Thursday, November 29, 2012

Solving for the National Healthcare problem should start by solving for Medicare beneficiaries

Matt Miller over at the Washington Post proposed a fun idea in his column yesterday: that Obama should tap Mitt Romney, management consultant and data-driven problem solver extraordinaire, to analyze the healthcare mess and propose solutions.

According to Miller, we need "an authoritative analysis that identifies exactly what’s driving our costs so much higher than everyone else’s — as well as a set of lessons we can learn from the nations that do more (including insure everyone) with much less." Followed by a summary of main options and scenarios that could move us towards better care for less (or at least better care for the amount we spend).

And of course we should involve all the "sector leaders" and stakeholders to be part of this commission and presentation of options.

You know, the leaders of those sectors that stand the most to lose from us making healthcare more patient-centered, effective, and higher value per dollar spent. (Sorry but I'm talking about you, insurance companies, hospitals, pharma, and the specialists' lobby (aka AMA).)

Don't worry, the sector leaders won't hijack the process. We can just ask them to "to step beyond parochial concerns to address these questions in the context of the broader national interest."

(Um...I suppose theoretically that might work. My theoretical physicist father also used to tell me that theoretically all the atoms and electrons in a table might move and allow my hand to pass through.)

In summary, Miller is proposing the creation of a commission that can summarize why we are where we are, how other countries do it better, and some key options for how we might move forward constructively.

 

How to improve this proposal


I'm skeptical that Miller's commission would be very successful. But with some changes something similar could be really helpful. Here are my four suggestions for a National Taskforce on Healthcare that really helps the nation move towards better care at a more affordable cost:

1. Make the group focus on the Medicare population. Just solve right off the bat for the 600 pound gorilla in healthcare. This is the most complicated and important group to serve, healthcare-wise. It's pretty obvious why, but I'll name a couple reasons anyway:
  • Beneficiaries generate the bulk of national healthcare costs.
  • They suffer the most from the existing fragmentation and duplication of services (just talk to anyone whose mother or grandmother's been sick lately.
  • They are medically the most complex cases, requiring the most change in how we deliver care.
  • They number in the tens of millions as a patient population.
  • There are tens millions of younger Americans involved in caregiving for the Medicare population. This affect the working population's health and availability to do other work.
  • Medicare finances are the most pressing issue affecting the long-term federal budget deficit.
By the way, solving for the Medicare population means addressing Medicaid and long-term care financing too. Everything the older person needs for health and wellbeing, prepare to fix and improve.

2. Start with academics and other experts without a large financial and political stake. Plenty of academic experts can tell you what the main drivers of our expenses and dysfunction are. (Heck, I could summarize this myself, and could give you good references if I spent a few hours digging through the literature.)

Why ask sector leaders, who can't help but be insanely biased (plus they have their constituencies to answer to)? There are also plenty of well-published and widely-respected experts available who could easily summarize what other countries do.

Start by getting a summary of the problem from the most objective, qualified group you can.

This same group, by the way, can brainstorm scenarios for moving forward. Don't worry, we won't make any scenarios policy without hearing from the stakeholders. We just shouldn't let the stakeholders dominate the discussion from the get-go.

3. Get geriatricians at the table. Figuring out what healthcare for older people in this country should look like means talking to experts on compassionate, comprehensive, whole person-centered healthcare for older people.

Ergo, geriatricians. (Disclosure: I confess to being a geriatrician, and admit to hereby shamelessly promoting my specialty.)

Sure, the geriatricians will advocate for their own self-interest. But that's ok, because our interests as geriatricians have the best match with what patients and families want for themselves, and what the nation needs overall (better care that fits with people's values, at lower costs).

And we have some fantastic geriatricians available who are experts in quality improvement, policy, and making change. Consider our MacArthur geniuses: Diane Meier and Eric Coleman. Plus we have many more that I could nominate (don't worry, I promise to not nominate myself; I'm not qualified plus I'd much rather play the gadfly in the peanut gallery).

Another source of good experts on this subject are family caregivers, and older adults who've cycled through the system a few times. Bring them to the table too.

4. Bring in black-belts in negotiation and masters of communication. It goes without saying that solving for better care at less cost in the Medicare population (aka saving the nation financially) is an enormous political challenge:
  • Beneficiaries and older adults are a vocal and powerful constituency
  • Medicare payments constitute the largest and most reliable stream of income for most of the big sector leaders named above --> massive lobbying and pressure on politicians 
In other words, they don't call Medicare the third rail of politics for nothing.

Which means that once your objective group of experts has come up with some possible solutions, you need expert negotiators present when you bring in the stakeholders to talk turkey.

And then you need master storytellers and communicators to engage in the public in a constructive discussion, so that as a nation we can pick between the several challenging options that we'll be presented with.

Because the average American, beneficiary or no, doesn't understand nearly enough about what a thorny problem solving Medicare is. That needs to change. We need to identify some key options forward, and highlight the trade-offs inherent in each scenario. We need people to understand that every option involves downsides, and we need to highlight the very serious downsides of continuing as we are (such as the current crummy federal support for aging-in-place).

In a nutshell:


We need to convene an ace taskforce to address the National Problem with Healthcare, and this team should focus just on the Medicare population. This is the group that has the most healthcare needs, and where as a nation we'd reap the biggest benefits if we could deliver better care at lower cost.

The work of the National Taskforce should start with experts free of significant financial or political stakes in the process. (Bring in the big bellowing stakeholders later, and have black-belts in negotiation present.)

Geriatricians are experts in compassionate, comprehensive, whole person-centered healthcare for older people. So are family caregivers. Use them on the taskforce.

An effective communication strategy is essential. The American people need to be engaged and informed in order to participate meaningfully in solving this critical national problem.



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