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This story bears repeating, if only to remind us that while the quarry where the marble came from may have been controlled by the government, or perhaps by the Holy See, it was a talented individual who knew that the angel was in the marble. The government didn't quarry the block, it did not transport the block to the garden that morning and it didn't create the angel. It didn't even have the capacity to ask about the inspiration and talent of the sculptor.
In our world, certain elements of the government appear to believe that they can perform all of the roles required to re-sculpt our health care system. They will attempt to appear inclusive and even-handed. In March, the White House hosted a forum at which the administration gathered input from a variety of constituencies. Everyone who is anyone was there, but as the Cato Institute's Michael Cannon observed, "They all want to be at the table, because they don't want to be on the menu."
At that meeting, President Obama seemed ambivalent about a "public plan" (aka some version of government health care) that would compete with the private sector. He told the gathering that if everyone could be insured "at an affordable rate and have a choice of doctor, flexibility in terms of their plans and do that entirely through the market, I'd be happy to do it that way." The problem is that the lack of a public plan is a deal breaker for the left and the inclusion of such a plan is equally unacceptable to the right.
Chip Kahn, who conceived the Harry and Louise characters who helped to defeat the Clinton health care initiative, is president of the Federation of American Hospitals. Quoted in Newsweek on March 23, he said, "Things are different today." Kahn worries that soaring health costs are reaching unmanageable levels, hurting hospitals, insurers and patients alike. He told Newsweek he believes there is now wide acknowledgement that the quality of care has eroded since 1994 and something needs to be done.
Bringing the issue into focus
Setting aside the ongoing problem of conflating quality and cost -- two different, though related issues -- there is actually quite a great deal being done. It is not being done by government any more than the Medici family or Pope Alexander VI carved Michelangelo's angel in the garden. The first step toward accomplishing real change is to understand both the nature of the problem and those who will be able to effect change.
Speaking at the 2009 Wharton Health Care Business Conference, Mike McCallister, president and CEO of Humana Inc., set the stage with a powerful keynote address. During my tenure with Humana, one of the things I enjoyed most about Mike was his ability to crystallize complex issues into a couple of definitive sentences. As he told the audience, in spite of all of the political and economic talk going on, there is no single "health care system" in this country that needs to be reformed. He suggested that instead, the health care "sector" -- a gigantic mix of varied players -- is "broken, but can be fixed."
McCallister, quoted in Forbes on March 19, suggested that because of this, "we have the wrong objectives. We have the wrong forms of competition. The wrong geographic markets have been established, the wrong strategies and structures. The incentives are wrong for virtually everyone, including providers, payers and patients." He believes that universal coverage is a laudable goal, but contends that, "in a nation as wealthy as ours, everybody should be covered in some fashion." His belief is that we cannot get to that goal without "cost and quality improvement."
McCallister is crystal clear about the difference between the cost of treatment and the price of health insurance. He understands that overutilization and defensive medicine is a major cost driver. "If you lie down long enough, someone will scan you," he told the conference. Being the consumerist that he is, however, McCallister doesn't lay the blame solely on doctor-owned CT, MRI or PET scan facilities. He is quick to point out that patients who can't get enough medical care are part of the problem. In consumer land, that's how it works. Or at least that's how it should work.
Every solution doesn't have to require a massive government program or some new, multi-million dollar piece of gee-whiz technology. Sometimes simple steps can have a huge impact on overall costs. A simple checklist -- a piece of paper on a clipboard or attached to the patient's chart -- can make a huge difference. A report in the Jan. 2009 issue of the New England Journal of Medicine studied surgeons who followed rules such as: "Before the patient is given anesthesia, make sure the part of the body to be operated on is marked," and "After surgery, check that all needles, sponges and instruments are accounted for."
You are probably thinking that these rules fall in the category of medicine colloquially known as "Duh," but they have made a huge difference in outcomes. Based on the pioneering work of Dr. Peter Pronovost, a Johns Hopkins University doctor who conducted a similar "checklist" study several years ago to reduce the infection rates from intravenous tubes, the Joint Commission is considering the adoption of a wide range of checklist steps.
Bringing power to consumers
To be sure, there are improvements that can be made on the insurer side of the equation as well. Consumers need information in order to make intelligent decisions. McCallister has long decried the needlessly complicated explanation of benefits statements (EOBs), which he refers to as "C.R.A.P." He has told audiences for some years that he throws his EOBs in the trash, noting that, "We're going to have to step up and make things simple, clear and easy to understand. The power has to be in the hands of the consumer."
No one does "consumer" like Wal-Mart. Today, only 14% of physician practices use electronic medical records (EMRs). As we have previously reported, doctors see the cost of moving to electronic records as prohibitive.
The Wal-Mart-owned Sam's Club retail warehouse chain is out to change that. Earlier this spring, Sam's Club announced that it had joined with EMR vendor eClinicalWorks and computer manufacturer Dell to sell systems at a deep discount. It estimates that a physician's office can be up and running for less than $25,000. The government didn't tell Sam's Club to do this, and the participants believe that there is enough profit in the venture that they are willing to take the risk.
Not everyone is a Michelangelo, who could "see" the angel in the block of marble. Not everyone is a Mike McCallister, who has a clear vision and can express it in a simple and provocative manner. We aren't up to our IV poles in medical professionals offering simple solutions that yield major impacts. No one would mistake a Sam's Club for the halls of Congress. Yet these folks are out there and they -- not governments or health effectiveness boards -- will be the leaders. At the end of this path -- regardless of where it takes us -- one thing is clear: There will be consumers making choices.
Theodore Forstmann, founder of the private equity firm Forstmann Little & Co. and one of the world's richest businessmen, once noted that, "The gentle government that promises to hold your hand as you cross the street refuses to let go on the other side." This is the lesson that some of the banking and insurance industry learned after the government passed around trillions of dollars and became their not-so-silent partner.
As a country trying to find our direction on health care, we have a choice. We can take the hand that is trying to help us across the street, or we can use our own leadership to navigate.
Let us be clear, however: Our choice will dictate whether we are at the table or on the menu.
Readers may write to David Saltzman at Carolina Care Plan Inc., 201 Executive Center Drive, Columbia, SC 29210. He is a past president of NAHU and has been a health, disability, life and employee benefits broker for more than 25 years. He is director of the large group segment for Carolina Care Plan.
