Future Now
The IFTF Blog
Interview Summary - Dr. John Toussaint, ThedaCare, April 10, 2009
HC2020 Interview Summary: John Toussaint
Interviewer: Richard Date: April 10, 2009
1. His/her work
Trained as an internist. Has held many roles at ThedaCare
(in Wisconsin) -- practicing physician, chief medical officer,
CEO for the past 8 years. Last year, moved to head the new
"Center for Health Care Value" to promote the approach pioneered
by ThedaCare, working with providers and payers to change the
market place to reward value. [Today, providers are punished
by the payment system for providing high qulaity care.]
NOTE: 6 years ago, ThedaCare adopted Toyota's Continuous
Quality Improvement model and has implemented it throughout
the organization. The Center for Healthcare Value" is intended
to promote this approach among other healthcare providers.
TRENDS/CHALLENGES
2. How optimistic about future of health/healthcare in 2020?
3-4. Biggest trends or challenges & responses
1) Biggest challenge is a change in health care systems to move
toward a culture of continuous improvement. Many American
businesses have increased productivity but moving from an old
system of top down control to one that empowers lower level
staff to initiate change: the "Andan cord" model [ability of
any worker on the assembly line at Toyota to stop the line if
a problem is found].
US health care system still based on guilds that protects
individual autonomy - allows "terrible defects" to go undetected
and unadressed.
At ThedaCare, they have to RETRAIN every new employee. Change has
to happen in each individual unit: each one has to go through its
own process to improve care delivery.
The current medical education system is "the hardest nut to crack"
to bring about needed change.
Challenge now is to identify places where change is happening,
get others engaged. They have lots of visitors. As soon as people
see what they are doing, they get it.
Need a process to bring about change: give people hope that change
is possible, then offer a process for changing that involves training
& evaluation
They are currently developing an executive leadership program,
probably NOT with a university, since they don't want to require two
years of study to get a degree. Want a program that is geared to
working professionals.
2) Leadership challenge. People in the industry today are trained to
control the system while keeping doctors happy. ("Taylor/Sloan" style
of management) Leaders don't work to foster staff engagement in
solving problems. Leaders need to move from being a general to being
a mentor/teacher to staff.
3) Market place challenge. Current marketplace is disfunctional in
terms of how care is paid for. Example: they redisigned their inpatient
care, created a "collaborative care model" that resulted in zero medical
errors, increased patient satisfaction, and a 30% reduction in cost through
reducing the length of hospital stays. But they got paid $2000 less by
Medicare (invoked a "Medicare Discharge Penalty" that was designed to
discourage moving patients prematurely to 'step down care' to save money.)
Another example: Massachusetts is going bankrupt because the state did
not include any of the key features needed to promote VALUE in expanding
health coverage to its residents.
If we can create a marketplace that rewards quality & value, we may
get systems that chose to focus just on providing a limited number
of services that they can do very well.
5. Have these trends surfaced before?
6. Challenges/responses not on radar now?
- We have to do more with prevention to deal with the epidemic
of lifestyle diseases. AMericans need to take more responsibility
for themselves.
- To get coverage, people will need to take a mandatory Health Risk
Assessment every year, then follow up with a primary care physician
to review the results and develop a plan to respond to risks.
FUTURE SCENARIOS
7. Most preferable scenario
Rather than just providing discrete units of care, health care
system is focused on "population health management" -
actually improving the overall health status of Americans.
Providers will focus on going "upstream" as far as necessary
to understand patients' conditions. Success is measured in
terms of the overall health of a population of patients that
are the responsibility of a system.
First step: get data on outcomes by "episodes of care"
[Wisconsin Collaborative for Healthcare Quality, WCHC,
is collecting data on costs & outcomes from 2.5 million
claims]; can rank provider groups by quality of outcomes.
Second step: With data available, people can make good
decisions about where to go for care; it will be possible
to build incentives in benefit plans to use best providers.
8. Most plausible scenario
There will be some proxies for controlling cost and quality.
There will also be rules limiting the number of services in
a community -- e.g., only 5 heart care units. Otherwise we
will go bankrupt.
There Will be some performance standards, perhaps for the
10 most expensive conditions, and some attention to
episodes of care. There will be some recognitiion by commercial
insurers that there are real differences in quality, and their plans
will includ incentives to steer patients to higher quality providers.
9. Most negative scenario
We will have government-run health care insurance like Massachusetts
- will have extended coverage to almost everyone, but not paid enough
attention to changing how care is delivered. Universal coverage will
lead to universal rationing as costs continue to rise: "We can only do
30 CAT scans this month."
Information technology alone won't lead to improvements - just
add an additional $500 million in costs.
This is "a scenario for complete disaster."
10. Wrap-up
Only solution is to create "regional multi-stakeholder groups" --
with employers, insurers, government, and providers -- to
change how healthcare is delivered.
Federal government can create a high-level template, but it
cannot dictate actions for every community. Each region
needs to respond to conditions locally.