Linking health management with health reform

President Obama has made health care reform the cornerstone priority for his administration. An indicator of the seriousness that he is placing on health care is the quality of the persons that he has selected to fill important decision making roles who will be tasked with reshaping the healthcare payment and delivery systems. By and large, these appointees are individuals with great skill and experience in the areas of health policy or health economics.

I do not question for even a moment that meaningful health care reform needs to be established on sound economic principles and based on policies that can be agreed to by the largest number of key stakeholders. However, from our perspective, there is an important element that is missing from the public conversations about health care reform. Where is the discussion about the impact of health reform on the organization and, more importantly, the patient.

We must recognize that policies and economic decisions made without consideration to implementation at the organizational level and ultimately at the bedside are a serious oversight. The law of unintended consequences reminds us that policies or actions taken without thinking through how those actions might affect real people can play out in ways that have unplanned and often serious outcomes. As President Obama and members of the executive and legislative branches think through the myriad of ways that health care might be reformed, we recommend that the following points be kept in mind with the respect to the implementation of any chosen policy:

Strive for Excellence
No one wants average or even good health care for themselves or their families. There is a general expectation that health care received in the United States will be uniformly excellent. The question then is--how do we define and operationalize excellence? In our experience, clinical excellence (usually thought of as the outcome) is a necessary but not sufficient condition. In addition, patients want and expect to be treated with dignity and respect, in a culturally appropriate manner, in settings that are clean and accessible. And outstanding patient experiences do not take place without staff who feel valued, are given the tools they need to do their job, and are surrounded by other high performing colleagues.

Chaos and Complexity
A hallmark of US health care is that it is a series of interconnected systems as opposed to "the US Healthcare System". The implication for health policy reform is that optimization of a single component of the system (whether at the macro level involving access, costs, and outcomes, or at a micro level of direct services provision) has the potential to simultaneously create both improvements and disruptions in intended changes. The inherent chaos embedded in a structure of variability requires that policy change provide for substantial flexibility at the operational level to both create positive enhancements to the provision of health care and to minimize the negative effects deriving from sweeping change. An example of this is seen in the efforts of hospitals to reduce unintended deaths and injuries during the time a person is in the hospital. Rather than think about health care delivery as a whole set of interrelated subsystems, most efforts in this area still attempt to find the person who made the error and fix what went wrong in that specific instance. We retain the old maxim of "blame and shame" or "blame and train" rather than look more critically at the larger system.

All Health Care (or at least most) is Local
Meaningful change in an environment as fragmented and diverse as the American health care industry will require implementation of and experimentation with multiple potential solutions. The state-level reforms that have promise in Oregon and Massachusetts may not be feasible in West Virginia or New York. Broad national mandates across large population segments will likely guarantee less than optimal care delivery n regional or local settings. Extensive input from health care providers at the state and local level will be required to insure that health care networks are not made less responsive as a result of national policy. The development Regional Health Information Organizations (RHIOs) show promise as a mechanism to coordinate national policy imperatives while incorporating variation in health services delivery mechanisms at a local level.

Healthcare is an Industry
Health policy is obviously directed at improving the health status of our citizens, but the implementation of policy must recognize the economic realities the health care sector. The mantra "no margin, no mission" acknowledges the importance of profit motives as drivers of organizational performance, regardless of the legal and tax status of the health care entity providing services. And business competency is no more a given in this industry than in others such as finance, banking, housing, and retail, where seismic changes have resulted in long-standing, ostensibly well-managed corporations disappearing virtually overnight. The health care industry is not immune to these potential disruptions, regardless of the intent of policy implementers to create a rational "system".

Think Outside the Box
Is there a way to deliver care that is timely, efficient, safe, and effective and yet works to address the terrible stress on hospitals and physicians caused by the growing number of elderly coupled with 45 million uninsured Americans? Using the current models of care (private physician office practices and private hospitals) is one answer but this is not sufficient. Instead, we need to think about non-traditional ways to deliver care. These can be in pharmacy based clinics, urgent-care centers, public health clinics, or any number of alternative delivery settings. Again, solutions should consider the needs and resources of local populations. The current excitement over the concept of a patient-centered medical home is no more the ultimate solution to the efficient delivery of health care services than was the gatekeeper model of capitated care in the 1990's. However, the goals of this approach, such as avoiding duplication of services, helping to eliminate medication errors, coordinating the timely dissemination of crucial medical information, and reducing administrative costs utilizing a comprehensive electronic health record are clearly what we want to achieve.

There is no question that comprehensive health care reform has to begin with careful consideration of policy and economic questions. However, health care reform without equally careful attention paid to where and how care is delivered will result in the sub-optimization and ultimate failure of even the best-intended policies. We urge President Obama, Nancy-Ann DeParle, newly appointed director of the White House Office for Health Reform, HHS SecretarySebelius and other key decision leaders to include examination of the structures of health care delivery as part of their deliberations.