The above links will take you to the Center for the Health Professions
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Objective: To bring together health care providers, purchasers, payors, policy leaders and educators to participate in discussions about future models of health care delivery and their implication for primary medical care practice, education and financing. Keynote Address: "What Will the Future Hold
in Health Care?" Panel One: "Three Models for Health Care Delivery 2005?"
Panel Two: "The Three Models--A Closer Look at Their Implications for Health Care and Primary Care Delivery"
Luncheon Speaker: "Impact on At Risk Populations and the Uninsured" --Sandra Hernandez, MD Chief Executive Officer, The San Francisco Foundation Concluding Remarks Edward O'Neil, PhD Executive Director, University of California San Francisco, Center for the Health Professions Keynote Address: "What
Will the Future Hold in Health Care?" Historical Context Between 1950 and 1990, the US did something with its health care system that no one else has, and it is a peculiar bubble. The health system is unique to our experience, and to the way that most of us have learned the system and its dynamics. During this time period, the percent of gross domestic product devoted to health care went from 5% to 14%, 3-4 percentage points ahead of other industrialized countries. How did we do this? By adopting a cost plus, third party reimbursement system that was almost entirely provider dominated and generated. The payors, for the large part businesses and government, tended not to ask any questions about what anything cost. The public became educated to a paradigm that said the more and the newer the technology that your doctor applies to you, the better the medical care. Quality is cost, quality is intensity. If you aren't getting costly and intense care, you are not getting good medical care. This is a uniquely American health care bubble. If you spend any time at all outside the United States working with professionals in other health care systems, they just look at us and cannot imagine how we got into it or why we would do it this way. Nonetheless, this has been our experience. Late in the 1980s, we began to see a change as purchasers, largely corporate purchasers, began to say health care costs too much. Lee Iacocca started saying "there is more money in this car in health care than steel." His comment echoed a trend among corporate managers who started saying we have a problem with how much we're spending on this employee benefit, and we're going to have to do something about it. The run-up to the '88 and '92 elections was marked some turbulence developing in the system: people were asking the questions that they really hadn't asked before, questions like "why does it cost this much?," and "what can we do to get a handle on it?" It is still too soon to have a clear view of health care in the 1990s. We had a major event in '93 and '94 when the President wanted to reform health care and for a variety of reasons, the basic elements of his proposal were not acceptable to the majority of the body politic. His proposal did not go forward, but change went forward. The people paying the bills continued to have the same questions that started in the '80s. That has been the driving force creating today's situation. The Current System As Ms. Moon said, the current health care system is wacky. Today's system of organizing and financing is very unstable, and does not represent the next 20 to 30 years of health care - we're going some place else and that destination is very unclear, though certain known issues will need to be negotiated. Today, our current system is significantly different than it was 10 years ago. It is an aggregated system more than a disaggregated one. Provider groups feel the necessity to grow, in part to capture and maintain market share, and in part because they are better prepared to manage risk. Purchasers are actively trying to shift risk to providers, such that they pay a set amount to manage the health of a population, and let the providers figure out how to deliver health care to the group for the contracted amount. Currently, 90% of Americans get their care in some arrangement known as managed care. The vast majority is more accurately termed managed cost systems, in which the provider is the adversary, because it is the providerwho generates costs. In some far future, we may have many truly managed care sy stems, insofar as the quality of health care services is actively being managed, but that is not the norm. Not surprisingly, managed cost masquerading as managed care results in a system full of tensions, turf battles, and interface fights. Everything a provider does costs, every cost is being looked at, everything patients want costs, and that has an implication for providers' bottom line. In the era of post-Clinton reform, the percentage of Americans who have formal coverage for basic health insurance is drifting down and the percentage of total expenditures coming out of individuals' pockets is drifting up. The system itself is becoming more and more risk adverse. The best way for insurers to guarantee their bottom line is by taking on a known quantity of risk, which demands that populations and contractual obligations are tightly defined. Costs are also very carefully controlled. Risk aversion is nothing new in classical insurance, but it is a newer element in health insurance. It represents a shift from a forgiving cost plus environment to a very unforgiving fixed cost environment per unit of provider. In all of this, one significant thing has been accomplished: the bubble has quit growing, and the percentage of GDP going to health care services has been at 13.6% for the last three years. Issues to be Addressed for System Stability There are three issues that have been around as long as health care problems have been addressed, but they are most often pushed into the background because they are complicated, controversial, and because there is no clear resolution for them. We've tried to avoid them thus far, and we can't avoid them any longer. Issue #1: Do we regard medical care in the US as a social good or market commodity? If we believe that health care is a social good, logic says it should be available to all on some equitable basis. If we believe it is a market commodity, like other things available through the market, it may or may not be available to everyone and access to health care services will depend on individual resources permitting access. The market will sort out competing needs efficiently, and even though everyone will not have what they want or need, the level of services provided will be most efficient. The US economy runs in largely this way. Our culture is flagrantly schizophrenic about where we want to end up. We want market efficiency but intellectually, can not face the thought of medical have-nots. We don't like those 10:00 news stories about Baby Doe who needs a critical operation and isn't eligible for any funding. So what do we do? We have a bake sale, or some equivalent, because Baby Doe was featured on television. Meanwhile, we turn our heads away from all the Baby Does who didn't make it onto television, because we haven't resolved this fundamental social policy question. We can construct and run a system on either basis, be it one or the other. What is very difficult, and what we are trying to do right now, is to believe passionately in both of them without acknowledging that the implications and the logic within each of the two views are an unavoidable, one hundred percent conflict. Issue #2: What is the role and value of individual choice in a medical commons? The use of the term commons comes from the biologist Garrett Hardin, who described 30 years ago the social/environmental principle of a commons, or finite resource. The theory of the commons goes as follows: If there were a community surrounding a commons where all of the community's sheep grazed, individual owners of sheep have an absolute incentive to purchase more sheep and graze them on the commons, because everything they earn from raising sheep is theirs alone. The more sheep, the more profit, and it's all happening in the commons. The problem lies in the fact that if every sheep owner follows the same rules and does the same thing - grazing more and more sheep - eventually the commons will become overgrazed and crash. The concept of the commons represents the critical balance between individual decision making and maximization of individual interests within the framework of a finite common resource. What is the role and responsibility of the individual patient and the individual patient's physician or provider in accessing resources that, in aggregate, are finite? This concept applies not just under the assumption that health care is a social good, but in a market-based system as well. In a totally market-based economy for health care, where individuals with the resources have health insurance, pooled risk represents the commons. Is it right for every patient and every physician to seek to maximize their individual interest in the commons, and what are the implications of that? This is a conundrum that we have struggled with, but don't like to face up to. On the patient side, we've had 40 years of more is better, more is quality, less is poor quality. If a physician says "We shouldn't do this, it may not be cost effective," the patient says, "What does cost effective mean for me? I want it, and even if it is very low on the cost effectiveness scale, its cost utility to me may approach 1." On the physician side, most of us have been trained under an ethos that we are our patient's advocate, singular possessive. Physicians have learned to advocate for our patient without regard to finite resources. Physicians have not done a good job sorting out whether or not there is a balance of responsibility related to the patient in front of them versus all of the patients in the practice versus all of the patients in the population or risk pool. As with the first issue, we've been trying to finesse this issue but there are some basic laws of logic and resource that can't be finessed. There is a medical commons that we all share, one way or another, whereby utilization by individuals has implications for the utilization of the group. Issue #3: What about the impact of personal behavior on risk and cost? Twenty-five percent of our current health care expenditures go to treat conditions that are caused or affected by patients' voluntary use of alcohol, tobacco, drugs, sexual behavior, and lack of use of seatbelts. That figure gets even higher when adding in the medical consequences of individual choice on lifestyle, exercise, and diet. If our resources are finite, however we decide to ultimately define our health care system, what is the role and responsibility of individuals in making decisions about their own behavior that cost resources that need to be available to all of us? Yes, we have some insurance products that are rated differently whether someone smokes or not, but we don't have many examples of differential pricing for coverage based on all the other behaviors. Were we to suggest to do so, there would be a major social controversy as to whether or not it is any of our business. Should someone who voluntarily has a caloric intake of 4,500 a day and doesn't exercise have the same premium of someone whose caloric intake is two-thirds of that, and who runs 10 miles a day? We think there are identified differences in health outcome and utilization of health services, all of which come out of the common, but is there a role for individual behavior, and should we treat individuals differently? Implications There doesn't appear to be a way of getting to a steady-state health care system where we know what the pool of resources is for health services, what the rules are for access to services, and what the incentives and disincentives are, until we resolve these three questions. The problem: we're not talking about these three issues. The October 8, 1998 Wall Street Journal had a series of editorials by policy analysts, economists, and legislators talking about what needs to happen to address our current health care problems that, though useful, failed to address these issues directly. The reason: these issues, at their heart, are very controversial and consensus isn't going to be reached easily. Whenyou start talking about whether medicine is a social good, people hear "socialized medicine," jump to the conclusion that it is definitely bad, and the debate ends. The concept of penalizing an individual for personal behavior is similarly controversial, but ignoring these problems isn't going to make them go away, and these fundamental issues are at the center of us determining how our health care system is going to be put together in a more stable way. The burdens of those individuals who would argue one set of resolutions or the other are several. Those arguing that health care is a social good will have to acknowledge that there will be trade-offs between individual wants and needs and the collective good - there will not be unfettered choice in a social good model. A social good model is not a federal model. You can have models of financing an organization where everyone is defined-in without it being run from Washington or Sacramento. You can't have a model where everyone is defined-in, without the acknowledgement that we all participate in a commons, which requires an understanding that what each of us uses will not be available to others, and that therefore behavior must be modified according to the need of the general welfare. Those who would argue that the best way lies in making health care a market commodity must acknowledge that inevitably, there will be a wide variance between access and health status of individuals. The system will be efficient and supportive of the needs of those individuals with resources and the ability to access the system financially. For those without resources, the system will by and large not exist. The challenge is to organize and defend such a system in the face of a significant amount of the population who believe that health care is a right and a social good. There are those who would argue that the choice between social and market health care systems is a false one, and that it is possible to create a system where health care is a social good, available to all, and operated on the basis of market efficiency. They bear the burden of explaining how such a system can be constructed, financed and maintained, and how the behaviors of individuals and providers in that system can follow the maxim of the market, which is maximization of individual interests, without threatening the common good. A template of this model is very attractive, because it puts off some hard choices. This argument has yet to be made. Much of the current debate is back and forth between whether health care is a social good or a market commodity. Conclusion In closing, consider the role of the professions in navigating this landscape. Many have a preferred outcome that reflects their own personal values. The only way to get to an outcome is for there to be significant leadership in the debate from individuals who are knowledgeable, committed, and willing to sacrifice or re-examine some of the precepts that they have been operating on. The old way is too unstable to persist very long into the next century. The voice of the professions, primarily medicine, has, unfortunately, been soft and self-interested. If we have a concern about our professional community and our patient community, we are going to have to take a stand, and negotiate some things within the profession. This will be a helpful discussion, because the medical profession has a bit of a blind spot, such that the total commitment is to the patient in front of the physician, while pretending that the patients in the waiting room or the community don't exist. Medicine can be practiced this way only so long as it is hypothesized that there will be a never-ending expansion of resources devoted to medical care. As soon as we as a profession acknowledge that that is not a likely future, we have to acknowledge that choices must be made among existing resources, and those choices involve the patients in front of us, and the patients not in front of us. Those choices have to do with how a commons is maintained for the benefit ofthe individual, and the benefit of the community. If there is one particularly unique contribution the medical profession can make in the next three to four years, it is for the leaders of the profession to acknowledge that we can't have it both ways, that resources are finite, and individual needs must be balanced with the implications for the general good. No one is in a better position to articulate the rules and process by which that takes place than an individual, personal physician. We haven't been comfortable doing that thus far. As a profession, we have been very interested in our own prerogatives, and interested in making sure that no one else tells us how to practice medicine. The latter is good, the former needs to be examined. The current environment has more intrusiveness into physician prerogatives, and the physician-patient relationship, than anything we've seen before. Thus the stabilization of the current system, where costs are managed and not all are covered, is not a very good outcome. The challenge is finding a way of engaging in constructive dialogue and making choices about the three core issues. Then we as professionals need to take on the responsibility to say we know more about this than anyone else in the community, we will take this on not to protect our own prerogative, but to preserve the best in the public good. Questions & Answers Question: From the patient's point of view, what would good, well-run managed care look like? Answer: It is ideal to think that patients would like to have a known, long term, comfortable source of medical care, a doctor, group of doctors or professionals so that there is no doubt who they call when they have a health care question. Everything behind that office is transparent. The needed care is there, and they know what the rules are, but the patient can emphasize quality of care and service without being concerned about cost. Today, the concentration for both provider and patient is on cost, because that's what we're trying to manage. We need to get to second and third generation systems where you know you go there, you get good care, you're comfortable with it, and you've been going there 20 years. Medical care in a stable system is one of the most basic of human services systems. It has to be very personal, because people have to know you not only for comfort but medical reasons. Based on a service system, everything supporting that system is irrelevant. A patient should know as much about the hospital's cost or payment of CT scans as the general public knows about servicing jet engines when they get on an airplane. Question: It was indicated that medical professionals need to make choices to preserve the common good. What type of training is going to be required to enable the professions to help preserve the common good? Answer: Not standing up for change is more a failure of values than a failure of education. The question is, what are your values, as a physician, and are you living up to them? What if the credo was "first, allow no harm to come to pass" - this is very different than "first, do no harm." To get to a point of greater good, the medical profession is going to have to back off of some of its positions. Question: For which parts of our health care system do you think
the market approach is useful, and for which parts is this approach not
helpful? Answer: It remains to be seen if the market system will function effectively if we decide that health care is a social good. To answer the question, you need to know which way you see health care - as a market good or a social good? If you believe health care should be available to the population as a market commodity, it should function the way the transportation system works, which is a highly efficient delivery model based largely on market principles. If you say we're in the social good system and everyone is defined-in, then market principles won't work at all, because there is a trade off between individual interests and community interests, which the marketdoesn't sort out very well. To answer the question, you have to indicate where you want us to go in terms of the basic choice. It is conceivable that if you had some kind of voucher system, and everyone had a voucher to buy into a provider of services and that looked like a nationwide federal employee health benefit corporation, maybe it works to have the two integrated. This gets back to the third way, in which everybody is in the boat but we have some degree of market principle. What you cannot have as part of a market principle in a social good system is maximizing individual wants and needs without considering the rest of the group.
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 The
links below will take you to the Center for the Health Professions web site. |
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