John D. Damore
George Halverson does an exceptional job at laying out the major issues facing the United States health care sector and systematically making practical suggestions for reform. Having been on the inside of Kaiser in California, Halverson has an in-depth knowledge of the complex interplay between physicians, payers, patients, providers, hospitals and the government. Four of his most powerful messages are how to harvest existing personal health records, the need to focus on chronic disease, how to create intermediary agents that pursue high quality and efficient care, and the fundamental necessity of universal health care coverage. Although that last reform is left-leaning, the author's perspective is balanced and he supports reforms to make health care markets work and reduce unnecessary administrative waste. One of his most resounding messages is that we get what we pay for in health care; currently we have over 9,000 billing codes for treating disease and not a single way to bill for a cure or maintaining wellness.
As a health care professional for the past six years, I highly endorse this book to both novices and experts alike. The challenges that await health care reform are large and complex, but it is the articulate and well-though advice of veterans like George Halverson that will make long-term advancement possible.
Halvorson has initiated a public conversation about health care in the United States. Halvorson postulates that adequate healthcare can be provided to everybody without increasing the cost of care. He would take advantage of the following:
* A small minority of the health care consumers use the major portion of health care dollars. The bulk of this is attributed to chronic illness that goes untreated until it becomes an acute (and expensive) crisis.
* The multi-provider model of health care currently in the market is extremely inefficient, especially when coupled with paper medical records.
* Cost shifting as the uninsured present to hospitals or emergency departments where they cannot be turned away. This is the most expensive care possible. These costs are shifted to private insurers.
Halvorson designs the idea of an IV or Infrastructure Vendor. The IVs will create medical record systems allowing individual providers access to all the information they need for a patient's total care. Reminders for tests and treatments for chronic illness will come up.
Halvorson sees that one primary problem with the American health care system is a badly incented market. Financial incentives exist for treating illness, not for securing health. His solution is to capitate payments for chronic illness so that the providers have more incentive to keep their patients healthy.
Finally, Halvorson would require health coverage for everybody so that no cost-shifting occurs. Halvorson embraces the "six sigma" concept for health care providers adhering to best practices and evidence based medicine.
Halvorson's reliance on medical information systems to help solve health problems is wishful thinking. The system deployed by Kaiser has been described as implemented in a way that fails to fulfill the requirements that Halvorson raises. One employee told me that she could order a vasectomy on a woman without raising any errors or flags.
Another problem is Halvorson's failure to address the roles of line workers. While he cheers for 6-sigma, he ignores the wisdom of Total Quality Management or other programs designed to allow worker input to help solve system problems. Again, this is a complaint of Kaiser employees who have some influence in corporate processes, but are mostly ignored when it's time for the big decision.
Still, Halvorson has good ideas, which ought not to be totally discounted. Providing preventative health care for chronic conditions CAN drastically lower care costs. Kaiser is one of the few insurance systems that provides full chemical dependency care at no extra charge, thus saving the costs of liver transplants, heart failure, pancreatitis, and other drug and alcohol related problems.
Think of this book as a conversation starter ... a point of starting a national dialog to move national health care forward.
As a former Senate staffer working toward my PhD in health care policy, I looked forward to reading a book on health reform written by the CEO of one of the largest health plans in the U.S, but I was very disapointed by this book. First of all, I thought Halvorson made many similar arguments Michael Porter makes in his book, Redefining Health Care.... Porter makes a convincing argument that we need a true "market" for health care that rewards quality outcomes (and considers costs). but Halvorson's patronizing "aw schucks" writing style and boring, yet self agrandizing personal anecdotes about his own health and leading Kaiser really wear on the reader (compared to Porter's book which is a great read).
In addition, through reading this book, I started to question how much the CEO of a membership based HMO really knows (or cares) about the uninsured. If Halvorson (and Kaiser) for that matter really wanted people to have coverage, they would see their fair share of charity care cases (uninsured) instead of sending them to the safety net...something Kaiser is notorious for, at least in California.
Instead, in his chapter on a plan for universal coverage, Halvorson proposes using a sales tax and employer fees to give everyone coverage...which would mean, more paying members for Kaiser. Not exactly health care reform now when you get down to it.
Loyd E. Eskildson
Halvorson's book is an excellent background source for anyone looking for an overview of health care economics. The book clearly benefits from his years of experience as a health care administrator - now CEO of Kaiser Permanente. Halvorson begins by pointing out that acute (non-chronic) health conditions often get the most public attention because each case can be very dramatic and made visible by the media. However, the most frequent uses of acute care (cancer, maternity, trauma, infectious diseases) are relatively minor cost contributors - eg. cancer and maternity care respectively contribute only 4% and 5% to total health spending. Five types of chronic care (diabetes, congestive heart failure, coronary artery disease, asthma, and depression) generate the overwhelming costs (75%). Each tends to be progressive, and those getting the most expensive care usually have two or more of the five, or at least an added acute problem. (Additional chronic problems are usually referred to as 'comorbidities.') Hypertension is also an important health care problem because it is the underlying condition that leads to heart failure and exacerbates the complications of diabetes.
Diabetes is the chronic condition that receives the most attention from Halvorson, and he makes a good case for doing so. About 32% of Medicare costs go to treating diabetes, kidney failure in the U.S. is most often a complication of late-stage diabetes, and it also is the #1 cause of new blindness, foot/leg amputations, and is strongly linked to heart failure as well. Despite these potentially serious outcomes, diabetics only receive proper treatment 8% of the time per expert-determined care protocols, the rate of U.S. obesity has nearly tripled since 1980, and it is now 2.5X that of the OECD average. Halvorson also cites a source indicating that with appropriate and consistent care supported by patient behavioral change, the number of diabetic-related kidney failures could be cut by at least one-third. Another indication of the potential for improvement - Pima Indians over age 65 on the U.S.side of the border with Mexico have over 5X the rate of diabetes of their relatives on the Mexican side with the same genetic makeup. The difference is attributed to greater activity, and better diet by the Mexican Pimas.
The latter portion of "Health Care Reform Now" is taken up with several proposals for how to restructure health care to improve preventive care. The first problem is that health care is built around 9,000 billing codes associated with treatments and procedures, with none for 'cure' or 'prevention.' A second is that most physicians are paid accordingly - for providing services, not prevention. A third is that various physicians involved in treating chronic patients with comorbidities have no incentive or easy mechanism to share information, and most don't - duplicating tests, providing conflicting care and drugs that interact. Halvorson is convinced that electronic medical records (EMRs) are a must - ideally, providing not just treatment records but test, scan, etc. results, and millions of data records for analysis as well. (Taiwan, spending slightly more than one-third that of the U.S., uses a small credit-card sized device that patients carry around with them.) Side benefits of detailed EMRs are that computers could then also feed physicians appropriate findings from recent (30,000/year) published clinical trials to assist care while they are with patients.
Unfortunately, probably due to recency, Halvorson does not provide information on Kaiser's new EMR system. Business Week 4/7/09 tells readers that less than 2% of acute-care hospitals have a comprehensive EMR in place (Kaiser and the V.A. are major examples), with a similarly low proportion of physician offices as well. ((Less than 4% of U.S. physicians work in practices with at least 50 physicians, making strategic analysis or major investment, about $75,000/physician for a small office, in EMRs impractical.) Kaiser's efforts began 40 years ago, and include a $400 million joint project with IBM that was scrapped in 2003. Kaiser has invested over $4 billion to date. Within the first 18 months of the recent installation of EMRs within Kaiser, physician office and E.R. visits dropped by 7%. Patients can also make appointments on-line and correspond with physicians using e-mail. Patients can also take their records with them on a small flash-drive. (Information included on the drive includes medical problem lists, medications, allergies, immunization records, lab results from the past year, most recent EKGs and chest scans - both images and readings.)
Halvorson also says little about the Archimedes computer simulation program (aka SimHealth) it uses to analyze treatments for and the status of diabetic patients and others. Funded by Kaiser, though developed independently by Dr. David Eddy beginning in the 1990s (also a PhD mathematician), the system required only 30 minutes to simulate the results of a thirty-year trial regimen that in practice reduced heart attacks and strokes by 60-80%, while saving $350/patient/year. Other diseases covered by Archimedes include coronary artery disease, hypertension, colon cancer, congestive heart failure, stroke, obesity, asthma, breast cancer, lung cancer, dyslipidemia (high cholesterol and triglycerides), and metabolic syndrome (risk factors that occur together and increase the risk of diabetes, stroke, coronary heart disease).
Bottom-Line: Thoughtful readers of "Health Care Reform Now" and related materials will find it difficult NOT to get excited over the enormous potential for improving patient outcomes, without spending more money. His thinking is well-organized and focused - making a big dollar and health improvement impact through focused improved prevention and early alleviation efforts that include patient responsibility.
The chapter on chronic conditions is a very interesting read--as is the author's argument that we need to identify people with these conditions (based on better data) and intervene before their conditions progress to a higher cost state--chronic disease costs the health care system a fortune. The problem with this chapter (and a central argument in this book) is that it has already proven to be unworkable and untrue. The Congressional Budget Office analyzed the watershed of literature on disease management and concluded it does not lead to savings. The interventions the author speaks of are often not successful, nor cost saving. Indeed, if the argument were true, the own author's health plan--which rigorously practices case management and disease management--would have already seen the cost savings. The fact that the health plan's costs (and premiums) are no lower--and in some cases are higher--than the industry average is a strong counterargument. Moreover, the author himself--a self acknowledged heart attack patient is yet another example of why early interventions for chronic disease patients are often not successful. An overweight patient with high cholesterol can visit his physician--who may prescribe diet, exercise and cholesterol medication...but then, it in the patient's hands to follow doctors order and modify his or her lifestyle accordingly. Many do not. How to not only encourage--but ensure--high risk patients purse lifestyles that include healthy eating and active living may be the central challenge facing medicine--and our county--today.