It’s been a month since I posted the last recommended articles, so it seems time to suggest some new reading. As I write, the Senate could take up debate on combined bill as early as this week, the House having passed their bill by a very close 220 to 215 vote.

I have two posts from The Health Care Blog. To start, a little about The Health Care Blog. Its web banner proclaims: “Everything you always wanted to know about the health care system. But were afraid to ask.” They mean it! There are typically 2-3 articles a day. Some can be long, technical and full of jargon. Some are not. There is also a certain perspective you pick up quickly from each of the routine contributors.

What strikes me is that here is where real debate goes on. To read something on this site and then pick up what the political leaders are saying shows the wide gulf between real debate and political rhetoric. To an outsider such as myself, it can appear at times like an intellectual fraternity but it is worth reading. Bottom line: There are things discussed here that we, the general public, should be exposed to for our own benefit. Since many of our political leaders are less inclined to do so, here you go:

One article appearing last week, “Saving Health Care, Saving America” by Brian Klepper, David Kibbe, Robert Laszewski and Alain Enthoven, condemns the current reform legislation for its total avoidance of dealing with the real issues of cost reduction and provides the overriding reason for this. When you read this article you will see why I am suggesting it for your reading list.

The other post, “Time to Put Aside the Intellectual Disputes for Now,” is by Matthew Holt who founded Health Care Blog in 1993. This particular piece is telling as it gives insight into the thinking of those who support the current legislation and why they are willing to overlook the so-called short falls to realize the dream of universal coverage.  I don’t necessarily agree with Mr. Holt, but understanding his logic is critical to understanding reform and the people driving it today.

I share an article by David Leonhardt that appeared in the New York Times Magazine on November 8th. A friend recently recommended it, saying excitedly “This is what we should be talking about.” I was so gratified to find that someone who had gotten the spark to pursue and examine healthcare issues from this website was now contributing to it! We are acting and reacting together, learning and sharing with each other information on life’s most important issues. A recent AP opinion poll, conducted from October 28^th through November 8^th, suggests the public is becoming more attuned to the fact that when it comes to health care, details often make all the difference.

As for the article itself, my favorite part is how it points out that the best reform ideas will most likely come from within the industry itself, especially from physicians. This is something I’ve advocated in A Healthcare Letter.

To end, I have a “lighter” article from the November 10th New York Times that sums up some of the latest thinking coming out of the Senate.

In case you missed it, I did update my latest opinion on the output of the reform process in a post dated October 21st. Sometimes I offer others’ opinions, while sometimes I offer mine. Most importantly I hope this helps you to form your own.

I was recently asked to rate the current reform process on a 1 to 10 scale. I paused. Two months have passed since I first published the Healthcare Letter in which I identified four concerns with the current reform process and offered an alternative. Clearly I would have ranked the process and its output on the low end two months ago. But sitting here in mid October, I wanted to do justice to the question so that others would be able to develop their own rating.

On a scale of 1 to 10, I came up with a 1. That ranking even surprised me. Let me explain my logic.

Given that there are approximately 300 million Americans, I began by asking the question, “With the current five bills in Congress waiting to be merged, what will be the most likely impact on Americans if a merged product passes?”

Positive impact would be:

• Improved access to healthcare (i.e. primary care versus ER visit, access to life saving treatments, etc);
• Reduced cost;
• Sustained or improved quality; and
• No less and preferably increased patient choice and control

Easy enough. Now the math. I divided up the population and gave 1 point for every group of 30 million people for whom a positive impact would be created. Positive impact to all 300 million would yield a 10.

Based on the latest legislation to come out of the Senate Finance Committee, the CBO estimates that all but 6% of Americans would have insurance. We started with 15% not having insurance or 45 million. This means that about two-thirds of our uninsured or 30 million people will now get insurance. So that is 1 point for positive impact.

I then paused and asked this, “Should I be allocating points on behalf of the 85% of Americans who have insurance but see the tragedy when their neighbor does not?”  In a recent CBS poll 59% of Americans said they wanted to see people get access. Obviously this speaks to the compassion of the American public. While I may have insurance, it is inconceivable that my neighbor goes without.

But as I began to add points to my rating scale, I had to subtract as I thought about my positive impact criteria.

The bottom line is that for the 85% of Americans, our healthcare costs are still going to increase beyond inflation each year.  For our family, that means that the cost of our insurance will reach close to $20,000 in five years, increasing a predicted 10% each year. The picture unfolds that more and more Americans will need government assistance (i.e. taxpayer assistance) as they are priced out of the private market.

Why? Because the current reform does not address the complexities, inefficiencies and misaligned incentives that drive up healthcare costs.  In fact there are arguments that our costs will increase even faster as a healthcare system with this reform. And it is in this arena that I believe our political leaders have been negligent in their duty to inform the American public, and why I have asked you to become a more engaged citizen in Healthcare Letter to Americans.

For the 85% of our America, the status quo yields a cost trajectory where a more centrally imposed rationing system becomes not an “if” but most likely a “when” for the sole reason that our current structure is not sustainable. This is what every American must understand.

For most, we may not see this overtly right away, especially if our employers pay for our insurance. But it all comes out of our pockets eventually. Even today, just look at the job situation. As the economy improves a little, the hiring isn’t coming back. The employers understand the liabilities that lay ahead including increasing healthcare costs. Salary increases are giving way to hiring and pay freezes as employers deal with escalating healthcare costs and a very uncertain future. Our paychecks aren’t growing if we are lucky to have one.

The drawbacks continue. The smallest estimate for costs to reduce the number of uninsured is $900 billion.  What is so striking is that we are bringing more people on, not by reducing costs for all and therefore making access easier through lower price points, but instead by adding people to the same spiraling cost structure.  Think in contrast of the price pattern realities for flat screen TV’s, cell phones and computers. As volume… and quality went up, prices came down, making them increasingly attractive and affordable to more people.

More importantly, I cannot say that I feel more certain as an American, knowing we have avoided dealing with one of, if not the biggest, economic issues facing our nation’s future. It feels like a false victory. All we will have done is put more people in a life-boat. Are we a country that wants to drift in the ocean hoping for rescue knowing at any moment we might sink?

So based on my “positive change” criteria, on a 1 to 10 scale, I give the current output of this reform process a 1.

Ultimately I am concerned about what this tells us about the state of our governance in general. I believe we should elect leaders who create an environment in which the ideas that are produced score better than a one. Perhaps that is the biggest lesson we are learning today, and one in which each American must take personal responsibility to change.

Yesterday the Senate Finance Committee passed its healthcare legislation on a 14-9 vote. The legislative process ratchets up a notch, and the trillion-dollar sausage making really begins. As a citizen, it is important that you continue to stay engaged and have a say.

I share three articles as they represent a “personal” perspective on reform. Each one is unique but seems to converge on the same conclusion: we need something different than what is coming out of Congress right now.

One is an opinion piece from the Wall Street Journal on 10/10/09 titled “Paying the Health Tax in Massachusetts.” If you read one, read this as I think it is a signal of things to come if current legislation passes.

The second one is an interview with Whole Foods CEO John McKay about the controversy created when he wrote an op-ed piece on healthcare reform. It is important as it represents the views of a successful CEO who articulates a very clear set of values about corporate behavior. You can also find his original piece at the Whole Foods Blog.

The third article, “Obama’s Healthcare Horror,” by Camille Paglia appeared in Salon magazine in August. Wikipedia describes Ms Paglia as American author, teacher, social critic and dissident feminist. I just know she doesn’t mince words and is writing in a magazine whose articles by and large strongly support the current legislation.

I find some of the best information comes not from groups or associations but from individuals speaking out courageously. Stay tuned.

On Monday, I had an opportunity to appear on national cable TV during a Fox & Friends morning segment. It was a first for me, and thanks to the professionalism of everyone on the staff and with the moral support of my daughter by my side, it was a great experience.

What has happened since has very much motivated me. My website in two days had over 16,000 unique views. I have received hundreds of emails with support, ideas, concerns and offers to get involved. People are posting comments and sharing ideas. Almost 500 people have taken the “Have you contacted your elected official?” poll with almost 90% saying yes. And yes, my family says they are proud… and I think my husband is glad I didn’t ramble too much!

Right now I am going through the emails, answering them and planning a summary of them. I will keep posting articles and have done so today under Twitter. But I wanted to share something right away. The clear theme continues – people want to be involved and they want our leaders to offer clarity of ideas and a transparent dialogue that is not wedded to a political party. This a crucial national issue that demands our best thinking.

In getting ready for the satellite interview, I was in the Fox Chicago office with my daughter, the camera man and a wonderful gal who did my makeup. It was before 6am and still dark. But even in the early hours of the morning, we were having an earnest conversation, concerned citizens all, about what healthcare reform should be and our shared desire for more information and less “selling.”

Monday reminded me that that the best thing we can do is to be confident in our voices that call for reason, compassion and integrity. Today the Congressional approval rating of 21% reported by Gallup should be a wake up call.

This week the Senate Finance Committee continues its work on its healthcare bill. As the intensity of the discussion heats up I would like to offer some recent articles that I thought were insightful and/or informative.

To start I thought both the Washington Post article by Ezra Klein and the Wall Street Journal article “Doubling Down on a Flawed Insurance Model” by John Cogan, Glenn Hubbard and Daniel Kessler were very good at getting at some of the nuts and bolts of the healthcare industry and what drives costs, prices, offerings and behavior. To me the articles are successful at educating, not just advocating.

Then there is the recent article by former Senator Bill Frist of Tennessee (R) in US News & World Report in which he looks at the costs/benefits of a mandate for healthcare insurance and provides a very concrete yet manageable first step for reform. To me, this article is important not so much for a policy he is advocating but for the rational measured approach, the examination of historical experiences, and the transparent review of costs/benefits that he brings to the discussion. It is this type of thinking that I believe is lacking in our politically charged debate.

Finally I would like to offer an editorial by David Brooks in the New York Times. It has nothing to do yet everything with healthcare. He advocates a move away from consumption and towards economic self-restraint. What Brooks identifies is actually one of the root causes I believe of our healthcare system failings. We have an industry of significant consumption but the consumer isn’t tied to the immediate paying of the bill. It is as if someone said I could eat all the chocolate I wanted for a week and not gain weight. (I’d bring chocolate to bed.)

In my Healthcare Letter, I put forth that healthcare reform is much more than “payment” and “coverage” reform. It should be about the transformation of 17% of our economy in a methodical, deliberate way that begins to unwind the interwoven complexities of a system that is expensive and cumbersome but still offers brilliant innovation, life-saving treatments and comfort to many.

I hope these articles help illuminate some of the critical issues we are facing in this transformation. I know they did for me. It seems as if these authors had an opportunity for lucid thought in contrast to the constrained environment in the windowless Senate Finance Committee room.

Yesterday, in my local paper, the Gazette, guest columnists Susan Turney of the Wisconsin Medical Society and David Newby of the Wisconsin State AFL-CIO offered in an opinion piece three issues healthcare reform needs to address: access, cost containment and basic system design. If you read it, there was not much with which to disagree.

But in this fairly benign piece was a key statement that underscores how the current reform process is not tackling the true barriers to cost-effective, superior healthcare. Specifically they say that, “We can control costs if all employers pay fair shares of essential health costs, insurers truly compete and we reward providers for quality care.”  Most notably missing is the patient/consumer and our role.

As my English teacher, Ms. Newberry used to say when I would use the word we inappropriately, “Oakleigh do you consider yourself royalty or do you have fleas? If neither is true would you use the word I.”   While I appreciate what the politicians and leaders of advocacy groups are doing for me, I wish they would structure a greater role for me as the consumer of healthcare.

Much has happened in a month since I wrote Healthcare Letter To Americans. I went to my first Town Hall ever as Americans turned out in record numbers to hear and voice opinions to their elected officials.  President Obama spoke to the nation in an unusual joint session of Congress on September 9th. Senator Baucus released the fifth and final piece of legislation expected from Congress.

I would like to offer these observations about the President’s speech, viewing it as one of the most important indicators for strategies and principles guiding the current reform.

First, I thought it was well drafted and delivered. I appreciate the passion that the President brings to the issue. There was also evidence of moving the conversation to the middle ground. Most importantly it revealed how public opinion had affected the Administration’s strategy.

That said, what I would most importantly like to share is what I was looking for in the speech: an indication for a different direction for reform. What I walked away with was confirmation that the problems and missed opportunities I have identified in Healthcare Letter continue.  Why this conclusion? Here are some of the key statements that continue to show how the current reform process is misguided:

Statement #1 “I am not the first President to take up this cause, but I am determined to be the last.”

I appreciate the passion and persistence but believe it is unwise to think in such a narrow political timeline.  Instead I have articulated a viewpoint of transformation that involves everyone from consumers, doctors, hospitals, researchers, regulators, and legislators, over time. In the end, I go back to my argument in Healthcare Letter that making healthcare reform a once-in-a-life time, this-is-bigger-than-all-of-us, rise-to-the-occasion type of event is setting it up to fail. Do the opposite; break it down into manageable deliverable pieces.

Statement #2 “I will not waste time with those who have made the calculation that it’s better politics to kill this plan than improve it.”

What if someone showed there was a better way to do this outside of the current legislation? If this is too important too fail, let’s call out the big elephant in the room – that we might be better off starting this over. I go to a lesson learned in economics. Sunk costs are just that – sunk costs. The time we have invested so far in producing healthcare reform legislation should not impact the decision to start over if that is the best course going forward.

Statement #3: “While there remain some significant details to be ironed out, I believe a broad consensus exists for the aspects of the plan I just outlined…”

I wish there was broad consensus but believe just the opposite is happening. The more people learn about the potential impact of the reform as laid out in the current bills, their anxiety increases.  Interestingly in a USA Today poll this week, well over a majority of Americans didn’t believe that what the Administration is proposing will actually improve our healthcare situation, even if they support the plan.

Statement #4: “To my progressive friends, I would remind you that for decades, the driving idea behind reform has been to end insurance company abuses and make coverage affordable for those without it.”

Having worked in healthcare for over 20 years, I know we are not in the current situation we are today just because there was insurance abuse. By making the insurance industry the focus of concern and even vilification, we have only cheated ourselves of the opportunity of true reform. In fact what we should be working on is the creating the environment and foundation for a healthcare industry and consumer transformation, not creating scapegoats. That has had dangerous consequences throughout history

Statement #5 “So let me set the record straight. My guiding principle is, and always has been, that consumers do better when there is choice and competition.”

While I appreciate and agree with the statement, it sets a tone of protector versus empowerment. The stronger statement to me is that consumer power with education and information will create choice and competition. If someone else tries to do it for us, choices are made on our behalf that might not be in our best interests. What if the statement read something like this: I believe that above all else healthcare should be patient/consumer driven where the individual feels control over the financing and provision of the healthcare they receive and takes a leading role in the management of their care and well-being. Okay, now I am listening.

It has been my goal in writing Healthcare Letter to Americans: Is There Another Way? to avoid falling prey to political lines and to propose a new way of thinking about healthcare reform. In listening to our President’s speech, I walked away with the conclusion that political lessons had been learned but that the fundamental reform process was still fundamentally flawed.

If this analysis of the speech leaves you pessimistic about innovative reform, don’t be. On the contrary, I am optimist. The fact that the speech was made at all is a huge testimony to the power of the individual American voice. In fact what happened in August took me back to the founding of our nation where the local pub was the political gathering place to hear and debate current events. In 1776 Thomas Paine wrote Common Sense, articulating in plain language why we should have independence from Britain. In August 2009, the healthcare conversation left D.C., and it improved. It is in our power to continue that and affect our political leaders views.

It has been about a month since I posted Healthcare Letter on the web. I have been asked by others to recommend articles that I believe help improve our understanding of how the healthcare system works and therefore identify needed components of beneficial reform. Knowing the volume of material, most of it very good, I want to start small by recommending two pieces:

How American Healthcare Killed My Father by David Goldhill appearing in the Atlantic September 2009

Why do I recommend it? It is from an outside Beltway perspective, it is extremely thought provoking and daring, and it holds important insight into how healthcare works from the view of the patient/family. It is a Must Read in my mind. The length is approximately twice that of Healthcare Letter but it is well worth the investment of time.

On the lighter but not less important, I offer an article that appeared in the Wall Street Journal on August 8^th, 2009.

Man vs. Mutt by a British Physician Theodore Dalrymple, Wall Street Journal

With the seriousness of debate I truly appreciated his sense of humor coupled with important observations and opinions. I will continue to post articles so look to the bottom right side of home page.

August 2009

Healthcare letter to Americans: Is there another way?

I read an article recently that compared the healthcare reform in Washington to sausage making. It is messy, and you aren’t quite sure what is inside. The problem is that Americans are going to have to “eat” what ever is the final product.

In talking to friends and family, many share concerns regardless of their political allegiance. Almost everyone says we need reform in healthcare but question if the current process will deliver what we need. A sense of hopelessness appears as if this “healthcare mess” is so complicated and so big, that the normal American couldn’t begin to understand the detail.

I do not believe this needs to be the case and have written this letter to help more people be confident and passionate about participating in the reform process. To do, this I believe it is important to:

• Share how the current reform has failed to address the key components of timing, participation, goals and motivation; and
• Offer what could be a true strategic reframing of an industry through an outcome-oriented approach that is led by industry reformers including consumers and physicians not just politicians.

What motivates me? I have worked within healthcare my entire professional career from hospitals to clinical laboratories to pharmaceuticals. This exposure even included time beyond our shores when I spent four years working with the UK National Health Service to modernize its laboratories. Living in England, we received healthcare both from the National Health Service and the private system. As a family we have had to shop for healthcare insurance and faced the possibility of not being insured. As a mother, I am the healthcare organizer, appointment maker and expense keeper. And I have been a patient at MD Anderson Cancer Center since 2002 and know that my active role and the relationship I was able to have with my physicians in a world-class organization impacted my good health today.

I. The Current Process for Healthcare Reform

Timeline Challenges: Speed Can Cause Accidents

Let’s start at the beginning. The House and Senate have worked at a frenetic pace to bring a bill to their respective floors, so we can have Health Care Reform taken care of before August recess. If this had occurred, Washington D.C. would have solved the healthcare problems which consume 17% of our economy and 1 out 6 jobs in just under 90 days. That is from May 11^th, when the administration first announced its three principles of healthcare reform, to August 7^th.

While the timetable has changed, we already have the impact of what an artificial timeline has on quality of plans. Senator Snowe (R-ME) spoke very specifically about this during a TV interview on August 4^th. She complained that the early deadline had impacted their ability to think clearly. The timeline had heightened anxiety and deteroriated the process. In July, Peter Orszag, the White House Budget Director, shared with Congress that even if he could be a benevolent dictator for a day, he wouldn’t know how to fix the very complicated Medicare fee structure. While I appreciate his honesty, I believe it shows the current disconnect between political timelines and the real issues at hand.  Or in the words of Thomas Edison, “Vision without execution is hallucination.”

We do need a timeline laid out, but one that is driven by the challenges we must address and opportunities we want to create not because of a “recess” date. Washington is not good at predicting long-term outcomes. When Medicare was created, it was estimated that by 1990 Medicare would cost taxpayers only about $12 billion (in real dollars). The actual cost was nine times that at $107 billion. Today’s numbers are even more staggering. What is the value creation of the current plan – do we know?

Biased Participation: Don’t let the Wolves Tend the Sheep

Perhaps the passion around the timeline is driven by fear that those who have signed up to support the current legislation will start to fade. I flash back to an image I remember in the paper not too long ago of leaders of various lobbying organizations testifying to Congress about healthcare.  In the end, with government brokered-healthcare it is a zero-sum game: if someone wins then someone loses. The lobbyists want to make sure their industry is on the winning side. In keeping score, it seems the consumers of healthcare are losing. True healthcare reform is about value creation, making a system work better for you and those who spend tireless hours working to provide that care.

Americans should have a healthy dose of skepticism that most “Associations” are supporting this effort. These national organizations have been the keepers of the status quo for decades. Regina Herzlinger, a well-respected professor at Harvard Business School and long term advocate of consumer driven healthcare, looks at how these various industry players and Congress have actually harmed healthcare in Who Killed Healthcare.

There are individuals within these industries with great ideas but most of the time their voices are not being heard.  The average players are having their say in D.C., not the exceptional.  We need to change this.

As the old guard keeps control of the reform process, transparency and honesty are hard to find. One of the most concerning issues is the lack of public effort to shed light on the various options to accomplish the goals of healthcare reform.  Do you know that there are many ideas on how to impact healthcare including specific alternative legislation such as the Patient Choice Act or Healthy Americans Act? They receive little focus and discussion.

As a taxpayer and consumer of healthcare, you can find out about the alternative ideas and options but you have to do legwork. Organizations with varying agendas and purposes compare plans with easy to use websites, but you will not get that information from our political leaders. Imagine just for a moment that a political leader laid out various options and their pros and cons. I would start hoping things had changed. Just the opposite is most likely – many on the House Floor will not have read the bill when they vote on it this fall.

The artificial timeline is impacting everything. If you are intent on hitting a deadline then the idea of more options only creates more thinking which creates a need for a different timeline.

Above all, Americans are going to need specifics – not just town halls, principles or speeches but detailed explanations of the options and how each one impacts positively and negatively against the stated objectives.

The world of information and media has changed our lives, and we have for the most part embraced it. I hope we can allocate some of the time we spend each year to selecting our favorite singer on American Idol to participating in this healthcare dialogue.  If you are reading this now, you are making that commitment.

Misleading Goals: A Game of Shuffle Board not Breakthrough Change

If we had more transparency and real dialogue versus sales pitches, I think we would be able to start to address real reform. There are two major issues shaping up: We need to increase access to those who can’t afford healthcare at current rates and reduce the cost for those who have it now. We are focusing on the former issue of access, but I think this prioritization is flawed.

Current legislation is mainly focused on how can we find money to include more people versus saying how can we get more value out of how we provide care, something I discuss in the second section. It isn’t dealing with dynamics that create care. Massachusetts very explicitly chose the path of getting everyone on insurance because it was a moral imperative. But three years later the state is still dealing with escalating costs and the difficulty of actually providing care to all these new entrants.

Looking at the current legislation in Congress, Gov. Phil Bredesen of Tennessee, a Democrat, said he feared Congress was about to bestow “the mother of all unfunded mandates. Medicaid is a poor vehicle for expanding coverage,” added Mr. Bredesen, a former health care executive. “It’s a 45-year-old system originally designed for poor women and their children. It’s not health care reform to dump more money into Medicaid.”

There are discussions around reforming the system but those details are much sketchier. The President has mentioned implementing this reform through an independent board looking at best practices and mandating care based on these new rules. Many say this is the road to a nationalized health service similar to the UK, and the arguments are valid and important to discuss. For example the NHS in the UK pays for a cervical exam and mammogram once only every three years. A group of experts appointed by the government determines this.  An independent board in the U.S. could easily put forth such guidelines.

Whether this is the beginning of rationing care or not, a critical point is being lost about our current healthcare system. We have best practices today.  For example, if you go to the hospital with symptoms of a heart attack, there are certain things the hospital should do. Hospitals must report the statistics on these actions taken, a system called Core Measures. All over the country hospitals are focusing on these Core Measures because they publicly report them.

However, these statistics measure what we do or the process followed, not the outcomes we deliver.  We have literally created an industry of recipe books. To make it easy to understand, you would get an A+ if you followed the directions exactly in making a cake regardless of how it tasted or turned out. I see daily healthcare leaders being over-whelmed by best practices. There is more regulation in healthcare than most other industry I have seen.

There is an art and science to medicine. The best doctors and organizations are the ones that use the science and their art to manage each patient experience in the context of a supportive and logical system. This gets at the crux of health reform. Are we going to mandate reform and have the government try to keep industry and doctors honest?  Or can we create the right alignment of interests so the people who want to build specific cultures and practice medicine because of the outcomes they create, are able to flourish and thrive?

On one side of the spectrum, Nancy Pelosi is approaching reform this way. “We want to squeeze as much savings out of the system as we can before we seek any [new tax] revenue. [But] you can only go so far.” Squeezing a system that isn’t working well is a recipe for collapse.

But there are other voices out there. In the words of a nationally respected medical writer and physician Dr Atul Gawande – “Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can.”

Dr. Gawande was one of the conveners at a recent conference in D.C. where different healthcare success stories from across the country were showcased. These communities had shown you could deliver high quality care and bend the cost curve.  This type of event didn’t garner the media attention it should have. These are true reformers who are working from within the industry.

In the end what is shaping up appears to be a focus on using government wisdom to mandate good decision-making. Unfortunately there are many examples of mandates, while well-intentioned, causing significant unforeseen negative consequences.

Here is one example that illustrates the point. On June 7^th of this year, the Telegraph recently printed an article uncovering an example of a mandate or target gone haywire and causing harm. People arriving at ERs in the UK with symptoms indicating aggressive spread of cancer were waiting weeks for diagnosis and treatment while “routine” cases were prioritized. Hospital managers told researchers that treating desperately sick patients more quickly would “reflect badly” on their performance against Government cancer targets that only cover those referred to specialists by the patient’s primary physician.

Everyone in the UK is horrified. But in the managerial world of healthcare not the value driven world overseen by the patient, I have seen far too many times where the scorecard or the target of whatever you are working on becomes the end itself. The ultimate reason we serve in healthcare, to serve the patient and the family, becomes secondary, which brings me to a final and most pressing concern – what is the role of the patient and their motivation?

Lack of Motivation: No Skin in the Game

I feel as if we the patients, the consumers, are in the room but no one is really talking with us. They are talking to us. They quote us all the time. They speak to the terrible tragedies. I am moved by these stories having seen them firsthand. But to succeed, healthcare needs to be shared responsibility by putting an informed and motivated consumer at the center of their healthcare.

A few months ago, I was working in the ER. A patient came in with chest pains, anxiety and shortness of breath. The patient was okay, in the short term. But the doctor discovered that this patient drank no water during the day and consumed 8- 10 sodas a day. Both parents and grandparents were diabetic. The patient had good insurance and therefore access. Life style was impacting health, something the patient acknowledged.

One would think this patient would have strong reasons to improve diet. But here, as in myriad cases, the patient took no action. This is troubling and complex. Is it culture, education, and-or upbringing? We have to examine this.  What incentives and basis for informed decision-making are we creating for patients?  One of the most disheartening things for our physicians today is having to care for patients who don’t care. They tell me that this issue and dealing with the rules and regulations imposed by the government and insurers demoralize them.

The issue extends to every American. Our family has a high deductible plan. The cost of the plan is roughly $12,000 paid for by my husband’s company. We pay the first $4,000 of out of pocket expenses and the insurance company pays 100% after that up to a life time limit. We review the bills carefully and think about what things costs. But something happens after we hit our limit; we behave differently. We aren’t as concerned about the costs, the extra procedure here or there, because we aren’t paying for it.  But we are.

At the end of the day these types of high deductible plans have been effective at lowering the rise in healthcare costs compared to traditional plans as pointed out by Professor Herzlinger in Who Killed Healthcare. But as Professor Herzlinger also notes they don’t fundamentally empower the patient to demand something different over the long term. They show promise and potential but haven’t unleashed the full role of the consumer. My family experience echoes that.

The last example shows the positive-power of the patient/consumer, the fight against breast cancer.  Almost everyone can say they have lost a friend to breast-cancer but more importantly we all have friends and loved ones who are survivors. What makes me puff up with pride is what women everyday are doing to combat this disease. Bless the doctors, the support, the researchers, but it is the patients who are rising up and taking this disease head on in partnership with the health community. And the efforts are working. If you live in the US you have one of, if not the highest rate of survival for breast cancer in the world. It is consumer advocacy at work.

At the end of the day, personal accountability and responsibility count and could make the US the model of healthcare for the world and an economic engine for our country, not a resource to be rationed.

II.  What can we do differently?

Frame the Problem Differently

The good news is we have a common starting point. The country agrees we have a serious issue. But I think we would be better served by being more outcome oriented about the healthcare dilemma.

The framing of the problem defines every future step. Can we as Americans hold up our healthcare as not just the best quality, but also the best in value? We need what Southwest did for the airlines, what Apple did for the personal computer and what Henry Ford did for the car, multiple times over by multiple participants.

Economic growth drives national success. Can our healthcare system become an economic engine for our country and create value? Can we have accessibility, affordability, and quality/service? But more importantly, what would that look like in measurable outcomes?

For example, what if we stated as a goal to have best outcomes in the world for the top five diseases while setting a target for cost/person affected. Below, I share more examples of national outcomes, not to advocate those goals, but to show that specifics then guide development of action steps. What we have now are more lofty principles that build consensus initially but a political battleground shortly thereafter.

Potential Outcomes

• Percent of Americans that believe they exercise significant control in managing their health and feel they receive very good care.
• Ease in navigating the reimbursement system as measured by time physicians spend in administrative/reimbursement issues versus practicing clinical care.
• Percent of household income spent on wellness and nutrition versus treatment
• Reduction in personal bankruptcy due to healthcare costs
• Costs per insurance plan per person as % of personal household income
• Net exporter of healthcare goods and services to rest of world
• Accessibility for Americans as defined by visits to primary care doctor annually

Move on to Discovery and Close the Gap

With a set of hard outcomes in our hand, an unbiased exploration begins. In history, we have seen that whether it was electricity, flight or medical innovation, breakthroughs come from a relenting and disciplined approach to unbiased discovery in relation to a certain vision. Just as how you frame the problem influences the end result, the questions you ask and the people asking the questions bias your outcome. Time magazine recently identified the 10 people shaping healthcare reform. All of them are Washington insiders. Ultimately we need to move from a bartered political exercise to an industry-realignment over time affected by consumers, healthcare providers, financial agents, change experts, politicians, and others.

In a separate document, True Healthcare Reform – Are the Right People asking the Right Questions, I share a series of questions to illustrate the point.  It is a document to which I hope you add. In a trial, the discovery process will absolutely impact the verdict. We need to avoid contempt prior to investigation. That is why we would benefit from different people asking different questions.

From the discovery efforts, the process moves on to how we close the gap.  You close that gap in increments and with discipline. Neil Armstrong got to the moon safely forty years ago because of how NASA went about closing the gap between what was possible in 1961 and what it would take to land on the moon eight years later. In contrast, Health and Human Services Secretary Kathleen Sebelius in an Op-Ed column for The Washington Post on August 4^th wrote that “We can’t let the details distract us from the huge benefits that reform will bring.”

To improve execution and start to close the gap, we need to define what are the different milestones that can be created along the way to the ultimate goal. Instead of betting the bank that we will get it all right in 1,200 pages of legislation, we need to identify early wins and stop approaching healthcare reform as once-in-a-lifetime opportunity.

Many leaders in their field have offered solutions that are pragmatic and focus on the Pareto Principle that 80% of the effects come from 20% of the causes. What are a few things we can do now that have the greatest positive impact? One example is allowing people to buy insurance across state lines, opening up competition and choice. Defensive medicine is one of the most cited reasons by physicians for additional ordering of tests. Have we addressed this?

What would a milestone incremental approach look like? As just an example: it might address change in this priority:

• What types of catastrophic insurance can we provide now to the different segments of uninsured or underinsured now?
• What needs to happen short, medium and long term so that insurance isn’t tied to the jobs we change frequently?
• What needs to happen now versus the long term to have a common filing system for healthcare expenses and reduce administration costs?
• What can we do now to build pricing transparency for the consumer?
• How can we develop a customer satisfaction system for healthcare insurance as has been done recently with patient satisfaction with hospitals?
• How can we further promote healthy eating in our public school systems?
• How can we start to change the complicated fee for service Medicare system?

What drives momentum and a sense of purpose is results or personal accomplishment. When you achieve a little success, it pushes you further. The goal is to start to take apart a complex landscape and create specific building blocks to reform.

Pie in the Sky?

The cynics will say that this new approach I have espoused is not how Washington operates and is not realistic. Legislators run Congress, and they are especially good at cobbling together deals. Perhaps this true, but the problems with which we are dealing require a different approach if we are going to be successful at improving our society and leaving something better for our children. The country that gained independence over 230 years ago, banished slavery and maintained the union, and prevailed in WWII, can tackle Healthcare successfully if we approach it with a non-Washington perspective.

Many Americans voted in November for doing things differently in D.C. including a different type of thinking and discipline. Healthcare is presenting this opportunity. If we don’t seize it, we may have just voted in a new party to practice old politics.

III. What can you do?

Be an Advocate in the Reform Process

I am asking that you as an individual contact your elected officials and voice what is important to you. I personally believe we will have an equal chance in influencing the reform process if our voices are heard as individuals.

In fact, I have been inspired and amazed by the thoughtful responses to my initial Letter. Each person shared something different after reading my concerns and recommendations. Some of these responses touched me to tears, some made me think a little harder and motivated a re-write of a section, and some thanked me for being involved.

For too long I sense we have been scripted, managed and hyped up. We need to find our voice as individuals. My hope is the first two sections of my Letter inspire something in you. Most of the emails I received back would be excellent letters to Senators, Congressman and the White House.

If you do like this letter, please feel free to share it with those you know as well as your Representatives. If you have questions feel free to email me. To help build the dialogue, I launched healthcareletter.com as place for people to openly share comments, to contact to their Representatives and to add to the Questions I started.

What ever happens in Washington, it is certain we will not solve all the problems of healthcare and its delivery and financing systems this fall. At this point, my sincere hope is we do not simply add to the problems.

Ultimately please don’t think of healthcare reform as a one-time political process happening this fall or not at all. That is the how we can start to change the reform process. Think of it as an evolving transformation in changing the way Americans think about our health, how we manage it, how we improve it and how we finance it. And if we do this right and we are involved, we can achieve successes and breakthroughs along the way.

IV. Conclusion

I finished my six weeks of radiation in Houston, Texas in 2002. I remember the day well. They have you ring a bell when you are done. I am trying to ring that bell today. Ferdinand Foch, Allied Commander during WWI said, “The greatest force on earth is the human soul on fire.”

I agree.

Oakleigh Ryan lives with her family in Janesville, WI with her husband Tobin, and two children. She can be reached at oakleigh@healthcareletter.com or by visiting healthcareletter.com.