A False Summit?


A False Summit?

While a divided Congress met at the Blair House to attempt to reconcile differences, America hunkers down , chilled by cold economic winds and unnerved by the gathering storm brought on by fiscal shortfalls and unsustainable deficits.  As our elected officials argued over a way forward, it was obvious that there would not be enough common ground found to chart a coherent course that improves access, reduces medical trend and moderates ballooning federal and state deficits driven by increasing obligations to existing entitlements through Medicare and Medicaid.

In between stumping and finger pointing, inconvenient truths tumbled like falling rocks on the heads of policymakers locked in the heated debate over whether to begin reforming healthcare by expanding access to 30M Americans or by addressing the underlying cost drivers of a system that all unanimously agree needs fixing.  While Kent Conrad ( D-ND), and Paul Ryan ( R-W ) came across as lucid scouts describing the decades deep crevasses of entitlement deficits and the imprecise orienteering of CBO accounting, other Congressional exemplars reinforced our belief that they were simply no longer fit to lead a next generation of climbers eager to move up the mountain.

The sad truth is we face a formidable obstacle in healthcare reform.  It is a Darwinian wilderness where the strong survive and individuals are unevenly protected.  It is a foreign land where neophyte consumers believe that “quality care” is getting unrestricted access to all the services that they believe they need for as low an out of pocket cost as possible. A diverse ecosystem of for profit and non profit stakeholders seek to accommodate this insatiable expectation and in doing so, assert that they create great value through the services they provide.  It seems no one believes they are part of the problem. Yet, people continue to die from exposure.  We fail to rope in the most vulnerable among us and have sadly become more indifferent to their personal tragedies.

We are in desperate need of reform but experiments such as Massachusetts that seek only to expand access to the uninsured  have taught us that the summit of universal coverage cannot be conquered without an underpinning of affordability.  They will end in financial disaster. The ropes that safely bind us to a fiscally sustainable path must be anchored by employer based insurance and woven with universal reforms in reimbursement, Medicare/Medicaid, access, consumerism and stakeholder engagement. The entire process must be reinforced with chronic disease management,  transparency and balanced regulation of the small and individual insurance markets.

Enormous time has been spent vilifying insurers, as if to convince us that aggressive oversight of payers can somehow fix our healthcare system.  Singling out a particular stakeholder as the primary barrier to our goals of quality, access and affordability is the reckless equivalent of telling an obese person that they can lose all the weight require simply if they just stop eating bread.  The mountain’s crest offers no easy access. The route is marked by tombstones of idealistic reformers who fell short of their objectives.  Stakeholders must recognize that we are all part of the problem but we do possess a map that can safely lead us to the top.   Ironically, many of the legislators attending the Blair House summit actually helped contributed to the treacherous conditions in which we now find ourselves – as we consider a future where public and private healthcare expenditures exceed an insurmountable 20% of our GDP.

In considering the rhetoric and reality of our circumstances, we must understand why the current House, Senate, GOP and Presidential proposals are false summits for conquering our current healthcare crisis.   Congressional leaders, desperate for re-election, will simply not commit to an honest discussion of the risks and realities of fixing healthcare. To conquer the mountain of public and private healthcare spending we must belay our way with:

1)   Reimbursement reform – 30M uninsured people will be entering a healthcare system that is graduating less than 2% of its medical school graduates as primary care doctors. This means no care coordinator to assist those who have historically accessed medicine through the most expensive setting in America -the emergency room.  Massachusetts as the first state to adopt universal coverage and individual mandates has discovered in their first years of universal coverage that ER visits are increasing by 8%-10% as individuals – now covered – default into old patterns of access.  The rural and urban family practice physician is disappearing as a disproportionate amount of federal, state and private sector reimbursement is going toward specialists and facility care and their treatment of chronic illness – – instead of its prevention. We must restore the role of the primary care provider as the control point and care coordinator for a first generation of consumers committed to health improvement. Reform should focus on higher reimbursement and educational incentives to study and practice primary care.

2)   Medicare and Medicaid reform – If the US government were an insurer, it would have been seized years ago by regulators for serial underfunding of present value obligations.  To propose $500B of physician fee cuts while promising seniors no benefit cuts and an expansion of the presently unfunded Medicare part D prescription drug program is irresponsible.  To even qualify to expand its role in covering more Americans, Medicare and Medicaid need to address an estimated $ 100B  in annual fraud, abuse and overtreatment.  The current programs achieve “ affordability” by rationing reimbursement to doctors.  Another 21% in fee cuts will only reduce the number of doctors willing to accept payment from the federal government. The ethical and moral no man’s land surrounding end of life care in America make funding the last six months of life in the US, more expensive than five decades of life preceding them.

3)   Access Reform – Consumers must accept and be willing to enter into medical home/gatekeeper delivery systems where primary care providers coordinate care and authorize access to specialty and tertiary care services.  Over 110M Americans access the healthcare system through the emergency room each year.  More than half of these individuals are insured but not under the care and control of a primary care provider.  Self-referrals and self diagnosis is leading to overtreatment of insured individuals – consuming, according to Overtreated,authored by Shannon Brownlee, as much as $700B each year that might otherwise be available to finance care for the uninsured and the underinsured.

4)   Consumer Reform – With 60M Americans overweight and slowly descending into lifestyle based chronic and catastrophic illnesses, we are not requiring those who might be eligible for expanded coverage to engage in healthier lifestyles.  Asymptomatically ill and chronically unstable individuals are more likely to incur catastrophic claims.  5% of Americans treated in Medicare and private insurance consume 50% of all services.  Subsidies and minimally credible coverage mandated for the uninsured should include plan designs that require biometric testing, lifestyle coaching, and compliance rewards for managing chronic conditions. Consumers must be limited in their ability to sue a treating physician if that doctor has followed evidence based medicine guidelines for treatment.

5)    Stakeholder Reform – There are myriad opaque pricing and payment practices that plague the $ 2.2T healthcare system.  Transparency of services should not just extend to insurers but to brokers, agents, hospitals, pharmaceutical benefit management, specialty and other third parties who play a role in the healthcare delivery chain.  Affordability must focus on demanding value for payment.  You cannot improve what you cannot measure.  Consumers, employers and government are often ignorant to cost shifting, clinical variability, hidden remuneration and perverse incentives that threaten to compromise the objective treatment, advice and service support that must characterize a world class system.

The Blair House healthcare gathering reinforces our notion that Congress understands the logistical complexities of fixing healthcare but in its failure to find common ground, it was merely a false summit.  While our public policy guides argue on the best way forward, we lose confidence that neither group is actually carrying the essentials necessary for quality care to survive. The prevailing sentiment among Democrats is to follow the uncertain fiscal direction of Massachusetts choosing a less intimidating path of achieving universal access before tackling the more jagged and dangerous step of affordability reform.  The GOP has counseled a conservative route to the top – opting for an incremental and sluggish pace with no clear timeline to ultimately conquer the peak.

It remains to be seen whether Congress and the American people will fatigue before conquering healthcare.  For 180M Americans covered by employer-sponsored healthcare, the fear of leaving their base into the unknown thin air of change creates doubt and concern.  For 45M uninsured, the prospect of climbing higher seems a worthwhile alternative to their current circumstances.

The risk of getting to the top too rapidly is fiscal edema and a Darwinian rationing as we realize that we have finite resources.  If we move to slow, additional fellow climbers may perish from inaction.  One thing is for certain.  Storm clouds are gathering and conditions are deteriorating. We are in the “death zone”.  We have to go up or go down.

We simply cannot remain here.

3 thoughts on “A False Summit?

  1. David Sloves February 27, 2010 / 6:04 pm

    Mike — I appreciate the elegance and coherency of your analysis. A couple of questions that I’ve been thinking about and suspect you’ll be more capable of addressing than I …
    (1) Is there such a thing as major medical even available these days? E.G. policy that only kicks in after like $10K annual family/individual expenses? I know about HSA, but I’m talking even a higher deductible.
    (2) Is there a regulatory requirement that the initial intake point be a doctor — versus say a nurse or physician’s assistant? I know that such folks exist and do “most of the work” in PCP offices, but I’m talking about a more radical approach still. I recognize what the AMA would think of such heresy, but given the 2% and declining VS biz req for this intake point, maybe all parties ought take a big step back and regroup.

    • Michael Turpin February 27, 2010 / 11:41 pm

      Mr Dave, thanks for the kind words. (1) Major medical policies are a big part of what people are buying on the individual market these days. A $ 2k, $5k or even $10k deductible is not uncommon with coverage for catastrophic events. The problem is many of these policies have lifetime maximums of $ 1M or $2M. One would think that should be adequate but a preemie can cost $ 1M and a child with a serious chronic condition can burn through the lifetime max and render coverage useless. Regulating lifetime maximums and other coverage limits out of individual policies is an essential ingredient to reform. Many of the horror stories you hear are people who thought they were buying insurance but limits maxed out or pre-existing conditions were excluded from coverage (2) Ironically, some of the biggest opponents to RNs and nurse practitioners playing a bigger role in healthcare have been the docs themselves. There is a clear and undisputed opportunity for nurses practitioners to fill the family practice void and help triage patients in a new medical home model where plans sold require people go through a primary care facility to receive a referral to a specialist. The law does not require this. Moreover, employers yielded to their employees when people started to revolt against managed care. We gave in to demands for open access and the ability to self refer. This opened the floodgates to a generation of people who routinely self diagnose and aggressively ask for specialty care from individuals all to willing to accommodate them – partially out of fear of malpractice and partially motivated by the financial incentive to deliver fee for service care.

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