A Health Care “Moon Shot”

By Kim Bellard, November 15, 2011

There was a great op-ed in the New York Times a few days ago, in which Frank Moss – a former Director at M.I.T.’s Media Lab – called for a radically different approach to health care, a technology-driven approach he calls “consumer health.”  It would use technology to monitor and advise consumers about their health, with technology-based consultation with physicians or other health care professionals as appropriate.  Moss argues that not only might this approach improve health and reduce costs, but also would create significant export opportunities.  I like many of the ideas, but what I especially love is the call to be truly bold, like President Kennedy’s call to put a man on the moon in the 1960’s.  You don’t see much boldness in health care reform these days.  

There are things about Moss’s future that trouble me – it can seem a little Big Brother-ish – but the technology is, in many ways, the easy part of reforming the health care system; it is the rest of the infrastructure that stands in our way.

To that end, and on the advice of Daniel Burnham (“Make no little plans; they have no magic to stir men’s blood…”), here are sacred cows I’ll take on:

• More consumer responsibility: for all the complaints about how expensive health care is, most consumers have been spoiled.   I.e., only 31% of covered workers have a deductible of $1,000 or more, their average copayment for a primary care physician is still only $22, and their portion of premium contributions was only 18% for single coverage/28% for family coverage (Kaiser Family Foundation).   Certainly some individuals and families are devastated by health care costs – and this is unacceptable – but the frustrating part is that the system, by and large, doesn’t reward consumers for managing their health effectively. 
  
  We don’t want to punish people who have high health costs simply because of what is, essentially, an accident – whether that be genetic, physical calamity, or unexpected exposure to infections, to name a few.  Regardless of what their health status is or how it got that way, we do want to reward people who actively take efforts to maintain and improve their health.  Various wellness programs – typically employer-based – attempt to do this, but their ability to monitor, intervene, and reward has historically been fairly limited.  With the new technological tools that are or soon will be available, we will be in a much better position to actually observe desired behaviors – and we should use those to strongly reward individuals who actively exhibit those behaviors.  If auto insurance companies can base rates on monitored safe driving patterns (see, for example, this), why wouldn’t we want the same kind of rewards in health insurance?  Lower premiums, real-time lower cost-sharing, and/or actual monetary rewards are all be options that should be used.  Consumers who do not take appropriate actions, or who do not choose to be monitored, need to be willing to bear the financial consequences of those decisions.
  
  
• End employer-based coverage: Employer-based coverage has been the dominant form of health coverage in the U.S. since the 1940’s.  Employers have pushed insurance companies into many of the innovations of the past thirty years, such as care management, more aggressive provider contracting, an emphasis on quality and outcomes, and more focus on wellness.  In many ways, it has been the employers – particularly large, self-funded employers -- who have been the leaders in innovation.  That being said, employers can also be blamed for ending community-based premiums, for “job lock,” and for creating such a myriad of distinct benefit plans that few consumers or providers can understand them, much less compare.   
  
  There are a few reasons why ending employer-based coverage will or should happen.  One is the money.  The tax preference for employer contributions to health coverage remains one of the largest federal tax preferences.  With our soaring budget deficits, it is only a matter of time before this preference is eliminated or sharply reduced – the so-called “Cadillac-plan” tax in ACA is just the start.  The second is the existence of a viable alternative.  Currently, there are many barriers to widespread adoption of individual health insurance, but once ACA’s exchanges and prohibition of medical underwriting go into effect in 2014 (unless the law is repealed or does not survive its various legal challenges), obtaining individual coverage will become much more attractive.  Indeed, McKinsey estimated 30% of employers would drop their coverage once the exchanges become operational (although this estimate was not without skeptics).   Personally, I wonder why the number is as low as 30%.  Third and finally, in the kind of monitored world that Moss calls for – which is already starting to happen – there will be increasing privacy concerns about what information one’s employer has access to.  We’ve already seen employers making employees pay more in premiums based on participation in various screenings or wellness programs, and even prohibitions against certain types of non-job behaviors (e.g., smoking).  With the kind of monitoring Moss discusses, the type and amount of potential data becomes much more personal.  At some point, consumers are going to rebel about their employer’s oversight of their lives.
  
  
• Reform medical education & licensure:  With the much lamented trend towards specialty and sub-specialty, by the time a physician gets into practice much of his initial training may be out-of-date, not to mention his/her having spent a small fortune.   Victor Fucks has eloquently argued for more distinct yet faster approaches to training, and that is the kind of fresh approach we should be considering.  I would go even further.  As a layman, the distinction between allopathic and osteopathic medicine has always been murky to me.  Throw in chiropractic, podiatric, acupuncture, nurse practitioners, and the array of health care practitioners begins to look like something from the 19^th century medicine.  One is surprised that phrenology is no longer on the list of extant medical professions.  We need a Flexner Report for the 21^st century, not focused just on allopathic training but on medical education period.  Blow it up and start fresh, with a comprehensive, empirically based approach, based on validated medical practices rather than on historical professional silos, and with different end points based on type of practitioner.
  
  As for licensure, I’ve previous blogged about the seeming ineffectiveness of state medical boards and on issues relating to licensure’s impact on telehealth.  Public Citizen’s analysis indicates fewer than half of physicians who suffered clinical practice actions also had state licensing actions.   It leads one to wonder: whose interest is the current system serving?  If we can monitor individuals in real time and advise them on better health behavior, certainly we should be able to do the same for physicians, and to use data to make better decisions about which health care professionals are practicing appropriately.  Licensure shouldn’t be based on reputation, state of residency, old boy networks, fear of impact on malpractice suits, or other constraints that aren’t keenly focused on better patient care.  It should be based on ongoing, proven performance.  We can do better. 
  
  

I could go on with this list of reforms – and I may in future blogs – but I’ll stop for now.  Each of the above changes would be a monumental task in itself, with many interest groups heavily entrenched in the status quo.  Still, to use another oft-quoted line – if not us, who?  If not now, when?

Comments

[Daryle Gardner-Bonneau]

I especially like your next to last paragraph regarding telehealth and physician licensure. Telehealth has HUGE potential for cost savings and improved care, especially, but not exclusively by any means, for people with chronic medical conditions. But the primary barriers to its effective implementation (and reimbursement for it) concern bureaucratic red-tape issues like the state licensure of physicians.We need to remove a lot of these barriers to provide effective and efficient services in the 21st century - where people expect so many services to be provided any time and anywhere.

[kim bellard]

Interesting article in the NYT (http://www.nytimes.com/2011/11/17/health/policy/smokers-penalized-with-health-insurance-premiums.html?_r=1&ref=health) on employers' surcharges for smoking & other unhealthy behaviors.