U.S. Health Care Reform: Continued...

As the debate over U.S. health care reform continues, much of the controversy seems to center on the creation of a "public option" for health care coverage, and the widely-held fear that private plans cannot survive in competition with such an option. Why should private plans survive if they cannot perform in a competitive environment? This question seeks to justify the public plan in the ideological context of its opponents. It is not yet clear whether this logic will be effective in the political process.

In reality, I think that private plans should not survive in their present form as they appropriate either undeserved financial benefits of not-for-profit status - or excessive profits and CEO salaries - while they fail to provide services to American citizens. Other industrialized nations have designed single payer national systems that provide superior care to their citizens at a cost generally half of the per capita cost in the U.S.. (It is interesting to note that neither the Kennedy bill, nor HR 3200, contains reference to a "national system" or "national infrastructure," but the prevailing ideology as well as an essentially "bottom-up" system change process are assumed throughout the text of the legislation.)

Those who doubt the necessity of rapid reform should review the unfolding story of Remote Area Medical Volunteer Corps. While this organization was founded in 1985 by Stan Brock to deploy health care relief services in the developing world - it now has a growing mission in the United States. RAM recently offered free dental and medical services in Wise, Virginia, where as many as 1600 people showed up each day to receive free care, and on August 11-18, a clinic will be open in Los Angeles where as many as 10000 people are expected. (CBS 60 Minutes produced a segment on RAM in March 2008.) The success of RAM in the U.S. is a testament to the suffering of ordinary citizens across the country and a document of third-world America.

On June 15, President Obama made a speech to the American Medical Association in which he pointed out some of the disastrous economic effects of the dysfunctional U.S. health care system:
Our largest companies are suffering as well. A big part of what led General Motors and Chrysler into trouble in recent decades were the huge costs they racked up providing health care for their workers; costs that made them less profitable, and less competitive with automakers around the world. If we do not fix our health care system, America may go the way of GM; paying more, getting less, and going broke.

According to Obama, not only the health care industry but all of "America may go the way of GM." He is right. He is attempting to convince health-care policy holders that the reform legislation under committee review will improve their coverage in the following ways:

1. No Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.
2. No Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.
3. No Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.
4. No Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.
5. No Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.
6. No Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.
7. Extended Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.
8. Guaranteed Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won't be allowed to refuse renewal because someone became sick.
   (Source: The Washington Post)
   
   Background:
   National Conference of State Legislatures: Federal Health Care Reform:
   Congressional Budget Office - Special Collection on Health
   Commonwealth Fund
   National Academies Press: Health and Medicine
   
   On July 15, Congressman Kevin Brady (R-TX), the lead House Republican on the Joint Economic Committee, unveiled a detailed flow chart of the complex health care reform proposal by Democratic congressional leaders.
   
   Kennedy "Affordable Health Choices Act"
   CBO evaluation - Letter to Senator Edward Kennedy (June 15, 2009)
   
   HR 3200 : ‘‘America’s Affordable Health Choices Act of 2009’’(July 14, 2009)
   CBO Analysis - Letter to Representative Charles Rangel, Chairman: Committee on Ways and Means (July 17, 2009)

Qualitative Case Analysis for Study of National Health Care Systems

Research in science policy, institutional economics, telecommunications, and organization theory has contributed to the growing literature on health care system performance, management and control. The current focus on health care system reform in the U.S. has made apparent the lack of relevant research evidence from country level studies. While many policy makers point to a fragmented health care delivery infrastructure, few reform efforts are framed at the national system level. Systems thinking seems anathema in an ideologically restricted political process.

The premise of my program of research is that study of configurations of virtual institutional health care infrastructures is critical to understanding global and regional health care ideologies and market dynamics. Little research has considered the effects of telecommunications and internet infrastructures on these dynamics, largely because theory, methods and tools have not been adapted adequately to analysis of these structures and processes profoundly transformed by new technologies at every system level.

Such analysis requires qualitative research strategies because of increasing system complexity and high rates of social, cultural and technological change. First, case analysis facilitates validation of patterns identified in data collected from diverse sources and construction of comparative frameworks from grounded theory principles. Historical analysis exposes the logic and possible path dependence of system evolution as in the phases of system creation through local unit design, control through centralization, and integration through horizontal coordination.

Another promising qualitative approach is system mapping for sociometric analysis of virtual infrastructures and their contributions to health care services markets and hierarchies. System configurations reflect institutional patterns of information management and control, including free market and centralized social medicine dynamics. For example, density or connectedness may describe the number or proportion of possible linkages appearing in a network, while hierarchy or dominance may describe the distribution of linkages throughout the network. Configurations may be interpreted as complex systems or as cases embedded in a broad context.

Taken together, case analysis, historical analysis and system mapping offer strategies to approach study of the important coherence between underlying ideologies and virtual health care infrastructures.

Some published research programs address country level case analysis of national health care systems - with a view to creation of an evidence base for comparison. Most extensive among these is the program of the European Observatory on Health Systems and Policies of the World Health Organization. The data collected for the 25 member states of the European Union include: (1)Health Systems in Transition (HiT) profiles, (2) other health-related information such as reports from institutions and health reform policy papers, and (3)
links to health-related web sites - ministries of health, national public health institutes, and research centers for health policy, public health and health economics.

The most recent template (2007) for development of Health Systems in Transition (HiT) country profiles includes some data on HIT in sections on planning and health information management (4.2) as well as physical resources (5.1). Information technology must be defined for each country profile in the context of a national IT strategy for the health care system as well as general statistics on Internet access and usage.(page 74)

Another research program on ehealth in national health care systems was initiated by the Rockefeller Foundation in the series of conferences at the Bellagio Center on Making the eHealth Connection organized by the World Health Organization-July-August 2008. The themes covered in the collection of country case studies include:

1. The path to inter-operability


2. Public health informatics and national health information systems


3. Access to health information and knowledge-sharing


4. eHealth capacity building


5. Electronic health records


6. Mobile phones and telemedicine


7. Unlocking eHealth markets


8. National eHealth policies

One background paper addresses The Case for a National Health Information System Architecture: A Missing Link to Guiding National Development and Implementation (by Stansfield, S.; Orobaton, N.; Lubinski, D.; Uggowitzer, S.; Mwanyika, H.) According to the authors, "a national health information system (HIS) plays an important role in ensuring that reliable and timely health information is available for operational and strategic decision making that saves lives and enhances health."(page 1) While this definition is generally acceptable, the strong ideological bias evident in the report is not. The enterprise architecture framework has been applied in the context of the U.S. federal government, but requires a careful adaptation to each country culture under consideration for health care sector applications. For example, in the Latin American social medicine tradition, the definition of health care work flow as a business process would be unacceptable.

The country case studies available in the collection are South Africa, Turkey, Vietnam, Rwanda, and Peru. These studies are generally organized according to the conference themes listed above as adapted by the authors. The greatest weakness of this research program is the lack of a theoretical framework or logic to guide methodological choices as well as data interpretation. Comparative analysis of the cases is especially hampered by lack of theory and the convenience sampling of country cases. According to Yin, selection of a single case for analysis may reflect a typical, critical, or unique set of observations for theory development. I have learned in my study of BIREME (Brazil) and INFOMED (Cuba) that regional leadership dynamics must be taken into account in case selection, and that regional network structures may be critical in the understanding of national health information systems.

Other collections of country studies of interest to researchers on national health information systems include Health Systems Country Briefs produced by USAID (August, 2007) to identify areas for investment in effective health systems strengthening. Published briefs include Mozambique, Rwanda, South Africa, Tanzania, and Zambia.

Earlier case studies (2005-6) examined the systemwide effects of the Global Fund to Fight AIDS, Tuberculosis and Malaria on the national health care systems of Benin, Ethiopia, and Malawi. The interim report on findings from these three cases focused on Global Fund effects on the policy environment, human resources, the public/private sector mix, and the pharmaceuticals and commodities markets.

The larger Global HIV/AIDS Initiatives Network including researchers in 21 countries conducts research on how these programs affect national health care systems. The GHIN promotes cross-country case comparability through common research methods, builds research capacity, informs health care policy through multi-country comparisons, and coordinates dissemination of research conclusions and recommendations. The GHIN has contributed to the WHO Positive Synergies Initiative to strenthen its institutional role in national and global health policy. The WHO also publishes a very useful set of country profiles including data for cross-country comparisons.

The International Telecommunication Union offers country case studies by region and topic-providing context for analysis of national health information systems. (Many of these cases require an update.) Another series of ITU cases (2000-2004) addresses Internet diffusion in various stages of country development. (See also publications of the Mosaic Group on the Global Diffusion of the Internet Project.)

Porter's Value-Based Strategy for Health Care Reform

The New England Journal of Medicine has just published an article entitled "A Strategy for Health Care Reform — Toward a Value-Based System" by M.J. Porter - which has already attracted some international attention. (I learned of the publication as I read a communiqué from the Indian Association for Medical Informatics.) The principles of his approach to health care require critical review-especially as they are aligned with the U.S. health care industry for the promotion of competition as a driver of value, defined as health outcomes achieved per dollar spent. I am particularly concerned about the misuse of Dr. Porter's influence to pedal a U.S. model for health care reform where there exists no evidence in support of such a model.

According to Dr. Porter, while both universal health care insurance coverage and national system redesign are necessary to achieve "true reform", value takes precedence over universal coverage. It seems to me that he is confusing the concepts of universal access to services and universal health care insurance coverage. (In the U.S. system, the private health care insurance industry effectively denies access to millions of U.S. citizens - either by demanding prohibitive deductibles and co-payments or refusing to cover a particular claim for treatment.) Dr. Porter suggests that lower health care costs in other countries are due to universal insurance coverage, but this advantage too is unsustainable without improved value. He fails to recognize the single payer system design with publicly funded health information infrastructures as critical to controlling costs in other national systems. While certainly there has been "no convincing approach to changing the unsustainable trajectory" of the U.S. system, it is inaccurate to suggest that other countries such as Finland, far more advanced than the U.S. in design of an efficient national health care system, should reform their systems according to his recommendations. Rather, the U.S. should be learning from the examples set by other industrialized countries such as the UK, France and Taiwan as well as developing countries such as Cuba and Brazil.

According to Porter, there are six principles to guide health care system reform - all of which address financing:

1. Reform health insurance competition to focus on improvement in subscribers' health.
2. Motivate employers to stay in the system by penalizing "free riders". (The presence of employers in health care insurance markets will foster competition based on value.)
3. Address the unfair burden on those without access to employer-based coverage by equalizing tax deductibility of premiums paid by individuals independently or through their employers.
4. Create regional insurance pools (instead of a national pool) similar to the Massachusetts Health Insurance Connector. Regional pools apparently would be more effective in promoting value-based competition. Reinsurance programs are also critical to "spread risk" related to coverage of very expensive conditions.
5. Create income-based subsidies to assist low-income citizens in purchase of insurance.
6. Require all citizens to purchase health insurance.

This value-based delivery system requires "mutually reinforcing" steps to implementation. The most important features of such implementation appear to be outcome measurement, organization of care according to medical conditions with bundled payments for reimbursement of care, value-based competition for patients across geographical boundaries, adoption of HIT architectures and standards for electronic medical records, and patients' responsibility for their own health.
While many of these features seem painfully obvious, Porter offers no evidence in support of his claims that his framework will bring about the needed reforms in the U.S. system. The use of electronic medical records, for example, is assumed to bring about improved health care efficiency and quality by many researchers and policy-makers. Porter also asserts that "electronic medical records will facilitate both delivery restructuring and outcome measurement" without providing any qualitative or quantitative empirical support for this "bottom-up" change process. Porter's statement has not been demonstrated in any health care system. It would be just as reasonable to suggest that HIT infrastructures for health information exchange form a prerequisite for implementation of electronic health records. The existence of such national HIT infrastructures is certainly required to deliver the comprehensive program of outcome measurement at the foundation of Porter's strategy.
The framework does not mention the role of the public sector in health care system reform, except to affirm the superiority of the private sector to create accountability and value-based care through competition. (Again, there is no research evidence to support this claim. On the other hand, Amartya Sen has pointed out that national health care system performance is related to rate of public health investment. See Sudhir Anand and Martin Ravallion, Human development in poor countries: on the role of private incomes and public services, Journal of Economic Perspectives, 1993, 7: 133-150.)
Porter suggests that his reform strategy requires new independent institutional roles to oversee outcome measurement, set HIT standards, and regulate bundled reimbursement; and that Medicare might be able to "take the lead in some areas." (These new roles should probably be assumed by state or federal entities to assure their independence. Controversies surrounding the Certification Commission for Healthcare Information Technology (CCHIT) illustrate this dilemma.) The Commonwealth Fund has published a comparison of public investment per capita in HIT (2005) (slide #72) showing that the U.S. lags far behind the U.K., Canada, Germany and Australia. This lag probably reflects the lack of public infrastructure to support EHRs and health information exchange at the regional or national levels.
Aside from a significant pro-business ideological bias, Porter's strategy lacks clarity in the definition of "value" as "the health outcomes achieved per dollar spent." Although in the past he has emphasized the role of physicians in health care reform, his perspective has shifted to the system level of analysis. However, value is consistently defined at the individual rather than the population level. In my opinion this conceptual definition is impossible to operationalize for measurement as prescribed - primarily because "value" is to be measured at the individual treatment level of analysis, while the relevant outcome may occur in the aggregate - at the family, community, or population level.
"Value" is a highly subjective dimension at the individual as well as the collective level. How can consensus be developed to prescribe the definition of "value" for such a comprehensive program of outcome measures? Criteria for patient, doctor and provider choices are also very subjective. Objective characteristics of health care delivery would be more useful to inform subjective patient choices. (Porter has not addressed the immense costs associated with production of his outcome measures, including the conduct of extensive comparative effectiveness research programs required to serve as an evidence base.)
The definition of value related to "bundled" services poses substantial methodological problems. Bundled services and reimbursement schemes assume a level of standardization not consistent with the complexity of individual cases - including comorbidity. This design feature would also encumber the dynamics of market competition. (Certain provider organizations would integrate their services in competing industry clusters.) In any event, there is no research to substantiate Porter's far-reaching claims on the benefits of health care services bundled according to medical condition. A CMS (Medicare and Medicaid) initiative to introduce bundled reimbursement in the mid-1990s failed due to provider resistence. The reasons for this failure should be examined to ensure the validity of new proposals in the current environment.
Porter also needs to clarify how the dynamics of consolidation and competition co-evolve in health care services markets. While he deplores "hyperfragmentation and duplication of services", such duplication of services is implicit in the competitive environment he advocates. Certainly the regional structuring of risk pooling would create boundaries to competition and structural redundancy across regions. I do not understand why Porter considers that regional organization "will result in greater accountability to subscribers and closer interaction with regional provider networks, fostering value-based competition." The case of McAllen, Texas and Doctors Hospital illustrates the possible dysfunction of such a model at the local level of analysis-including the exorbitant costs in public CMS reimbursement. (Hear an interview with Dr. A. Gawande on NPR.) Some dimensions of health care in the future will remain anchored in geographic proximity, but others will be more efficiently organized at the national level. Not only will HIT contribute to efficiencies redefined at the national level, but patients will probably be more mobile in pursuit of both work and health care services.
My review has suggested only a few of the many questions to be answered concerning Porter's strategy for health care reform. As many American authors on policy for U.S. health care reform, he needs to consider other national health care systems to identify an evidence base relevant to the American challenge. He refers only to his own publications, and mentions the case of Finland not as an example for study, but as an illustration of the universal crisis in controlling health care costs. One very instructive country case is Taiwan where single payer system reform was implemented in 1995 after thoughtful examination of other national systems to identify desirable features transferable to the Taiwanese context. U.S. policy-makers would have much to learn from this change strategy.
I would like to conclude this review by deploring the excessive emphasis on finance to the exclusion of any reference to medical ethics in the debate on U.S. health care system reform. While financial incentives are certainly important, especially from a business standpoint, physicians and health care professionals should not require micro-management through financial rewards to motivate their service. Implementation of such complex reward systems is very expensive as well as vulnerable to fraud and legal challenge. The most important incentives should be the intrinsic rewards associated with the privilege of offering a public good through health care service.