A review by Malcolm Coon
The Future of Healthcare
I recently had the opportunity to attend, along with Linda Elliott and several other members of the Healthcare Think Tank, the REACH Symposium on the Future of Healthcare hosted by Trinity University in San Antonio, Texas.
The symposium was structured to address trends in healthcare policy and delivery at both the local and national level. It should be noted that this post represents a summary of the discussion from the perspective of the author (a member of the audience). Some of the points could be refuted and are based on statements made by the speakers during the conversation.
A special thanks goes out to the co-sponsors of the event: Centene Corporation (based in St. Louis) and Trinity’s Department of Healthcare Administration for organizing, bringing together top-notch speakers and hosting the event in a world-class facility.
The six panelists, the moderator, and the keynote speaker were all extraordinary. You can click here to get more details on who participated in the program.
How Consumers are Dealing with Care
I knew this would be an interesting discussion when, within the first few minutes, it was suggested that there is an issue using the word “wellness” to describe our system. Wellness providers would get paid for keeping people well. What we really have is a system of sick providers. We take care of those who are sick. If you really want to disrupt healthcare, we are going to have to focus on keeping people healthy.
Unfortunately, in our society, sicker populations get punished. Often they don’t have access to healthcare facilities, nutrition, technology, or transportation. When people have to take a day off work that they can’t afford, and spend that day riding a bus or train to get to their doctor or hospital, they will typically forgo care. There is a large percentage of the population who don’t have a grocery store in their neighborhood. Their only easy access to food is the processed food from a convenience store or fast food restaurant. Unfortunately, in this country, it is cheaper to eat poorly.
The right path to disrupting healthcare is going to be some form of outcome-based care focused on keeping people healthy.
How Providers are Coping Under the Current System
It was pointed out that the bulk of the cost of healthcare is in our hospitals. Our current system is plagued by health problems that are a direct result of the “big four”: smoking, excessive drinking, drug abuse and obesity.
There is an increasing burden on the healthcare system to comply with ever-changing regulations. Almost no other industry has to deal with the same level of regulations or the fast-paced change in regulations due to an ever-shifting political environment.
Regulators impose tools such as readmission penalties in an attempt to force institutions to adopt a more “outcome” based methodology. Unfortunately, the readmission penalty only hurts the patients. Patients are encouraged to do everything possible not to be readmitted which means there’s often very little follow-up or hospitals get creative to funnel follow-ups to another facility that won’t count against them. Penalties for access are never going to be an effective solution or lead to an open, fair, reliable system.
Regulators attempt to get hospitals to track metrics in an effort to find out what is working and what is not working. The problem is few agree on which metrics should be tracked.
We are bipolar when it comes to healthcare. Providers want to do the right thing and keep up with data but society, the system, regulators, and politicians keep adjusting what there is to measure. The rules keep changing with every shift in administration. With the winds of political change altering the rules, it is no wonder that hospitals and doctors don’t want to commit to any long-term strategy.
We need to give our care providers the freedom to figure out the solution outside of the political environment. We need to trust the hospitals and other care providers who are on the front line in the battle for quality healthcare. We need to give them the freedom to transform the system and create a new healthcare model.
We need to quit changing the rules on the providers. We need a level playing field. The federal system is zero-sum. If one hospital gets bonuses for “good behavior” based upon some metric we are tracking today, then another hospital gets less. Too often we are holding the providers accountable for things that are not under their control.
It simply has not been effective to allow the government to manage our healthcare system. As it was pointed out, government-run healthcare has the compassion of the IRS combined with the efficiency of the Post Office.
A New Paradigm
There is a new paradigm that is coming in healthcare. And it is coming whether we are ready for it or not.
In the old days, you went to the same doctor for most of your life. The provider-patient relationship lasted a lifetime. It is not that simple today. Healthcare has become episodic. Patients seek help from different providers based on their circumstances and symptoms. It’s common today for patients to manage their own care, by tapping into an increasing pool of online medical resources.
Creating a new model of healthcare is not enough. We have to train consumers and providers under that new model.
Basically, consumers of healthcare don’t care if a box is checked on a form. The only thing consumers care about is that their health is better after seeking and receiving care. Conditions such as “Out of Network” are a huge problem with the existing system. The new paradigm of care must be driven by the delivery of quality care when it is needed, where it is needed and to whom it is needed, rather than being about checking boxes on forms or finding the “right” network.
We have been trained by technology companies that it is possible. When you want to watch a movie, you no longer get in your car and drive to Blockbuster to rent a video. You stream your video on Nexflix on whatever device you have with you at the time. You use your phone to make reservations, order products and call a car to pick you up. If Amazon Now can deliver a product to your home in two hours, then I should be able to connect to a healthcare provider and get treatment recommendations in the same or quicker time frame. It’s what the patients want – faster, cheaper, reliable. It’s what the providers want – easier and more efficient ways of delivering high-quality care. We know it is possible. We just have to make it real for healthcare.
One interesting fact is there are 91 counties in the State of Texas that do not have a primary care physician. For the people in those counties, Internet Based Medicine is not a luxury, it is an essential part of a quality life.
Our phones have become a medical device. That is a reality now. The medical capabilities of these devices will only continue to expand. Consumers of healthcare have the ability to monitor health statistics in real time and send automatic alerts to their preferred healthcare professionals.
Our old paradigm of healthcare is based on providers being heroes. Being heroes, waiting until people need saving, is not cost-effective. The future model is about connecting with populations in such a way that they think about healthcare every day. The new paradigm is about people taking responsibility for staying healthy and using providers as soon as something is “out of the norm.”
We can’t continue the model of healthcare we have now. It is simply not sustainable. We have a lot of good minds in healthcare. At some point, we have to get politics out of healthcare and trust the healthcare providers to do what they do best. We can give them incentives and time frames and then turn them loose and trust them.
The Healthcare Workforce
The future of the healthcare workforce seems bleak.
First, historically, medical professionals have been trained in “do it my way” as a way to both educate and interact with consumers of healthcare. There has been absolutely no focus on training in customer service or the “consumer experience.”
Moving forward, we have to combine competencies. We have to train healthcare professionals not only to be highly competent in the field of medicine but to also be able to provide great customer service and be focused on the patient’s overall experience of care.
Not only is there a shortage of this kind of training, but there are insufficient numbers of professionals entering the field. There are high turnover rates and many professionals experience burnout or retire early. Many new doctors are not going into private practice. They want discretionary time and are not willing to put in the double shifts or be on call 24/7, conditions that the industry has expected in the past.
Today the average age of a nurse is well over 40 years. That is up from 28 only twenty years ago. We have an aging workforce and one of the biggest challenges is to keeping cynicism from creeping into the staff.
We need team-oriented players – multiple professionals in different disciplines who are trained to work together to provide patients with high quality, readily available, well-rounded care. In one study, 41% of the doctors polled stated that they wanted a dietitian on their team. Another missing piece to many healthcare teams is a mental health professional.
All that being said, we can’t put all this on the providers. As consumers, we have to take responsibility for our own care. We have to educate ourselves about what it takes to stay healthy. For some of us, that means learning a tough lesson about consequences. We can’t keep abusing our bodies and then just expect the healthcare system to work its magic. Smoking, drinking, overeating, not exercising all come at a price. It could be argued that our healthcare system is paying the price today for our poor choices yesterday. Rising healthcare costs and premiums are at least in part due to us not taking responsibility for our own health. We may be coming to a time when we are charged premiums based on behavior defined by how well we take care of ourselves backed up by real-time data from our personal devices.
The Partisan Battle
One of the biggest problems is that healthcare has ended up on the partisan battlefield of Washington DC. Unfortunately, in our society today, there are few big issues that don’t get passed through the Red/Blue filter. Some have described the political healthcare battle as the second Civil War.
The whole idea of the Affordable Healthcare Act (ACA) was to share the risk and force consumers to be responsible by making them pay a fair amount for care. In this battle, basically, the Republicans favor economy while the Democrats want to share risk.
Healthcare is not about ideology. The question we should be asking ourselves is what will it take to move the system toward higher efficiency. We have to look for the best way to get efficiencies when delivering care.
On the one side, there is the thought that if you limit the amount of money that people can spend they will make adjustments. The other side argues that people won’t make adjustments, they’ll just forgo medical care and, in the end, that will cost the system more.
Political parties have less control than in the past. It used to be that when a political party came to power, they were able to steer the ship for multiple terms. The past couple of decades we have experienced rapid shifts in political power. The back and forth as political parties pass through both Congress and the White House means that often political policy will not live long past the administration that conceived it. This uncertainty drives the state of the system and creates an industry where people are not willing to take risks or make long-term plans.
Consolidation and Uncertainty
Unfortunately, the only certainty in healthcare is uncertainty.
Essentially, care providers are consolidating to capture a bigger piece of the available pie. This has led to a monopolistic marketplace that encourages players to find workarounds which lead to price gouging, antitrust issues, and billing rates that are 15 to 23 times what Medicare will pay. These have become standard industry markups which lead to higher premiums and the cycle perpetuates.
There are states where a single payer has over 90% of the market share. We have created a system with a few big players who have a vested interest in maintaining the status quo of rising healthcare costs.
People feel the system is rigged. Many of us are numb to crushing premiums because our employers subsidize all or part of the cost. That is not the case for everyone. This system of continually rising costs will crash down at some point.
What happens if you don’t/can’t pay your hospital bill? There is a small town in New Mexico where the hospital has sued one out of every four of its patients. There are millions of disenfranchised people who have their wages garnished after being unable to pay hospital bills and losing a legal suit brought on by a provider. These are the people the ACA was supposed to reach.
The point of the ACA was to eliminate pre-existing conditions as an issue for providing healthcare and make it affordable to help solve the uninsured problem. We have not solved the uninsured problem and now we have created a single-payer problem.
As surprising as it sounds, with all of this, profit is not the number one reason people train to be healthcare professionals. Overwhelmingly, people go into healthcare to make a difference.
Given that, there are many unanswered questions:
How do we maximize efficiency versus sharing the risk/cost?
What is the role of the states?
Should there be a Federal Standard?
These are not helathcare questions. These are political questions.
In a survey of over 2000 doctors, the doctors estimated that 21% of care is waste. Doctors, not government, can act on clinical waste.
For what we spend in healthcare, we can afford to give everyone care if we cut the waste on both the administrative and clinical sides, charge a fair and reasonable price, start to measure the appropriate measures and use those measures as feedback to improve the system.
Some think healthcare will cause the next recession. If it does, it will be a be a uniquely American recession.
When we talk about fixing a broken healthcare system, the conversation quickly turns to how do we finance a broken healthcare system. Within the context of financing, the only choices seem to be between either regulating government funding or limiting the supply of care. That’s the thinking that created the situation have today. As Einstein put it, “we can’t solve the problem using the same thinking that created the problem.”
So the question is: How can we transform the system we have at the same time we are using the system? It’s a little like trying to take apart an airplane and then put it back together, all while you are in flight.
Is there a Solution?
Consider first and foremost that we don’t have a healthcare system. We have healthcare systems. We have Medicare and Medicaid. We have private providers. We have city and county providers. We have federal providers like the VA.
The solution will not be found in the existing systems but rather in creating a radical new model of providing the highest care possible to those who need it, when and where they need it.
If we had the luxury of designing a new system from scratch, then before we began designing, we might ask ourselves what would be the principles which will govern our new healthcare system design?
Consider these as candidates for such principles:
Healthcare is for everybody.
Healthcare is affordable.
Healthcare is of the highest quality.
Healthcare is responsive.
Healthcare is innovative.
Healthcare provides choices when selecting the type, source, and location of care.
If we can agree that we could unite around these (or similar) principles, then we would have a starting point for inventing a new model of healthcare.
Healthcare is not meant to be ideologically debated. It’s not meant to cause an ideological divide. And yet we are left with the question of who decides when, where and how patients are treated. There are many challenges for us to overcome in answering that question.
First, there’s regulation. We need balance. We need an approval process. But the process should not cost as much as it does today. It’s estimated that the cost of compliance under the current healthcare system is over $2 trillion.
A second challenge is drug prices. We have to find a way to balance safety with approval process efficiencies.
Another challenge is bundling services and payments. Everyone wants value but healthcare is not a widget. We treat healthcare like the provision at one place and time is the same as at another place and time. But care is not like that.
In the future, there will be less demand on the brick-and-mortar healthcare system as technology begins to take hold and people use their personal devices to both monitor their current health status and send alerts to their doctors. Who can say that the value of telemedicine is more or less valuable than walking into a doctor’s office? The future of healthcare will likely have more touch points and fewer points of entry into facilities.
Another challenge is the workforce. We are dealing with a 20-year pipeline for medical professionals entering the field. We are also dealing with doctors and other professionals experiencing burnout and retiring early.
We are dealing with future technology that offers yet to be imagined solutions where robots can deliver care and where wearables send consumer data to artificial intelligence. People can access their own status in real time and send alerts to their doctors or other providers when necessary. Artificial intelligence is able to read x-rays and MRIs faster and more efficiently than human providers.
We’ve reached a point in time where people want healthcare when and where they want it. It’s dynamic. Healthcare is not static. Perhaps it has never been. We just thought and acted like it was. We have to be open to a flexible system that provides high-quality care to people when, how and where they want it.
Our current political environment is perhaps the biggest challenge of all. We have allowed politics to get in the way of developing and fostering a high-quality healthcare system that is in alignment with the principles stated above. It has been said that Congress does two things well: the first is nothing and the second is to overreact. It’s up to us to talk to our representatives in Washington. Let your representative know what you want in healthcare and what’s important to you and your family. It’s important for us to come together as a nation to solve these issues.
Moving forward, we want to keep those six principles in the forefront of our mind as we create a new dynamic, efficient healthcare system that provides options of high-quality care for patients across our entire nation, not just those who can afford it, not just those in big cities, not just those in counties that have facilities.
One such change which may be on the horizon is that the federal government is looking at letting small groups, who are not otherwise economically aligned, come together and be counted as a group for the provision of healthcare. This is just one possible change that may be part of a dynamically, fast-changing and constantly improving system.
Most importantly, the issues we face in healthcare will not go away. If we continue the way we are going, then financing alone will determine the future of our healthcare system. Right now 70% of the federal budget is mandatory. This means it goes towards things like Medicare and interest on the national debt. Only 30% of the federal budget is for people and programs. Every time we have to increase the interest paid on the federal debt or the mandatory spending for Medicare, it pinches that 30%.
We cannot continue down the road of having funding dictate our healthcare policy or programs. That’s how we got where we are today.
There are a lot of smart people working in healthcare. There are a lot of smart people working to solve this problem. We have to be open to considering new, dynamic solutions and, most important, we have to be willing to work together.
It was once said that “Americans do the right thing, but only after exhausting every other alternative.” 1
I say we can not afford to keep exhausting alternatives. Now is the time to do the right thing.
1. This quote is often attributed (undocumented) to Winston Churchill. (Others attribute a variation of the quote to Abba Eban during a 1967 visit to Japan.)
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