It's Time for Deep Reform

Mainstream proposals for reforming health care take a superficial approach to the central role of our care delivery system in driving up costs and obstructing change. But some health policy experts suggest much more radical approaches to reform. These ideas, which collectively might be called “deep reform,” address the need for systemic changes in health care that go far beyond insurance coverage or quality incentives. Recognizing the inadequacy of the financing-focused measures that pass for reform today, these thinkers propose alternative methods of structuring the delivery system and reimbursing providers. While their ideas differ in many important ways, they could form the basis for a grand compromise between the left and the right.

    Deep reform encompasses the entire political spectrum. For example, Arnold Relman, MD, former editor of The New England Journal of Medicine and author of the book A Second Opinion: Rescuing America’s Health Care, wants us to switch to a single-payer insurance system in which care is delivered by competing group-model HMOs. He rejects the conservative idea of “consumer-driven health care,” regarding it as a way to shift more costs to consumers while motivating poorer patients to skip necessary care. In contrast, Michael Porter and Elisabeth Olmstead Teisberg, the authors of Redefining Healthcare: Creating Value-Based Competition on Results, favor the consumer-driven approach. In their model, specialized teams of providers would compete on the basis of their outcomes for particular procedures or episodes of care. These teams would be independent business units, rather than part of the large, prepaid multispecialty groups that Relman supports. But like Porter and Teisberg, Relman would have his physician groups vie for patients on the basis of published quality reports.

     In my own book Rx for Health Care Reform, I advocate replacing competition among insurance companies with competition among primary-care groups, which would set their own budgets for professional services. Similarly, Harvard Business School professor Regina Herzlinger, in her new book Who Killed Health Care?, writes, “In a consumer-driven health care system, providers will be free to create focused factories and to name their own price…[Thus] the doctors will regain the freedom to provide the kind of medical care they feel is appropriate.”

     While many more examples could be provided, the point is that deep reform has aspects that transcend ideology. Whether the proposal is coming from Relman, Porter, Herzlinger, George Halvorson, Alain Enthoven, Len Nichols, Victor Fuchs, Arnie Milstein, Donald Berwick, Tom Daschle, Alice Gosfield,  Francois DeBrantes, or Kathleen O’Connor of CodeBlueNow, the core message is the same: we need to overhaul health care financing and delivery.

     All of these thinkers, regardless of their political orientation, also believe that market competition is essential to reform. In this respect, their analysis differs from that of the “Medicare-for-all” proponents, who maintain that a government takeover of health care would solve our problems. Relman, despite his espousal of the single-payer approach, observes that this is insufficient: “Any reformed system that stands a chance of controlling costs, while still providing universal coverage and improving the quality of care, must change not only the present insurance system but also the organization and style of medical practice.”

     Deep reform views our health care crisis from a perspective that stands outside the current political debate. Instead of asking “how do we reach universal coverage?” or “how do we reduce insurance costs?”, deep reform poses a more fundamental question: How do we rebuild the system so that it delivers high-quality care for everyone at a cost we can afford? It might seem that our system is too big and complex to reconstruct it without destroying it. But in fact, it can be done, and there is no other way to save U.S. health care.

     This is not to say that significant reform cannot be achieved within the current system. Deep reformers are already busy in a number of areas. The leading example is the work of Donald Berwick, MD, president of the Institute for Health Care Improvement. Best-known for his efforts to improve patient safety in hospitals, Berwick also launched a campaign to reengineer primary-care practices, which led to the currently fashionable “patient-centered medical home.” Berwick’s writings and statements clearly show that he believes in the need for systemic change. For example, he is one of the principal authors of the Institute of Medicine’s epochal Crossing The Quality Chasm, which calls for a complete reorganization of health care around chronic disease management.

     Another example of a deep reformer who is trying to change particular aspects of the system is Joann Lynn, author of Sick to Death and Not Going to Take It Anymore! Reforming Health Care for The Last Years of Life.  Lynn, who understands end-of-life care as few others do, offers a comprehensive plan to make that care more humane and effective while relieving some of the burden on family caregivers.

    So far, deep reform concepts have had little impact on the political establishment. But as the health care crisis deepens, and as it becomes clear that our political leaders don’t know how to halt our system’s slide into chaos, more people will start to discuss these ideas. They might even lead to some legislation that has a chance of being passed and implemented.

    One example is the Minnesota health care reform bill that was first vetoed and, in a modified form, later approved by Republican Gov. Tim Pawlenty. This enlightened legislation, passed overwhelmingly by the Democratic legislature, allows provider groups to set their own budgets for “baskets of care” for such chronic conditions as coronary artery and heart disease, diabetes, asthma, and depression. They can then compete for patients on the basis of published cost and quality data. (The groups may also be eligible for coordination of care payments from insurers.) Corporate, labor, health care, and insurance leaders supported the measure, which aims to cut the state’s uninsured rate while lowering costs by 12 percent within the next seven years.

     A report from a state-appointed panel that helped devise the legislation proposed an even more radical change: Physician groups and “care systems” would take financial responsibility for the total cost of care. Insurance companies would still take overall financial risk, but wouldn’t negotiate prices or manage care. Their role would be limited to helping consumers navigate the system and manage their own health.

     Of course, the opposition of the national health care, pharmaceutical, and insurance industries to any change that threatens their profits should not be minimized. It will not be easy to mobilize the kind of public and corporate support that will be needed to overcome the objections of those whose incomes would be imperiled by real reform. But over time, I believe that even these self-interested parties will come around to the view that the biggest threat to them is the continuation of the status quo.

    To increase the chances of deep reform ideas being adopted, we reformers should come together, exchange ideas, and find out what we have in common. We might discover that we have a lot to offer one another, and that we can cross political divides that continue to separate politicians and policy makers. This is important work. Let’s get to it.