Where will reform come next, and who will lead the way?

Posted on | April 16, 2018 | Comments Off on Where will reform come next, and who will lead the way?

Mike Magee

“On résiste à l’invasion des armées; on ne résiste pas à l’invasion des idées.” – Victor Hugo.

It’s useful for all health professionals to reflect on the words of this 19th century French writer. The translation: “Greater than the tread of mighty armies is an idea whose time has come.”

As the AEI chart above illustrates, there is growing collective awareness that our health care system is breaking the bank as it fails to deliver a healthy America while robbing resources from other critical societal needs that contribute to our health and wellbeing.

Hospital cost inflation over the past two decades tops the inflation list above at over 200% with general medical care weighing in at 125%. One in every five dollars consumed by health care today goes to our medical-industrial complex.

Warren Buffett’s assessment that “Medical costs are the tapeworm of American economic competitiveness” is right on. His critique has focused on data, cost, and level of engagement. We are challenged by the virtual absence of national health planning and a massively inefficient delivery system.

One of the pillars of resistance to addressing the status-quo, the medical establishment, is eroding as we speak. More than half of all physicians are now corporate employees. Teams with “physician extenders”, known by their patients as health professionals, are the standard, not they exception. Physicians sloppy prescribing has ignited the opioid epidemic and exposed them as easy marks for health product marketers. And it’s not just opioids. Witness anti-depressant addiction especially in women over 55 or poly-pharmacy in seniors nationwide.

Quality issues beg for health delivery disruption. Add to this that there is more than enough money in the system were it to be redirected. The centralized standardization of basic benefit packages and billing systems alone would deliver a 15% savings on our $4 trillion plus annual spend right off the block. Centralization is not socialization. Delivery solutions in all developed nations involve public/private solutions executed on a local level.

In our own country, we are witnessing the emergence of “disruptors.” The current favorite for speculators in the health sector is CVS who has a $69 billion offer to purchase Aetna on the table. In this week’s JAMA, the new Panning Dean of the new Kaiser Permanente School of Medicine, geriatrician and medical ethicist Christine Cassel offered her analysis.

She notes that CVS has 9700 stores nationwide and 1100 attached retail clinics thus far. Leaders of the corporation envision providing “10,000 front doors” to patients of the future.

CVS’s growth in direct care thus far has been based on access and convenience – and sometimes physician choice. For example, when I was due for a shingles vaccine recently, my internest ( who is employed by a corporate health system) elected to send me to the pharmacist next door rather than spend time (and money) himself.

Another CVS standard is pharmaceutical continuity and delegation of care to non-physicians. Offerings at first were limited, but they are rapidly approaching the offerings of most primary care offices, quite a feat since CVS has made a minimal investment as yet in adequate brick and mortar to house the services. Cost-effectiveness is also a goal with almost all services coming in under $100, and insurers welcome.

CVS has also been making a run at the status-quo with data (They now own a dominant PBM and will soon add a major insurance database). All that’s left is engagement. Specifically, they need to connect to existing health care systems. With Aetna, they may have a running start since the insurer has been active in the Medicare Advantage plans and in Medicaid risk bearing health delivery, both proposed as vehicles for a public march toward universality.

But they needn’t wait for Aetna – and as it turns out, they haven’t. Four years ago, the Advisor Board reported that CVS already had formal relationships with 350 hospitals in addition to clinics and physician groups. In the D.C. area at the time they were integrating their electronic medical records with MedStar Health’s 10 hospitals and 4000 doctors, and promising the system’s patients the future ability to access their medical records at any of the CVS stores nationwide. And it wasn’t just MedStar. At the time CVS had 41 similar health-system agreements formalized. That was four years ago.

But has “the time come” as Victor Hugo professed?

Consider the politics in addition to the financials. For the past two years we have witnessed our worst tribal instincts on full display. In general, America’s goodness has so far survived and appears to be growing in strength and organization whether it be teens rising up against gun violence, media on hyper-alert as they face off “fake news” or the independence of our Justice System reinforcing through action that “no one is above the law.”

The 2018 election could create the momentum for a push toward solidarity and a refocus on positive values. If so, at least based on the chart above, health care reform and educational reform will likely lead the way.

“On résiste à l’invasion des armées; on ne résiste pas à l’invasion des idées.”