More Health, Less Management, Please
by Peter Block on December 2, 2011
The Columbia Journalism Review included in a recent issue a positive report on how health care is reforming. The report is distributed by the Commonwealth Fund. Well meaning, hopeful by design, but interesting to these eyes for its narrow vision of what constitutes reform.
Here are five elements that the health care industrial complex is betting on to reform health care. I am quoting from the content and structure of the Commonwealth Fund report (emphasis mine),* which says that the most common innovations fall into these categories:
- Accountable care organizations (ACOs). “Under health care reform, ACOs are networks of physicians, hospitals, and other health professions that coordinate patient care and share in any savings they generate for the government by keeping Medicare patients healthy. These new networks would be led by primary care physicians and would share the risk for cost overages.”
- Medical homes. “A medical home is a health care setting, such as a primary care practice, that serves as the central base for all a patient’s health care needs. Medical homes provide patients with timely, well-organized, and coordinated care, and easier access to specialty care and other providers when needed.”
- Bundled payment. “Driven by Medicare, insurers and government payers are becoming increasingly interested in paying not for discrete health care services, but for the overall management of patient health.”
- Enhanced care coordination/chronic disease management. “Our current health care system is frequently fragmented and uncoordinated. … New delivery models are being developed to improve disease management and care coordination across the spectrum of needs.”
- Health information technology. “Spurred by substantial financial incentives, providers are accelerating their adoption of electronic health record (EHR) and clinical support systems. The Health Information Technology for Economic and clinical Health Act of 2009 (HITECH) provides $34 billion in financial incentives for Medicare providers who make ‘meaningful use’ of EHR systems to improve patient care.”
What’s the Problem?
These five innovations, at face value, are the best of what we might expect from institutions. What is interesting is that they are based on the belief that the health care crisis is a “systems problem,” a problem of things like organizational un-accountability/inadequate incentives, poorly organized and uncoordinated care, payment structures that result in poor professional management of patient health, and inadequate use of technology.
The Commonwealth Report innovations think that the system needs fixing and the way to do it is by applying more of the disease. This might be considered an “iatrogenic” solution, a fancy term for doctor-induced illness. The industry solutions to a system that already suffers from over–management, and the high cost of management, suggest we provide even more management.
These solutions believe that more coordination, more technology and more incentives will improve a system that increasingly has been so run like a business/corporation that most physicians, nurses and administrators wonder what happened to the calling that brought them into the work in the first place.
The romantic idea is that a more efficient system will produce more healing and better health. The incentive changes are the most amazing: they advocate that health professionals share in any savings they generate…by keeping Medicare patients healthy! As if professionals produced the health.
The Alternative Reform Is in the Community
The other view is that systems have reached their limit of what they can do. Let them reduce costs and increase efficiency—it will not make much of a difference, since these systems have been trying to be better managed for decades. What is needed for better citizen health is to have less management, less private, corporate involvement and to remove system thinking from the center of the debate. Health care reform will occur when we acknowledge that 85% of our health is in the hands of the individual and the community.
There is already a movement in this direction. It has the support of all those committed to community health, which focuses more on health than disease. There are physicians like Paul Uhlig that quiet the focus on disease and balance the voices of the professionals with the voices of families and communities brought into the discussion of healing. Paul, a surgeon, knows that health is so much more than the absence of disease. And that health is in the hands of citizens, not professionals.
There also is the holistic health movement that knows that health is about the person, not the services we receive. We might consider reform to be anything that takes the label “Alternative” away from those wisdoms and practices that know about food, healing and health. Instead, let us call hospitals, physicians and drugs “Alternative Medicine.” Let us place at the center of reform considerations like how people live with each other, the importance of support groups, a health conscious life style.
Let us acknowledge the impact of the physical environment on our health and put the money we spend on drugs, hospital equipment and parking lots into environmental health. This is where more understanding is needed. This where education and attention are needed. This is what journalists should be reporting on as front-page news.
Call all this reform. And if you want to hold onto the childish, unproven notion that money motivates us for actions other than buying flat screen TVs, give the incentive pay for better health to citizens, who are the real creators of health.
~ Peter ~
* The New Wave of Innovation: How the Health Care System Is Reforming, The Commonwealth Fund, Columbia Journalism Review, Nov/Dec 2011 supplement.
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