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Health Reform On The Edge: Stage 1 and Stage 2.

Posted Nov 15 2013 10:01pm

Posted on | November 12, 2013 |

This past week, in a speech at Bowling Green State University, I described health transformation as occuring in two phases. Phase 1 was the acknowledgement that the status quo in U.S. health delivery had run its course, that is to say it is no longer affordable or defensible. Phase 2, as I defined it, was building out a new and better system.

I went on to say that it had taken nearly three decades of fighting, cajoling, politicing and convincing to reach a point where the powers that be generally agreed that that the status quo was no longer a viable alternative. The Affordable Care Act – supported publicly by the AMA, the AHA, the AAMC, and PhRMA to name a few – essentially declared the end to the status quo and chose as its primary dismantling weapon the reform of the U.S. Health Insurance Industry.

Healthcare.gov , and “kickers and screamers” aside, getting beyond Phase 1 is an enormous achievement. But it doesn’t answer the core question embedded in Phase 2, “Do we know what we want to build?” At Bowling Green I said that what we do know is that, 1) behind the scenes, key thought leaders have been quietly teeing up this question under the radar for some time, and 2) we have a ways to go in embracing a common vision and delivering the goods.

I said this with some knowledge that this week JAMA would be publishing a special theme issue on “Critical Issues In US Health Care” featuring the opinions of luminaries such as Don Berwick, Harvey Fienberg, Uwe Rheinhardt, Zeke Emanuel, Denis Cortese, and others.

As the editors of this issue explain, “ The US health care system has reached a tipping point when there is both little doubt about the kind of change that is needed and much uncertainty about how to achieve it…There is no shortage of prescriptions for improving the delivery of care, and several Viewpoints in this issue of JAMA present potential solutions for core challenges.”

A few of the viewpoints:

“The best remedy for toxic politics would be unprecedented professional mobilization, recruiting unprecedented public support for new health care.”

“Investment in health research does all this and directly contributes to the alleviation of disease, distress, and pain and offers the best hope for long and healthy lives for the current generation and for generations to come”

“The US health care system needs a new BHAG(Big Hairy Audacious Goal): By 2020, per capita health care costs will increase no more than gross domestic product (GDP)+0%. That is, by the end of the decade, health care costs per person will not grow faster than the economy as a whole.”

Reinhardt’s DATA TRANSPARENCY: “Inside the fortress will increasingly be disrupted by what is now celebrated elsewhere as ‘disruptive innovations’  trained on the fortress by energetic insurgents, some of them equipped with a potent new weapon: modern electronic information technology. These insurgents’ banner reads Transparency.”

Cortese’s NEW AGE PATIENT ENCOUNTERS: “The patient will find that new delivery models no longer require a trip to the waiting room for a traditional office visit with the doctor…. Care will increasingly be proactive with a continuing emphasis on follow-up.”

“In a system this complex, there is always the risk that a step forward causes 2 steps back. With so much “change in the air,” it may be difficult to determine what is working and what is failing.”

Which is to say, the status quo may be dead, but it ain’t buried yet. Why? Try 2.7 trillion changing hands in health care each year. It’s a huge job market in a slow economy. And we Americans remain ambivalent about federalism, and the poor, and policies that advance human potential and productivity without mentioning our proclivity towards associating any success (individual or collective) with the words “God”, “patriotism” and “bootstraps.”

And yet, it’s useful to read the entire JAMA issue (as messy as it is), and to focus on Berwick’s final words.

Berwick, arguably the most personally assaulted of the luminaries touched by health reform in the past decade, the Obama’s Congressionally unapproved leader of Centers for Medicare and Medicaid Services, reflects in his opening: “When the President asked me to come to Washington, DC, to lead CMS, I thereby acquired responsibility for implementing much of the Affordable Care Act (ACA). Opponents of the ACA turned their general political vehemence into specific, deceptive attacks on my beliefs, hopes, capacity, and agenda. The absence of inquiry and dialogue about what I actually do believe was stunning.”

OK. It hurt. But in the short time since his departure, he’s clearly gained some perspective. His final words place him squarely (with the rest of us) between Phase 1 and Phase 2:

“ACA has begun the most significant tectonic shift in the nation’s health care since Medicare and Medicaid arrived in 1965. Professionals have an opportunity to guide this country out of the battleground and into the creativity needed. The toxins of politics have only one effective antidote: the memory of the shared purpose of care, which is to heal. The needs of the patient come first. That is the guidepost to success for a nation whose vision is clouded at the moment by the fog of conflict.”

And if you’re interested in my own vision for Phase 2, you can find it here .

For HealthCommentary, I’m Mike Magee

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