March 06, 2010

Time to transform state’s health care

Originally posted in Star Tribune

At a University of Minnesota leadership seminar last week I posed this question: “Rather than waiting for Washington to devise the ideal national system, what should Minnesota’s leaders do to transform the state’s health care?”

The Humphrey Policy Fellows in attendance concluded that the national debate was neglecting the most important issue, which they framed this way: “Each of us should take responsibility for our own health, supported by our health care team, composed of physicians, nurses, health care and wellness professionals.”

This notion, as self-evident as it sounds, would represent a profound shift from the current philosophy, which assumes the health care system is responsible for curing disease and healing us.

Even if the current federal legislation eventually passes, it will only address one aspect of health care: expanding access to insurance.

Every American should have health insurance, regardless of their age or health status. But access is only one element of the complex health care equation.

Virtually overlooked at the federal level are three equally important aspects of health care: cost, quality and personal responsibility. Without addressing these essential areas, the health care crisis cannot be resolved.

One lesson from the federal effort is that health care at the national level is too complex to yield to a single comprehensive solution. America’s health care needs are too diverse geographically to devise a “one-size-fits-all” formula. Instead of waiting for Washington, Minnesota’s health care leaders should seize the initiative and move forward with the optimal health system for Minnesotans.

State is national model

If you have a serious health problem, there is no better place to get well than Minnesota. Our state is a model for the nation in health care efficiency, quality, cost-effectiveness and integrated care. Yet we, too, face a deepening health care crisis.

Before offering suggestions for transforming Minnesota health care, let me share what I have learned in the last 20 years of examining health care systems throughout the United States and comparing them to countries around the globe:

•There is no organized health care system in this country. Instead, we have very fragmented and expensive sick care.

•Incentives in the reimbursement system drive higher usage, more procedures and tests and lack a focus on wellness and prevention.

•Ever since the discovery of antibiotics to cure infectious disease, we have searched for cures to chronic diseases. The breakthroughs in medicine in recent decades — and there have been enormous advances — have helped us get well and extended our lives, but haven’t eradicated chronic diseases. Cancer research, for example, has produced treatments that help millions of people. But there is still no universal cure for cancer.

•Unhealthy lifestyles account for more than half of the cost of health care. We label our problems as diabetes, alcoholism, heart disease, cancer and back and joint disease. Yet in over half the cases these diseases emanate from a lack of focus on wellness and prevention.

Living a healthy life starts with the responsibility each person has to focus on wellness and disease prevention. Rather than waiting until we get sick, we need a diverse team of health care providers to educate and assist us in staying healthy.

Personal responsibility

When we get sick, we are responsible for getting and staying well, with the full support of our health care team. They can help us on the road to recovery, but we still have the responsibility to take the necessary steps to avoid recurrence. For many people this represents a major shift in outlook.

How do we make this happen in Minnesota?

First, we need a public awareness and education campaign to encourage healthful lifestyles, modeled after the successful anti-smoking campaigns. This campaign should be led by public health experts and funded through public-private partnerships that include state funds.

Second, we need to recognize that primary care and specialty care have very different purposes and organize accordingly. The purpose of primary care is wellness and prevention and treatment of acute disease. These days people should not depend on a single physician to provide care. Instead, they need a team of people to get well and stay well.

Primary care needs to move away from costly one-to-one care by physicians. Primary care teams should be led by physicians, who oversee teams of nurses, nutritionists, health and fitness coaches, stress-reduction experts and complementary practitioners. Their goal is to keep people well, prevent illness and treat acute disease. Primary care should be compensated for helping people stay well, not just for procedures and tests.

Lack of access to health care remains a serious problem driving up health care costs. To address it, we should expand our community health centers, where everyone can access teams of wellness, prevention and primary care practitioners. Much of this care can be provided in groups of people, rather than in individual sessions. Payment for these services would be based on ability to pay, with state government supplements for those who could not afford these services.

Specialty care

People who develop serious diseases need teams of specialists who are expert in that disease. Specialty care should focus on the coordinated management of chronic disease, instead of treating it as a series of acute events. The specialists should be paid for managing people based on outcomes, not just for doing surgery or procedures.

The rapidly rising costs of chronic disease, which accounts for 75 percent of health care costs, could be dramatically reduced if patients enrolled in chronic-disease management programs. Through these programs specialty teams would help patients develop personalized health plans, based on integrative medicine principles. These include the mind-body connection, physical exercise, healthful eating and stress management skills. These principles are key to both quality of life and preventing disease from recurring.

To cover the staggering cost of chronic disease, all Minnesotans should have the opportunity to purchase catastrophic care insurance, using statewide health insurance exchanges. Catastrophic coverage should be based on low-premium, high-deductible plans that kick in when individuals incur expenses beyond a pre-determined dollar amount, based on their income level. Paperwork can be dramatically reduced with fully electronic billing systems. Medtronic pioneered these plans a decade ago with great success in terms of wellness and cost.

Every legal resident of the state should be eligible for these plans, regardless of preexisting conditions or employment status. For individuals, the costs of catastrophic coverage would be deductible from state taxes, with tax credits applied to those who lack adequate income to afford the premiums. To help pay for this coverage, the tax-free portion of employer-based plans would be limited to $10,000 for individuals and $18,000 for families, with any excess treated as ordinary income for state income taxes. Initially, catastrophic coverage should be voluntary, with a firm future date set in which coverage becomes mandatory, just like it is for automobile insurance.

Minnesota has long been the national leader in health care. From the University of Minnesota to the Mayo Clinic, leading hospitals in the Allina, Fairview and other hospital systems, pioneering nonprofit insurance and health maintenance organizations like Health Partners, the Blues, and Medica, and the medical technology industry, we have many of the finest health organizations in the world.

Minnesota is uniquely positioned to create the optimal health care system that serves all Minnesotans by shifting from disease care to wellness and prevention and integrated care for the sick.