What ails the medical system which most Americans, especially those of us who are disabled, rely upon? According to two executives at the Mayo Clinic, the main problem with the U.S. health care system is that it isn’t a system.
In an essay entitled “America’s Ailing Health Care System” in the April issue of Mayo Clinic Proceedings and reported by Newswise, Mayo’s chief executive officer, Dr. Denis Cortese, and its chief administrative officer, Robert Smoldt diagnose problems in U.S. healthcare and prescribe major reform based on the new concept of the “Learning Organization.” To promote dialog about the reforms they outline, the two executives are hosting a May symposium at the Mayo Clinic.
Cortese and Smoldt claim a “confluence of issues” needs immediate attention and action. “Something [must] be done to fix—not patch—the system. In reality there is no healthcare system [in the U.S. today].” Although a myriad of professionals and organizations currently provide healthcare, “no vision has ever been articulated for these disparate parts to function together and learn from each other.”
Dr. Cortese compares the problem in today’s health care system to a disease of the human body. “As healthcare professionals, we marvel at the complexity of the human body, extraordinary when its systems perform in concert, devastating when disease or disorder invades. One malfunction within the body, not making insulin for example, may lead to serious problems such as blindness, peripheral nerve damage and heart disease. Our job is to bring the entire human body back into balance so the patient can lead a full productive life. A similar holistic approach should be used to examine the way we provide healthcare in the United States. Like a person suffering from a debilitating disease, healthcare in the United States is ailing. There are many signs that it is in serious trouble.”
Smoldt says current financial incentives are seriously misdirected. “Medicare’s payment model creates a built-in financial incentive for medical centers to provide more services, even though recent studies involving patients with chronic diseases show no evidence that doing more improves either medical outcomes or patient satisfaction. Reducing payment rates for office visits has led to shorter, more frequent and less effective appointments. Because their financial responsibility for patients ends when Medicare coverage begins, insurance companies don’t have financial incentives to best help patients over a lifetime – especially if the costly complications are unlikely to show up until [after] age 65.”
The core concept for the reform proposal comes from Peter Senge’s book, The Fifth Discipline. In it Senge describes learning organizations—places “where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together.”
Mayo’s executives believe health care organizations need to be transformed into such learning organizations in order to ensure quality care in the future. “Health care as it exists in the United States isn’t sustainable,” says Dr. Cortese. “Health insurance premiums consistently increase faster than inflation or worker earnings, 46 million Americans lack insurance, and the percentage of employers offering health coverage dropped from 69% to 60% in the last five years. Nearly half of physician care isn’t based on best practices, and each year 98,000 Americans die from a medical error. Five years from now, when the first baby-boomers qualify for Medicare, we will be on the cusp of a crisis if changes aren’t made.”
The authors say a new view of American healthcare begins with a common vision of seeing health care providers as patient-centered learning organizations that provide the best care at the right price, the first time. Key elements of such a learning organization for healthcare would include:
• Health care professionals in a learning organization should expand their knowledge through perpetual education, pass on knowledge through teaching or mentoring, and add to the body of knowledge through basic, clinical or health sciences research.
• Physicians need training in engineering principles and partnerships with engineers to improve the processes of care. One familiar example of such a partnership is unified medical records, which long ago replaced the practice of each Mayo physician keeping separate notes. About eight years ago, Mayo began working with IBM to develop an electronic medical record to collect, store, and retrieve data; distribute and analyze information; and generate knowledge.
• All helpful information about an individual’s healthcare should be available to physician and patient, anywhere in the world, within seconds of pushing a computer key. Examples of such information include medical and family histories, medication lists that automatically check for potentially dangerous drug interactions, test results and radiology images, best practices with links to the latest medical literature and disease management strategies for the patient’s condition, the individual’s unique genetic profile to individualize treatment, and clinical trials for which the patient may be eligible. Unfortunately, at present only 15% to 20% of U.S. physicians’ offices and 20% to 25% of hospitals are using electronic medical records.
Cortese sites a recent example of this shift toward making information widely accessible. During the past 10 years, “Kaiser Permanente, which provides healthcare coverage and medical care to more than 8.3 million members throughout the U.S., has invested $3.2 billion in a comprehensive electronic health information [product]. The overriding goal is to improve the quality of care. Once fully-implemented, patient medical information and clinical decision support will be available all the time, more than one clinician will be able to use a single patient’s information simultaneously, and patients can more easily participate in their own care. We must become team members. The team approach fosters an ongoing analysis of the outcomes and processes of care, a key step in any systematic approach to improving quality care.”
The authors suggest the learning organization vision for health care could be best achieved through a “consumer-driven, market-based model that delivers universal coverage to all Americans, a model similar to the Federal Employee Health Benefits Plan (FEHBP) or the Universal Health Voucher Plan. Relying on market principles can help us achieve our vision for healthcare.” Within this model, providers, patients, insurers and government must all modify their roles. A market-based insurance model similar to the FEHBP, which functions well for government employees, would ensure fair, universal access to private insurance, with the government providing financial assistance to those who need help purchasing insurance, they write.
“FEHBP … is affordable, offers choice, covers drugs, has no state mandates and allows people the right to purchase more options. Employers would not be required to provide health insurance, but, in the interest of their business or employees, could choose to contribute to the cost. Employees could use the employer payments to cover all or part of the cost for any insurance plan on the national menu. The federal government could coordinate these insurance offerings through an organization like the Office of Personnel Management, which currently runs the FEHBP at a relatively low administrative cost.”
Smoldt says the FEHBP model would enable the government to focus its limited resources on those who need help, would preserve consumer choice by enabling patients to be more fully engaged as the purchaser and the customer, and would allow a dynamic private market more freedom to provide the innovation and increases in productivity that can contain health care costs. “It also would prevent people being excluded from coverage because of a pre-existing condition, because all of the insurance companies would be required to accept all patients during the open enrollment period,” he says.
The authors believe patients should pay a portion of their care “so they are aware of healthcare costs and can become better consumers. Everyone must have health insurance that includes a basic benefit package. This is a matter of individual responsibility and analogous to requirements for individuals to have automobile insurance. The federal government would help finance insurance for those who are in need.”
The authors stress the need for many voices, not just theirs, to enter the reform discussion. “We also realize that others have creative ideas about how to transform health care in order to meet the needs of patients.” Dr. Cortese says it is crucial that the discussion begins in earnest, and to that end Mayo is hosting the Mayo Clinic National Symposium on Health Care Reform, May 21-23, in Rochester
As Dr. Cortese concludes, “For true reform, and for a health system that is truly a system, we need a common vision that can only be developed through a national discussion. We look forward to being part of that discussion, and hope to facilitate moving from discussion to concrete action.”
Details are available at www.healthpolicysymposium.org. Dr. Cortese can be contacted at [email protected]
In his wheelchair in Jacksonville, FL, Herb Drill writes and edits www.notaccessible.com and is a charter member of the Society of American Business Editors and Writers. His e-mail address is [email protected]