Future Now
The IFTF Blog
Dr. David Warner interview summary
Health care change will require
1. breakdownprofessionalism—
a. too much sub optimizing by over-specializing andover credentializing
(read Freidman’s piece of professional licensing)
b. hospitals and docs must not define the industry
c. need some way for “consumers” to be more empowered (most still cede it to the system)
With modern technology, there is noreason why educated people (and most people in the US are educated) why theindustry can’t just say ok, here’s your situation, here are risks, here areproblems, what might happen, here are the paths that you might end up goingdown, people have better sense of medication/risks they might face
Routine medication management--noreason why you have to have a doctor for that
2. Answering the question: How do you enhance someone healthstatus over a lifetime?
Is it more giving people moreinformation about their individual health risks?
Or is it better socialdeterminants of health?
2. Deciding whether or not the medical care systemactually helps for anything besides acute eruptions.Part of the problem is that the advocacy organizations aremostly tied to docs not patients; they are not advocating for radical changefor delivery system
Controlling costs:
<o:p> Figure out some way to get control of marginal/dangerousprocedures</o:p>
Devices—approved for one thing
Stent for heart bypass
Suddenly, that same stent nolonger needs to be approved; can be applied to additional procedures littleor no proof that it is effective in new procedures (Wray, Nelda (2003)--$2b in VA and$5b in Medicare knee surgeries; random trial—no difference (all patients gotbetter). Pay-for-performance: covering only truly cost-effectiveprocedures—moving a little bit from letting the profession direct everything
Bring back some kind of managed care
profession managed to demonizemanaged care
without it, essentially the docsnow are just charging whatever they want; even though the PPO doesn’t pay thewhole amount (consumer picks up the rest)
RBRBS was an attempt to change the waythe doctors make money
Quantitiesget high Rates—everyonegoing to go down 40% until they get solvedRationalize medical care, France/Germany/England doesn’t seemso socialized, Privateffs docs (rates are set nationally)
Refine the role of the PCPs
Why do you have 8 pediatricianspracticing together?
Needsome sort of reformation: One or two with10-12 nurses and social workers, Socialworker and psychologist along with doctors, that could payspecialists less rather than PCPs more
End the arms race in hospital thru implementing:
1. certificate ofneed—local approval (still only exists on east coast)
2. Insurance and Congress decidethat they’ll only pay for one so if there is two, we’ll pay you half
3. Local communitiesresponsibilities—no reimbursement by Medicare or federal (European model)
Employ more internationalization of treatment and oftraining
Getting Medicare to pay abroad maypass as much to get Mexicans to go home as it is to get Americans to retireecheaply
In Europe—medicine hasn’tcontrolled things at the European level; Cross-border acreditization was aboutsocial welfare/work force, not health
Recent legislative changes: If you are in one country and you wantto go to another country, you can. If it’s outpatient care, the provider can charge what the going rate isand/or the country must pay what would be standard care
Future:
Not a big believer in prevention leading to reduced costs
Hospitals business model: they thought it was to put together physicians networks thatwould be related to the hospitals; basically the balanced budget act of 1997 knockedthat model out; the moved into maybe enhanced long-term care; taking care of apopulation that needs different kinds of support
Community hospitals do pretty well too (have been lately)
Trying to control as much as industry as they can; basicallytrying to get control of indigenous care clinics; have pretty good pricing becausethanks to Richard Scott
Amassing resources
Tenet/HCA—may be a different story;privatization deals—loaded down with debt; for everyone that puts equities in
Medicare—looks the same except we probably ration proceduresto at least be effective; predecessor to ARC (national center for health centerresearch) convened a group of experts—half of back surgeries are dangerous andunnecessary; orthopedics tried to shut them down
Medicare benefit package: what part is the bad idea?
Not the benefit package, we let awhole bunch of unnecessary stuff get down, pay too much for procedures; and welet everyone have really fancy technolog
Cautious with the doomsday scenarios—
Example: Medicare will take the whole US budget always assumesmedical spending is higher than inflation
If it’s true that Europe candeliver the same quality of care for 40% less, it seems to me that we couldreduce the rate of medical inflation for a few decades
Nota binary thing
(Interview conducted by Rachel Maguire)