After some initial reluctance, I come forward with my “Top 10 List” of things to do…
As the nation stopped to reflect during our annual Thanksgiving holiday, I’m sure there were many discussions during dinner among friends and family on the many issues which require our careful consideration. We’re still progressing through the nation’s worst recession in nearly a century. Piled on top of the lingering recession, the recent midterm elections sent a clear message that a new direction is required. During the past year, our nation’s leaders made one of the largest bolus investments in history with the stimulus package and then rolled forward with healthcare reform. So, what’s next?
First, let me start with a disclaimer. Philip Tetlock, Ph.D., a psychologist at the University of California has been studying “pundits” and “opinion makers” for the past 25 years. His research has focused on 284 prominent economists, foreign-policy specialists, and journalists (I’m not one of them) – all of whom are opinion leaders. He’s evaluated more than 82,000 predictions and the essence of his findings are the vast majority of experts perform “worse than random” with an accuracy rate of less than 50 percent. Further, liberals, moderates, and conservatives were “equally ineffective” in their predictions. He has summarized his findings by stating that, “Our political discourse is driven in large part by people whose opinions are less accurate than a coin toss.” So, I’m humbled by his research. It may mean this piece is totally irrelevant. I hope not…
Second, much of the healthcare reform package that passed in March 2010 related to insurance reform. We need to have a broader approach. Most of us who are following the discussions in Washington would agree we are only at the beginning of true reform. Most of us would agree the reform package – while an important first step – only represented insurance reform. It did not include payment reform or a host of other important issues that clearly need further discussion. I’ve noted in some of my messages during the past several months that “the reforms will continue for at least the next five years.” In fact, I referred to the healthcare reform package as the “Kevin Fickenscher Full Employment Act of 2010”. Following that blog, I received a number of emails from readers asking the question, “What’s next on the legislative front?” In particular, one of my colleagues wrote back and said, “Okay, Kevin – so we’re not done!” He went on to ask, “What are the next 10 things we need to do?” I’ve pondered that question for several months, and it is among the most frequent questions I’m asked in my travels both here and abroad. The question, and a proposed list of things to do, presuppose that healthcare reform is not yet done. I’m sure there are lots of perspectives on what we should be considering as next steps, but here are my thoughts:
1. Plant a Flag and Pursue “The 30 Percent Solution” – I know this will sound outrageous to some, but as an industry, let’s adopt the 30 percent solution. What is it? Here is the suggestion:
The healthcare industry should increase the quality of care by 30 percent, increase the availability and capability of service by 30 percent, and reduce the cost of care by 30 percent during the next decade – all on a comparable basis. So, the goal for healthcare in America is the 30 percent solution by 2020.
The healthcare industry should increase the quality of care by 30 percent, increase the availability and capability of service by 30 percent, and reduce the cost of care by 30 percent during the next decade – all on a comparable basis. So, the goal for healthcare in America is the 30 percent solution by 2020.
The goal may seem audacious! To some, it may even seem outrageous. But, if we don’t have a simple objective like the 30 percent solution, it will be difficult to capture the energy and initiative of leaders and followers throughout the industry. There are many reasons why we need to pursue this agenda. For starters, as a society, we simply cannot afford to have healthcare costs continue to outstrip overall inflation, which is what it’s done for the past five decades. As one of the largest pieces of the overall gross domestic product (GDP) for the United States, managing the cost of healthcare is crucial for our future position as a continuing world economic leader. Second, globalization of our nation’s economy requires us to be efficient and effective in the use of resources. Third, the demographics are compelling. After all, our society is getting older so without some modifications in our approach, we will simply outpace the ability of the U.S. to continue supporting Medicare, Medicaid, and Social Security at the levels we’ve all come to expect. Fourth, the Internet has moved us from an information theocracy (“Hi, I’m Dr. Fickenscher, and I’m here to help you) to an information democracy (“Hi, I notice that you’re not following the latest protocols on the treatment of prostate cancer.”). Transparency of process and outcomes is the new norm. And, the list goes on.
For those of us who are intimately involved in healthcare, we know that the 30 percent solution – while a stretch – is possible. Meeting the objective will require focus. It requires cross-disciplinary collaboration. It requires data and information. It requires a host of changes in the way healthcare is delivered today. Is a decade too audacious? I don’t think so if we take the challenge seriously. After all, the generations that follow us deserve the very best from us, and so far, we have not performed. Let’s pursue the 30 percent solution!!
2. Accelerate Comprehensive Coordinated Care (C3) Models– We are moving far too slowly on some of the ideas imbedded in the healthcare reform initiative. The pursuit of alternative care delivery models is not only important for the U.S. but also for the world. After all, the world looks to us – at the present time – as a leader in healthcare delivery. Let’s not lose the mantel. With healthcare consuming ever greater quantities of our national budget and GDP, the healthcare industry must address the quality, service, and cost considerations now! Unlike many places throughout the world, we have the advantage of 50 “laboratories of democracy” in the form of our states. We need to push the laboratories to creatively develop the new (some would say old) ideas on how to improve care, reduce costs, and make it easier for consumers to gain access.
But, we also need a formal process for capturing the best ideas for replication from across the country. The approach of fostering innovation is a consistent theme of America during the past 150 years, whether we are talking about the manufacturing of cars, the implementation of Social Security, transforming the airline industry, welfare reform, or your favorite national initiative. Creating “accountable care organizations (ACO)” with the appropriate infrastructure, knowledge, and management capability is a project that demands support and must move forward. But while I love Kaiser, Geisinger, and the Cleveland Clinic, the vast majority of the U.S. healthcare system (and the rest of the world) is based on individual providers and hospitals. Therefore, we need to focus on increasing amounts of time and energy on developing other models that support comprehensive, coordinated care, regardless of who’s pushing the model. What is frequently not well understood is that building a new process for care delivery requires as much investment as building a new widget or a new building. Is our national investment for fostering comprehensive, coordinated care models adequate? I don’t think so. We should redouble our efforts. Research and development in “process” needs to be equally important as the R&D related to technical capabilities. We need to triple the CMS budget for innovation investments, not reduce it – at a minimum.
There are multitudes of technical ways to accomplish this mission. One of the best ideas that can serve as the platform for creating comprehensive coordinated care organizations is to revise our whole approach to health insurance. Specifically, if we’re going to be successful in “bending the cost curve,” we need to get the American public engaged. That means we need to consider adopting two core principles. First, we need to create “incentives” for individuals to alter their behavior and utilization of care services. Second, the focus needs to shift from a procedure-oriented, retrospective “take-care-of the-problem-once-it-occurs” mentality to an upstream, wellness, and disease-management philosophy in our care delivery models. While this idea has been around for as long as I’ve been in healthcare (… that’s getting to be a long time), we’ve never been successful in getting the industry to adopt the approach. Why? I think it is primarily because of the way health insurance has been structured.
During the past decade, we’ve seen a dramatic increase in the co-payments where individuals pay out-of-pocket for a portion of their care on the notion that it would discourage the consumption of services that provide little or no value. However, the literature suggests that by simply increasing co-payments, individuals actually decrease the use of both high-value and low-value services. As an example, studies have shown that if you increase the cost-sharing for medications of asthmatics, the overall cost of care actually increases rather than decreases because patients either reduce their medications or discontinue them entirely. It defeats the whole purpose of preventive medication use for a problem that should largely be managed on an ambulatory basis – and, where individual behavior strongly predicts potential outcomes. So, how to do this? Well, it’s a much longer conversation around ideas like value-based insurance design that embraces certain core principles, including: 1) value equals the clinical benefit achieved for the money spent, 2) actual healthcare services differ in the ultimate value they produce, and 3) the value of the services depends upon the individual who receives them – or, the value we as individuals place on services depends on our perspective related to value that depends on our economic, cultural, and personal backgrounds. There are smart people in the industry working on these types of solutions. We should listen to them.
Simply trying to reduce utilization of care without considering the impact on the individual does little to move the ball forward. So if you accept the above ideas, we need to consider four basic approaches as part of our efforts to remodel the healthcare payment system. They include: 1) design the insurance program so that services known to be effective are supported and encouraged (e.g. prescribing statins for patients with high cholesterol levels), 2) design the insurance program so traditional high-cost problems are automatically covered (e.g. comprehensive diabetic care), 3) support care delivery programs that actively manage the disease problem (e.g. active, in-home management of congestive heart failure), and 4) encourage the use of services and programs known to be more cost effective (e.g. if you participate in a smoking cessation program, your chance of actually stopping is considerably higher). As leaders in healthcare, we need to embrace these concepts. It’s an idea that is garnering attention across the healthcare world. We need to consider it, figure out how to make it work, and … adopt it.
3. Change the Workforce Model– The current system relies on a “physician centric” workforce delivery model. We should stop talking about “who” is providing “what” services and instead talk about “which” jobs make the “greatest difference.” All of the healthcare professions have created a plethora of regulations, rules, requirements, and certifications that permeate the federal and state policy framework. With all due respect to my colleagues, the approach we take to our workforce is based on the guild mentality. We need to reconsider.
First, in a world that increasingly recognizes the impact of genomics and other associated sciences as a critical component for defining disease, are we training physicians and other members of the health team properly for the future? I don’t think so. Second, if we were to dramatically increase the size of medical schools and residencies tomorrow morning, do we really think we would resolve the shortage of providers that will be needed in a world with dramatically aging demographics, let alone a sizeable new chunk of people who will now be given access to care via the existing healthcare reform programs? I don’t think so. Even if the floodgates were opened to medical school tomorrow morning, the likelihood of having a sufficiently sizeable physician workforce that meets the healthcare delivery demands in the next four to 10 years would be marginal, at best. Third, in an information theocracy where the physician guild members held all the knowledge, it may have made sense to have them in charge. In an information democracy where knowledge, capabilities, and skills are increasingly ubiquitous, does “control” make sense? I don’t think so. There is no way a physician-centric, control-oriented, top-down model will work for delivering care to people throughout the world. Physicians know it. Let’s deal with it.
We need to create a cross-disciplinary model. I will be even be so bold as to suggest we need to establish a workgroup that reconsiders all of our existing policies so we can develop a new model for delivering care based on outcomes and accountable care – not professional guilds. The guilds are dead! Let’s face it and deal with it. Make the new reality work. In our quiet, back-channel circles, we – in the professions – know this is the new reality. If we consider public opinion polls, the medical and healthcare delivery professions are frequently “at the top” in terms of public credibility. We got there because we care about people. We engender the trust of people throughout society. Let’s put care in front on us – not, behind us. It’s by putting the public at the forefront that we got to a premier societal position in the first place.
4. Focus on the Low-Hanging Fruit– The healthcare industry tends to be a bit scattered in our approach to solving problems. If we want to meet or exceed the 30 percent solution, we need to focus our energies – as an industry – on the areas that consume the most resources. But, if we look at the landscape today, we’ve got initiatives all over the place. The spine guys are doing stuff. The thoracic surgeons are promoting changes. Every specialty and every ultra-ologist group is proposing infinitely complex changes in the care delivery process for the ultimate ultra-ology problem. These efforts are all well and good. I don’t mean to dismiss them. But, as an industry, we don’t focus on the low-hanging fruit. So, how do we focus?
First, let’s come up with the list of the biggest problems in healthcare today. That should be relatively easy since 80 percent of the 2,423,712 U.S. deaths last year were caused by just four problems: heart disease(616,067), cancer (562,875) [NOTE: a complex matrix of inter-related and yet disparate problems], stroke/cerebrovascular diseases (135,952), and chronic lower respiratory diseases (127,924). Rounding out the top-10 causes of death in the U.S. were accidents/unintentional injuries (123,706), Alzheimer's disease (74,632), diabetes (71,382), influenza and pneumonia (52,717), nephritis, nephrotic syndrome, and nephrosis (46,448), and septicemia (34,828).
My vote? Rather than focusing on the death area directly, let’s focus on the reason those death problems are on the list in the first place. If we cut to the chase, it seems to me the first piece of “low-hanging fruit” is we need to tackle obesity with a vengeance. At the outset, let me state that I believe if you’re going to call for tough love on an issue, it’s important to have walked in the moccasins of those who currently trod the path. So, some of you know this, but I’m a formerly obese – no, I offer “fat” person. I got up to 398 pounds before I came to the realization I was more than just a little overweight (i.e. fat). I tackled the problem and have been at a more reasonable 175 pounds for the past five years. It was – and is – the most difficult journey of my life. But as I speak to the issue of obesity, please know that I’ve been there, done that!!
As a society, obesity is the prime healthcare problem! It’s complex. It’s difficult. It’s emotional. And, it’s social. There are very few problems in healthcare more complex than obesity. It probably contributes to one-third of our overall national healthcare costs, requiring us to spend multi-billions of dollars of the sequelae that occur as a result of the problem. So, just solving this problem gets us far down the road of the 30 percent solution. There are lots of different ideas on how best to solve the obesity problem. I’m a firm believer that if we put in place the proper incentives, people will do the right thing. So, if we want to support individuals losing weight, incentives make a difference.
Obesity is one of those “healthcare problems” that – except in the unusual circumstance – is pretty much under our individual control. And if one’s obesity is not, for some reason, under individual control, as a society, we need to take any “not-under-my-control” issues into account. But if you are “in control,” we all need to be held accountable. And, we need to put the right infrastructure in place to support you with programs, services, and policies make it possible for you to deal with the problem. It was not until I recognized I was “fat” that I decided to deal with the fact I was “fat.” It’s my mantra. Personal is stronger than forced. So, let’s encourage personal action. What fosters personal action better than anything else? Incentives! A number of companies have realized this solution. Steven Burd, the CEO of Safeway, has dramatically altered the cost structure of their healthcare programs, resulting in lower monthly premiums for all employees. The company requires employees to meet internal standards on tobacco use, weight, blood pressure, and cholesterol (note: three out of four of these issues relate to obesity) and they’ve seen a difference while their overall healthcare costs, as a company, have stabilized.
If you want to be obese and put yourself at risk for heart disease, create a strong possibility of adult onset diabetes, get into hypertension and all of the attendant problems associated with it – so be it. But why should society simply pay for bad decisions? The discussion on this issue is similar to the one we had as a society several decades ago on the requirement for using seat belts in cars and helmets for motorcycle drivers. We don’t allow cyclists to ride without motorcycle helmets anymore – despite the more than a decade-long debate on the issue – because we came to the conclusion that the societal costs of head injuries were far more than the personal infringement on rights to sail down the highway without a helmet. As a society, we said that if you didn’t want to wear a helmet, if you didn’t want to wear a seat belt – you could do that but there would be an associated fine. The end result is that virtually all motorcyclists wear helmets and I know very few people who do not buckle up.
While we can blame others for “our” problems, the incentive for solving these types of problems is at the personal level. Yes, we can blame fast food places, the large portions served at restaurants and a host of other considerations for our nation’s obesity problem. But at the end of the day, it’s about me and my attitude towards myself. The change of perspective on obesity in society will be a sticky wicket. Again, we need a dialogue. But we need to start somewhere. Let’s consider placing the burden of obesity on the individual – with appropriate protections – rather than on society. Jamie Oliver and Michelle Obama are on to something with their challenge on the obesity issue. We should take note of their efforts. After all, icons can help us solve our problems in healthcare…
Quite frankly, obesity makes a lot of other problems pale in comparison. But I won’t say that for cigarettes because they’re just plain bad, if not worse – which brings me to my second “low hanging fruit” consideration. It’s been shown with absolute clarity that the rate of teen smoking is directly tied to the tax rate of smoking. The higher the tax rate on cigarettes, the lower the smoking rate among teenagers. I suspect there’s a corollary for obesity. We tax alcohol and cigarettes. Perhaps there is a way to use the same approach for the obesity problem, which is pretty much 95+ percent about personal decisions. We also need to invest the cigarette settlement funds appropriately. If we don’t invest, we will not get results. And that has been the experience of the states related to smoking. Ever since Surgeon General C. Everett Koop, MD, issued his famous report on smoking, the rate of smoking in the U.S. has continued to decline from over 40 percent of the total population to 19 percent in 2009. But for the first time in several decades, the smoking rate went up in 2010 to an estimated 20 percent. Why? Primarily because of growth in teen smoking.
The focus on cessation and prevention has been whittled away because of lack of investment by the states in this area through the use of the tobacco settlement fund. While the tobacco settlement program was generally a good outcome, the implementation has been flawed. Why? Because the states were not required to use the funding for smoking cessation and prevention. They only “promised” to do it. So, in the end, the tobacco settlement funds simply go to the state general fund. As a result, the states are using the tobacco settlement funds for infrastructure like sewage systems and highways or refurbishing state buildings or any number of other favorite state legislative issues, rather than for public health purposes.
In 1998, when the multi-state tobacco settlement was finalized, the states promised to use a significant portion of the settlement funds — estimated at $246 billion during just the first 25 years — to attack the enormous public health problems posed by tobacco use in the United States. Beyond “the promise” – which has gone largely unfulfilled – the states also collect billions of dollars more in tobacco taxes.
Despite the estimated state resource pool of $25.1 billion in 2009 derived from all forms of taxes and the settlement fund, the states are spending less on tobacco cessation and prevention programs. In fact, cuts in state funding for such programs were reduced by more than 15 percent from 2008 to 2009. Only one state – North Dakota (my home state) – funds a tobacco prevention program at the level recommended by the U.S. Centers for Disease Control and Prevention (CDC). Only nine other states fund tobacco prevention at even half the CDC-recommended level, while 31 states and the District of Columbia provides less than a quarter of the recommended funding.
By the way – in another mea culpa – I used to smoke four packs of cigarettes a day as a young physician and quit rather abruptly on December 17 at 11:32 p.m. when I developed chest pain (a much longer story). But I don’t look back. The decision to quit smoking was the best decision I’ve ever made in my life – aside from marrying my wife. We need to support more people quitting and we’re not going to make it if we do not reinvest the money in smoking cessation and prevention programs. We are simply misallocating the tobacco settlement funds for non-public health purposes. Also – again, full disclosure – I’m a bit over-the-top on this issue as my Dad and my brother both died of lung cancer – from smoking. Trying to be transparent… Smoking is the worst…
A third potential “low hanging fruit” opportunity is to create an industry-wide initiative to reduce the cost of congestive heart failure care by 30 percent during the next three years. By the way, congestive heart failure probably consumes about 20 percent or more of the healthcare costs for the nation at the present time. Is it better to have people show up in emergency rooms and get treated in hospitals for two days, or to be preemptively recognized that they are going into failure – a very predictable event for Stage I & II CHF – and not go through treatment and admission to a hospital? It’s clear when you talk with clinicians that we know how to solve this problem. I know we can do it. And what’s our next biggest healthcare problem? Diabetes? Oh – we’re back to obesity…
But rather than having me pontificate on what we should focus on, I suggest that we convene the major leaders of healthcare from all segments of the industry to make the case on where we should focus our time and energy. It will not be a long meeting. I suggest we could solve the problem of “focus” with one long weekend of debate and discussion. So together we pick the favorite “next” big ticket items. And then? Let’s focus on them! I’m not suggesting that we let other problems go. There are lots of other problems in healthcare that require our attention. I’m simply suggesting that if we decided – as an industry – to tackle a problem by collaborating together, we’d make much more progress in a relatively short period of time and meet the 30 percent solution. Let’s define our work and focus on a simple set of healthcare problems for the next three years. Then, let’s reconvene the group in three years to evaluate our success and determine the next five things we want to accomplish for healthcare.
The healthcare world tends to get lost in the weeds when the answer is in front of us. Let’s develop a consensus and go for it. It’s sort of like seat belts or helmets for motorcycle drivers. Does anyone in healthcare believe we should not have seat belt laws or requirements for motorcycle drivers/riders to be wearing helmets? We went through those debates and came to the conclusion that the cost to society related to potential infringement upon an individual’s right simply does not outweigh the costs. Does anyone think that having headlights on cars is a bad idea? Or what about text messaging when you’re driving down the road? The data is pretty compelling. These are all favorites of various constituencies. Let’s pick our list and make it happen…
5. Support Open Standards for HIT Usage– While “meaningful use” has gone a long way toward pushing the industry in the right direction, we need to recognize that we are engaged in the long march of having information technology contribute substantively to quality care. We need to continue our push. One of the major impediments is the lack of agility in moving information from one provider to another and from one system to another. What about “open standards?” We should not only demand it, we should require it as soon as possible. If we had not developed open standards related to the distribution of electricity at the turn of the last century, we might still be trying to light corner gas lights in cities throughout the world and be using candles in our homes. Why do we tolerate proprietary sequestration of healthcare information that impacts individuals or the public health? The data for moving toward open standards is compelling. The issue is not about the electricity, it is about how to create the tools and products that require electricity and how they can change, modify, or make our lives better. The difference in our ability to care for people would be remarkable under an “open standards” framework. But our process of sharing information in today’s world is extremely difficult. Let’s change it – now!
6. Replace Our Dependency On People– Healthcare is extremely dependent upon people resources for the delivery of care. Yet one of the facts I've learned during my career as a physician is that technology can replace what we think are requisite “people activities.” In fact, one of the biggest detractors in the quality of healthcare services is the handoffs between people that create inefficiency, ineffectiveness, and errors. We need to move in the opposite direction and pursue an agenda of appropriately using technology to reduce our dependency upon people as part of the care delivery process. An increased focus on “technology enabling” capabilities ultimately increases quality, enhances services and reduces costs. It allows us to spend more of our healthcare dollar on the appropriate “real people activities” that are so very important in the healthcare setting. As an example, if I have chest pain in the emergency room – do I want a nurse there to be by my side guiding me through the process of care? Absolutely! Do I need a nurse to be capturing my biologic data? No, I think not. Do I need a nurse to be coding me correctly for billing purposes? I think there’s a better way. Rather than having people supporting services or capabilities that can be handled by appropriate technology, we need to shift the system and refocus our people investment. If functions can be handled by technology – let it happen. Such an approach frees up time and space for people to support people – one of the most important mantras of healthcare. I’ve been in the intensive care unit. There is nothing more comforting than the support of a nurse when you’re feeling incredibly vulnerable. We need to change the equation so that nurses and other care delivery experts spend time on activities and services that technology cannot provide. How many interactions can you think of in healthcare that do not require a person? There are too many to count, and yet in today’s world we require human intervention for far too many of the tasks. You get the point… Let’s invest in technology that can make us more efficient and effective and help to reallocate the limited human resources more appropriately. Let’s invest in people where technology does not – and can not – make a difference.
7. Require Provider Transparency– The literature is replete with many, many examples on where we provide direct information to physicians and they change their habits. If you give information to individual physicians, some behavior changes result. If you give information to groups of physicians, the results are better. If you publish the information in a transparent way so that the world knows, the results are phenomenal. In early Sept. 2010, the American Society of Thoracic Surgeons – who in 1989 developed a program that enlists more than 90 percent of the nation’s 1,100 U.S. cardiac surgery programs in the country – decided to go public. They are publishing the results of their database in a very public way – through Consumer Reports. The “transparent” report covers the procedures at 221 programs throughout the U.S. based on 11 performance measures endorsed by the National Quality Forum. And it includes a simple one, two, and three star evaluation system – something the public understands. We need more of this approach to the complexities of healthcare in ALL fields and ALL specialties. Thank you to the Thoracic Surgeons! Now, how about the Orthopods? What about the Dermatologists? And the Cardiologists? And we should not forget the primary care providers, either…
8. National Licensure– In our current situation, the licensure of healthcare professionals is handled at the state level. In a world where healthcare is increasingly provided on a national or even global basis, where information is handled “in the cloud,” and where interpretations based on the manipulation and use of digital information occur as a result of a conglomerate of providers working together on a virtual basis – confining our licensure process to a state-level approach seems far from adequate. As physicians, nurses, pharmacists and other direct providers of care begin to offer their capabilities and services on a virtual basis not only across the nation but throughout the world, the arcane process of state licensure needs to be reconsidered. The state commissioners of K-12 education recently made the decision to develop a national standard for graduation from high school. Why? Because the rest of the world operates this way and we were losing our competitive position in education. We are at risk, from my perspective, of losing our competitive position because of the same considerations in healthcare. We need to pursue national licensure so that we can fluidly provide healthcare throughout the nation – and for the world – as needed. We currently hold the best healthcare resources in the world. Let’s not let artificial impediments get in the way of continuing our leadership position in this most important service capability. Again, now is the time…
And while we’re at it, we should shift our model of continuing medical education (CME) to an outcomes education model. Rather than the pedantic “take-this-course-and-get-these-credits” approach, let’s shift to “outcomes accreditation.” I’m actually not sure how to make this suggestion a reality. But there are a tremendous number of bright minds in medicine. I’m sure we can manage. It takes focus and energy. Such an approach to CME fits with a move toward national licensure.
9. Tort Reform– As a physician, I can’t believe we’re not moving forward with tort reform. It’s central to getting clinicians on board and does, in fact, contribute to the bottom line. Even the most conservative estimates project a direct savings of 1.0 to 1.5 percent of healthcare costs – at least $30 billion dollars – which in some circles may be considered small potatoes in a $2 trillion-plus healthcare system. However, in my book, every billion counts. Other studies that include the indirect as well as the direct costs of liability insurance project savings in excess of $100 to $150 billion dollars. It seems, however, that the lack of movement forward on tort reform is purely about politics. The two primary arguments against tort reform are that it’s a states’ rights issue, and it would limit the ability of injured individuals to gain restitution in liability cases. In fact, in states where liability reform has been accomplished, these two issues have not been the case. Texas and several other states created model tort reform legislation during the past decade and it’s proven incredibly beneficial for reducing costs and re-invigorating the physicians workforce. I’m sure we can manage our way through this discussion if we had the perspective of keeping the individual’s rights in place while making the system work much better. It’s commonly said that the most expensive tool in healthcare is the physician’s pen, and ordering excessive tests as a shield against liability is something that can be changed. Let’s put the issue of tort reform aside and make the change happen. Come on… give me a real reason why we should not do tort reform?
I know I’m near the end of my top 10 list, so there’s one more thing we need to do which may also be one of the most important. It can’t be legislated. It’s not about policy. It’s about how we can truly make a difference…
10. Find Elvis– My favorite metaphor comes from Dr. Michael Roizen of the Cleveland Clinic: “we need to find Elvis!” I’ve been working to help increase quality, enhance service, and reduce costs for too many decades now. My focus has been on the use of technology for making healthcare better. Some of us during the last several decades worked to create operational improvements. Others worked on creating innovative solutions to intransigent medical problems. Still others got outside the box and look at the world in a whole different way.
What was pointed out to me several months ago is that perhaps we’ve been working on the wrong stuff. While technology, operational improvement, and delivery problems are important, there are other elements that are even more important. So the question I was asked is: What individual reduced the cost of healthcare over the shortest period of time in the last century? I immediately thought of the issue of smoking and the contribution of C. Everett Koop, MD, the former U.S. Surgeon General who issued the famous report on smoking. When the Koop Report was released, about 43 percent of the American public smoked cigarettes. Last year, the figure had dropped to 19 percent. But the answer was not Koop. It was an improbable Elvis Presley! Why? Because, on Oct. 28, 1956 Elvis went on an ABC-CBS-NBC simulcast and had his polio immunization done on national television by Dr. Jonas Salk! The end result? The polio immunization rate in the U.S. went from 0.6 percent to more than 80 percent during the next six months. Polio was solved because it’s all about herd immunity. Iron lungs were redundant. Rehab services were not required. Suddenly, we were faced with a situation where a whole bunch of healthcare infrastructure and capability which cost society lots and lots of money was no longer needed – because the name of the game had changed. We moved from responding to the situation to solving the problem. Elvis was an “icon,” not a healthcare delivery person. He changed healthcare in ways that all of the physicians, administrators, and other leaders of the health industry could not.
But then one of my close friends pointed out if you need to find Elvis – just look in the mirror! He reminded me that I consider the first time I walked onto the floor in my white coat with stethoscope in hand. I was beaming with pride and the desire to “make healthcare better.” In fact, I’ll never forget that first clinical rotation when one of my patients turned to me instead of my internationally-known attending and said, “So, Dr. Fickenscher – what should I do?” I was humbled in the presence of my professor and the team. So I’m coming to the conclusion that we need to “be” the icons rather than “find” the icons in healthcare. I think of Jamie Oliver – the famous chef whose restaurants are infamous – and his battle against obesity. He’s done a lot to raise our national awareness. But we need to pick up his banner and make it happen. Jamie Oliver can’t change the lunch programs in every school across the nation. But together – we can! Icons stimulate and make things happen. Icons also pick up the banner and help make concepts reality. As good leaders, we need to mobilize all of the icons – famous or not – and, more importantly, we need to mobilize ourselves. Who’s your favorite icon? Look in the mirror. There are lots of icons out there, but “we” are the most important resource. So go find Elvis!
So that is my “top 10 list.” It may not be the right list as it has not been vetted by a lot of people. But I present the list as a set of germinal ideas that require further rumination, development, and – perhaps – rejection. Regardless, we need to move beyond the current insurance reform debate to the much bigger – and much more important – issue of how to truly transform healthcare delivery. While I may be a voice in the wilderness, I offer my list as a starter kit for moving the agenda forward.
As I’ve told many audiences during the last couple of months, if we – the healthcare leaders – do not step forward with solutions, we will bankrupt the country. I’m very serious. We are moving in that direction because we are not bringing forward solutions for quality, service, and costs of healthcare. As healthcare leaders, we got into the business because we wanted to make a difference. We have an obligation to society to do our part and contribute to the solution. Protecting our interests and simply pushing back does not help. We should seize the responsibility. We can do better! Let’s make it happen. If you want to join me on this effort, send me an email at email@example.com or firstname.lastname@example.org and we can discuss. Any feedback and alternative perspectives are appreciated. We are facing one of the most important periods in the history of American healthcare.
I hope you had a great Thanksgiving. Now the Christmas tunes have taken over the airwaves as the time of reflection moves aside. I appreciate you considering these ideas, and if you don’t like them – send me your list. After all, it’s only through dialogue, discussion and debate that we – as healthcare leaders – will find the way. Now, let’s make a difference…
Christmas is only 25 days away. Enjoy your families and consider the possibilities…
Follow Dr. Fickenscher on Twitter @MDKev