Tuesday, December 20, 2016

Health Care Should Be Five By Five

People love to talk about "moonshots" in health (e.g., Joe Biden, GE).  I'm not exactly sure why that is a good goal.  The actual moonshot took thousands of people many years and tens of billions, all to send a few people far away for a short period and never again.  It may or may not have produced otherwise useful technological advances (Tang, anyone?).  Sounds a lot like health care now, actually.

I suggest a different goal: let's make health care "Five by Five."

Five by five is a communications term to quantify the signal-to-noise ratio.  It means the best possible readability with the best possible signal strength.  I.e., the signal is loud and clear.  By contrast, "one by one" would essentially mean "I can't figure out what you're telling me but that's OK, because I can't really hear you."

Health care is full of signals but also, unfortunately, full of "noise."  Many people don't get care when they need it, some people get the wrong care, too often people don't get better -- or get worse -- from their care, and everyone has their own horror stories of health care bureaucratic nonsense.  And we pay way more than any other nation for all this, without getting much for it.

Here's my proposed Five by five: 
  • No more than 5% wasted care
  • No more than 5% administrative costs
Let's take each of those in turn.

Wasted Care

Estimates are that as much as a third of U.S. health care is "waste" -- mostly care that isn't necessary or appropriate for the patient.  It may be care that statistics show won't benefit most people receiving it, or it may be care for which there really aren't any efficacy statistics available at all.  Both situations are much more common than most of us, or even physicians, realize,   

It is easy to see how that happened.  Physicians learned what they were trained, which was highly variable, and by practicing, which historically was in solo or other small practice.  Everything was paper-based, which made collecting statistics hard and applying any learnings from them harder.  John Wennberg and his colleagues have been documenting the resulting geographic variability in care for decades,

As physicians like to say, medicine is more of an art than a science.  

It doesn't have to be this way.  Although our current EHRs are clunky, loathe to communicate with each other, and hard to get meaningful advice from, this is a transitional issue.  With more data, better interfaces and more use of artificial intelligence (AI), we should be expecting EHRs (or their technological successors) to participate in the evaluation, diagnosis, and recommended treatments for patients.  They should be able to do real-time searches for comparable patients, check the latest applicable research and clinical guidelines, and produce statistically-based recommendations for the clinician (unless, in fact, the AI is the clinician).    

As patients, we shouldn't passively submit to treatments that are of dubious value, nor pay for ones that do not produce expected outcomes.  And in this connected day and age, there is no reason we shouldn't know patients' outcomes.  

With the right data and the right analysis applied to it, we should know what appropriate care is, and expect it (and only it).  Maybe 5% is too high a bar.

Administrative Costs

If there is one thing about our health system most people seem to agree on, it is that its administrative costs are too high.  Too much of our health care dollar is spent on tasks that are not directly involved in delivering care.  Estimates vary, from lows around 15% to highs of 25% or more.  And virtually all of the job growth in the health care sector in the last fifty years has come from administrative jobs

Much of the administrative costs are associated with payment: who is going to pay how much for what.   We have thousands of health plans (included self-funded employer plans), each with their own schedules of allowable amounts, and each with their own benefit designs.

Those benefit designs vary not just in cost sharing provisions but also the "fine print" of what is covered.  Since no one knows what care is appropriate, we've fallen back to incomprehensible benefit designs to define it, and those designs do not well serve the patients/members, their providers, or the health plans themselves.

No wonder no one ever seems to know who is covered for what, or for how much. 

Again, it doesn't have to be this way.  Here are a few changes we should make:
  1. Uniform patient identifier: Most industries are using cell phone numbers to identify customers, and heath care should follow suit.  Put the security around who can access what information about such a number, not in creating it.  It will make tracking and transactions much easier.
  2. No provider networks: Provider networks have outlived their purpose.  Their existence creates confusion and frustration for consumers, and involve significant cost to both providers and health plans.  We should want people to go to the best providers.
  3. Clearinghouse: Rather than providers and health plans doing direct connections with each other -- count all those! -- in an era of cloud computing (or blockchain!), providers be able to simply submit transactions to a neutral database, which patient's health plan can use to act on and return to the provider. 
  4. Appropriate care: Health plans should pay for appropriate care; period, end of story.  Health plans don't get to unilaterally decide what that is; nor do individual physicians, or patients.  As described above, determining this will be more clear-cut.  Benefit design and premiums should just reflect how much of the care the health plan pays versus the member, not which care.
  5. Real prices:  Providers must cease their nonsense about "charges," and charge actual prices, which should be transparent.  Health plans should only pay market prices -- pegged at some level of what other providers charge for the same service and same outcome (and higher for better outcomes).
Why Not?

None of this is easy.  None of it will happen overnight.  But nothing in it is impossible either.  I believe in making big plans.  Moonshots are nice, but Five by Five provides meaningful, measurable goals for changes that would benefit the health care system, and each of us.  Maybe we won't get to those goals, but we certainly can do better than the current 33 by 25.  

It'd be easy to point out why Five by Five won't happen, but it's harder to argue that it shouldn't.  

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