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Four Steps Toward Solving Our 'Grand National Problem'

HealthLeaders Magazine , By Fred Goldstein, for HealthLeaders News, July 20, 2006

Years ago, I had a conversation with a very successful physician about his booming practice. At the time he had more than 40 offices in seven states and was responsible for a large percentage of admissions at a number of hospitals owned by the company I worked for. As a young and aggressive assistant administrator, I asked him why he hadn’t built his own hospitals as another source of revenue. To this day I have not forgotten his response: “Fred, when you go to the trough you can be a pig or you can be a hog. If you’re a pig and let others feed at the trough you will be okay, but if you’re a hog and don’t let others feed, ultimately someone is going to kick you off the trough.” Unbelievably, this rationale from the 1980s no longer applies to healthcare. The healthcare trough is now so big and ever-growing that it can support many hogs in every sector. As we look at the American business landscape, is there any other industry in the United States that can simply grow its revenue, price new products or provide services with little or no useful data available to the payor or end user? Moving in the right direction So, what can be done about the current healthcare crisis and the lack of ethics that results in this massive feeding from the trough? Developing ethical people is difficult and may take generations, but changing current behavior is possible through a system of accountability, information, rewards and data. If we are to fix healthcare we must:

  1. Hold people and organizations accountable for their actions. Unfortunately we are well past the point where we can honestly say to the public, “don’t worry, we can handle it.” Many well-meaning groups are self-policing, but the era of self-policing should be declared dead. The proof is in the pudding, every sector of healthcare has too many bad apples. What we need is stronger enforcement efforts by payors as well as state and federal attorneys. These groups must make a real and substantial effort to hold accountable those who choose to do the wrong thing. Accountability must also extend to those who pay, investigate and prosecute. Over the past year, there has been a lot of press for many state and federal programs announcing record fraud recoveries; but if one looks at the dollars recovered, they are a pittance when compared to the total healthcare spending and/or estimated fraud within the system. There is no excuse either inside or outside of healthcare to allow this to continue any longer.
  2. Require more transparency. Consumers know infinitely more about the car they are going to purchase than they do about their doctor, hospital, medications or devices. Not only should we report costs and process measures, but we should report true outcomes like mortality rates and clinical laboratory results such as A1c values for a physician, clinic or health plan. Let’s get the statistics, publish the data and let the chips fall where they may. People still buy cars that were not ranked No. 1 by JD Powers, but at least they have the data.
  3. Reward those that do better, both the providers and the patients. Systems such as pay for performance, enhanced benefits for patient adherence and additional funding into flexible spending accounts for better self-management will incentivize providers and patients to do the right thing. Why can’t we pay people to be healthy? Rebate some of their premium if they maintain A1c values below a certain level or lose weight or have an undetectable HIV viral load. It is now possible to directly correlate these true measures of patient health with costs savings. Why not let them share in their success?
  4. Invest in technology. Our current healthcare crisis is the “Grand National Problem” of the 21st century. As such, we need to learn from previous grand American efforts like the Manhattan Project and the moon landing. The government should lead a major initiative with a partnership of healthcare providers, payors, consumers and others. The healthcare partners cannot look at this endeavor as a way to continue to protect their turf. This is an effort to protect healthcare in America and ensure a future of quality and reasonableness.
Imagine the possibilities A major component of this effort should be the funding and development of a National Health Care Informatics Center similar to the Lawrence Labs. This information center should house a supercomputer with a database of all patient records in the U.S., including claims, laboratory results, medical records and other services. All providers of services including physicians, hospitals and ancillary providers such as pharmacy benefits managers, laboratories, imaging centers and regional health information organizations should be required to submit data from claims, electronic medical records and other sources. The center should be organized along multiple divisions targeted towards unique areas of research and analysis, including evidence-based medicine, fraud detection, chronic illnesses management, prevention, pharmacy utilization, infection monitoring, surgical outcomes, and many others. To staff this national center we should recruit the best and the brightest in medicine, informatics, epidemiology, fraud and abuse detection, disease management, and statistics. A facility of this magnitude would become a gold mine of information. The outcomes from this center could then be given to the providers, patients’ government entities and others to implement changes and make adjustments to the system. Imagine if we had data on every diabetic in the U.S. and knew what medications they were taking, how often, what provider they were seeing and what their laboratory results were. The ability to determine if certain therapies were working or failing would be amazing. Besides being able to identify problem areas, we could target them for intervention and measure the results. Such a database would undoubtedly present many problems that would have to be overcome--including privacy concerns--but I believe these could be addressed. To expect us to fix ourselves, at all levels through out the healthcare system, is naïve. People don’t change their behavior without some negative ramifications being assigned to maintaining the status quo or positive rewards associated with making a change. For too long the American people have waited for the system to fix itself. I believe that the time has come to look for an outside presence with input and assistance from the industry to identify the problems and implement the carrots and sticks required to fix our failing healthcare system.
Fred Goldstein is founder and CEO of Specialty Disease Management, a disease management firm based in Jacksonville, Fla. He may be contacted at fgoldstein@specialtydisease.com.