What we don’t need is religious adherence to doctrine.
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Amen, and very nice analysis! IMO, what we do need is some kind of adherence to practice guidelines and especially standards, and these standards must be well founded, kept effective, and evidenced based. These standards will NEVER come from the consumer of services upward, NEVER!

Everything else falls eventually into place if this kind of overall data and practice standardization could be implemented. Assaults on people are generally considered illegal in this country, and it used to be considered unethical to steal from the sick. However, in the healthcare system in America, these rules have never gained firm ground. I know market freedom is good and all and caveat emptor is the American market motto, but in some social endeavors that were designed from the top down to begin with, it is just disingenuous to think they will be able to change from the bottom up!

Perhaps it is a good idea to standardize treatments for particular “disease conditions” in order to improve quality and minimize variations (not even dealing with the variability of patients with regard to co-morbidities, tolerance to particular treatments, etc.); but it is also necessary to compare apples with apples in measuring patient outcomes when applying these standards and claiming that the market offers a “homogeneous commodity” for each “disease condition” among which “consumers” can make “rational choices” about “maximizing their utility.” In order to do this, physicians must be using the same practice guidelines. However, in the real world, some don’t even subscribe to, or even aren’t aware of, the “best practices” recommendations of their own specialties.

The “competitive market” model of healthcare decision-making is of such limited utility that it’s a wonder that there is so much persistence in designing “build-it- and-they-will-come” “solutions” based purely on market theory. First it’s necessary to understand the real meaning that “good health” (or even just “health”) has for individuals, patients, and their families. What we don’t need is religious adherence to doctrine.

It seems that everyone adds insights from all sides of the debate and all of these comments are constructive, even when the philosophies disagree.

What seems to be different in the new efforts is that CMS, AHQR, NQF, IOM, purchasers, payers, hospitals, providers, patient groups, etc..are all in the same room. Once, the “situation” room was filled only with economists, then only politicians, next only payers…

What Porter and Teisberg suggest is that we bring everyone into some form of accountability for our national health. It is a multidimensional problem that needs a multistakeholder solution.

I am pleased to see the wisdom of all the experts – healthcare economists, masters of business competition, providers, patients, purchasers, payers, etc…When we measure each and every aspect we will define extraordinary complexities that will not accept a simple solution. Still its a step in a problem-solving direction we have never taken before. It is worthy of everyone’s attention.

Just maybe, starting with something simiple enough could craft a culture of change that will open our minds to solutions for more complex challenges.

I believe you are refering to my comments concerning the EMR.

I could not agree with you more. Technology alone will not lead to transformation. The implementation of comprehensive EMRs and the adoption of business management principles/practices that have been developed for other industries alone will not lead to the most meaningful and most enduring changes. This is because the health care system and all of its componenets, (i.e. health networks, professional practice groups, etc.) are fundamenatally social systems and the forces driving substantive changes are social in nature.

Significant changes will be much more about people and relationships than they will be about technology. On the other hand this technology is incredibly empowering.

When implementation of the EMR fails, I suspect that this “failure”, in the vast majority of cases will ultimately be traced to an attempt to use the technology to support current processes and to maintain existing professional boundaries. This is not reengineering. In fact, there is no such thing as reengineering part of anything.

I suspect that the various groups of stakeholders in health care delivery tend to be bit “too introverted”. Perhaps the decision that Health Affairs has made to initiate this “Blog site” is a response to this situation.

The point that I wanted to make in my previous post was that in terms of determining the value of and reimbursement for health care services, it is clearly time for us to do something different, and perhaps that members of the various stakeholder groups could work on this together.

Does the PT model require Congress or any government to pass any law before it can be implemented on a major scale? Absolutely not.

As a lawyer with 30 years in the field under by belt, I estimate that about half of the $2 trillion spent annually on health care could adopt the PT model without a single law being passed.

More good practical news for the PT model from this lawyer. Unlike HMOs, capitated and premium based ideas, none of the 52 state (including DC and Puerto Rico) insurance laws apply to the PT model and its re-arrangement of dollars spent to pay providers treating a patient’s disease system. State insurance law “101″ is these payments are not “insurance” (buying a house is not insurance; buying protection against the chance the house burns down is insurance).

Thus the public and private employers and other payers that do not buy state regulated insurance and are self-insured (about 130 million covered people) can implement the PT model tomorrow.

Has anything like this, without Congressional or other governmental action, happened before? Yes, and at iPod speed. Old-timers like me watched and participated in unprecedented switch to PPOs in the 1980s-1990s, for similar reasons — no law needed to be passed, costs were exploding and all the other ideas had failed.

Finally, the decision makers now that can make the PT idea happen are the same that made PPOs happened then, plus some new players — self-insured employers, and their current and potential benefits providers. The new players potentially include banks (with $7 billion ins HSA accounts already), IBM, Intel, Microsoft and others since no insurance license is required and collaborative networks, now involving health care science by disease system, are one of their core competencies.

They also solve major problem Uwe correctly raises about categorizing medical conditions. In an insurance world, categories are king. But in the self-insured world, it is the self-insured’s money, and the categories are only the beginning of a health care science, not an insurance, question: how to improve patient resulted and reduce total costs (not individual provider costs) for this condition, or a better definition based on what can be done to add value.

(In the interest of full disclosure, I was privileged to help Mike and Elizabeth over the last six years, and was so taken by their idea I published a book chapter “Science Teams By Disease When Ill” on practical aspects of their idea, in Unique Value (2004), and now run a company implementing it called Next Generation Healthcare, LLC.)

While gaming is indeed possible, the answer to that issue is transparency: markets can arguably assess the results from data appropriately submitted to credible third parties for confirmation (they’re already out there too). With time, I suspect the data endpoints and the analysis for many Conditions could migrate to a de-facto version of HEDIS.

I\’m also confused by the description of the bundling of RAPs into inpatient DRGs as clinically and economically “sound,” since this seems to be an endorsement of PTs vision.

As for EHRs (comment above), their mere existence alone won’t make a transformation happen. Future versions will need to possess sufficient process and outcomes data granularity to enable the uber-analyses necessary to support PT’s vision, and that’s only the 1st step. Assuming Ver 2 EHRs arrive, the same class of software products could be applied to these data…perhaps reconcile claims AND EHR data.

I really admire Matt Holt (and his blog!) but his anecdote about Sutter is only one more reason to start looking for ways to get “there” from “here” ASAP.