Neupert On Health

New delivery models will solve the cost crisis

pnblog — Wed, 28 Oct 2009 15:03:00 GMT

This week's question for the Washington Post Health Care Rx blog was:

Has Congress done enough to constrain long-term, health care spending growth? What cost containment strategies would you advocate pursuing?

My response, New delivery models will solve the cost crisis, below:

I was again reminded at last week's Partner's Connected Health Conference about how much potential there is for innovation in health - for industry transformation. The session titles speak for themselves:

Wireless Tech and Patient Self-Management: Opportunities, Applications, and Barriers
Get Your House Smart: Aging in Place, At Home, Aided by Technology
The Emerging Use of Videogames for Health: Innovations, Impacts, and Issues
Mobile Health: Leapfrog technology for the developing world?
And the list goes on...

What this showed me is that there are many innovations starting to happen with promising implications for tomorrow's health care system. To get there, we need less focus on the costs of today's system, and more on enabling a new delivery model for the future. We, as consumers, manage the rest of our lives from our phones or our PCs - our finances, our travel, our shopping. When we want to make any purchase or investment, we have all kinds of services we can leverage to get informed and act. Every industry that touches our lives has been transformed - complex, expensive products and services once only available to few are now accessible and affordable to the masses and provided by those (people or even software) with far less training.

In health, if we continue to 'do it' the way we always have, costs will continue to skyrocket. Not to mention that our current delivery model simply won't be able to keep up with the advances in medicine - think about a world of personalized medicine (we're on the cusp of some amazing things). Today's delivery model just isn't set up to handle the amount of personalized data, decisions and so on.

We can see pointers to the future -- virtual care from American Well, new delivery channels such as Minute Clinic, patient self-serve at Kaiser-Permanente, personal health management platforms like HealthVault and Google Health. We're seeing an influx of investment into health start-ups focused on making treatments or healthcare information more cost-effective and accessible to patients. But we haven't yet seen widespread change or adoption.

Why? Congress has carved into stone our current system, but this traditional 'fee-for-service' model just isn't flexible and won't enable the kind of innovation required.

We need Congress to create a new framework that drives value, rewards experimentation and enables innovation. This is what will transform health and ultimately drive costs down.

Learning from Singapore and Switzerland

pnblog — Fri, 23 Oct 2009 17:59:00 GMT

So this week’s question from the Washington Post RX Blog was:

Which country has the best health-care system and why? Can the U.S. follow its model?

My response -- Learning from Singapore, Switzerland -- is below.

To realize the goals of providing increased access while maintaining fiscal responsibility, we have to dramatically change how we 'do health' today -- whether we're doctors, hospitals, or consumers.

Health is complicated no matter where you go in the world, and there are different challenges in every country. There is no 'best' system anywhere, but there are best practices from around the world worth exploring. Two immediately come to mind:

Singapore's system has characteristics that reflect what we'd expect to see in our own system - personal responsibility, competition and choice. Working people are obliged to put money into a personal savings account for out-of-pocket expenses. The money remains completely in each person's control; each decides how to spend it. And there's choice -- at the Raffles Hospital, one can choose a $1,438 luxury suite with a 24-hour nurse and other amenities OR a $99 a night dormitory room with the six other beds. Procedures cost the same, and are transparent (Publication of the cost of hospital procedures is mandatory, turning the purchase of a hip replacement into something similar to buying a pair of shoes), but there's choice. Contrast this to our system where it's difficult to even get a price in advance, let alone make choices.

Switzerland's system also offers interesting models for consideration -- universal access, individual choice from an array of private insurance options, and a higher level of personal accountability (shared costs by individuals). All citizens are required to buy health insurance and private insurers are required to offer coverage to everyone - regardless of age or any previous medical conditions. Insurers offer a basic package on a not-for-profit basis, and supplemental packages on a for-profit basis that consumers can choose for things like home care, alternative medicine, and so on. Competition is basically about price and service. For those who can't afford the basic package, the government offers direct cash subsidies. In addition, the system provides incentives for consumers to avoid unnecessary treatments by requiring them to share some costs at a higher level than in the U.S. It's not perfect, but it is customer-driven.

In a democratic nation where capitalism flourishes, personal accountability and choice ought to be at the heart of the system.

Please feel free to comment with your own thoughts – I’d like to hear from you.

Personal Accountability

pnblog — Tue, 13 Oct 2009 21:44:00 GMT

So this week’s question from the Washington Post RX Blog was:

The Senate Finance Committee passed a bill containing its version of the health-care overhaul. Are you satisfied with this bill? What does it miss?

My response is below.

There's a long road ahead for health-care reform -- five bills to be merged and countless hours of debate still to come. A lot could change over the course of the next few months, and the content of the final reform bill is likely to vary from any of these individual bills. The question we need to keep asking ourselves is whether reform will drive the kind of wholesale transformation needed for the industry and consumers -- the kind we've seen in banking, travel and other service industries. Ten years ago, we wouldn't have imagined that people would do so many things themselves. Technology and business model innovation enabled new types of services -- putting consumers in charge, dramatically changing engagement and economics. Imagine the possibilities for new services in health.

Taking this into account, what's needed is a new 'health delivery' framework that drives value, rewards experimentation, puts consumers in charge, and enables innovation--essentially changing the attitudes, beliefs, and behaviors of everyone involved in health delivery. We all have to be prepared to work together in different ways.

We have an opportunity now to move the traditional healthcare business model in a new direction:

Shifting the value of healthcare from treating people when they are sick to finding ways to keep them well (allowing physicians to focus on and be accountable for outcomes vs. volume)

Transferring the management of routine diagnosis and treatment from highly-skilled professionals to newer, more efficient/convenient, and cost-effective delivery methods like minute clinic, self-serve, nurse practitioners -- so doctors can focus on using their skills in the most effective way possible (allowing physicians, health systems, and 'new entrants' to be accountable for value and innovation)

Encouraging consumers to make better lifestyle choices. We need to help them engage in their health differently, be wiser purchasers, and understand the trade-offs involved.

At the end of the day, the ultimate success of health-care reform will depend as much on how we will work together and change our behaviors as on the legislation ultimately passed by Congress and signed by President Obama. I applaud the administration for shining the light on health care as it has never been done before.

Reflecting on the healthcare system while waiting at the hospital for a loved one

pnblog — Wed, 30 Sep 2009 03:12:00 GMT

Often when we talk about healthcare reform, it can be a rather abstract discussion -- you watch some tv show with ‘experts’ reflecting on some 20 page bill or hashing through the merits of a public insurance option. Last week, however, all the intellectual and abstract ideas were brought into something very personal for me and my family.

My wife had a Hysterectomy, and I spent three days at Swedish hospital in Seattle caring for her. With all the waiting time, it was hard not to reflect on the experience and think about it in the context of health reform. I’m happy to say that my wife is now recovering on schedule, and she’s given me permission to share the story and my insights.

Once she had decided surgery was her best option, we became even more avid information seekers; we shopped for the procedure with the best outcomes and then the surgeon with the most experience and best quality results for this procedure. The best available counsel we found was for a Robot-Assisted Hysterectomy because there was less risk, less pain and faster recovery times vs. the alternatives. We didn’t have to shop for ‘price’ (thanks to Microsoft’s benefit plan, but that is a different future post)…but even if that were the case, we probably would have chosen a more ‘expensive’ option if it meant less risk and more productive days -- getting back to normal life as quickly as possible.

We all know that surgery can be pretty scary. Throughout the experience, everyone from the doctor’s office to the staff at Swedish helped to make the experience a positive one, allaying any fears and making us feel comfortable and confident. We often forget that healthcare is truly a people business. In just three days – the number of different people we dealt with was amazing -- five docs, seven nurses plus the ancillary folks (lab techs, transport and other helpers). They all took time to connect with our emotions while doing their jobs.

Swedish is leveraging technology to improve their systems. You see it throughout the organization, starting in the lobby, with signs advertising the hospital’s new EMR system. During the course of our stay, when there was time I asked various staff members about their experience with the new EMR, and they were positive about the system because they had all the information in one place. While a common complaint was that the data entry took them more time, they felt overall it made them more productive and effective.

This highlights that we need to remember that technology is a means to an end. It is NOT the introduction of technology that will make a difference, but rather how leadership leverages the right technology to make a difference…in both quality results and economic outcomes.

I also saw a real focus on patient safety, starting with the pre-op processes. Each member of the care team carefully checked her arm band, her chart and asked several specific questions to be sure she was getting the right action. For us, the repetition became frustrating, but if this process were to improve patient safety, then it would be worth it. Despite the technology investments, the core safety process was in the human factors.

After the surgery was completed, she spent two days recovering in the hospital. This was a day longer than originally planned due to very low blood pressure and a declining hematocrit. While I used the guest Wi-Fi for work and email, it was even more critical for answering key questions about her condition, the trade-offs, the next steps – which helped me to get some context and understanding to a) engage more thoughtfully with the care team about questions/choices and b) assure my wife about what was going on during the long time periods when neither doctor or nurse was around. I think hospitals should consider leveraging their video and wireless infrastructure more effectively for patient specific education and connecting with their care teams. This is potentially a big opportunity for improved patient compliance and care team coordination.

Because the low blood pressure persisted, I called her primary care physician to get her baseline BP. If we had stored this information in HealthVault, I wouldn’t have had to make the call – I would have just been able to look it up. Furthermore, I would have preferred to have gotten her discharge information automatically transferred to HealthVault. We were given paper copies. This should be easier.

So, what’s the moral of this story?

· We can’t lose sight of innovation and there’s a risk that could happen if the government were to become the primary funder of health.

· Technology is a means to an end, but we have a long way to go to figure out how to use it smartly.

· We can’t lose sight of how important the personal aspect of healthcare is. The emotional support and human caring delivered by the care team was the critical component of our overall satisfaction.

This experience reinforced for me that a ‘healthy’ health ecosystem requires consumer choice -- it is a critical component to the effective functioning of markets and innovation. We made the decision to ‘save time/hassle’ vs. saving dollars as we do in other aspects of our lives. This really drove home for me that the debate about ‘rising health care costs’ doesn’t really account for improved patient outcomes in terms of fewer lost days of work/productive living. I am all for comparative effectiveness of various options and knowing what things cost, but it needs to include patient values -- like less pain and getting back to normal faster -- or it may lead to bad unintended consequences. I am more concerned than ever that increased government financing of health will ultimately lead to fewer consumer choices and will stifle future innovation with tangible economic benefits.

I haven’t received the multiple confusing bills and outrageous line items of detail from the hospital stay yet. Nonetheless, when it comes to getting a quality outcome from an advanced surgical procedure, I prefer the current U.S. health system with all its flaws to the alternative future of less consumer choice and innovation.

Empowering Consumers

pnblog — Sat, 26 Sep 2009 20:48:00 GMT

So this week’s question from the Washington Post RX Blog was:

In the Baucus bill, insurers would pay a tax on the value above $8,000 for an individual policy and $21,000 for a family plan. What do you think of Sen. Baucus' proposal to impose a 35 percent tax on "Cadillac" health insurance plans?

My response is below.

We should have faith in consumers to make the right choices for their health -- only then will we reduce costs, expand coverage and drive value.

The motivation driving this tax is that health insurance plans (Cadillac or not) are another form of compensation -- something your employer provides for you with pre-tax dollars versus your paying yourself with after-tax dollars. The employer's ability to use pre-tax dollars creates a misalignment. Rather than tax a small percent of plans, it would seem better to correct the core problem. Until consumers are educated and empowered about how their health-care dollars -- both pre-tax and post-tax -- are spent, real reform won't happen.

One of the big snags in reform conversations is the idea that employment and health insurance are inextricably linked. Health insurance should be portable so that it can be taken from one job to the next and will cover you when you're temporarily unemployed. Labor mobility is one of the underlying strengths of the U.S. economic system, and health benefits connected to employment unnecessarily weakens labor mobility.

Moreover, the concept of health insurance should be more focused on 'major medical' needs like other insurance where you pay into a system to prepare for a catastrophe. But the norm of the current system is first dollar coverage which pays for every routine procedure. The fact that employers can use pre-tax dollars and ostensibly provide greater benefits for each dollar spent has led to this situation. This has driven up total health costs through misaligned incentives, extra administrative costs and limited provider innovation (e.g. packaging of services to meet routine needs). If there were a consumer-driven market, consumers would understand how their dollars are spent and there would be a more innovative insurance market.

The Wyden-Bennett Act provides this foundation. Consumers would receive cash from their employers equivalent to what the employer spends on health insurance. They'd have the option to buy the insurance they considered most appropriate, based upon need and determined by behaviors, through a health insurance exchange, which would be regulated by the government and encourage insurers to compete for their business.

Consumers make health choices every day, so why shouldn't they decide the coverage they need and the amount they will pay for it? People don't need the government to help them pick their car insurance.

Let's give people the right information to make the right decisions.

In the Health Reform Recipe, the Missing Ingredient Is the Consumer

pnblog — Wed, 16 Sep 2009 01:28:00 GMT

So this week’s question from the Washington Post RX Blog was:

What's Your Take On Obama's Speech? What did you think of President Barack Obama's Sept. 9 speech to a joint session of Congress? Was it effective? Did it "move the needle?"

My response is below.

I applaud the administration for shining a bright light on health reform. The government -- as buyer, regulator and leader -- must be a part of any solution. The political calculus has created a real sense of urgency to do something about this complex system which touches everyone and accounts for one sixth of our economy. The consequence however, through a lack of transparency and understanding, has reduced the public dialogue to be between "public insurance options" vs. "death panels." Framing the debate this way and consuming available public attention on "wedge" issues won't lead to a sustainable future system.

My attendance at an Institute of Medicine workshop this week in the midst of the buzz about the speech served as a stark reminder about the depth and breadth of the hard problems:

• Access (too many uninsured)
• Costs (growing faster than inflation)
• Demographics (aging populations driving up systemic costs)
• Quality (not enough -- as measured by comparative outcomes, disparity in care geographically)
• Worsening health (people dying because of a lack of focus on improving the care delivery process).

I was struck by the number of smart, passionate people representing the major stakeholders working together to drive change. Veterans of the process recognize that change is imperative but hard -- because the details matter. We are in this predicament because incentives, tax policies, government reimbursement schemes and increasing specialization and capability of medicine have led us here.

The president delivered an inspirational speech, laying out basic principles: everyone should have access, nobody with insurance will have to change it and cost growth must be slowed. Voters know there is no free lunch, and health is no different.

We can't achieve reform without educating the public. A sustainable system is not as simple as providing more access. Consumers are ultimately responsible for their health and their daily choices cost the system. We need to help them engage in their health differently, be wiser purchasers, and understand trade-offs. As long as they believe the price of care is their co-pay and continue to engage as they have, there won't be sustainable reform.

There are best practices at organizations like Geisinger that have re-invented care delivery and consumer engagement models. These leaders will tell you that success is about aligning incentives, understanding the details and making trade-offs.

The difficult work of figuring out the details and making hard choices is still ahead.

Three Simple Truths

pnblog — Wed, 26 Aug 2009 22:20:00 GMT

So this week’s question from the Washington Post RX Blog was:

Recent polls show declining support for President Obama's handling of the health-care issue. What should he do to get the effort back on track?

My response is below.

Today's debate is mired in details about the wrong topics, chiefly public insurance options and the best government bureaucracy to determine what gets reimbursed. To drive the unprecedented reform vital to our country's future, we must up-level the conversation and focus on real reform: analyzing the system holistically and figuring out how health care can be delivered in better ways to improve outcomes and value. The challenge is how to leverage market-based solutions while dealing with the unique properties of health, such as the moral imperative to provide for the under-privileged.

Much of the justification driving reform has been economic, yet the debate has been politically focused, obfuscating the economic issues rather than illuminating them. The result? A missed opportunity to educate citizens on the fundamental issues and frame a public conversation about the choices that will bring change.

To refocus, we should acknowledge three simple truths:

Healthcare isn't free. A recent Los Angeles Times editorial highlights a clinic offering free health care that turned people away because too many showed up. The editorial suggests mandating charity care by doctors as part of the solution. Unlimited health care will be paid for by all tax payers either directly or indirectly. Free goods are always over-used as evidenced by the classic example of The Tragedy of the Commons.
Reform and innovation are inseparable. The history of industry transformation has shown us that change and ultimately better value aren't possible without innovation. We need Congress to change today's rules to enable health service delivery innovation, allowing new entrants, solutions, business models and types of care delivery.
Change is a function of our willingness to change. As consumers, we have to be more accountable for and sensitive to the care we're using. Providers and insurers have to engage with consumers differently and offer new products/services that focus on outcomes and offer real value. The system that governs has to provide the right incentives to drive the right behaviors.

There are pointers in the right direction -- the Healthy Americans Act provides solid thinking about improving outcomes by focusing on prevention, wellness and disease management, and tying accountability and incentives appropriately. In the words of Sen. Ron Wyden (D-Ore.) -- "passing a reform bill that doesn't really reform the health care system is just about as wrong as not passing any bill at all."

Individuals and Personal Responsibility May Be the Tipping Point in Health Reform

pnblog — Thu, 13 Aug 2009 05:16:00 GMT

The latest turn in the healthcare debate is the increasingly sensational coverage of town halls happening across the country. While they’re described as rancorous and sometimes violent, I’m pleased to see my fellow Americans so passionate and involved in one of our country’s biggest long-term challenges. For most of us, we think of health care personally -- it’s about my relationship with my doctor or my insurance company -- versus considering the system as a whole.

But this dynamic seems to be changing. There are a number of forces -- the media and current political agenda, technology trends, the economy -- converging on Main Street that are pushing people to get educated and more engaged in Congress’ proposed changes than they ever have before. Our sensational media machine is in full swing highlighting healthcare across every communications vehicle available 24/7. Technology’s influence over other industries has created consumer expectations for more convenience and value from healthcare. And the downturn in the economy has forced many to face the stark realities of healthcare tied to employment. So perhaps out of all this turmoil will come something good -- people coming together around the cause of improving the healthcare for today and tomorrow.

What many fail to understand is that the personal connection people have with their own healthcare is the very core we need address in order to make some of the greatest changes to the system. People make choices every day that impact their health – and the system as a whole. The diabetic who decides to not follow the course of action prescribed by his doctor costs the system. This is evidenced by two studies I read this week. The first is from the CDC, which states something we all know – that by losing weight, not smoking, getting exercise and sticking to a good diet, we will dramatically lower the risk of chronic diseases, such as diabetes and heart disease. Imagine the impact we could have on the system given that 70% of current costs stem from six chronic disease states.

The second from PricewaterhouseCoopers highlights some stark realities:

About half of surveyed individuals indicate their current lifestyle was less than healthy
90 percent said they would become active in improving their health if they were diagnosed with a chronic illness, which is obviously too late
Disease management programs are rarely used -- employers report than less than 15 percent of eligible patients participate in the programs
25 percent of surveyed individuals are not more involved in their healthcare because they don't know where to go for good information
15 percent aren't more involved because they aren't interested
25 percent of people in poor health are not involved in their healthcare and treatment choices

The juxtaposition of these two studies really brings to light for me how much our reform efforts need to focus on our citizens -- educating them and involving them in the health system in very different ways than they have been in the past. For the health system to work for all, economic incentives and costs need to be aligned with consumer behaviors and choices. We can’t continue to support the diabetic’s decision to make poor choices and drain the system for all of us. There have to be some consequences for actions. If something’s free, I think we all know that there is a strong possibility that people will not appreciate its value. We can look to many examples of this over time.

While we can argue that patients absolutely need to step up and do more for themselves (and their children), we also have to acknowledge that our system hasn’t been designed to support them. We have a provider-centric system, not a patient-centric one. Today, the average time a physician spends with a patient is 18.7 minutes. There isn’t a lot of room in 18.7 minutes for much “education.” In Maggie Mahar’s new documentary, one physician describes how he’d love to spend time with the diabetic educating him on how he needs to get involved, but he gets paid more to do procedures.

“We are paid to do things to patients,” said one doctor. “We are not paid to talk to them.”

In addition to patients needing to take more responsibility for their own health, our government needs to set up (or get out of the way) a new framework that will enable "healthy" markets to develop new value chains to deliver services like education, motivation, etc. at lower costs than high-cost professionals. We need highly educated physicians focused on the right things -- like diagnoses, solving major health crises, etc. If we look at chronic care today, much of it is about helping patients stick to a particular course of action prescribed their physician. But today’s chronic care "business model" is based on physician and hospital care -- acute care. A totally different type of "business model" or offering is required to keep people well. We’ve already seen innovation like this in other health related-areas like veterinary medicine, dentistry, and cosmetic surgery where consumers have taken more control of their on-going care.

The decisions we make today will impact generations to come -- financially, socially, and medically. We have an opportunity to come together, influence our elected officials and shift the debate in Washington to drive real change.

Lessons from Medicare and Medicaid

pnblog — Fri, 07 Aug 2009 07:34:00 GMT

So this week’s question from the Washington Post RX Blog was:

Do you think that a government-sponsored health insurance option is needed to help control rising costs and "keep insurers honest," as President Obama says?

My response is now live: Lessons from Medicare and Medicaid.

My main points:

· How will another government-managed option be better at building a health system that works for the 21st Century than the one we already have (Medicare and Medicaid)?

· While these programs began with admiral goals and are politically popular, in reality, over the past 40 years, they have done little to control costs or drive innovation.

· What's needed is a new framework to drive innovation, better value, improved outcomes and increased access.

Please feel free to comment with your own thoughts on the public option.

Health Care Needs New Rules to Enable Innovation and Reward Experimentation

pnblog — Wed, 29 Jul 2009 03:00:00 GMT

(cross-posted on Microsoft on the Issues)

Technology is playing a major role in helping bring healthcare into the 21^st century. Many of us have seen it first hand in treatment from our doctors, from MRI scans to laser surgery.

But these clinical advancements represent only a small piece of what technology can do to transform health care. The power of technology lies in the potential to transform the rest of the health care system, enabling new ways of working and communicating, new economics and new business models. As consumers, we’ve experienced how technology impacts nearly every other area of our lives -- how we manage our financials, travel, communicate, shop and so on -- with more self-service, more control, more convenience and ultimately better value for what we spend.

Similar business innovation and consumer engagement has been slow to reach health care, where many physicians still opt for a pen-and-paper over a computer to maintain patient histories and chronicle treatments. Patients continue to navigate frustrating and hard-to-understand medical and insurance organizations, physicians don’t always talk to one another about care and medical errors, waste and duplication drain the system of resources.

Today, we are finally seeing the first signs of systemic change in health care. This change was clearly highlighted with the President’s recent visit to the Cleveland Clinic, which has leveraged technology to improve efficiency and health outcomes and give patients an active role in their health decisions. But the Cleveland Clinic is just one example. There are other health care institutions -- the Marshfield Clinic, Kaiser Permanente, the Mayo Clinic -- whose leaders have embraced technology to improve efficiency and quality while reducing costs. And newer players are showcasing the possibilities brought by innovation, including virtual care from American Well and new delivery channels like Minute Clinic.

But we haven’t yet seen widespread change. The rules governing health care simply haven't allowed this to happen. Congress created rules that have in fact stifled innovation (e.g. Medicare) by reinforcing volume over value -- reimbursing on a per-procedure basis rather than on the number of patients who remain healthy year over year. Now Congress needs to look to the organizations that have used technology to create a new health care reality -- such as the Cleveland Clinic -- and develop a new framework that drives value, rewards experimentation and enables innovation. Only then will we realize the policy goals of increasing access to health care while maintaining fiscal responsibility.

Reform efforts should focus on enabling the kind of transformation that Clay Christenson describes in his book "The Innovator's Prescription". He describes how almost every other industry has been transformed -- complex, expensive products and services once only affordable to the wealthy have become accessible to the "masses" and provided by those with far less training.

As I described in my post this week on the Washington Post’s Health Care Rx blog, real change requires:

Figuring out what works (and what doesn't)
Enabling supply-side innovation
Letting consumers do some of the work that expensive health-care professionals shouldn't be doing anymore

With our ailing economy and worsening health, it’s imperative Congress act quickly and tear down the barriers that exist to enabling innovation.

A New Place for Health Care Policy Debate

pnblog — Wed, 22 Jul 2009 20:34:00 GMT

About a month or so ago, the Washington Post launched their new Health Care Rx blog, and I was asked to participate as a panelist. Every Monday, questions are sent out, and a variety of “experts” from across the health care industry respond. It provides a great snapshot of the many different perspectives that exist.

This week’s question:

The Blue Dog Coalition worries the health bill in the House does not address fundamental cost drivers in the system. Is it possible to rein in costs in the current system? How?

My response is now live: It's Not About Costs, It's About Enabling Transformation

My main points -- real change requires:

Figuring out what works (and what doesn't)
Enabling supply-side innovation
Letting consumers do some of the work that expensive health-care professionals shouldn't be doing anymore

To read the full post, click here. Please feel free to comment with your own thoughts on how to rein in costs in the current health care system.

And you can see my responses to previous questions:

Who Pays for Whose Heath Care? [Posted July 14]

The political debate is often framed around covering the uninsured. At the heart of this is the supposition that health care is a moral obligation -- that everyone has a "right" to it. But it's difficult to separate the moral from the economic because there is no other "liberty" that requires payment.

Defusing the Health Care Bomb [Posted June 16]

The "big red wire" that needs to be clipped first is the fee-for-service payment system driven by the government today through Medicare reimbursement decisions. Until that's addressed, the ticking bomb won't be stopped.

Diagnosing and Treating the Health Non-System [Posted June 7]

We do not currently have a health system at all: it is a health non-system.

If you want to follow the conversation, you can add the Health Care Rx blog to your RSS reader here: http://views.washingtonpost.com/healthcarerx/atom.xml, and I will be posting summaries of my responses on this blog.

Another milestone on the journey forward…

pnblog — Tue, 23 Jun 2009 03:43:00 GMT

Over three years ago, we started on a journey -- to empower consumers with tools to help make better health decisions and drive better health outcomes. We believed that the simplest, easiest way to start was to give consumers their data in a secure and private way, and allow them to share it from provider to provider, keep it in one place over time, and learn about it in order to make better daily health decisions. That simple idea was the beginning of HealthVault.

Back then, there were a lot of objections. Consumers don’t want their data. Consumers can’t understand their data. Their data might actually do them harm…blah…blah…blah…

But fortunately, things have shifted. Consumers have made it pretty clear that they want to be involved in their health – as evidenced by looking at social networking sites like PatientsLikeMe, the raw numbers of health Internet Searches, or research reports like The American Public on Health Care: The Missing Perspective, released by the CEG, Accenture and IOM:

· 78% of American favor giving doctors the ability to share access to their medical records if done with their permission.

· 66% said that they see the value in including their own information anonymously in a large database to help researchers.

And I’m happy to say for a number of reasons that consumer products like HealthVault and GoogleHealth continue to gain market traction.

Today marks another milestone – the first Industry-wide initiative to establish a “Declaration of Health Data rights” to support patients’ rights to access and share their own health information – https://healthdatarights.org will go live tonight, along with blog posts and endorsements from thought leaders and organizations across the country.

While we’re making change, and it's great to see so many organizations and thought leaders coming together, it’s important that we not stop here…that we continue to move forward—specifically by ensuring that consumer access to their data is included in the definition of “meaningful use.” While I’m optimistic about what I see -- what’s been laid out seems to focus on driving real outcomes improvement in the health care system -- we will not be successful without further refinements. Consumers cannot just be given access to data in static form, but must be provided with an electronic copy of their data so they can easily share it, use it, add to it -- creating a lifelong health data asset. In the end, consumers are the ones accountable for their own health.

The willingness to succeed is only exceeded by the willingness to prepare

pnblog — Fri, 19 Jun 2009 06:24:00 GMT

After many long months of discussion and debate, the first draft of Meaningful Use has come out. I’m optimistic about what I see -- what’s been laid out seems to focus on driving real outcomes improvement in the health care system.

It’s important that we keep this in mind -- that we’re not just trying to implement technology. We’re trying to improve the performance of the health system. And our willingness to succeed should only be exceeded by our willingness to prepare, and as part of that preparation, we must ensure that flexibility, scalability, and interoperability are inherent traits in the system. Why? Because, health is fundamentally data-driven. Nobody -- physicians, consumers, hospitals, insurance companies, governments -- can make good decisions without good data.

So driving data liquidity -- that is the ability for data to flow throughout the system -- has to be the critical focus. For years, we’ve been building systems in a “top-down” way to reach information, but what we need to do is build from the information up. One thing Carol Diamond said at a Health Affairs event that I attended with her really struck me -- the idea of bringing the question to the data -- leaving the data where it is and bringing the question/problem/issue to it. For a long time, what we did as an industry was use expensive research grants and complex tools to cull and compile data that was intended to answer one specific question, and by the time we’d sorted through the data enough to answer that question, it was either out of date or ten other, more pressing questions had popped up in the meantime. What we need is a system that unlocks all of the data that exists already in the health care sphere, and allows it to flow between silos so that when questions arise, we can bring those questions to the data for quick, evidence based answers -- rather than the other way around.

Given this, as discussions/refinements continue around meaningful use, I believe it’s critical for the following to be a part of the final definition:

· We can’t just capture data, it must be available in “real-time” in order make the right decisions and improve outcomes -- whether we’re talking about patients or populations.

· We have to enable data to become liquid -- specifically, doing this by separating data from applications. This is one of the recommendations from a study by the National Research Council of the National Academies that takes a look at what types of computational technology and investments are best for improving health outcomes. Let the excuse not be that the data is trapped in systems that we built, that we have to wait for standards.

· We’ve got to give consumers access to their data -- not just in static form -- but empower them with an electronic copy so they can easily share it, use it, add to it–creating a lifelong health data asset.

· We should accelerate the objective of having PHR access to EHR data to the 2011 Objectives and Measures. There is no need to wait until 2015. These technologies are available today and will bring real, sustainable benefits, not just for consumers, but for the overall health care system.

· We must ensure that we do not have an overly-prescriptive certification regime that focuses on certifying features and functions every-other-year. This will produce the unintended consequence of stifling innovation. Software vendors will be forced to develop towards a certified feature list rather than look for new and better ways to improve clinical processes and health outcomes,

The foundation of success is based upon data liquidity, and so it must be central to our thinking as we prepare for the future.

Aligning policy, technology, and business innovation – perspectives from the Connected Health Conference…

pnblog — Sat, 13 Jun 2009 01:59:00 GMT

We’re just wrapping up our annual Connected Health Conference. I wanted to share some insights and observations from the past three days. We had 925 attendees representing 409 organizations -- attendance more than doubled from last year, which is pretty amazing given that conference attendance is down all over the US… At this year’s conference, our Amalga and HealthVault customers and partners all came together for the first time. The most frequent comment I heard from attendees was excitement about the breadth of work we are doing and the new opportunities they see as a result. The main issue that came up over and over again was the importance of driving and aligning innovation in health IT, health policy (e.g. reimbursement strategies), and business.

This topic first came up during our opening keynote panel on Thursday with Professor Uwe E. Reinhard, Dr. David Kibbe and former HHS Secretary Mike Leavitt. Secretary Leavitt introduced the notion that advancements in reimbursement reform are needed as much as stimulus for technology adoption. According to Leavitt, health IT will become ubiquitous when consumers demand it from their healthcare providers. While I agree with Levitt about informed, engaged consumers being key drivers of change, I also think that physicians, industry and other partners must demand a smarter approach to reimbursement from policymakers. One place to begin innovating and experimenting with a better reimbursement system is at the state level. During this morning’s keynote, Dr. Mark Smith of the California Health Care Foundation, made several insightful observations about factors affecting HIT adoption such as; better, simpler solutions for physicians, a stronger voice for government as purchaser in mandating effective standards and a reimbursement policy that rewards outcomes vs. volume. However, as David Harlow pointed out during a conversation today, our tough economic climate makes it difficult for states to take the lead.

Dr. Kibbe emphasized the need for web-based tools that could be assembled in a modular way to qualify for stimulus dollars. Both Kibbe and Smith made the strong point that physicians haven’t adopted existing technology solutions for a reason and that any stimulus/policy reform needs to be flexible enough to allow innovation in solutions vs. trying to “jam” solutions that don’t meet current needs or practical market requirements. In speaking with our Amalga partners, they too are interested in understanding how meaningful use and certification will be defined and applied. Our customers shared many examples with each other of liberating and unifying data which makes measuring quality and proving effectiveness easier and automatic. As much as health IT has the potential to help cut inefficiency and improve operational throughput, we still need the right policy solutions to bring greater transparency to what patients are purchasing from their providers and that quality of those services…as Leavitt demonstrated humorously with his story about colonoscopy pricing.

You can see some of the highlights of the panel discussion as well as Mark Smith's keynote below.

Our commitment to connecting technology, policy and business innovations is central to our vision of unifying a fragmented health ecosystem. In his remarks, Microsoft Chief Research & Strategy Officer Craig Mundie highlighted the major role health plays in economies around the world and the huge opportunity for software to improve peoples’ lives. Our Connected Health Conference this week brought together many different "perspectives" from across the fragmented health ecosystem -- what really struck me was everyone's energy and desire to let innovation reengineer the health system. I hope that the public and private sectors can work together to drive real change. We all know that that it's not going to be easy, but it will -- and must -- happen.

And the debate rages on…about access…

pnblog — Wed, 10 Jun 2009 05:01:00 GMT

I think we’d all agree that the healthcare debate continues to intensify. Many say it has entered a new stage as conversations move to proposals -- with Senate Democrats recommending a bill that will amplify the debate even more -- to decide if the US will adopt universal coverage.

Access seems to have replaced change as the word of the day. Everyone seems to be focused on it -- including Peter Orszag and Virginia Postrel. There’s no doubt that access is important -- but addressing access prior to reengineering the system is like adding passengers to a sinking ship. And in this case, the ship is going down in a sea of red -- the growing debt that will be incurred.

What we really need to do is what I highlighted in my contribution to the Washington Post’s new Daily Dose Panel Blog, Diagnosing and Treating the Health Non-System.

It’s not just about access. There are multiple symptoms and ailments that interact with one another. The three principal "diseases" are:

· Access (too many uninsured people)

· Value (too much spending for the health results delivered)

· Ignorance (at every level - who really pays for health, misaligned incentives, true costs, quality measures, transparency and more)

The most important to fix is value -- how do we improve health outcomes for the same or lower economic cost? Why is this most important? Everyone acknowledges that health spending is already in an economic crisis -- both in the near term and certainly in the long term (Medicare's unfunded liability exceeds $36 trillion!). Even if everyone in the country woke up tomorrow morning with health insurance coverage, it still would not address the hard economic truth -- we must get more value, as measured by better health outcomes, for every dollar we spend on health. The recent article in the New Yorker illustrates this particularly well.

The whole operating framework surrounding the health delivery system requires re-engineering to realize value. We need a system that supports and rewards innovation in health around new drugs, new devices or new procedures. Today, this innovation happens on a small scale, at times producing great results. But what we need is broad-scale innovation around health delivery for chronic disease management (which accounts for 70% or more of total spending) as well as prevention and wellness.

The reason this innovation and re-engineering isn't happening right now in the delivery of health services is because of the inflexibility in the payment system and misaligned incentives -- largely the result of Medicare rules and regulations driven by Congress today.

Each of us pays for health care (taxes, lower incomes, cash) whether we realize it or not, but as consumers, we’re rarely informed and engaged with our own health. We can’t get the basic data we need to make the right daily decisions.

I believe that Congress must focus on building an operating framework of rules and regulations that aligns physician and hospital payment with health outcomes and encourages innovation on how best to deliver it. This is evidenced by an amazing statistic I read this week. In June 2008, the Congressional Budget Office estimated that up to one-third of 2006 spending – roughly $700 billon or nearly 5% of our GDP – did not improve health outcomes. And we want to add more people into this system?