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:

1. 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.
2. 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.
3. 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."

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.