After talking with people about health reform for almost 20 years I’m no longer surprised by how simple many people think it is to fix the US healthcare system.  If people really want to engage in conversation, rather than just vent, I often explain the practical realities, (and complexities), of health reform by breaking it down into 4 levels – which I think it pretty good since Dante had 7:

1. Identifying Problems is Easy
Almost everyone agrees that costs are too high, access is uneven, (including various disparities), and quality is variable – at best.  In addition, there is agreement that these problems have negative consequences for economic growth, productivity for companies and individuals, and that lack of health insurance negatively affects individual’s health.

2. Understanding What’s Causing the Problems is Hard
More so than 10 years ago, there is growing consensus that the incentives of the illness oriented fee-for-service (FFS) reimbursement system which dominates healthcare payments in the US are at the root of many of our healthcare system’s problems. Specifically, FFS payments encourage more healthcare services and procedures regardless of their value, and it also minimizes incentives for prevention and overall efficiency. In addition, many of the problems are interrelated, i.e. if healthcare delivery wasn’t so expensive, then insurance premiums wouldn’t be so high, and paying for insurance coverage for the 45-50 million uninsured wouldn’t be so difficult.

3. Developing Practical Solutions is Very Hard
“If it was easy, someone would have done it already,” is the aphorism that applies to developing solutions to the healthcare system’s problems.  Two practical solutions that have been developed include reorganizing care delivery to be more team-based around primary care and prevention, and shifting from FFS payments to some type of bundled payment system.

The goal of bundling payments is to both create more localized incentives for cost effective, value producing care, and to prompt the reorganization of care delivery as described above. The two are related because using bundled payments will be much easier in a team-based healthcare delivery system. Therefore, while each of these could be pursued independently, their synergism means it is more productive to address them simultaneously – although for practical and political reasons, they may need to be implemented sequentially.

Not only does the interrelationship of payment and delivery mean that shifting them both at the same time makes sense, but it also makes it more difficult – although economists and others often advocate for first changing economic incentives with the belief that the delivery system will then follow.  (Of course a noted health economist recently told me that there are three kinds of economists, those who can count and those who can’t.)

Which brings us to #4

4. Successfully Implementing Practical Solutions is Way Beyond Very Hard

While developing proposals that combine the type of financing and delivery system changes described above is hard, and forming consensus for a single proposal is even harder, successfully implementing solutions is exceptionally hard because it requires behavior changes for individuals and culture changes for organizations.

Three publications that provide some insights into the time and effort required to implement such changes are:

• “Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home,” by Nutting et. al. in the May/June 2009 issue of the Annals of Family Medicine.  This article describes 6 lessons and 8 recommendations from the NDP experiences, and the article includes two statements about current or planned policy initiatives:
  • “Our early analysis raises concerns that current demonstration designs seriously underestimate the magnitude and time frame for the required changes, overestimate the readiness and expectations of information technology and are seriously undercapitalized.  We fear that with current assumptions, many demonstrations place participating practices at substantial risk and my jeopardize the evolution of PCMH as unrealistic expectations set up demonstrations and evaluations for failure.” [Emphasis added]
  • “The PCMH will need adequate funding from a combination of federal, state, local, insurance industry, and health system participation.  Having practices front the costs of transformation with the hope of more appropriate reimbursement in the future is unlikely to succeed.” [Note – the incentives for adoption of health IT included in the Federal stimulus bill are a percentage of Medicare and Medicaid reimbursements and thus will provide greater financial incentives to practices that need it the least, (because they have greater capitalization from higher previous reimbursements), and primary care practices will be getting less incentives, although their adopting HIT would be the most beneficial to the healthcare system.]

• “Implementing Health Care Reform in Massachusetts: Strategic Lessons Learned,” by Jon Kingsdale published online by Health Affairs on May, 28 2009. This article by the Executive Director of the Massachusetts’ Commonwealth Health Insurance Connector includes the following insightful statement that”… implementation of major reform takes years and will create unforeseen challenges so a truly comprehensive approach must be sequenced.”

• “The Future Is Now: Implementation of a Tele-Intensivist Program,” by Rabert and Sebastian in the January 2006 issue of Journal of Nursing Research.  In this article about the preparation required for implementing a telemedicine system for the intensive care units in a small multihospital system, they reported that, “The project team met weekly for almost a year between the time the [tele-ICU] product was chosen and the system implementation date.  Many specialty subgroups, composed of key stakeholders, were created to complete the huge challenge of creating and tailoring the system to meet the needs of patients, users, and the organization.”

And of course, the many years the Institute for Healthcare Improvement has worked with hospitals across the country speaks to the time required to successfully implement changes by individuals and within organizations.

A Quicker Explanation
While the descriptions above can have traction in a moderately long conversation, for quicker exchanges, I use two other sets of analogies.  For #1-3 above, I liken changing the health system to renovating a house, or remodeling a kitchen or bathroom – whatever the person I’m talking to has suffered through most recently.  This creates a connection to something they’ve experienced up close and personal which seemed so simple in concept, but quickly became a morass of minute, interconnected decisions coupled with escalating costs – not only for the actual renovations, but also for their ongoing living expenses while their house, kitchen, bathroom, etc. were unavailable for weeks or months – during which time they still had a need to sleep, eat, and bathe.

And to illustrate how long the changes described in #4 take, I remind people about how long it took to change the attitudes and behaviors around smoking, (particularly in public), seat belt use, and picking up dog poop from sidewalks.  It’s taken decades to get to today’s attitudes and actions from “smoking’s cool,” “seat belts are a nuisance and cramp my style,” and “Gross! If you don’t like it there, you pick it up.”

Bending the Curve
If the goal is really about bending the curve of cost growth, quality improvement and prevention, we need to start soon since results will take time to achieve.  However, the effects will be cumulative as the slope of the curve changes.  The alternatives generally involve the type of “solutions” used in the past that only result in changes for a year or two because different parts of the healthcare system rapidly adapt to the new rules while the shape of the curve remains essentially unchanged and any short term gains are quickly extinguished.

Conclusions
So next time someone says that health reform is simple, remind them about their last home improvement/renovation project.  (People who haven’t gone through one in the last 3-4 years seem to have amnesia for the turmoil.)  Fixing the healthcare system’s problems are very similar:  Many individuals will be effected, it will take more time and money and time than expected, and while everything (or anything) is being changed, people will still need to get healthcare…..Simple to explain, hard to do.

And of course, this explanation doesn’t include any of the complexities that politics add to the passage of legislation at either the state or federal levels.