Health Reform’s Challenges – Some Things Don’t Change

A few years ago I was asked to write a Forward for a book about the transformation of healthcare in the US.  I recently came across what I’d written about the rapidly changing US healthcare system and the challenges of controlling the growth in spending.  I’m sharing it below (in the original Courier font) because what I’d written still is applicable for today’s situation, and particularly the summary sentence: “If today’s leaders — both health professionals and politicians — make wise decisions to support and foster integration of the delivery system and administrative standardization, while guaranteeing universal coverage, we will have a strong health system to support a strong nation.”


     Health care in the United States is changing very rapidly. This seemingly obvious statement has taken many people by surprise despite the fact that the environment for health care has been evolving for decades.  Both the actual delivery of health care and its financing are dramatically different today than when my father first started practicing medicine.  I do not make this personal reference casually.  Rather, I believe it is very important to remember that for everyone, illness, health, death and dying are among the most personal of issues within their lives and the lives of their family.  I state this up-front because just as health is a very personal concern, health reform is an issue of people, personalities, and their relationships.

    Just two decades ago, well after my father started practice, diagnostic testing was much more limited — MRIs were experimental, and fiberoptics were being introduced.  Treatment options have similarly expanded with new procedures, (ambulatory surgery, fiberoptic surgery, and home IV), and new pharmaceuticals, (ACE inhibitors, antivirals, EPO, and new biologics), are standards of care.  Similarly, reimbursement and financing of health care has also changed dramatically:  Fee-for-service was predominant with payments made for submitted charges.  Discounting and capitation were basically nonexistent for most physicians.  Managed care was an unrecognized concept except in the form of care management by personal physicians prior to the explosion of specialists.

     Clearly health care in 1993 is very different from health care in 1973 — for both patients and physicians.  It is also very different for hospitals, insurance companies and businesses.  To imagine in 1973 that General Motors would be spending more for health care than for steel in the 1990s would have been as inconceivable as imagining that AIDS would redirect the force of the 1960s sexual revolution into a social philosophy of safe sex. Situations such as these permeate American society, and have added many new moral and financial issues to the current round of reform debate.

     Every time I talk with groups of professionals involved with providing or paying for health care — physicians, nurses, hospital administrators, business owners — I try to impart the perspective of rapid change and evolution to them.  I have also tried to convey this to the policy makers with whom I have worked in Washington D.C., both in Congress and on President Clinton’s Health Reform Task Force.  The key is to remember that dynamic change is always a constant process, and health reform — either market driven or legislatively directed — is definitely a continual process.

    Some have argued that “health reform” will result in great losses for many Americans — losses of quality or choice or autonomy or benefits.  Although guarantees are impossible to make in such a sweeping process, I strongly believe that in the end — perhaps after a rocky transition — the gains will greatly outweigh any downsides.  This applies for everyone, not just for those who will gain the most, i.e. the uninsured or the underinsured.  For example, increased organization and uniformity in our health care system will allow health care professionals to focus on delivering health care, maintain control of clinical decisions, and worry less about multitudes of benefit structures and paperwork mazes.  Patients will benefit by having a rational system which provides guideposts to assure coordinated quality care rather than by default having to undertake their own care management because the disorganized system provides little or no assistance.

    This evolution of health care delivery will be tightly linked to reforms of financing and risk assumption.   Successful integrated health delivery systems will be able to accept the risk under a capitated payment system, but their ultimate success will depend upon providing their core “product,” i.e. health care services, and being able to document the quality of the care.  The ability to coordinate these two functions will require a tight working relationship between the system’s administrative management and the systems “product” managers, i.e. physicians and other health care providers.

     In thinking about how to achieve success in health reform, the relationships between individuals is extremely important to remember, and surprisingly easy to forget.  It must be recognized and remembered that health reform is a people issue.  Not only does it involve people’s basic needs, but it is a service provided by people for people.  And at its most basic level, the process of reform is a people puzzle, not a technological one.  This is clearly seen in the personal relationships and negotiations which encompass the politics of health reform.

     Even more striking is the people-centered nature of health reform in the marketplace.  Ultimately putting together a reformed health care delivery system requires the building of new relationships between organizations, i.e., hospitals, groups of physicians, and other providers.  However, these relationships are ultimately personal ones, involving the individual physicians, other caregivers, and the managers of the larger entities.  These relationships are not easy to build, but recognizing their necessity as a foundation for system development is the first step in the process.

     Thus, reform initiatives — both local and national — in the coming years will likely be characterized by the saying “Market Driven & Medically Directed,” because the marketplace will force integration to proceed, but the shape and control of the resulting integrated systems will be directed by health care professionals — predominantly physicians.

    The chapters of this book provide perspectives, information and guidance for health care reform leaders on how to think about health care delivery as a local and a regional phenomenon — an outlook often missing from national debates.  The overriding conclusion is that through appropriate integration and alliance building, health care can be improved and costs contained.

    This volume focuses on: 1) the market forces driving the current evolutionary process in health care, 2) the resulting niches which health organizations are being forced to fill, and 3) how they are responding in order to successfully fill these new niches.  Overall, the volume describes how health care professionals can think and prepare for the coming decades as our health system evolves from one marked by disorganization and multiplicity to one of more integration and uniformity.

     The issues discussed in this book are not the final word in health reform.  In fact, if market driven health reforms are the only changes seen in this country, it will be a road to disaster. One of the major downsides of solely market driven reform is that through integration and the alliances formed by health providers, businesses and insurers are able to reduce cost shifting within the system which has been used to support uncompensated and charity care.  This reduction of a hidden tax would benefit businesses, but carried to its extreme could also lead to a situation where the uninsured truly will be without access to any health care because those who can pay will no longer be subsidizing those who cannot.  This will cost our businesses and the nation more in the long run both financially and morally.

    In the end it will be the actions and decisions of front line health care decision makers which will determine the strength of the health care system the U.S. will carry into the 21st century.  If today’s leaders — both health professionals and politicians — make wise decisions to support and foster integration of the delivery system and administrative standardization, while guaranteeing universal coverage, we will have a strong health system to support a strong nation.  Less fortunate alternatives will leave us weakened both financially and morally.  Although I do not believe in utopian scenarios, I do believe that progress will be made, and problems addressed in a positive and significant manner.  It is clear that the marketplace participants — health professionals and their organizations, being driven by businesses — are following through on their end of this equation.  It remains to be seen how well the political leaders of our country follow through on their end of this balance.

Michael D. Miller, M.D.
November, 1993
Washington, D.C.

18 years later it is clear that the issues and solutions haven’t changed significantly: Cost containment, quality improvement and expanding access were (and are) the goals, and the solutions involve creating “a rational system which provides guideposts to assure coordinated quality care rather than by default [patients] having to undertake their own care management because the disorganized system provides little or no assistance.”

2011 is clearly as different from 1993 as 1993 was from 1975. One of the biggest difference is that political leaders have finally followed through by passing significant legislation – which didn’t happen in 1994. Another significant change is the ability of information systems to acquire, analyze, and distribute data and comprehensible/actionable information to clinicians, payers, providers, and patients.

While we’re making progress, it won’t come unaided and unguided. The pieces necessary for making dramatic improvements are being put into place from a variety of sources, including legislation (e.g., HITECH and PPACA), other government actions (e.g. Medical Home and innovative payment demonstrations), non-profits (e.g., RWJ Foundation’s AF4Q and Care About Your Care), and initiatives from companies (e.g., Prometheus, Leapfrog, and redesigning health benefits).  The challenge now is for businesses, providers, payers, clinicians, regulators, legislators, and patients (or at least their advocacy organizations) to follow through and turn those pieces into a coherent and integrated system – or really connected and coordinated systems – that provides greater value and more accountability for both clinical and economic outcomes.

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