Wednesday, July 18, 2007

Health Care Reform – Who Should Come to the Table?

Health care reform is not a new topic; different groups have been talking about it for the last 20 years, but are now becoming louder and both more insistent and consistent.

The voices calling for change in health care have typically been the following:
1. The government: those who regulate and fund Medicare and Medicaid. Although governmental representatives should have a place at the table for this discussion, I believe that the most effective and logical solutions (those that work in practice and not just in theory) must be ultimately formed by experts who don’t have hidden political agendas and have worked in the health care field. These are the people who know best how to bring about the changes which are necessary.
2. Employers. When I worked at Henry Ford Health System, the cost to insure one employee at Ford Motor Company exceeded the cost for steel for one automobile. Insurance costs for employers continue to rise, and so they need a voice, especially as long as they are expected to foot the bill for much of the insured health care in America.
3. Patients and their families, long-term care residents, etc. Many of these are self-pay or must provide increasing insurance co-payments when receiving health care. Therefore, they are now stepping up to plate and saying, “I need to be heard.” As they are at the center of this discussion, it seems most important that they have the opportunity to participate.

As these groups gather around the table and embark on this ambitious journey, they should keep some additional things in mind.

First, do we have the resources to provide truly universal health coverage? Can we “cure” the health care system in America in one fell swoop, or does it make more sense to make changes incrementally? (I covered my opinions about this in last week’s post—obviously I believe that an incremental solution is best.)

Second, issues of quality remain paramount. We can’t afford to consider costs alone, but first and foremost must be able to ensure consistent and predictably high-quality outcomes. Providing consistently high quality health care must be at the top of our priority list.

Third, what is the incremental cost? When I worked at Henry Ford Health System, the number of Ford Motor Company retirees exceeded the number of people actively employed by the company. In many instances, start-up or up-front costs are more expensive, so we must be able to see a cost benefit over period of time, which is why we need to look at least 10 years into the future as far as actuarial costs are concerned. We must also be able to stabilize the system as we make the transition.

Fourth, since we are designing this system to last well into the future, what can we expect 10-15 years from now and beyond? We know that many baby boomers are expected to retire in the near future and that seniors today are aging very differently than our parents did. Today, the average length-of-stay in a long-term care nursing facility is less than 9 months. Yes, seniors today are entering nursing homes later and staying there less time than in the past, which is wonderful. Today, most seniors prefer to “age in place” and retain their independence as long as possible.

Fifth, funding, as opposed to quality, must be variable. I recently returned from a trip to Bogota, Colombia which gave me the opportunity to become familiar with the health and social systems there.

While I admit that Colombia is not perfect and of course cannot condone any human rights violations in the country, I found the social system to be an interesting one. In Bogota, there are 50 private agencies that provide programs of quality for their members that affect all three aspects of daily life: health, education and social. There are three levels of payment for services, based on one’s ability to pay:
1. If an individual can afford to pay, then they pay 100 percent of the cost (full sticker price).
2. If an individual earns four times the poverty level, then they are offered a 40 percent discount.
3. And finally, for those who are at or below the poverty level, the government provides a $400 a month subsidy.
In this way, everyone receives health care, education and social services at a price they can pay.

We must ensure that in whatever system is created, funding is variable but quality is not. Everyone must receive the same level of care regardless of their ability to pay. One life is just as important as the next, no matter what their economic stature may be.

In our facilities in Mexico, we are able to operate clinics for the indigenous communities, most often the poorest of the poor, by utilizing distant monitoring, an innovative and cost-saving approach. Generally, this population lives in rural areas, so distant monitoring allows professionals who are trained in data and evidence-based medicine to monitor these patients remotely.

As a whole, CHRISTUS spent over $286 million last year in community benefit. Every CHRISTUS region must have a plan for caring for the uninsured and underinsured. Our system has always been committed to caring for the poor, and is implementing “medical homes” for the uninsured so they can avoid needing to receive care in our expensive emergency rooms. However, the question is, “Can CHRISTUS Health or any health system sustain this level of charity care into the future?” With declining reimbursement, the answer is no.

Therefore, all the voices of change must come to the health care redesign table in order to ensure that all people receive high-quality health care that is cost-effective and innovative, regardless of their ability to pay.

It’s obvious to me that the plan in place in Massachusetts to require employers to spend 8 percent of their payroll on employee health insurance will not work in Texas. In Massachusetts, less than 10 percent of the population is uninsured. By contrast, over 24 percent of the population of Texas is uninsured. Therefore, those at the table may need to find another system for providing this additional coverage for the large numbers of uninsured and underinsured.

However, in deciding who comes to the table, I trust that those who are chosen to redeem health care are not as important as what is on the table. In the middle of the table should sit a picture of patient surrounded by his/her family so that all the groups can retain their focus on why we’re really here: to provide readily-accessible patient and family-centered care of the highest quality and lowest cost possible. We know it is possible because we already have models to study and incorporate into our redesign!

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