I am less sanguine about their conclusion that ACA framework leads to ‘consumer driven’ care — but it is one possibility.
I respect Don Berwick and Zeke Emanuel as smart, thoughtful and well intentioned policy folks. Yesterday in an Op-Ed in the WSJ they tried to position Obamacare as ‘market-friendly’. The audacity of positioning Obamacare as ‘market-friendly’ vs. the proposals of Romney/Ryan is just so outrageous that it can’t be allowed to stand without comment. They must be subscribing to the theory the bigger the lie they tell — the more likely it is for the public to believe it. From a quick scan of the online comments — at least they aren’t fooling the WSJ online readers.
One should really worry about the diagnosis and treatment plan from their physician when they either don’t see/acknowledge relevant facts or miscontrue the evidence to fit their preconceived notions, as is the case here. Let’s go through some missing facts/evidence:
- Medicare Part D — prescription drug benefits: the market based approach of multiple plans, with different prices/formularies competing — with the consumer able to choose the right fit for them — has been a huge success and been substantially more cost-effective than any CBO or CMS projection at the time.
- Medicare Advantage Plans: super popular with Medicare beneficiaries — over 12M+ enrollees. Again a program where the consumer chooses and the market is competing for their business. Oh wait — maybe they didn’t mention this because Obamacare takes a lot of money from this program. Furthermore — the whole point of MA plans is to encourage a focus on value (not volume) as they say they want (and I agree is critical — see prior post) — but just not in this ‘market-friendly’ approach.
- Their approach is totally top down (ever see a top down, centrally controlled market work?):
- support point 1 — administrative costs lower in CMS vs. private insurance — this is a total red-herring of comparing apples and oranges — but demonstrates clear bias to government centered
- support point 2 — experts have determined that ‘bundles of care’ is critical to payment reform and CMS will help determine what payment models will work. The rate of innovation will be determined by CMS and is again ‘expert-centered’ or government controlled. This isn’t the way most markets work well. Now — I accept that somehow CMS payments have to be reformed. Seems like ‘vouchers’ with consumers choosing and suppliers competing might be a lot more likely to succeed here — even if it is messier.
- support point 3 — IPAB. This is the epitome of government centered without accountability. I accept IPAB might be better than Congress in making recommendations on how to control costs — but to position it as ‘market-friendly’ and innovative — really?
- Ryan Voucher plan: the authors simply assert the Ryan voucher plan is “inadequate” and imply that throwing Medicare members on the ‘private market’ is inhumane….but provide no evidence (see first two facts above). They prefer one size fits all vs. consumers/suppliers interacting in a marketplace to figure it out and drive continuous improvement. The IOM recently released a report that estimated 33% of today’s health spend is waste and does not add to “value” in the form of better health outcomes — that is $750B in annual spend. Here is some evidence to suggest there is no credible reason today to say the ‘vouchers’ are inadequate. It is more like the Chicago Teachers Union saying vouchers and charter schools can’t work — despite all the evidence that they do in the communities that have tried them.
After 60 years of a largely single payer, government run system in England the Cameron government has proposed real reforms that would move their system to be way more ‘market-friendly’, innovative in health delivery and empowering of consumer choice than Obamacare. I prefer their treatment plan tothe authors.
We need a real political dialog in this country about the best framework to get more “value” from our health care expenditures — public and private. The framers and spin handlers of Obamacare did not stimulate that objective debate….which was a huge disappointment and a lost opportunity.
Health care is a critical issue for a bunch of very good reasons:
- the rising cost of health care is squeezing our personal, state and federal budgets. We are spending more and more but don’t seem to be getting the type of health care we want — more convenient, on my terms, with better health outcomes.
- as a rich society — our ability to provide an adequate social safety net is key to how we feel our society is doing — and access to health care is a crucial part of the social safety net — and yet many don’t have access to health insurance. Can’t we do better?
- health care is nearly 20% of our economy. unfortunately a ton of that spending is of little to no or negative value, which hurts our overall economic growth and competitiveness. other industries self correct through markets – but the health industry doesn’t.
- Democrats (price controls) and Republicans (accountability and market forces) have very different approaches and hence want to either talk or demagogue about it, depending on your perspective
- being able to solve both the access and the affordability part of the equation will improve our economic security — both for us as individual citizens and for the nation’s competitive position in the world marketplace.
Paul Ryan said in his convention speech last night that it was time to have a political discussion about the future of Medicare — and he is right on that. I hope we can have an informed discussion. Unfortunately — there are many basics folks need to understand in order to have an informed discussion.
I strongly encourage anyone who wants to have an opinion on what we should do to improve our health system — including Medicare — to read this short pamphlet co-authored by Denis Cortese — former CEO of Mayo Clinic and chairman of the IOM Roundtable on Value & Science Driven Healthcare — where I was a roundtable member. You can download it here, (go to bottom of page for download link). Title is Roadmap to High-Value Healthcare Delivery.
I don’t want to summarize it – take 20 minutes and read the whole thing — it really will help you be informed on this crucial political and economic topic. Improving Value (Value = Patient Outcomes / Total Cost) and aligning incentives to accomplish is the roadmap. Warning — there is some math and charts in this pamphlet — but don’t let this get in your way.
These NY Times articles are worth reading. The optimist in me sees how medicine is on the cusp of being transformed for many. The pessimist sees how far we have to go.
Healthcare executives know and frequently recite that the majority of health care expenditures in a given year are from an incredibly small number of patients. I don’t believe our U.S. citizenry generally understands neither this fact nor its implications. I have heard various numbers over the years – 5% of patients account for more than 50% of the spend or as this WSJ article (sorry subscription required) on “The Crushing Cost of Care” reports — 10% of Medicare beneficiaries account for 64% of Medicare hospital spend in 2009. There are two main drivers for this concentrated spending distribution – people with chronic conditions (more accurately multiple chronic conditions) and as demonstrated by the WSJ article – end of life care.
I don’t claim to know the right answer or even how to frame a constructive dialog about end of life care. (Check out the comments to the WSJ article as a depressing start). Personally I have had to deal with several family members end of life issues and they are incredibly emotional and challenging without having to consider economic consequences. However, I believe and have frequently written that ‘health care’ is an economic good. As such, we (society) don’t have a limitless ability to supply ‘free’ health care. Our country is nearly broke today – and when one considers existing entitlement spending projected into the future, especially on health – we know we can’t afford it without some change. Furthermore, our current framework of indirect payments and complete lack of transparency of costs to both physicians and patients exacerbates the problem.
Neither political party is being responsible regarding this issue. The Republican sound bite about “death panels” is inappropriately used as a political weapon that shuts down public education and constructive dialog – and ultimately makes the problem worse. The Democrats fail to acknowledge that the current system is simply unsustainable economically and as a result forces the ultimate economic trade-offs to a faceless bureaucracy (the wrong place) and gives credence to the Republican argument. Both sides are being disingenuous if not dishonest – which is not helping society learn how to deal with the amazing benefits/possibilities/costs of modern medicine and the inevitability of death and the moral dilemmas for doctors, patients and families that result.
One can’t have a serious health blog and not discuss the Supreme Court decision to uphold most of Obamacare. My initial reaction was real disappointment — because I truly believe the law is a bad law and bad for the future of our country. I am not a lawyer and Roberts’ logic seems somewhat tortured, but after reading several legal blogs on the topic — I believe Roberts was sincere and apolitical in his reasoning and I support the outcome and the process.
As I have written previoulsy, the real problem is Obamacare does little to solve the true health care crisis in our country. Worse, the political dialog regarding Obamacare has done nothing to educate the citizenry about the dysfunctional health system which could have enabled a more sustainable set of solutions.
There are three pillars — Access, Cost and Quality — that are part of any discussion for improving our health care system. They are all important and intertwined. Obamacare primarily deals with Access (individual mandate, pre-existing conditions, insurance exchanges etc.) but it does nothing meaningfuj and systematic to improve either Cost or Quality. The biggest issue in our healthcare system is economic — we are not getting sufficient Value out of our huge healthcare spend (Value = quality of health outcomes – cost over time). For example, the IOM and other experts believe that 30+% of our $2.2 trillion of spend is wasted — that is $750B annually!!! The only sustainable solution to increasing Access is to make health care more economically affordable, which requires an improvement in Value, which requires changing the way the system is organized and incentivized. Obamacare does not do this and in fact, probably makes things worse re: affordability and sustainability. Increased Access to insurance within the current framework obviously does not drive or improve affordability — or we would not have the unsustainable health care cost trend we do.
I will develop further the themes of Value and affordability in future blogs. This WSJ op-ed is a good start. My strongly held personal belief is that free enterprise, marketplaces and competition amongst providers and payers is much more likely to improve Value and affordability than more government rules and bureaucracy.
Which leads me to my biggest concern resulting from the Obamacare political debate…which is; is our country headed more toward socialism vs. our traditional strength of ‘free markets and free peoples’. As Chief Justice Roberts noted in his opinion — it is not the job of the Supreme Court to “protect the people from the consequences of their political choices.”
I finally broke down and bought a GPS computer for my bike to track my rides and improve performance. I love it and the ability to track/share my rides on Strava. So then naturally, I wanted the same capabilties for my runs — but I chose the Nike GPS sportwatch instead of a Garmin one because of better usability. But of course the Nike data can only be uploaded with the Nikeplus website and at least from what I can figure out — one can’t export the file elsewhere (either from the device or the website). And neither set of devices are HealthVault enabled….which means I can’t easily utilize the results of my training with my HealthVault apps, like www.heart360.org or www.mayoclinichealthmanager.com.
I get I’m a bit of a gear/gadget head. But personal health devices work — they motivate and engage consumers. And it is clear there will be a lot more of them coming for fitness, for specific disease conditions and for lifestyle purposes. For them to really have an impact, they must liberate their data and make it available to other applications to use and share. As a user, I don’t want to have a silo’ed relationship with each type of device I use. I want them to contribute to a wholistic view of my health and for me to be able to decide how to leverage and share the data.
Come on device manufacturers and consumer products companies — continue innovating with cool new products and apps — but please liberate MY data!
Last week, David Brailer’s Health Evolution Partners (where I’m currently an Operating Partner) held its annual conference in Laguna Nigel, CA. What makes this conference really interesting is they get leaders from major companies across the health economy — health delivery system, research, big pharma, payers, tech — and add in a bunch of disruptive, small companies in the same setting which stimulates a diverse variety of interesting dialogs. Folks are both inspired and enabled to take some concrete actions to either collaborate, do business or simply be smarter for having participated.
The first night had a quick fireside chat with David Agus and then a later panel which had Eric Topol and Bob Galvin on it. Agus and Topol are leading researchers in genetics — but have a pretty different perspective on where to focus. It would have been fun to see them on the stage at the same time. Both have books out (I’ve finisherd Agus’, started Topol’s). Here are my takeaways:
- Agus is promoting a ‘systems biology’ approach to understanding and treating health and disease. Genes are important — but we won’t find the answer by just improving our understanding of the genetic variations. Our body is a complex system — which has many redundant capabilities and adapts to inputs. We really don’t know why certain treatments work — but we should follow the evidence even we don’t understand the causal pathway. I initially learned about ‘systems biology’, P4 Medicine and the challenges of building computational models of our body from Lee Hood in Seattle. You can watch Agus at the KhanAcademy here.
- Topol appears to be more firmly in the camp of truly understanding our genes will lead to the ability to treat and prevent disease. This focus is similar to Frances Collins head of NIH. In addition, Topol’s focus in his book (and other talks) is that technology convergence and consumerism will necessarily drive medicine through the digitial revolution that will unlock value. Naturally I share his enthusiasm for consumerism and technology — but so far I’m in the ‘systems biology’ camp as the more likely framework to right.
- Galvin made a key points about our need to be skeptical about technology as the solution to our cost problem and that we needed to focus on consumer/patient behavior. He described the need for incentive systems and feedback loops to consumers to drive better outcomes.
Jeff Trent (founder of TGEN and whose team is doing some great work) later characterized the differences between Topol and Agus in a way I found interesting as:
- Agus believes common sense trumps technology
- while Topol believes technology will trump common sense.
The discussion matters (one is not right and the other wrong) because it should impact where our research dollars and programs go. While average citizens don’t get involved in understanding and caring about our research priorities — they should. In his book, Agus also shows how a ‘systems’ approach really should influence our health regimen and approach TODAY. I agree.
There was no way I could keep up with the stream of incoming thoughts and people that I experienced at TEDMED. Plus TEDMED had their own blog — which provides better coverage than I can do — so here is the official blog…which is worth a scan.
I learned a lot from TEDMED — I was particularly interested to learn about my microbiome. The speaker — Jonathan Eisen — suggested it should be considered an organ, just like our skin. His blog on the topic is here.
There were many thought-provoking questions:
- the real impact of bias in the way data is published and shared from clinical trials.
- the evolutionary future challenge of drug resistant bacteria — and whether it should impact treatment today and how
- using gaming/crowdsourcing to figure out the right structure for a protein (go U of Washington)
One observation — which is further exemplified by the 20 grand challenges selected out of over 40 choices — is that there are SO MANY worth causes (diseases, fixing science in so many ways, engaging consumers etc) that real progress is on core issues (my definition — like getting a value driven, consumer centered health delivery system) is diminished as folks push their worthy agenda. As Mike Leavitt said while Sec. of HHS — it is not that we lack political will – it is that there is too much political will that stops progress.
I was also struck by the many ‘chance’ encounters I ended up having with thoughtful, motivated and energized folks. That is one of the great benefits of working in the health sector — the breadth and depth of the talent tackling the problems. I hope the community really makes some progress in the coming year.
I’m attending TEDMED 2012 in Washington DC and I will try to add thoughts/insights each night. The goal of TEDMED is awesome — to unlock imagination to inspire innovation. It brings together folks from all sorts of different disciplines who care about improving the health of our society — an ambitious goal! Jay Walker, who is now the owner/driver of TEDMED says he wants to build a community and a place for that community to come together.
Even though I’ve only listened to one session so far — I’m already convinced the conference will open my mind to both new ideas and new challenges — which is great. There was a compelling talk by Rebecca Onie about the genesis of Health Leads — which basically unleashes the capabilities of college kids to support the basic health needs of underserved folks in the health delivery system (getting heat, appropriate food and other basic needs) which are the foundation for healthy living. It accomplished its goal of being an inspirational talk.
I ran into a number of folks from the industry I already know – -but I also met a bunch of new folks doing interesting things or just trying to learn. They all want to make a positive difference. Here is one worth learning about — http://www.artandhealing.org/