Future Now
The IFTF Blog
Interview Summary - Paul Ginsburg, Center for Studying Health System Change - March 23, 2009
HC2020 Interview Summary: Paul Ginsburg
Interviewer: Richard * Date: March 23, 2009
1. His/her work
The Center for Studying Health System Change tracks changes in the
financing and delivery of health care in 12 metropolitan areas around
the country. They collect and analyze data that they collect. Began in
1996, make site visits to each community every 2 ½ years.
TRENDS/CHALLENGES
2. How optimistic about future of health/healthcare in 2020?
He was increasingly pessimistic until a year or two ago. But now sees some signs for optimism:
1). Growing use of evidence in determining care
2). More appreciation of “integrated delivery systems” (a multi-specialty group practice
with a relationship to a hospital; examples are Kaiser, Geisinger, or a smaller group
aligned with a hospital) – though this type of care is not really growing. In their
physician survey, they find declines in multi-specialty practices and growth in
single specialties, driven by incentives.
Causes for pessimism:
We are still reeling from the backlash against managed care.
Care is becoming more fragmented, less affordable, more people are
losing insurance coverage
Fiscal problems from the cost of healthcare is damaging the overall
economy; there seem to be few good options for bending the curve
of spending growth.
3. Biggest trends or challenges
1) Cost – can cause many undesirable effects; seems very
resistant to suppression.
2) Moving from fragmentation
to integration of delivery. Fragmentation is less and less
effective in delivering on quality and cost
3) Need to do resolve our attitude toward equity of access: How uniform should access be for people at different income levels?
4) Decline in health status of Americans due to obesity and related health problems.
4. Responses to challenges
1) Cost – There is growing interest in payment reform:
Fixing fee for service to align payments with costs
Greater use of payments per episode of care “partial capitation”
– examples are high performance networks (A “soft form of payment
per episode”); Geisinger Clinics payments by its captive insurer;
Patient Centered Medical Home (“a rudimentary form of capitation)
Virginia Mason’s response to Aetna’s high performance network
(HEALTH AFFAIRS article by him and Milstein)
2) From fragmentation to integration of delivery
There are examples of integrated care, but not of payment mechanisms
to pay for this type of care explicitly. See “Getting What We Pay For:
Innovations Lacking in Provider Payment Reform for Chronic Disease Care”
by Debra Draper – Blue Cross of North Dakota doing some interesting
experiments, but overall there is an unwillingness to invest integration.
Example of chronic heart failure – when better post-discharge care was
provided, hospital readmissions declined. But the care wasn’t reimbursed
to the hospital, and their payments decreased. The system won’t change
until Medicare changes
3) equity of access
Most important example is Massachusetts – but now they are struggling
with cost of coverage and with a shortage of enough doctors, especially
primary care physicians, to see all the newly insured patients.
4) obesity and related health problems
More awareness among policymakers of the seriousness of the problem,
but there is no silver bullet to solve this problem
5. Have these trends surfaced before?
6. Challenges/responses not on radar now?
- Possibility of infectious diseases becoming a bigger problem due to increasing
drug resistance, greater globalization
- Uncertainty about the implications of new technologies, e.g., personalized
medicine – do they provide opportunities for big improvements in care or
just marginal improvements at high cost? This is actually true now with
biologics – provide a short increase in cancer survival, but at very
high cost. Will we find a cure for Alzheimers?
- Will HIT live up to high expectations given fragmentation of the system.
Can it create “virtually integrated delivery systems,” provide more transparency?
Their study of e-prescribing found that high value applications are not being
implemented – e.g., giving MDs the ability to see patients’ formularies.
FUTURE SCENARIOS
7. Most preferable scenario
Coverage is nearly universal (60% chance of happening)
Health care system will be more efficient, more integrated
Health care is more evidence-based (“not that Therapy A works
and Therapy B doesn’t work, but which patients a therapy works
for – e.g., identify which 90% of patients should not get Vioxx
because of harmful side effects)
Elements of integration will be mainstream – at least “virtual
integration” – i.e., physicians in independent practices are tied
in to larger systems. [In rural areas, these larger systems are
missing, so will be difficult to achieve integration in large parts
f the country. In California, presence of Kaiser has had a big
influence on integration, even among non-Kaiser practices; but
there is less integration in Fresno where Kaiser arrived late]
8. Most plausible scenario
Will have “made a dent” in extending coverage, percentage of
uninsured will be lower, but will still be large gaps
Some progress will have been made in reforming payments to reward
quality
More evidence-driven care, but not dominant
Some fragmentation will be addressed but will still be widespread
Less than 50% of patients will be in “medical homes”
Costs continue to outpace inflation by ca 2%/year
9. Most negative scenario
More people are uninsured than today; a large part of the population
is using safety net institutions – free clinics, community clinics,
public hospitals
Fragmentation is still the rule
More money is being spent on “low margin” technologies, increasing
costs with few apparent benefits in outcomes
People can’t find a primary care physician – have to self-refer
to specialists
Costs increase at 2 ½%/year [costs have increased at 2 1/2 % since 1960,
about 2% since 1970]
Key variables in determining which scenario will occur:
Public policy – he is concerned about the policy process because
there are multiple powerful stakeholders involved. However, this
time, some key stakeholders are saying that they are willing to compromise.
Big problem is how to pay for reforms
Another big issue that requires attention is governance – how to
decouple decisionmaking about key issues from political process.
Daschle proposed a public board, something like an independent regulatory
commission, that can make hard decisions about payment mechanisms
(MedPac, the Medicare Payment Advisory Council, is just advisory
to Congress, can’t mandate any changes)
10. WRAP-UP
Other interview candidates:
- Len Nichols, New America Foundation
- Bob Berenson, Urban Institute (payments, policy, Medicare)
- Mark McClelland, Brookings/former head of CMS –
hard to reach but would be great to interview