Normally, I write most of the material in this blog. This morning, I was getting ready for work, watching the news (Fox) and I saw this lady talking about the healthcare letter she sent to Americans. I wish the morons in congress would take a look at this. The ladie's name is Oakleigh Ryan, she is married with two kids, has worked in healthcare for over twenty years. She has also survived cancer. This is long, but very informative.
August 2009
Healthcare letter to Americans: Is there another way?I read an article recently that compared the healthcare reform in Washington to sausage making. It is messy, and you aren’t quite sure what is inside. The problem is that Americans are going to have to “eat” what ever is the final product.
In talking to friends and family, many share concerns regardless of their political allegiance. Almost everyone says we need reform in healthcare but question if the current process will deliver what we need. A sense of hopelessness appears as if this “healthcare mess” is so complicated and so big, that the normal American couldn’t begin to understand the detail.
I do not believe this needs to be the case and have written this letter to help more people be confident and passionate about participating in the reform process. To do, this I believe it is important to:
•Share how the current reform has failed to address the key components of timing, participation, goals and motivation; and
•Offer what could be a true strategic reframing of an industry through an outcome-oriented approach that is led by industry reformers including consumers and physicians not just politicians.
What motivates me? I have worked within healthcare my entire professional career from hospitals to clinical laboratories to pharmaceuticals. This exposure even included time beyond our shores when I spent four years working with the UK National Health Service to modernize its laboratories. Living in England, we received healthcare both from the National Health Service and the private system. As a family we have had to shop for healthcare insurance and faced the possibility of not being insured. As a mother, I am the healthcare organizer, appointment maker and expense keeper. And I have been a patient at MD Anderson Cancer Center since 2002 and know that my active role and the relationship I was able to have with my physicians in a world-class organization impacted my good health today.
I. The Current Process for Healthcare Reform
Timeline Challenges: Speed Can Cause Accidents
Let’s start at the beginning. The House and Senate have worked at a frenetic pace to bring a bill to their respective floors, so we can have Health Care Reform taken care of before August recess. If this had occurred, Washington D.C. would have solved the healthcare problems which consume 17% of our economy and 1 out 6 jobs in just under 90 days. That is from May 11th, when the administration first announced its three principles of healthcare reform, to August 7th.
While the timetable has changed, we already have the impact of what an artificial timeline has on quality of plans. Senator Snowe (R-ME) spoke very specifically about this during a TV interview on August 4th. She complained that the early deadline had impacted their ability to think clearly. The timeline had heightened anxiety and deteriorated the process. In July, Peter Orszag, the White House Budget Director, shared with Congress that even if he could be a benevolent dictator for a day, he wouldn’t know how to fix the very complicated Medicare fee structure. While I appreciate his honesty, I believe it shows the current disconnect between political time lines and the real issues at hand. Or in the words of Thomas Edison, “Vision without execution is hallucination.”
We do need a timeline laid out, but one that is driven by the challenges we must address and opportunities we want to create not because of a “recess” date. Washington is not good at predicting long-term outcomes. When Medicare was created, it was estimated that by 1990 Medicare would cost taxpayers only about $12 billion (in real dollars). The actual cost was nine times that at $107 billion. Today’s numbers are even more staggering. What is the value creation of the current plan – do we know?
Biased Participation: Don’t let the Wolves Tend the Sheep
Perhaps the passion around the timeline is driven by fear that those who have signed up to support the current legislation will start to fade. I flash back to an image I remember in the paper not too long ago of leaders of various lobbying organizations testifying to Congress about healthcare. In the end, with government brokered-healthcare it is a zero-sum game: if someone wins then someone loses. The lobbyists want to make sure their industry is on the winning side. In keeping score, it seems the consumers of healthcare are losing. True healthcare reform is about value creation, making a system work better for you and those who spend tireless hours working to provide that care.
Americans should have a healthy dose of skepticism that most “Associations” are supporting this effort. These national organizations have been the keepers of the status quo for decades. Regina Herzlinger, a well-respected professor at Harvard Business School and long term advocate of consumer driven healthcare, looks at how these various industry players and Congress have actually harmed healthcare in Who Killed Healthcare.
There are individuals within these industries with great ideas but most of the time their voices are not being heard. The average players are having their say in D.C., not the exceptional. We need to change this.
As the old guard keeps control of the reform process, transparency and honesty are hard to find. One of the most concerning issues is the lack of public effort to shed light on the various options to accomplish the goals of healthcare reform. Do you know that there are many ideas on how to impact healthcare including specific alternative legislation such as the Patient Choice Act or Healthy Americans Act? They receive little focus and discussion.
As a taxpayer and consumer of healthcare, you can find out about the alternative ideas and options but you have to do legwork. Organizations with varying agendas and purposes compare plans with easy to use websites, but you will not get that information from our political leaders. Imagine just for a moment that a political leader laid out various options and their pros and cons. I would start hoping things had changed. Just the opposite is most likely – many on the House Floor will not have read the bill when they vote on it this fall.
The artificial timeline is impacting everything. If you are intent on hitting a deadline then the idea of more options only creates more thinking which creates a need for a different timeline.
Above all, Americans are going to need specifics – not just town halls, principles or speeches but detailed explanations of the options and how each one impacts positively and negatively against the stated objectives.
The world of information and media has changed our lives, and we have for the most part embraced it. I hope we can allocate some of the time we spend each year to selecting our favorite singer on American Idol to participating in this healthcare dialogue. If you are reading this now, you are making that commitment.
Misleading Goals: A Game of Shuffle Board not Breakthrough Change
If we had more transparency and real dialogue versus sales pitches, I think we would be able to start to address real reform. There are two major issues shaping up: We need to increase access to those who can’t afford healthcare at current rates and reduce the cost for those who have it now. We are focusing on the former issue of access, but I think this prioritization is flawed.
Current legislation is mainly focused on how can we find money to include more people versus saying how can we get more value out of how we provide care, something I discuss in the second section. It isn’t dealing with dynamics that create care. Massachusetts very explicitly chose the path of getting everyone on insurance because it was a moral imperative. But three years later the state is still dealing with escalating costs and the difficulty of actually providing care to all these new entrants.
Looking at the current legislation in Congress, Gov. Phil Bredesen of Tennessee, a Democrat, said he feared Congress was about to bestow “the mother of all unfunded mandates. Medicaid is a poor vehicle for expanding coverage,” added Mr. Bredesen, a former health care executive. “It’s a 45-year-old system originally designed for poor women and their children. It’s not health care reform to dump more money into Medicaid.”
There are discussions around reforming the system but those details are much sketchier. The President has mentioned implementing this reform through an independent board looking at best practices and mandating care based on these new rules. Many say this is the road to a nationalized health service similar to the UK, and the arguments are valid and important to discuss. For example the NHS in the UK pays for a cervical exam and mammogram once only every three years. A group of experts appointed by the government determines this. An independent board in the U.S. could easily put forth such guidelines.
Whether this is the beginning of rationing care or not, a critical point is being lost about our current healthcare system. We have best practices today. For example, if you go to the hospital with symptoms of a heart attack, there are certain things the hospital should do. Hospitals must report the statistics on these actions taken, a system called Core Measures. All over the country hospitals are focusing on these Core Measures because they publicly report them.
However, these statistics measure what we do or the process followed, not the outcomes we deliver. We have literally created an industry of recipe books. To make it easy to understand, you would get an A+ if you followed the directions exactly in making a cake regardless of how it tasted or turned out. I see daily healthcare leaders being over-whelmed by best practices. There is more regulation in healthcare than most other industry I have seen.
There is an art and science to medicine. The best doctors and organizations are the ones that use the science and their art to manage each patient experience in the context of a supportive and logical system. This gets at the crux of health reform. Are we going to mandate reform and have the government try to keep industry and doctors honest? Or can we create the right alignment of interests so the people who want to build specific cultures and practice medicine because of the outcomes they create, are able to flourish and thrive?
On one side of the spectrum, Nancy Pelosi is approaching reform this way. “We want to squeeze as much savings out of the system as we can before we seek any [new tax] revenue. [But] you can only go so far.” Squeezing a system that isn’t working well is a recipe for collapse.
But there are other voices out there. In the words of a nationally respected medical writer and physician Dr Atul Gawande – “Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can.”
Dr. Gawande was one of the conveners at a recent conference in D.C. where different healthcare success stories from across the country were showcased. These communities had shown you could deliver high quality care and bend the cost curve. This type of event didn’t garner the media attention it should have. These are true reformers who are working from within the industry.
In the end what is shaping up appears to be a focus on using government wisdom to mandate good decision-making. Unfortunately there are many examples of mandates, while well-intentioned, causing significant unforeseen negative consequences.
Here is one example that illustrates the point. On June 7th of this year, the Telegraph recently printed an article uncovering an example of a mandate or target gone haywire and causing harm. People arriving at ERs in the UK with symptoms indicating aggressive spread of cancer were waiting weeks for diagnosis and treatment while “routine” cases were prioritized. Hospital managers told researchers that treating desperately sick patients more quickly would “reflect badly” on their performance against Government cancer targets that only cover those referred to specialists by the patient’s primary physician.
Everyone in the UK is horrified. But in the managerial world of healthcare not the value driven world overseen by the patient, I have seen far too many times where the scorecard or the target of whatever you are working on becomes the end itself. The ultimate reason we serve in healthcare, to serve the patient and the family, becomes secondary, which brings me to a final and most pressing concern – what is the role of the patient and their motivation?
Lack of Motivation: No Skin in the Game
I feel as if we the patients, the consumers, are in the room but no one is really talking with us. They are talking to us. They quote us all the time. They speak to the terrible tragedies. I am moved by these stories having seen them firsthand. But to succeed, healthcare needs to be shared responsibility by putting an informed and motivated consumer at the center of their healthcare.
A few months ago, I was working in the ER. A patient came in with chest pains, anxiety and shortness of breath. The patient was okay, in the short term. But the doctor discovered that this patient drank no water during the day and consumed 8- 10 sodas a day. Both parents and grandparents were diabetic. The patient had good insurance and therefore access. Life style was impacting health, something the patient acknowledged.
One would think this patient would have strong reasons to improve diet. But here, as in myriad cases, the patient took no action. This is troubling and complex. Is it culture, education, and-or upbringing? We have to examine this. What incentives and basis for informed decision-making are we creating for patients? One of the most disheartening things for our physicians today is having to care for patients who don’t care. They tell me that this issue and dealing with the rules and regulations imposed by the government and insurers demoralize them.
The issue extends to every American. Our family has a high deductible plan. The cost of the plan is roughly $12,000 paid for by my husband’s company. We pay the first $4,000 of out of pocket expenses and the insurance company pays 100% after that up to a life time limit. We review the bills carefully and think about what things costs. But something happens after we hit our limit; we behave differently. We aren’t as concerned about the costs, the extra procedure here or there, because we aren’t paying for it. But we are.
At the end of the day these types of high deductible plans have been effective at lowering the rise in healthcare costs compared to traditional plans as pointed out by Professor Herzlinger in Who Killed Healthcare. But as Professor Herzlinger also notes they don’t fundamentally empower the patient to demand something different over the long term. They show promise and potential but haven’t unleashed the full role of the consumer. My family experience echoes that.
The last example shows the positive-power of the patient/consumer, the fight against breast cancer. Almost everyone can say they have lost a friend to breast-cancer but more importantly we all have friends and loved ones who are survivors. What makes me puff up with pride is what women everyday are doing to combat this disease. Bless the doctors, the support, the researchers, but it is the patients who are rising up and taking this disease head on in partnership with the health community. And the efforts are working. If you live in the US you have one of, if not the highest rate of survival for breast cancer in the world. It is consumer advocacy at work.
At the end of the day, personal accountability and responsibility count and could make the US the model of healthcare for the world and an economic engine for our country, not a resource to be rationed.
II. What can we do differently?
Frame the Problem Differently
The good news is we have a common starting point. The country agrees we have a serious issue. But I think we would be better served by being more outcome oriented about the healthcare dilemma.
The framing of the problem defines every future step. Can we as Americans hold up our healthcare as not just the best quality, but also the best in value? We need what Southwest did for the airlines, what Apple did for the personal computer and what Henry Ford did for the car, multiple times over by multiple participants.
Economic growth drives national success. Can our healthcare system become an economic engine for our country and create value? Can we have accessibility, affordability, and quality/service? But more importantly, what would that look like in measurable outcomes?
For example, what if we stated as a goal to have best outcomes in the world for the top five diseases while setting a target for cost/person affected. Below, I share more examples of national outcomes, not to advocate those goals, but to show that specifics then guide development of action steps. What we have now are more lofty principles that build consensus initially but a political battleground shortly thereafter.
Potential Outcomes
•Percent of Americans that believe they exercise significant control in managing their health and feel they receive very good care.
•Ease in navigating the reimbursement system as measured by time physicians spend in administrative/reimbursement issues versus practicing clinical care.
•Percent of household income spent on wellness and nutrition versus treatment
•Reduction in personal bankruptcy due to healthcare costs
•Costs per insurance plan per person as % of personal household income
•Net exporter of healthcare goods and services to rest of world
•Accessibility for Americans as defined by visits to primary care doctor annually
Move on to Discovery and Close the Gap
With a set of hard outcomes in our hand, an unbiased exploration begins. In history, we have seen that whether it was electricity, flight or medical innovation, breakthroughs come from a relenting and disciplined approach to unbiased discovery in relation to a certain vision. Just as how you frame the problem influences the end result, the questions you ask and the people asking the questions bias your outcome. Time magazine recently identified the 10 people shaping healthcare reform. All of them are Washington insiders. Ultimately we need to move from a bartered political exercise to an industry-realignment over time affected by consumers, healthcare providers, financial agents, change experts, politicians, and others.
In a separate document, True Healthcare Reform – Are the Right People asking the Right Questions, I share a series of questions to illustrate the point. It is a document to which I hope you add. In a trial, the discovery process will absolutely impact the verdict. We need to avoid contempt prior to investigation. That is why we would benefit from different people asking different questions.
From the discovery efforts, the process moves on to how we close the gap. You close that gap in increments and with discipline. Neil Armstrong got to the moon safely forty years ago because of how NASA went about closing the gap between what was possible in 1961 and what it would take to land on the moon eight years later. In contrast, Health and Human Services Secretary Kathleen Sebelius in an Op-Ed column for The Washington Post on August 4th wrote that “We can’t let the details distract us from the huge benefits that reform will bring.”
To improve execution and start to close the gap, we need to define what are the different milestones that can be created along the way to the ultimate goal. Instead of betting the bank that we will get it all right in 1,200 pages of legislation, we need to identify early wins and stop approaching healthcare reform as once-in-a-lifetime opportunity.
Many leaders in their field have offered solutions that are pragmatic and focus on the Pareto Principle that 80% of the effects come from 20% of the causes. What are a few things we can do now that have the greatest positive impact? One example is allowing people to buy insurance across state lines, opening up competition and choice. Defensive medicine is one of the most cited reasons by physicians for additional ordering of tests. Have we addressed this?
What would a milestone incremental approach look like? As just an example: it might address change in this priority:
•What types of catastrophic insurance can we provide now to the different segments of uninsured or underinsured now?
•What needs to happen short, medium and long term so that insurance isn’t tied to the jobs we change frequently?
•What needs to happen now versus the long term to have a common filing system for healthcare expenses and reduce administration costs?
•What can we do now to build pricing transparency for the consumer?
•How can we develop a customer satisfaction system for healthcare insurance as has been done recently with patient satisfaction with hospitals?
•How can we further promote healthy eating in our public school systems?
•How can we start to change the complicated fee for service Medicare system?
What drives momentum and a sense of purpose is results or personal accomplishment. When you achieve a little success, it pushes you further. The goal is to start to take apart a complex landscape and create specific building blocks to reform.
Pie in the Sky?
The cynics will say that this new approach I have espoused is not how Washington operates and is not realistic. Legislators run Congress, and they are especially good at cobbling together deals. Perhaps this true, but the problems with which we are dealing require a different approach if we are going to be successful at improving our society and leaving something better for our children. The country that gained independence over 230 years ago, banished slavery and maintained the union, and prevailed in WWII, can tackle Healthcare successfully if we approach it with a non-Washington perspective.
Many Americans voted in November for doing things differently in D.C. including a different type of thinking and discipline. Healthcare is presenting this opportunity. If we don’t seize it, we may have just voted in a new party to practice old politics.
III. What can you do?
Be an Advocate in the Reform Process
I am asking that you as an individual contact your elected officials and voice what is important to you. I personally believe we will have an equal chance in influencing the reform process if our voices are heard as individuals.
In fact, I have been inspired and amazed by the thoughtful responses to my initial Letter. Each person shared something different after reading my concerns and recommendations. Some of these responses touched me to tears, some made me think a little harder and motivated a re-write of a section, and some thanked me for being involved.
For too long I sense we have been scripted, managed and hyped up. We need to find our voice as individuals. My hope is the first two sections of my Letter inspire something in you. Most of the emails I received back would be excellent letters to Senators, Congressman and the White House.
If you do like this letter, please feel free to share it with those you know as well as your Representatives. If you have questions feel free to email me. To help build the dialogue, I launched healthcareletter.com as place for people to openly share comments, to contact to their Representatives and to add to the Questions I started.
What ever happens in Washington, it is certain we will not solve all the problems of healthcare and its delivery and financing systems this fall. At this point, my sincere hope is we do not simply add to the problems.
Ultimately please don’t think of healthcare reform as a one-time political process happening this fall or not at all. That is the how we can start to change the reform process. Think of it as an evolving transformation in changing the way Americans think about our health, how we manage it, how we improve it and how we finance it. And if we do this right and we are involved, we can achieve successes and breakthroughs along the way.
IV. Conclusion
I finished my six weeks of radiation in Houston, Texas in 2002. I remember the day well. They have you ring a bell when you are done. I am trying to ring that bell today. Ferdinand Foch, Allied Commander during WWI said, “The greatest force on earth is the human soul on fire.”
I agree.
If you agree with Oakleigh Ryan, please send this on everyone in your address book. The politicians in DC are close passing a bill. Keep calling and emailing your representatives about the most important issue we will deal with in our lifetime.
www.healthcareletter.com
www.congress.org
Joke of the day:A guy goes into a bar, there's a robot bartender. The robot says, "What will you have?" The guy says, "Martini." The robot brings back the best martini ever and says to the man, "What's your IQ?" The guy says, "168". The robot then proceeds to talk about physics, space exploration and medical technology.
The guy leaves, but he is curious, so he goes back into the bar. The robot bartender says, "What will you have?" The guy says, "Martini". Again, the robot makes a great martini, gives it to the man and says, "What's your IQ?" The guy says, "100." The robot then starts to talk about Nascar, Budweiser and John Deere tractors.
The guy leaves, but finds this very interesting, so he thinks he will try it one more time. He goes back into the bar. The robot says, "What will you have?" The guy says, "Martini", and the robot brings him another great martini. The robot then says, "What's your IQ?" The guy says, "Uh, about 50."
The robot leans in real close and says, "So, you people still happy you voted for Obama?"
Thanks to Phillip Barnett.
Quote du jour:"Here comes the orator! With his flood of words, and his drop of reason." Benjamin Franklin, Poor Richard's Almanack, 1735
References:
healthcareletter.com
founding fatherquotes.com
Phillip Barnett
