never before has the middle class been faced with the choice between the right care they need and losing all of their net worth, including their homes.
President Obama could be another Jimmy Carter, an intelligent, well-meaning man whose presidency was disabled by 13% inflation, gas lines, and being held hostage in Iran. Or he will be the next FDR, a president who remade America for generations to come, with Social Security, work programs, and a new economy.
Fortunately, Obama’s team is loaded with thought leaders who come with a strong interest in reforming and rebuilding healthcare. Tom Daschle, the new secretary of Health and Human Services has a long history of healthcare policy and can work well to move things through a Democratic Congress. Obama’s Director of the Office of Management and Budget, Peter Orszag, is a well-regarded health policy expert. Melody Barnes, his domestic policy advisor, was the executive director of a think tank, the Center for American Progress, which has developed a detailed road map for change in our healthcare system, involving some of the best minds in American healthcare, such as Don Berwick, David Blumenthal and Paul Ginsburg. You can read the center’s 120-page report at http://www.americanprogress.org/issues/2008/10/health_care_delivery.html.
While this group appears primed for a revolution, rather than just rearranging the deck chairs on the Titanic, at this point Obama and his team have been more visionary than specific. Here is my best guess as to what some of the aspects of a new healthcare approach might be. (And most of these changes are of more than a passing interest to hospital medicine.)
There is no doubt it is unsustainable for a first-class society to have so many citizens without access and payment for healthcare. Although this may start with covering all children and offering people affordable insurance not specifically tied to their employment, the U.S. must move closer to something that looks like Medicare for all. Along the way, this will lead to more regulation of insurance companies to raise the percentage of the premium dollar that actually goes for medical care (75% is just not tolerable). Do not expect the $2.1 trillion healthcare pie to expand, so doctors and hospitals will need to be more efficient and effective as they supply better, more accountable healthcare to a larger patient population. Some may perceive this as more work for less pay.
This expansion of coverage, however, cannot be a broadening of Medicaid and its dysfunctional payment system. It cannot be a single-payer, Canadian system, which creates irrational rationing and does nothing to address the need to bolster primary care. We need a new health paradigm where performance and access mean just as much as new technology.
More Primary Care
What good is insurance if you have no access? Just ask the citizens of Massachusetts, where the newly insured can’t find a primary care physician (PCP). One “benefit” of the economic downturn and stock market tumble is late-career PCPs can’t afford to retire. But primary care is in shambles, and throwing a few more dollars at PCPs or creating a “home” won’t make being a PCP more attractive to medical students. For a more revolutionary approach, check out the New England Journal of Medicine video roundtable (www.nejm.org/perspective/primary-care-video/?query=TOC) to hear of a “new” primary care model, which is more centered on population management than a series of 10-minute visits. Hospitalists, as much as anyone, need a strong, sustainable primary care partnership, if we are to tackle the difficult problems inside the hospital.
This new payment model is being pushed by Sen. Max Baucas (D-Mont.), the powerful chairman of the Senate Finance Committee. Value-based purchasing (VBP) basically moves us away from just paying for care by the unit of the visit or the procedure, regardless of medical necessity or outcome. This plays into the strengths of hospital medicine where performance and communication are valued. Paying more when the customer gets more is an American value, which, at times, has been overlooked in American medicine. It is time we brought VBP into the healthcare equation.
All politics is local, and in many ways all healthcare is local. By changing the payment for hospital care to a composite fee for the facility and all the health professionals, an opportunity exists for the physicians and the hospital at a local level to creatively reward work, performance, outcomes, and patient satisfaction. This is not giving the hospital the entire fee, but more relying on a physician-hospital organization (as currently exists in many places in the country) deciding how to allocate resources. Once again, hospitalists are managing up to 80% of inpatients at some hospitals, so we are right in the middle of a new distribution of compensation for inpatient care.
Transitions of Care
It is time to look at our healthcare system from the patient’s point of view. It is not enough to perform the surgery perfectly or order the correct treatment. Patients need to be involved in their care, to clearly understand what medications they should be taking, to know who is responsible to answer their questions, and what their expectations for recovery should be. It also is an opportunity to prevent unnecessary visits back to the emergency room or readmissions to the hospital. The current, 15% readmission rate within 30 days for Medicare patients points to how broken the system is. Patients deserve accountability, transparency and clarity on their terms.
Once again, SHM and hospitalists have taken the lead in this issue. With a grant from the Hartford Foundation, SHM already has demonstrated practical strategies to improve the discharge process.
What It Means to You
In calmer, less-chaotic times, I suspect there would be calls for tinkering around the edges. But these are dangerous times that call for decisive, some might say, disruptive change. A new, patient-centered healthcare system based on access, inclusiveness, performance, communication, and safety is coming. There will be those who feel less well-off in the new order—insurance companies, some physicians and some hospitals—but there will be many who feel, for the first time, that the system is equitable, open, and responsive to their needs. The latter group includes U.S. business, some physicians (e.g. hospitalists), some hospitals, and, most importantly, the American people.
Hospitalists are uniquely positioned to shoulder the full force of this change. Hospitalists now practice in most hospitals throughout the country, and they are right at the intersection of the patient and the illness, thrown into the caldron of change along with allied health and our institutions. We must embrace change and we mold it into a new system of care, a system that benefits our patients based on data, evidence, and compassion. There is an outcome where hospitalists and our patients both win; it is the future, and now it seems closer to reality. TH
Dr. Wellikson is the CEO of SHM