Breakout healthcare: A call for action

It is time for the U.S. healthcare system to take control of the future. Given the recent Supreme Court ruling on the Affordable Care Act, it is obvious that the political battle over healthcare reform will continue through the election and into the next few years with little change in the current convoluted process.

Ask anyone who is a real participant in the healthcare business (not a politician, and not an academic) about the Affordable Care Act and you will realize that it is neither “Affordable” or really directed at “Improving Care.” I have read the 2,700+ pages of this act twice and I get frustrated each time I review the provisions. This act appears to be compiled by people who know little about the workings of the healthcare continuum and who are more interested in pandering to certain groups than in addressing the real issues around quality patient care, empowering provider efficiency and using technology to improve process.

At the heart of the discussion should be how to support the creation of new processes to lower the cost of care, while advancing the ability for providers to guide patients to wellness. There are provisions in the act that have nothing to do with healthcare, but a lot to do with how the government will raise money to expand its reach into the lives of patients, physicians, hospitals and health plans. The act is about government expansion, not the improvement of healthcare. There are more ivory tower issues in this plan than there are real solutions to real healthcare process and quality problems.

I have worked in the manufacturing, financial services and technology development industries and I have been continually appalled, over the last 30 years in healthcare, at how inefficient the industry is and how much money is wasted on health information systems that show no return and, in many cases, create more work than is necessary. Healthcare is one of the most inefficient industries in the U.S. and too many senior managers in the industry are afraid to admit this to themselves and hold their organizations accountable.

The time has come for those who make up the healthcare continuum to take control and define a real future for the improvement of healthcare and stop allowing something so fragile to be dictated by government. In order to do this, the past 30 years need to be reviewed to determine how we arrived at the mess we are currently experiencing within the U.S. healthcare environment.

1. In the 1980s a movement was started to make healthcare more efficient; it was the Managed Care Movement. It began with the idea that providers should help manage the patient’s navigation through the healthcare system. Providers, working with health plans and understanding the provisions of a patient’s care coverage, could affect efficiencies that would be implemented across the healthcare processes and costs could be contained. Good idea, but it did not work. Costs rose and efficiencies were never achieved.

2. In the 1990s a new managed care model emerged that spawned Integrated delivery networks (PPOs, HMOs). These were designed to integrate health plans and provider networks of practices, facilities and clinics; coordinate the many areas of care and apply technology to make process more efficient, driving the cost of care down; and manage the quality of care that was delivered. Costs rose, technology was never really integrated well and quality was still hard to define and manage.

3. In the 2000s a new form of managed care was applied, driven by the health plans, and was defined around the attempt to put in place pay for performance, quality metrics, extended care management and faster ways of getting data from the care location to the health plan for improved payment and better patient care visibility. This did not work, due to poor implementation of technology, physician and payer distrust, and no well-defined process improvement models. Same old processes, disconnected systems and no cohesive plan for how constituents in the continuum of care were going to work together and integrate information for defining and measuring quality.

4. We arrive more than a decade later, and guess what? We are no further ahead than we were in the 1980s, except more technology has been applied and now the government is trying to take more control to solve the problem.

5. The problem is worse, since there is no cohesive “vision” from across the industry that is universally agreed to, and government is increasingly exercising control. Payers and physicians still do not trust each other and the continuum of care still remains fragmented.

There are pockets of progressive work going on in the healthcare continuum, but they are plan- or health system-specific. They are normally geographically contained within areas, communities or regions driven by a specific large healthcare organization. Hopefully the successful projects are scalable models that payers and providers will be able to execute.

I believe it is time for a “breakout” of the old ways. The industry has to take control of the situation. The angst of the Affordable Care Act is past; it is time for action. As those of us who recall a cartoon of the 1950s through the 1980s remember (POGO), “We have met the enemy and it is us.”

The new healthcare model needs to be implemented based on the integration of information and technology, driven by process automation, focused on continuous quality improvement and deployed on secure network architectures that can rapidly deliver integrated (clinical, financial and administrative) information for appropriate care decision making. I propose that this new model be based on the following tenants:

1. A true integrated health information system needs to be deployed. This system should closely integrate financial, administrative and clinical data. There can be no redundancy of data in the system, thus allowing for high productivity, ease of access and rapid decision support. The data model for this should be centered on the patient and provider relationship.

2. Claims are no longer the center of the universe in the new healthcare model. Care management and the ability to monitor and manage patients (consumers) to wellness is critical. Again, the integration of data and processes through automated tools and technologies should drive the focus on continuous quality improvement.

3. Patients (healthcare consumers) must have "guides" to help them navigate the new healthcare continuum and providers need to take on this role in a more meaningful way, through clinical teams, assigned primary care physicians, and health plan advocates who appropriately direct and coordinate care. The old family doctor model used to be highly effective and it needs to once again be implemented through integrated information from applied technology. Based on the growth of the healthcare consumer base, and the increase in provider-to-patient ratio in the future, the virtualization of primary care physicians and the “team” of caregivers will be paramount to success. This team (Primary Care Advocacy) is critical to patient wellness and appropriate and timely care.

4. Cost containment needs to be managed through applied technology that delivers visibility to operational, financial and clinical decision support. This capability needs to be real-time and delivered in dashboard metaphors so that performance metrics can be monitored and costs can be managed and controlled.

5. Healthcare information systems need to provide workflow models coupled with highly integrated data models, web-enabled access, with information readily available across all operations, from the medical practice through the health plan, facilities and ancillary services. The systems need to drive efficiency up, process improvement forward and costs down. For the first time in healthcare “return on information technology investments” has to be defined, managed and proven.

In the past too much money invested in health information systems has been spent with little to no return on investment. To most payers, including the government, those days should be over.

Too many high-level papers have been written and too many speeches have been made describing the “nirvana” of healthcare’s future in the U.S. None of this has been put into action and most of it involves decisions developed with too much continued pontification on how it should be, with no results.

The proposed vision is that
healthcare should be affordable, cost-effective, quality-driven and care-focused. Here is a roadmap for beginning the process of creating a world-class healthcare model for the U.S.

1. Health information technology is critical to success.

2. Committed, continuous process improvement must be implemented in all plans, with 
providers, and ancillary services.

3. Measureable management metrics must be established for operational, financial and 
clinical performance.

4. Integrated information and reduced data and process redundancy must be applied.

5. The patient (healthcare consumer)-provider relationship should be enabled across the 
continuum of care.

6. Governance must be established among plan, provider and patient advocacy in the 

7. Systems must integrate managed care and care management that enable the entire 
continuum of care encompassing portals and clinical repositories allowing for ease of 
access to care and information for all continuum constituents.

8. Data and access to data needs to be ubiquitous and available 7 days a week x 24 hours 
per day on a global scale to protect patients, providers, and plans regarding care and 

9. Costs in all aspects -- operational, technology support and clinical support -- need to be 
contained and leveraged for value investment.

10. Finally, care is currently available to everyone who needs care. Nobody is being turned away as we are hearing in political discourse. In the new model the healthcare industry (not the government) needs to define how care can be delivered and deployed at a reasonable cost, with evidence-based value, and in a context that can empower consumers and providers. The economic model should be value-based for both providers and patients, with health plans being the data and process enablers in the model.

In summary, healthcare needs to be re-energized and challenged to create a new continuum model that integrates all of the constituents and allows for a care- and wellness-focused environment that showcases U.S. innovation to deliver the first healthcare information environment supporting the well recognized world class health care delivery model we have in the United States today.

The industry must wake up and commit to make this happen in the next 3 to 5 years.

I believe the clock is ticking and the industry, with many old systems that are not integrated, is about to implode. With 2014 deadlines for healthcare reform fast approaching, the healthcare industry must take control or the government will mandate a course of action that is detrimental to patients, providers, health plans and plan sponsors.

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