Improving Health Care Value
Health Reform, as New America envisions it, entails building a universal coverage financing system on top of the backbone of a sustainable delivery system. In short we need to create a delivery system “culture of value” with a sense of urgency every bit as great as soldiers bring to close combat.
This delivery system has three components: a health information infrastructure, incentives linked with health outcomes, and comparative technology assessment.
Information System
The health infomation system should enable any clinician to learn all they need to know about any patient, plus diagnosis and treatment options, and then to share this information in real time for an informed, joint decision. This system would include electronic health records as well as decision support tools so that best practices and the best current evidence can be brought to every clinician-patient encounter.
Today a casino can determine the precise details of your credit-worthiness in real time, but no hospital in Las Vegas (or anywhere else) can find out what medications you are on when you arrive unconscious for unknown reasons (unless you are being treated in the VA system). This information is literally life-preserving, and better information flows are one huge key to our delivery system culture of value.
Incentives and Outcomes
We need a new set of payment incentives for both patients and providers. Today’s incentives mostly encourage unnecessary and low value care. Smarter incentives would encourage patients and clinicians to use resources prudently while promoting high quality, cost-effective care the first time. Demand and supply side incentives should be mutually reinforcing, not contradictory as in some schemes. Congruence and the spread of smarter incentives is what will improve our outcomes and save money in the short run.Part of the incentive reform process will be reform of the dysfunctional malpractice legal system. Evidence based medicine must be a safe harbor against spurious malpractice claims, and an electronic information system will help monitor, protect, and improve quality and safety throughout the health system. These new incentives can be developed and implemented through public-private partnerships to ensure effectiveness and smooth transitions.
The Right Technology
Overuse of new technology is the main long run cost driver today. At the same time, medical technology has clearly improved lives and future prospects are nothing short of breathtaking, not to mention potentially catalytic for our economy’s health. For all these reasons, we will need to establish processes for assessing the clinical value added of new technologies -- compared to existing treatment or diagnostic options -- and for whom, prior to widespread adoption and use.
One concrete way to illustrate this is to think about the FDA drug approval process. Today, to get a drug approved for a specific use, a manufacturer must show clinical trial data that indicates the proposed new drug did not kill anyone and did beat a placebo. There is considerable evidence that prayer beats a placebo. We could and should require a higher standard of efficacy: beat the best existing treatment, and determine for which patient sub-population the new treatment is better. To compensate for the longer and more expensive trial data this would require, we will probably need to lengthen patent life, once granted.
We should apply the logic of this example to medical devices and to new surgical techniques. Then we can become far smarter purchasers of costly but valuable new technologies, the primary cost drivers in our system. Only then will the health system be sustainable for all of us in the 21st century.
