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Mayo Clinic believes America's health care system urgently needs reform to ensure the future of quality patient care. Over the last two years, Mayo Clinic Health Policy Center has convened more than 400 national thought leaders for a series of events to help develop new, consensus-driven principles to guide the reform process. This report summarizes these activities to date.
To reform health care, providers, academics, medical industry leaders, business people, insurers, political leaders and patient advocates recommend four areas of focus: universal insurance coverage, coordinated care, value and payment reform.
Provide health insurance and access to basic health care for all Americans — regardless of their ability to pay.
Statistics from the U.S. Census Bureau show that the number of Americans without insurance increased by about 1.3 million from 2004 to 2005. During the same period, the percentage of Americans receiving employer-sponsored insurance dropped slightly, while the number of uninsured children increased from 7.5 million to 8.3 million.
Nonelderly adult uninsured workers by work status (2005)
"The health care system in the United States is broken," notes participant John Rother, J.D., AARP. "We have to change. The consequence of failure is simply too expensive and too costly in terms of human life." Participants noted that lack of insurance also creates significant economic problems for health care providers and employers. The American Hospital Association reports that hospitals provided $28.8 billion in uncompensated care to the uninsured and underinsured in 2005. And many companies — finding it difficult to compete globally when faced with paying billions of dollars to insure employees, retirees and dependents — are reducing or eliminating health insurance coverage.
"Every dollar that gets shifted to health care comes out of our customers' pockets," says Linda Dillman, Wal-Mart Stores, Inc.
For both humanitarian and economic reasons, participants at Center events overwhelmingly supported the idea that all Americans should have health insurance, regardless of ability to pay. They agreed that the issue must be considered within the entire framework of health care reform.
Participants envisioned several ways to move toward comprehensive insurance coverage. Participants emphasized that current insurance models should not be dismantled until a new system is in place.
Move from employer-based insurance to portable, individual-based coverage. Employers could still help finance a portion of their workers' health care expenses and should be encouraged to promote employee wellness.
Most participants agreed that individuals — not employers — should be accountable for having health insurance. The group endorsed a new role for employers: financing a portion of health care expenses (perhaps by providing employees with a stipend to offset premium costs) and promoting employee wellness in the workplace.
Participants also discussed that making the change to individual ownership may require reforming the way health insurance is treated for income tax purposes. The current tax system provides favorable tax treatment to employer-provided insurance, and the tax subsidy is greatest for higher-income workers.
Create a simple mechanism (similar to the Federal Employees Health Benefit Plan) to offer private insurance packages to buyers.
The group generally rejected a government-run single payer system, but expressed affinity toward the idea of individuals purchasing health insurance through organized purchasing pools.
Require individual ownership of health insurance, with sliding-scale subsidies for people with lower incomes.
Group members supported the idea of moving to individual ownership of health insurance, similar to auto insurance standards currently in place in our country. Individual ownership allows for portability, accessibility and freedom to choose plans and providers.
Some attendees noted that moving to individual ownership of insurance would, over time, allow citizens to keep their own insurance throughout their lifetimes, and eventually could eliminate the need for Medicare, Medicaid and other government-run programs. This would also create a stronger incentive for insurers to cover preventive care for younger individuals, knowing that savings would result in the long run.
Appoint an independent health board (similar to the Federal Reserve) to define essential health care services.
Attendees concurred that an essential package of health care services may include primary care, preventive care and coordination of care. They emphasized that services in the basic package must be rigorously evaluated from both a scientific and actuarial standpoint, suggesting that an independent health board (shielded from the political process) could help formulate the offering. The group also agreed that Americans should be given the option of buying additional health care services beyond the covered essential services.
Patient care services must be coordinated across people, functions, activities, sites and time in order to increase value. Patients must be active participants in this process.
If playing a symphony requires a well-rehearsed orchestra, then caring for a sick patient takes a devoted team of medical professionals. At the RAND Corporation forum on integrated systems, Mayo Clinic's Robert Smoldt presented an example of a liver transplant patient who, in the course of a five-day hospitalization, interacted with 75 different caregivers over 11 different shifts. He said the opportunity for problems with the number of hand-offs involved in patient care makes coordination critical.
"Health care, by its very nature, is a team sport," notes participant Larry Harrison of Scripps Clinic. "Those who must be the captain of their own ships should know that single-piloted boats are sinking."
The call for more coordinated care — whether through group practices, integrated networks of independent physicians or physician-hospital organizations — was a common refrain at all Center events. Still, the American Medical Association reports that only one-third of all physicians currently practice in group settings, with the majority in single-specialty groups of nine or fewer. A 2006 Commonwealth Fund Survey found that, across the board, American adults endorse the importance of well-coordinated care, perhaps because more than 40 percent of Americans have experienced "poorly coordinated, inefficient or unsafe care" at some point in the last two years.
Strong public support for well-coordinated care
"The only real point of integration right now is the patient himself," says Douglas Eby, M.D., Alaska Native Medical Center. "A provider's responsibility is to be in continual conversation, walking alongside in partnership with the patient."
Participants recommended that providers partner with patients to move toward a more coordinated delivery system. Guiding principles include:
Center care around the patient.
Patients must be at the center of the care system. Participants agreed that our current model is provider-centered, not patient-centered. What is most needed is a system that gives patients a single point of coordination and interpretation.
Realign the health care system toward improving health rather than treating disease.
Participants agreed that many changes are needed to realign the health system toward improving health. One important step is to encourage measurement and reporting of quality performance at the organizational level. Another is to create care models that allow electronic data and information to be shared.
Form coordinated systems to deliver effective and appropriate care to patients.
Participants concurred that it is important to foster an attitude of interdependence rather than independence among providers. There was also strong agreement that coordinated systems should extend to the local level and that providers at all levels should work together to improve health.
Group members also emphasized the need to conduct and broadly disseminate more research about the structures, processes and leadership that produce the best coordinated care.
Another high priority was relief from antitrust laws that discourage separate entities from joining forces to improve coordination.
Develop a "portfolio of incentives" to encourage teamwork.
Participants felt that a "portfolio of incentives" should be developed to encourage health professionals to work together. These could include financial, outcomes reporting and electronic medical records.
The group agreed that transparency and dissemination of outcomes data would be strong drivers of integration.
Increase support for health care delivery of science.
Group members endorsed the critical role of health care delivery science, which generates new knowledge by using common tools such as information systems, process improvement techniques and outcomes measurement.
Provide complete and accurate information so patients can make informed decisions about their care.
Attendees recommended that patients have appropriate, evidence-based care when they need it, and easy access to their personal health information from birth to death. The group supported a unified patient identifier to promote portability of information.
Increase quality and patient satisfaction. Decrease medical errors, costs and waste.
Research from RAND, the Institute of Medicine and the Dartmouth Atlas of Health Care reveals three fundamental problems with health care in America: 1) More than half of physician care is not based on best practices; 2) Nearly 100,000 Americans die annually as a result of medical errors; and 3) Medical professionals who provide high-quality, cost-effective care are "rewarded" by getting paid less.
"I think of our health care system in the United States as the poster child for underachievement," says Stephen Shortell, Ph.D., University of California, Berkeley. "We are in no way realizing our potential."
To address these issues and improve the effectiveness and efficiency of care, Mayo Clinic Health Policy Center participants recommended a fundamental restructuring of our current delivery and reimbursement systems, with improvements funded by eliminating waste. "If we do the right thing, five years from now we'll have a system that's safer, more effective and more patient-centered," says Don Berwick, M.D., Institute for Healthcare Improvement. "If we really do the right thing, it's also going to be far less expensive than the system we're paying for now."
Participants agreed that increasing the value of the health care system would afford every American the opportunity to contribute to and benefit from the creation, dissemination and use of health care knowledge.
Denis Cortese, M.D., Mayo Clinic, proposed that health care must become a learning system in which medical professionals freely share successes and failures, so all patients can benefit.
Participants created the following principles to guide the development of a health care system that creates and rewards value:
Develop a definition of value based upon the needs and preferences of patients, measurable outcomes, safety and service, compared to the cost of care over time.
Participants estimated that a large portion of health care activity doesn't add value to patient care and should be removed from the system.
The group strongly recommended that a common value equation — cast from the patient's perspective — be created so that stakeholders could collectively evaluate and improve factors that contribute to the overall care experience. The group also agreed that payment should be based upon episodes of care delivered over longer time periods, rather than paying for discrete services.
Measure and publicly display outcomes, patient satisfaction scores and costs as a whole. Create competition around results through pricing and quality transparency.
Transparency and standards of measurement are critical if stakeholders are to make value-based choices. Most attendees agreed that providers should measure and publicly display their outcomes, patient satisfaction scores and costs as a whole. The group agreed that health care providers must begin to compete on these elements — rather than focusing on cost shifting and bargaining power — to increase value to the patient.
Create a trusted mechanism to synthesize scientific, clinical and personal medical information for both patients and providers.
Participants acknowledged the deluge of medical information that clinicians and the general public must sort through each day. They recommended creating a group — funded by the government but not influenced by politics — to synthesize and disseminate knowledge that would improve patient care.
Reward consumers for choosing high-quality health plans and providers.
To help patients choose high-value health plans or providers, participants recommended that consumer information be easily accessible and understandable.
Hold all sectors in health care accountable for reducing waste and inefficiencies. The majority of participants endorsed the basic tenet that any reform proposal must demonstrate how it would reduce waste and inefficiencies, not simply shift cost to another sector. Group members bemoaned the silos — hospitals versus physicians; insurers versus providers — that fracture our delivery system, and recommended building agreement and accountability across multiple parties.
Change the way providers are paid in order to improve health and minimize waste.
Because our current reimbursement system rewards piecework — performing diagnostic tests, procedures and surgeries, for example — it's natural that U.S. health care is laden with these expensive, fragmented pieces of care that often don't form a coherent picture.
"The incentives are absolutely perverse," says Stephen Shortell, Ph.D., University of California, Berkeley. "We pay doctors the same amount or even more money regardless of whether or not they give good recommended care."
Participants at all Center events spent significant time discussing current payment systems in which incentives are skewed to foster the inefficient, expensive and often inappropriate care that riddles health care today.
Current payment models in health care
Some participants felt that tackling the financing system would be a good first step toward reform because other problems (i.e., overuse of many services and tests) would be resolved if the system paid for care differently.
Group members noted several problems with the current payment system. For example, there are financial penalties and disincentives for providing certain kinds of care (lower-cost services, "cognitive" care, preventive care) and incentives to offer expensive specialty care, procedures and repeat office visits. Participants also noted that providers offering coordinated, cost-effective care are often financially penalized.
"Currently, if you provide more efficient, high-quality care, you get paid less," says Don Fisher, Ph.D., American Medical Group Association. "You lose money at the end of the day."
Participants strongly endorsed the idea that providers should be paid based upon the value that they offer to patients (as defined in the "Value" section of this document). Overall, the group expressed very little support for the current Medicare pay-for-performance programs. For all other payment methods, however, there was wide variability of opinion about how the individual option might affect health care costs and quality. In the end, attendees felt that the following three payment approaches — which aren't mutually exclusive — should be explored further.
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