Reviving the health system demands closing the costly, unhealthy discontinuities in the health-seeking experiences of patients. The fault lines have widened as a consequence of the fragmentation accompanying advances in health science compounded by expanded patient knowledge and expectations. More quakes will follow from inflation-provoked reductions in health benefits. No one has the capacity or designated responsibility to fill the voids that patients experience because no provider is paid to fill them.
The inflation-driven, market-oriented, and consumer-choice lineage of managed care lasted long enough to help stabilize health care costs during the 1990s and to save, in the aggregate, more than a trillion dollars. Health expenditures were 13% of the gross domestic product (GDP) range from 1991 through 2000. This remarkable achievement was made by eliminating inappropriate, unnecessary, and potentially dangerous care. Unfortunately, most managed care has lost the opportunity to move beyond the outmoded health delivery structure. Too many health plans have relied on sophisticated payment schemes to preserve an ancient medical culture. Health care has become a scientific prodigy that is structurally challenged. Purely economic incentives do not enable patients to exert sufficient influence on this entrenched industry. The inevitable consequences will be camouflaged forms of risk selection coupled with patient hostility and anxiety.
We were wrong, 30 years ago, when we expected independent practice associations (IPAs) and, later, preferred provider organizations (PPOs) to become prepaid group practices. I no longer expect lucrative, comfortable single-specialty practices to evolve into seamless, sustaining havens for patients. On the contrary, technical and scientific progress facilitates organizational divergence and discontinuity.
 Paul M. Ellwood, MD |
Despite fragmentation, we can put the experience of the patient and the performance of the health system back together through the convergence of decision and analytic tools coupled with unifying information technology. Cost-containment measures must not be separated from quality and reliability. For the patient, the health system must be accessible, seamless, sustained, and transparent. The system’s structure should be reshaped continuously by advances in science, technology, and epidemiology and by changes in consumer needs and preferences. Government must see that everyone is insured and must restructure its responsibilities in concert with the private health care sector. The proposed reforms must be readily understandable and logical.
The mnemonic HEROIC can be used to refer to the necessary changes. H stands for the health organization, a new infrastructure for a new medical culture. HEROIC tools resemble public utilities stretching across medical communities, requiring common software, servers, accessible databases, evidence-based guidelines, and standards for transparency or accountability. Some new or subsidiary entity will be needed to sponsor and operate parts of the infrastructure. Reliance on system-wide utilities does not preclude various practice arrangements, choice, competition, and product differentiation. The tool kit of the HEROIC health system is designed to circumvent our unstandardized traditions while leaving independent practices in place. It is the 21st-century version of the IPA, PPO, and HMO.
E stands for evidence-based medicine. Relying on guidelines is the transforming concept that signals the advent of a revitalized medical culture. Evidence-based medicine links quality improvement to cost containment, and it allows us to quantify the value to patients of new technologies. It allows the adoption of safe, reliable, efficient medical production methods. Its algorithms have measurable outcomes; working from algorithms also eases the transition to electronic medical records. Evidence-based medicine revives results-based reimbursement, and it helps patients understand their responsibility and determine whether providers are fulfilling theirs.
R stands for responsibility shared by patient, provider, and payor. The joint responsibility can take the form of a contract, with the provider agreeing to use evidence-based guidelines while the patient agrees that adherence to scientific guidelines fulfills the health insurance contract.
O stands for outcomes accountability. The outcomes of health organizations are significant, and measurable, and are ignored by patients. The outcomes of individual physicians are rarely measured, and are unavailable to patients. Routine measurement and reporting of health outcomes by all providers are evidence of openness and trustworthiness to patients.
I stands for information technologies. Digitally collecting, storing, interpreting, and sharing health information is the key to quality, reliability, seamlessness, responsibility, cost control, and dynamism. All major reforms are tied to an electronic medical record, which should be enhanced by decision support, outcomes analysis, and patient communications modules.
C stands for commitment, which implies continuously available follow-up care and advice over a lifetime, in addition to constant health-insurance coverage. Individuals need to be linked to a lifetime medical information system. I favor the rapid introduction of personal medical identification chips allowing consumers to face emergencies and change physicians or insurers, yet immediately receive the help that they need.
It is ironic that this $1.4 trillion industry, employing 16% of the nation’s work force and projected to consume 17% of the GDP in 10 years, lacks the leadership or capital structure to spend its way into a better future for its customers. There are no profitable arguments for HEROIC health reforms. Those of us who must endure this broken system every day are best prepared to understand what is wrong and how to fix it.. First, we must agree on the architecture needed to correct the flaws. Second, we must proceed with implementation, one susceptible community at a time. Third, we must put the construction crew, architects, and contractor in cyberspace. Fourth, we must help the government help us.
The Jackson Hole Group will initially concentrate on the architecture and its designers. We will work with any person or group who is prepared to advance the tools and principles embedded in the HEROIC structure. We want to incorporate the experience of those who have devised and applied evidence-based guidelines in and out of the hospital and across entire medical communities. We are soliciting guidance from individuals and organizations who have experience with clinical information technologies, especially electronic medical records. We want to learn from experimental medical practices that employ combinations of HEROIC tools and principles. We need to confer with people who have operational responsibility in government about how their agencies can interact with each other and the private sector to keep the health system leaning forward. We propose to convene Jackson Hole Group meetings, after a 4-year hiatus, in September 2002; experts and policy makers will attempt to arrive at some working consensus on what should be included in the HEROIC structure.
Paul M. Ellwood, MD, is president, Jackson Hole Group & InterStudy, Bondurant, Wyo, [email protected]. This article has been excerpted from an address that he delivered to the Graduate School of Management, University of California Irvine, on October 2, 2001.
