Disaster
Contact a disaster preparedness person at either a local hospital, or local city or county emergency services agency. NORTHEAST OHIO
1. Blackout 2003
2. Chardon Highschool shooting 2012
3. Great blizzard 1978
Interview your contact, asking the following questions:
1) “What do you consider to be the top three disasters for which you prepare?”
2) “What would you say are your top three lessons learned about managing a disaster?”
What Would the Best Future for Health Care Look Like?
Introduction
The one thing the debate over reforming health care taught us all is that there are as many opinions as there are interested groups, and all of them differ in meaningful ways. To look at the views on improving the systems of care delivery, it is important to note where they have points of agreement and where they differ. They are all driven by the values and principles of the constituencies and what they hope to achieve from changes in the delivery system. This module will explore points of agreement and differences between important groups that will influence the direction health care will go in the next decade.
Patients
It is an interesting point that all constituencies, in their public statements, emphasize that a strong health care system should focus on getting the best outcomes for patients. What would that be, from the perspective of patients? Typically, patients relate that they want top quality in their care and the latest technology, along with immediate and unrestricted access to care, at the lowest possible cost. This triad has become the stumbling block of change initiatives, since to date, no one has figured out how to deliver all three. However, when patients’ views are explored and probed, some interesting facts emerge. When patients say they want top quality care, in general, they tend to define that as achieving a cure or return to health. They certainly do not want to leave the system feeling worse than when they came in. Patients have been heavily lobbied in the media by pharmaceutical and medical technology companies to convince them that the latest (and most expensive) technology will deliver the desired outcomes. However, very little real research on the true effectiveness of treatments and technology makes its way to most patients, and patients in general do not shop for their medical care as carefully as they would if they were purchasing new cars, for example. The language of research and medicine is difficult for patients to understand and is frequently not well-explained by providers.
So, the nuances of top quality care in terms of being able to deliver a cure or return to health are not well understood by the constituency with the most at risk. What patients do understand is whether they feel better or see improvement in their health and whether care was rendered without errors and in a compassionate way. The best health care system, from a patient’s point of view, is one that can consistently deliver the goods in terms of a cure and a return to health, in a way that is safe for the patient and does not hit them with unexpected or heavy costs, from providers they trust to have their best interests at heart.
Physicians
Physicians, in general, strongly believe that they are the most informed providers of care and are best placed to make the needed decisions about what care is best for the patient. They may or may not be interested in new research results, innovations in care, new drugs or technologies, or new systems of care. Physicians believe that medicine is an art as much as a science, and many of them develop entrenched patterns of providing care that can be resistant to changes unless and until those changes are proven over time. Since physicians believe they are the best primary decision makers on care alternatives, they may strongly resent restrictions on utilization, selections of drugs and treatments, or the requirements to preauthorize care, which are placed by insurance companies. Many physicians see these requirements as bureaucratic waste built into the system to cut costs, without regard for patient benefit. They also struggle with the need to contract with insurance companies for what physicians see as low-value reimbursement and feel helpless to negotiate better rates of pay overall. Their idea of an ideal delivery system is one where they have the freedom to practice medicine without regulatory or utilization restraints, without fears of malpractice claims when patients do not get the outcomes they want, and without worry about being paid appropriately for what they do. Their ideal system would not include any form of micromanagement by insurance companies but instead offers fair and reasonable (by the physician’s definition) payment for services immediately upon receipt of the physician’s bill. In the physician’s ideal world, nothing stands between the patient and his/her physician in determining and carrying out care.
Hospitals
Hospitals also tend to remember the days when they provided the services ordered by the physician to patients, submitted their bills, and were paid as requested in a timely manner. The current reality is that increasingly hospitals are being paid a flat fee, or case rate, for an episode of care. This leads hospitals to focus on procedures, which pay better, and to conduct their own utilization management in order to keep their costs down. This may also extend to the physician, who may be told that she/he cannot give a certain drug to a patient due to its high cost or must limit the choice of a hip implant to one or two vendors with which the hospital has contracts. Hospitals and physicians thus enter into a complicated relationship, where they both need each other but also continue to push against each other: the physician striving for more autonomy in providing care and services to the patients, and the hospital attempting to reduce costs below the case rate in order to avoid financial losses. Hospitals are extremely regulated by laws, rules, and regulations, which change frequently. One of the newest departments in hospitals is the compliance department, which did not exist in many hospitals decades ago. The constant monitoring of compliance to all the laws, rules, and regulations that apply to health care providers has added considerable cost to the system, of which most patients and many physicians are unaware. The ideal hospital delivery system would focus on providing top quality care in terms of using whatever was needed to get patients to their desired outcomes; would have much less regulatory load with which to comply; would have a steady and reliable payment source for all patients treated in the hospital; and, under tort reform, would have less malpractice liability.
Payors
Insurance companies and government payors also struggle in the current system. Their focus has been to contain costs, given the steady rise in expense during the last several decades. They attempt to reduce the costs of physician care by enabling more care to be done by less expensive midlevel providers, pushing physicians to agree to contracted rates of payment, and in some cases, establishing rates unilaterally on a “take it or leave it” basis, as done by Medicare and Medicaid. The payors are leaders in utilization review, case management, and pushing the shift from expensive inpatient care toward less costly care on an outpatient basis where feasible. They are in a continuous struggle with patients and employers, who do not want to see a rise in premiums; and with hospitals and physicians, who do not want to see payment rates decrease. In a payer’s dream system, the focus would be on efficient achievement of medical and health outcomes, with payment only when outcomes are achieved. They also would have stringent controls over unnecessary utilization of services by a simple refusal to pay for those services without preauthorization for the necessity. Standard protocols of care for particular conditions would be the norm, and these would be grounded in evidence-based research. Payments to hospitals and physicians would be global in nature, with one payment made to the joint entity, leaving the hospital and physicians to divvy it up. Above all, for the business side of insurance, there would be healthy profit margins for the payer to return to its stockholders.
The Community
The larger community looks at the current system of health care delivery, scratches its collective head, and wonders what is going on. It sees inefficiencies, competing interests, ballooning costs, errors and near-misses, unequal access to care, financial impacts, and controversy about who controls what and how care is delivered. In the community’s ideal system, there would be universal access to health care at an affordable cost, no waste or inefficiency in the system, care would be delivered based on patient needs and expected outcomes, health would be achieved and maintained through prevention activities, and there would be a method of managing the financial aspects of care in a sustainable way, so that all parties are made financially whole, but no one becomes obscenely rich. The cost of care is matched to the community’s available resources and does not exceed them.
Conclusion
As one can see, the various stakeholders in the current system have many overlapping desires and needs, along with some that are directly competing. Anyone who is planning to tackle health care reform and the design of a new and innovative system of care needs to be sure that they have a thorough understanding of the needs, desires, and wishes of all the constituencies. The search for a compromise position that meets some of everyone’s shared needs, without overloading on meeting competing desires, is the Holy Grail of health care system design.
