achieving health care reform in the u.s.: toward a whole-system understanding gary hirsch, jack...

Achieving Health Care Reform in the U.S.: Toward a Whole-System Understanding

Gary Hirsch, Jack Homer, Geoff McDonnell, and Bobby Milstein

Health Policy Special Interest Group

International SD ConferenceBoston, Massachusetts, USA

July 17-21, 2005

Meeting Agenda

• Background & magnitude of the problem

• Causal framework and why reform is so difficult• Feedback from HPSIG

– Illustration of adding stakeholder spheres of interest

• Moving forward

Causal Framework Overview: Stakeholder Roles and Interactions

Employers- Health coverage

Insurers/Payers(Public, Private)- Reimbursement criteria & rates for risk & disease mgmt and acute care- Number of competitors

Providers(MDs, RNs, Hospitals)- Risk & disease mgmt extent and efficacy- Acute care extent and efficacy- Specialty fragmentation - Lobbying of insurers & regulators

Patients- Health and risk status

General Public- Improvement of living conditions Funds available Citizen involvement

Drug/Device Makers- Developing high-tech products for acute care and risk & disease mgmt

- Lobbying of insurers & regulators

Regulators & Monitors(Public, Private)- Usage guidelines & controls

Health Care Costs- Risk & disease mgmt- Acute care- Administrative

Population Health Dynamics

Safer,HealthierPeople

People atRisk

People withDiseaseBecoming

at riskDeveloping

diseaseDying from

disease

Adverse livingconditions

-

Acute cases

Recovering orgetting cured

Becoming safer,healthier

-

B1

-

-

Effectively managedrisk and disease

Effective acutecare

Death limits thesick caseload

Growth of High-Tech Medicine


People atRisk


at riskDeveloping

diseaseDying from

disease


-

Acute casesHigh-tech acutecare capacity &

utilization



-

R1

B2

-

-


Effective acutecare

People withdisease and at

risk

Keeping theacutely sick

alive

Finding a cure

High-tech risk & diseasemgmt capacity & utilization

R3

Keeping thevulnerable

healthy

R2

Keeping the sicknon-acute

High-tech industryinfluence on providers,

regulators, and insurers

R4

High-techindustry growth

B3

Effective patient mgmtmay reduce acute care

demand

Inappropriate anddefensive use of

high-tech acute care-

Weak regulation,inappropriate use,

further industry growth

R5

Reduced Access and Reduced Quality of Patient Management as Side Effects


People atRisk


at riskDeveloping

diseaseDying from

disease


-

Acute cases

High-tech acute carecapacity & utilization



-

Use of multiplespecialists for patient

mgmt

-

-

-

Adequacy of providers inless wealthy & more

remote areas

-


Effective acutecare


risk


Quality ofinformation forpatient mgmt

B4

Fragmentation createsconfusion and hurts

quality of patient mgmt

R6

Fragmentation increasesgeographic concentration and

deprives poorer areas ofpatient mgmt

-

B5

Undermined patient mgmtleads to more acute care,even more specialization

Geographicconcentration limitsthe extent of acute

care

B6

Higher Costs and Cost Containment as Side Effects--Further Hurting Access


People atRisk


at riskDeveloping

diseaseDying from

disease


Insurance coverage &Reimbursement rates

-

Acute cases

High-tech acutecare capacity &

utilization

Health care costs

Costs of managingrisk and disease

Costs of acute care



-

Administrativeoverhead of

providers

-

-


Effective acutecare


risk


B7

-

Containingacute care costs

Containingpatient mgmt

costs

B8

R8

Multi-payercompetition

burdens providers

Variety of payer feeschedules andarrangements

R7

Containing patient mgmtcosts leads to more

acute care costs

Neglected Living Conditions as Another Side Effect of Cost Containment


People atRisk


at riskDeveloping

diseaseDying from

disease


Insurance coverage &Reimbursement rates

-

Acute cases

High-tech acute carecapacity & utilization

Health carecosts

Funds available forimproving living

conditions

-

-

Costs of managingrisk and disease

Costs of acute care



-

Administrativeoverhead of

providers

Efforts to improveliving conditions

-

-

-Effectively managedrisk and disease

Effective acutecare


risk

High-tech risk &disease mgmt capacity

& utilization

-

Variety of payer feeschedules andarrangements

R9

Less spending on livingconditions leads to morerisk, disease, acute care

costs

Some citizens aremotivated to improve

living conditions

B9

Some citizens aremotivated to improve

patient mgmt

R10

Types of Reform Initiatives

• Expanding access

– Improving coverage to employees, the poor, children– Providing health care resources to inner cities and rural areas

• Containing cost– Government limits on capacity, service provision, or reimbursement

– Employer shift to managed care plans

• Improving quality of care

– State regulation of facilities, professional licensure, Medicaid quality monitoring

– JCAHO setting of standards, NCQA evaluation of managed care orgs

• Protecting health

– Risk management, promotion of healthy lifestyles, family planning– Safer workplaces, better housing, safer neighborhoods

Why Reform is So Difficult (1)

Single-focus strategies are problematic and can generate resistance:

• Access improvement increases acute care costs, at least initially

• Cost containment reduces disease management and related investments more than it reduces acute care, so hurts quality of care, and may actually increase costs in the longer term

• Quality improvement initially increases costs, due to increased regulation and QA activity, or investments in IS and training

• Health protection requires investments resisted by those who would pay and who see more immediate payoff from funding direct care

Why Reform is So Difficult (2)

Philosophically “pure” approaches are also problematic:

• Single Payer addresses both access and cost, but threatens powerful interests

• Market Competition addresses cost, but could lead to inadequate coverage for many, hurt quality of care, and create disincentives to risk management

• Managed Competition attempts to strike a balance, but, because it does not mandate managed care for all, allows continued cost increases and loss of insurance coverage

Safer,Healthier

Population

VulnerablePopulation

Becomingvulnerable

Becoming nolonger vulnerable

Afflictedwithout

ComplicationsBecomingafflicted

Afflicted withComplications

Developingcomplications

Dying fromComplications

Health System Dynamics

Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Available at http://www2.cdc.gov/syndemics/Presentations.htm

Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Downstreamwork

Professionalconcern



Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onprogression

-

Effect oncomplications

-

TertiaryPrevention

SecondaryPrevention

Downstreamwork

Professionalconcern



Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout






-


-

TertiaryPrevention

SecondaryPrevention

Vulnerable andAfflicted Popn

Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

Publicwork




Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-

Effect on livingconditions

Effect onvulnerabilityreduction

GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

-

Publicwork



Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

-

PublicworkInstitutional/organizational

emphasis on diseaserather than vulnerability

-


Downstream lock-in: Delay in upstream effort guarantees continued growth in affliction prevalence and emphasis on treatment, which further delays upstream effort, as does mounting social disparity.


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

SocialDisparity

-

Citizen Involvementand Organizing

SocialDivision

-

PublicworkInstitutional/organizational

emphasis on diseaserather than vulnerability

-


achieving health care reform in the u.s.: toward a whole-system understanding gary hirsch, jack...

Documents

health care reform

acute care costs

acute care number

efficacy acute care

managed care plans

risk disease mgmt lobbying

disease management

access improvement