A Healthcare Reform manifesto: 2009

Health care reform is very much in the news these days. It appears that every one wants Health care reform but it is not clear if every one wants the same reform.

Here is what I believe we need to accomplish with health care reform:

We need to …

1. improve the access to health care for every one in the USA; and
2. improve the quality (mean and variance) of the care; and
3. reduce the cost of health care; and
4. that honors and encourages the professionals that work in this important area of public service

Now to look in more detail at each of these components of health care reform:

Improve access to health care means

Every person in the US can receive the appropriate type of care in the most comfortable and convenient care setting as possible as close to their need as possible.

“…appropriate type of care…” covers things like access to primary care doctors and specialists; access to medications; access to therapy; access to medical devices; access to surgical procedures and advanced equipment. What is appropriate should be decided by the patient (and their family) with their medical advisors within the boundaries of normal medical practice, ethics and the laws.

“...comfortable and convenient care setting…” encourages us to build a health care system that operates in the neighborhoods where people live, work and play.

“…as close to their need as possible.” We need to ensure there is sufficient capacity in the system such wait times are minimized. Most people access health care when they have a disease or an accident, either way they are in pain. A system that has long wait times is not compassionate.

Improve the quality of the care

It is typical for most processes to measure quality in with two broad metrics: the mean and the variance about the mean. If the mean is taken to measure the efficacy of the care provided in some combination of extending life, reducing discomfort and improving the quality of life, then the variance is how different incidents of care deliver on these three measures.

There is a lot of scholarly and popular literature that demonstrates that all measures of the quality of care are lower than what can be achieved. A simple sense of this is derived from the knowledge that if there is a large variance above the mean then that means there are some care givers who are able to some times provide care that is extraordinarily better than the mean.

When a quality oriented manufacturing firm sees data like this they immediately see an opportunity to raise the mean to the top end of the performance range and reduce the variance as much as possible. This provides the firm a fantastic competitive edge and gives the consumers beautiful products that were not possible before this kind of technique was applied.

We can and must do something similar in health care.

Reduce the cost of care

Health care is expensive for a number of reasons. There is waste. There is fraud. There is abuse. They are all significant. However a majority of the cost of health care comes from the need and use of health care.

We must not forget the value of health care. Human life expectancy would regress to the historical mean (about 40 years) absent health care intervention. Better diet, better hygiene, better protections from hazards is not and will not be sufficient to support the increases in life expectancy most people expect.

A lot of health care is used by people in the last years of their lives whenever that may occur. These years are as valuable to them and to society as their earlier years.

So we must reduce the waste, fraud and abuse. We must continue to evangelize diet, exercise, safety, life styles. Having done all that we must continue to invest prudently in life – both its quality and its longevity.

We must change the cost accounting of health care to value based accounting.

Honor and encourage the professionals in this area of public service

Health care is delivered by the people for the people. In all our reform discussions we seem to have lost the focus on the people on all sides of this equation.

• We have large and growing shortage of qualified nurses.
• We have a shortage of primary care / family practice physicians.
• Our doctors come out of medical school with crushing debt burdens.
• Malpractice insurance costs are so high in some specialties that physicians take home pay is so low that senior doctors retire much earlier than their health requires.
• Health insurance companies are laying off staff even as the needs of health care are growing
• Doctors complain that there is “no joy” left in the practice of medicine. Their day is sliced into so many little pieces that they basically doing battlefield triage instead of healing
• ER wait times are measurable only in hours

Every one in health care seems to defending their reason for existence. Is this any way to motivate the very folks who we need to save our lives? Save our financial future?

We need to invest in our health care professionals. We need to allocate at least some of the new funds for health care reform for more scholarships for nurses, physician assistants, lab technicians, physicians, medical coders and every other professional we need to have an efficient effective health care system.

We need to expand the capacity (supply) of health care professionals with more recruiting, training and opportunities for people in the health care system. We need to return the medical profession to the pinnacle of the public service pyramid it was on for a lot of known history.

We need to do this because we all use the health care system and I for one would like to know the smartest kid in class is the one who is working to save my life.