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Centering on...Practice Models and Reform

Last month in this space I laid out the argument that health care in the US costs 800 billion dollars more than it should, an amount rivaling the cost of the bailout of the banking system. The only difference is that we annually overspend by $800 billion for health care, while correcting the lack of liquidity in the financial system is hopefully a one-time expense. I also offered a few broad recommendations to fix health care that would be on the same scale as what we were then undertaking to address the larger economy. I have received a larger number of comments than usual, requesting that I expand on these thoughts about reform. Here goes.

Given the unsustainable level of costs for health care in the US, change will come. It will come about when we drive our current arrangements for health care headlong into the wall, or it can be a product of a renewed effort to reform the system. Reform efforts must extend beyond paying more money to gain access for the uninsured. First, because there is no more money and second, our current system is too expensive and performs too poorly to justify simply pumping more cash into it. The real problem is in the way we produce a unit of care whether this unit is a wellness visit for a newborn, a strategy for keeping a diabetic patient healthy, hospice care for a dying patient, or a complex cardiac admission to the hospital involving highly specialized care from nurses, physicians, allied health professionals, and a vast array of expensive technology. These processes are all part of our practice model, and it is our unwillingness or inability to change this model that is at the heart of the dysfunction in our system.

There are four rate limiting variables that keep our current practice model from becoming more responsive to costs and quality concerns. Sometimes these elements need to be addressed at the highest policy level and often they work their way into how individual institutions, practices, or even practitioners do their work. The problem is that we will not get changes until these variables are roughly aligned to a broad vision of what an improved system of care would look like in the US. We don't need the details for this, but we do desperately need a context for the reform, otherwise we will continue to go about maximizing the utility and value of all of the little parts, a practice that will never create an approach to health care that is either desirable or affordable. A new context for health care reform need not exist only at the broadest national level, it can work at the state, regional, or county levels too. But it needs to be a context that invites public and private health care providers, as well as consumers of health care services, to acknowledge their interests.

The four dimensions that will drive the re-crafting of health care toward such a vision are the same elements that keep us mired in the older paradigm, cursing it daily as we continue sacrificing money, health, and the well being of patient and provider alike to keep it afloat.

The first rate limiting element is what we finance. We pay for a highly specialized, hospital focused system that intervenes late in the disease process with interventions that often are in the form of miraculous medical technologies that are the envy of the world. We do this even though we know at a fundamental level that a more primary and community based approach would produce the same or even better outcomes at a fraction of the costs. This is validated by growing evidence based on our own experiences and those of other nations. But we continue on this path because the entire system is addicted to the revenue streams, as they have been for the past fifty years. If we made an analogy between energy and health care policy, our current approach to saving health care would be the equivalent of addressing dwindling energy supplies and rising costs by providing every citizen with a Hummer.

The second limitation on innovation is the regulation of professional practice, which essentially functions at the state level. Regulations place barriers for both individuals and organizations to providing care, and were a noble effort to protect the public's welfare when they were created at the end of the nineteenth century. Today, there are layers upon layers of public protection at the individual and institutional levels and practice regulations only serve the purpose of protecting the guild interests of the providers. The public's health would be better served and the cause of much needed reform advanced by loosening the limitations on scope of practice and requiring full and transparent reporting of costs and outcomes to consumers. The money we spend attempting to control quality at the front end could be much better spent monitoring quality at the production end, and then allowing consumers - either individual or corporate- to make their choices. We need innovation faster and more deeply than these century old regulations will permit.

Professionals need to leave training with a new set of skills and expectations as they enter practice. The worst outcome of a changed system would be one that turns the redesign exclusively over to non-clinical health professionals. But to lead such a change, nurses, dentists, pharmacists, physicians, and others have to see the need for change, to have the expectation that part of their roles as professionals is leading such changes and having the skills and competencies needed to produce the changes. Even if financing is aligned correctly and regulatory barriers are removed, innovations will need to flow from the clinicians, who must see themselves in a new light and have the abilities to be successful in this new world. While there will of course be pathways for existing clinical professionals to learn new skills - in fact, much of our work at The Center for the Health Professions is dedicated to this task - the real payoff will come when professional schools begin turn their attention to this vital task.

The final constraint on change is the continued hegemony of the professions. The impulse to retain control of whatever has been our purview is very natural. We tend to see the world through the lens of our own experiences, if not our interests. There are many words to designate "turf" in health care; I have always preferred the term "professional silos." However, our blinders are not constructed only by the professions, but are influenced by institutions as well. Our health care institutions lack a common purpose, vocabulary, approach to problems, mode of socialization, institutional loyalty and payment scheme. Given all that divides us, it is no real surprise that the calls for "patient centered care" have generally proven a weak basis for integration. When integration does work it comes about because of the vision and organizational skills of the professionals, both clinical and non-clinical, who lead our health care institutions past the boundaries of professional parochialism and institutional myopia.

To have a sustainable health care system that contributes to the public good of the nation, we need new and better practice models for specialty care in hospitals, primary care in the community, and services provided for an aging population. Freeing ourselves from the patterns that have not worked and encouraging approaches that we know have worked, should be our focus.

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