Cornerstones of a New Approach

Participants Review, Expand HPC Reform Recommendations

Former NBC Nightly News Anchor Tom Brokaw led a review and discussion of the four cornerstones that have emerged from Mayo Clinic Health Policy Center (HPC) discussions to date: insurance for all, coordinated care, value and payment reform. HPC participants who helped develop the principles over the last two years – including providers, academics, employers and insurers – contributed to the panel discussion.

Insurance For All

Panelists:
Michael Cascone, Blue Cross Blue Shield of Florida; Linda Dillman, Walmart Stores, Inc; John Rother, AARP; and Ashley Thompson, American Hospital Association

Goal:
Provide health insurance and access to basic health care for all Americans — regardless of their ability to pay.

Review of Forum Principles:
Require adults to purchase private health insurance for themselves and their families.

• Create a simple mechanism (similar to the Federal Employees Health Benefit Plan) to offer private insurance packages to buyers.
• Provide sliding-scale government subsidies for people with lower incomes.
• Appoint an independent health board (similar to the Federal Reserve) to define essential health care services. Allow people to purchase more services or insurance, if desired.

Because Americans highly value choice, panelists stress that a single payer system would not work in the United States.

"Just because we're recommending coverage for all doesn't mean we'll have socialized medicine," says Ashley Thompson, American Hospital Association. "It's a shared responsibility for the government, providers, employers and patients to ensure coverage."

Panelists also stressed that adequate funds exist in the current system in order to provide health insurance for all Americans.

"There's a lot of waste that, if redirected, could be used to provide health insurance to many more Americans," says Stephen Shortell, Ph.D., University of California, Berkeley.

Coordinated Care

Panelists:
Don Berwick, M.D., Institute for Healthcare Improvement; George Isham, M.D., HealthPartners; Andrew Mekelburg, Verizon; and Nancy Nielsen, M.D., Ph.D., American Medical Association

Goal:
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.

Review of Forum Principles:

• Center care around the needs of the patient.
• Realign the health system toward improving health rather than treating disease.
• Form coordinated systems to deliver effective and appropriate care to patients.
• Develop a "portfolio of incentives" to encourage teamwork among health care professionals.
• Increase support for 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.

"Large integrated systems are doing well at coordinating care, but the majority of medicine is not organized that way," says Nancy Nielson, M.D., American Medical Association. "Doctors need tools to participate in coordinated care. They also need to be trained in teams – with nurses, pharmacists and other health care professionals."

Panelists emphasized the importance of information technology (IT) to aid integration, but said that IT by itself is not a magic bullet.

"We are using the first generation of EMRs," says George Isham, M.D., HealthPartners. "While we have tools, we have a lot of work to do to make them interoperable."

Don Berwick, M.D., Institute of Healthcare Improvement, noted that coordination of care is not just an IT issue. "We could automate the wrong system."

Value

Panelists:
Larry Harrison, Scripps Clinic; Randy Moore, M.D., American Telecare; Steve Shortell, Ph.D., University of California, Berkeley

Goal: Increase quality and patient satisfaction. Decrease medical errors, costs and waste.

Review of Forum Principles:

• 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.
• Measure and publicly display outcomes, patient satisfaction scores and costs as a whole. Create competition around results through pricing and quality transparency.
• Create a trusted mechanism to synthesize scientific, clinical and medical information for both patients and providers.
• Reward consumers for choosing high-quality health plans and providers.
• Hold all sectors in health care accountable for reducing waste and inefficiencies.

Panelists emphasized that all stakeholders need to arrive at a shared sense of what constitutes value in health care, with the patient at the center of that equation. Panelists agreed with the general goal of improving patient outcomes, safety and satisfaction while reducing costs.

"We have to start seeing waste," says Dr. Isham. "We tolerate waste in health care& care that is not based upon evidence-based standards...for example, too frequent pap smears for women."

Panelists also noted that health care reform discussion often focus on one thing – insurance for all – without much consideration given to driving value through the care delivery system.

"We can't expand coverage and dump people into a delivery system that doesn't work," says Dr. Shortell. "We need to tell presidential candidates that they need to pay attention to the delivery system."

Payment Reform

Panelists:
Joe Antos, American Enterprise Institute; Clarion Johnson, M.D., Exxon Mobil; Michael Morrow, Blue Cross Blue Shield of Minneota; Nicholas Wolter, M.D., Billings Clinic

Goal:
Change the way providers are paid in order to improve health and minimize waste.

Review of Principles:

• Design payment systems to provide patients with no less than the care they need and no more than fully informed, cost-conscious patients would want.
• Create payment systems that provide incentives for colleagues (physicians, hospitals) to coordinate care for patients, improve care and support informed patient decision-making.
• Pay providers based on value. (See item #1 in "Value" section.)
• Further develop and test models of payment based on chronic care coordination, shared decision-making and mini-capitation (i.e., one bundled fee for the physicians and hospital delivering acute care).

Panelists said that health care payment systems are flawed and contribute to many of the problems in American health care by rewarding volume rather than value.

"Current payment systems drive volume and fragmentation," says Nicholas Wolter, M.D., Billings Clinic. "If we would pay for providers to manage episodes of care and care coordination for patients with chronic conditions, new delivery models would emerge."

Randy Moore, M.D., American Telecare, agreed, adding that costs will also decrease as when the payment system changes. "We pay for units of care," he says. "As we shift toward rewarding outcomes, costs can drop."

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