Healthcare Reform: We Can’t Wait For Washington

Eric Dishman

“Well, I guess you are done blogging since healthcare reform is dead now?”

Ouch! This comment came from a friend–from someone who says he actually likes some of my blogs and is eager for healthcare reform to happen. But I can understand his presumptions. The pages of ink spilled on the speculation about the demise of healthcare reform far outnumber the 1000 pages of the bill at this point. As I write this, the media are swarming around the proposed Feb 25th meeting–what has been called a “televised discussion”–that the President will have with the GOP about reforming healthcare reform. Much as I liked Obama’s televised Q&A with the House Republicans last week, I’m skeptical that authentic “discussion” will happen under the click and flash of cameras and crews.

Regardless, no, I’m not giving up on blogging or advocating for reform. I’ll stop blogging only when I’ve got nothing more to learn or say (and those who know me have rarely seen me at a loss for words). I’ll stop fighting for healthcare reform only when we’ve covered everyone with an affordable, prevention-oriented, coordinated system that no longer depends on experts and institutions for every care need. Even if a meaningful bill passes anytime soon, healthcare reform is something that will take decades–and dozens of more bills, amendments, and tweaks–to accomplish.

Presidential outreach to the Republicans notwithstanding, I am not counting on Congress to accomplish much in 2010 (not in healthcare reform, financial system reform, energy, or even jobs creation). The President’s State of the Union call for bipartisan civility and collaboration in this Age of Perpetual Electioneering is one that should be heeded and hoped for, but not depended upon. When every day is about electability, every syllable is soundbiteable, and every motive is me-oriented, it’s hard for Washington to tackle something as complex and conflict-inducing as healthcare. Adding a midterm election to that ongoing dynamic just means Silly Season will be more absurd, lengthy, and extreme than usual. We can’t wait for Washington to do healthcare reform; it is too critical of a priority to put all our eggs for healthcare reform in the Congressional basket.

So how do we make progress on healthcare reform without waiting on Congress? We forget sometimes that ARRA, the stimulus package, already provides programs and funds that the nation can use to begin to innovate our care system. And through this reform debate so far, the private healthcare sector should be able to see the writing on the wall (payment reform for outcomes, transparency, quality measuring, value over volume, universal coverage, care coordination, preventive care, etc.) for where healthcare in this country is ultimately headed, even if at a politician’s prolonged pace that leaves far too many people suffering under the old system for far longer than necessary. It would be much better for employers, health plans, unions, and advocacy groups to start driving grass-root reforms themselves now on their own terms than to be handed unfunded mandates and uninformed edicts from Congress later on.

Here are some of the opportunities I see to drive reform right now:

1) Put stimulus money to work: The ARRA stimulus money, still largely un-spent, has billions of dollars of investment to make in rural community health centers, rural care, broadband access, and much more. There is great opportunity to wrap these different funding streams into coherent innovation plans for care delivery experimentation–especially using community health centers as “hubs” to deliver telehealth and other services out into the community. There are also the Comparative Effectiveness Research, or CER, dollars that could be combined with discretionary funds that places like NIH and NSF have always had to put real money behind real change for healthcare delivery. Our nation’s first CTO, Aneesh Chopra, is still out pushing for healthcare innovation now with what we’ve already got available from stimulus and normal appropriations, so, while we can’t give up the fight to push Congress towards reform, we also don’t need to wait on them, either. With the President’s 2011 budget and his Strategy for American Innovation (seehttp://www.whitehouse.gov/omb/factsheet_key_innovation/), we have enough “air cover” and investment to take healthcare reform forward.

2) Foment “accountable care” competition: Ever since MedPac researchers starting using the phrase “accountable care organization” or ACO last year, the term has taken off and was included in many versions of the health reform bills. The ACO cat may be out of the bag now. Many private plans–both for profit and not-for-profit–that I work with are actively building strategies to become ACOs. They are looking at care management with an eye towards cost savings through better care coordination, providing a medical home for patients, bundling responsibility and payment, and putting in infrastructure like EHRs and quality reporting tools to drive transparency. The true leaders will likely reinvent themselves well ahead of Congressional mandates to be ready for this new world order of ACOs, medical homes, or whatever phrases-of-the-moment we come up with to characterize these trends.

3) Follow the lead of the States and Governors: Many of our nation’s governors and especially the National Governors Association, NGA, were very concerned (with good reason) about unfunded mandates coming to them out of healthcare reform bills from Washington. These governors now have a great opportunity to get ahead of the curve–to use their health departments, purchasing power, Medicaid funds, ARRA monies, and other means to drive payment and delivery reforms through creative programs that fit their unique geographical and economic needs. In fact, we will probably see better ideas like the reforms done in Massachusetts emerge from the states–with BKMs shared among governors–that can become national models from the ground up, instead of being handed down from on high from Washington. If done right, healthcare reform at the state level should also be a source of new jobs growth and industry catalyzation if these states include innovative reform proposals in their state strategies.

4) Enable Medicare innovation: There is one thing we need Washington to do quickly that doesn’t require a major new piece of legislation: we need a new leader for CMS, the Centers for Medicare & Medicaid Services. The President and HHS Secretary need to choose–and the Senate needs to confirm–a new CMS administrator as soon as possible. With a new leader in place at CMS who has expertise in–and commitment to–care innovation, we can use the regular appropriations process to fund a CMS Innovation Center, which was included in the healthcare reform bills to Congress. New leadership and new funding can/must set a new tone for CMS, who has a history of resisting and restraining innovation. But I have met many CMS experts and well-intentioned administrators who, frustrated with their own bureaucracy, are eager to put CMS at the head of the innovation charge and to invent a 21st century care system for our country. Since the private pay market often follows the payment and practice models authorized by CMS, they can lead the nation towards healthcare reform without waiting on new legislation from Washington.

5) Leverage the ONC to facilitate care innovation: Most citizens have never heard of the ONC, the Office of the National Coordinator for Health Information Technology, in the Department of Health & Human Services in Washington. It is a new office founded by the Bush administration to help coordinate the build-out of a national information technology infrastructure for healthcare. Dr. David Blumenthal, the current head of the ONC, wrote a recentpiece in the New England Journal of Medicine that explains the strategy to expand the “meaningful use” of electronic health records (EHRs) across the country with interoperable, standards-based technologies. His office, as part of the HITECH Act in the stimulus packages, has announced $2 billion of new programs to enable EHR adoption. As Blumenthal puts it: “It is impossible to imagine a high-performing U.S. health system that does not take full advantage of the computing technology that has transformed virtually every other aspect of human endeavor.” So once again, the tracks have already been placed through the stimulus package, there is investment, and there is assistance. We can already move a long way towards true healthcare reform through ONC programs like the Beacon grants and many others, and with successes and learnings from these programs, we will be far better equipped to push for future pieces of legislation from Congress that adjust-as-we-go.

6) Support small physician practice ventures: At the end of the day, it is small physician practices–often with just one to three physicians–who are the front lines and lifeblood of much of the American healthcare system. They are the “small business” part of healthcare that cannot be ignored or underestimated as we drive for healthcare reform. Today, we already see “concierge” physician practices popping up from retail clinics to special-service physician practices to meet the hungry demands of a retiring Baby Boomer population who want and expect a very different kind of healthcare experience than perhaps their parents did. Many of these practices are already delivering a fee-for-service “medical home” for frustrated patients dealing with multiple chronic conditions who feel like they don’t have a single point of contact–a care champion–orchestrating their care across all the specialists. Other private pay services for chronic care or home care are emerging. We ought to look at existing appropriations for SBIR (small business innovation research) grants and see how they could be deployed to support small doctor practices who want to deliver innovative services, perhaps with state matching funds or private Venture Capital funds brought to bear to give these programs a better chance to scale and survive. This, again, is innovation from the ground up–from the front lines of care–that we can enable with existing laws and programs; the key for the federal government to play is to shepherd this innovation and then get out of the way!

7) Explore employer-driven prevention initiatives: Finally, I believe large employers–especially large, self-insured employers–have far more innovation potential than they realize to be at the forefront of healthcare reform. And they don’t need Congress to do this for them. Simply put, large employers should be going to their healthcare vendors and demanding new care models and services that save money and produce better outcomes. They have the clout to demand cost transparency all the way to the consumer/employees who are utilizing those services. As I collaborate with dozens of large companies, I am surprised at how passive most of them are about the healthcare they offer their employees. They are too accepting of the status quo from their healthcare service providers. Employers should use the power of their purse strings to demand continuous innovation and improvement from the healthcare marketplace, sitting down at the table with their suppliers to invent wellness & prevention, disease management, and caregiver support programs that Congress can then be forced to catch up with through legislation later on. A little healthy competition would go a long way to accelerating healthcare reform without waiting on Washington.

While I think Washington is failing in its duty to serve the country first by driving meaningful healthcare reform over partisan politics, Congress and the Administration may have also inadvertently done the nation a favor. They have highlighted many of the principles and directions for reform, but then left it up to American ingenuity and competition to deliver upon those reforms and innovations, probably more quickly than any piece of legislation ever could.

Much of the scaffolding and strategic direction for achieving healthcare reform in America is already in place, and the demographic, economic, and moral imperatives are already urgently omnipresent. So the time to begin reform–which will ultimately be messy, iterative, and decades long–is now. We really have no excuse not to get started. While we should still demand that Congress tackle big problems like covering the uninsured, ending the denial of coverage for pre-existing conditions, and driving incentives and insurance towards preventive, coordinated care, there are resources and reasons not to wait on Washington.

So for driving a healthcare reform campaign, perhaps we need only heed the immortal words of the Nike marketing campaign: we need to “Just Do It!” Or let’s echo the President’s campaign for the office which he now holds…maybe we just need to realize that “Yes, We Can!” when it comes to doing healthcare reform ourselves. Or taking a cue from other recent headlines about the politics of Washington, perhaps we should just go do healthcare reform without telling anyone–the “Don’t Ask, Don’t Tell” policy for healthcare reform. Don’t ask us if we are doing healthcare reform, and we won’t tell. But we’ll just keep doing it anyway.