The Doctor Weighs In

Brian Klepper

A detailed new study from the Economics Policy Institute confirms what many of us suspect but haven't had the data to easily nail down. This weightily-titled report by Jared Bernstein and Heidi Shierholz - A Decade of Decline: The Erosion of Employer-Provided Health Care in the United States and California, 1995-2006 - provides more granular information about the enrollment dynamics over time in employer-sponsored health coverage than we've seen in a while. Based on an analysis of the March 2007 Current Population Survey, the numbers reported here are mostly in sync with (but deeper than) similar studies that have attempted to size the enrollment and erosion characteristics of the employer-sponsored coverage market. Strap yourself in; this isn't pretty.

There are two important points here. The first is that, in the six years between 2000-2006, the percentage of American workers with employer-sponsored coverage fell from 51.1 to 48.8 percent, a 2.3 percent absolute or 4.5 percent relative drop. 6.4 million workers (and presumably, another 7.6 million of their family members) lost their health coverage in the process. These losses exceeded gains made between 1995-2000, when the percentage of workers with coverage rose from 49.6 to 51.1 percent. 

It might be tempting to interpret the last few years' coverage erosion as cyclical. But it occurred during a period of relative economic prosperity. As Bernstein and Shierholz point out, this suggests a structural change in employer-sponsored coverage that is almost certainly related to unrelenting health care cost growth. In other words, even though employers as a group were doing relatively well financially, the explosion in health cost - about five times general inflation and four times workers earnings from 2000-2006 - encouraged employers to move away from coverage.

Second, the erosion of coverage hasn't just occurred to those at the edges of the workforce, but across the board, eating into high paying, stable employees as much as low-income workers whom we might expect to be marginalized. The report provides extensive tables that break out the findings by industry sector, educational level, corporate role/position. The results are consistent. Here's the authors' comment:

The burden of these employer cuts is not carried by part-time or marginal workers. Rather, the most dramatic loss is among workers with the strongest connection to the labor force.

To me, these points have bigger messages.

Employers Cover Only Half Of Workers
Let's take the smaller one first. These numbers - remember they're from reputable surveys conducted for years by the Feds - say that only half (or less) of all US workers have health coverage. This is not a new or unique finding. Here's a quote from a Bureau of Labor Statistics report, Employee Benefits in Private Industry 2007, issued last August 22:

Seventy-one percent of workers had access to medical care benefits, and 52 percent participated in a medical care plan.

(I should acknowledge that these two sources are at odds with the Kaiser Family Foundation/Health Research and Educational Trust (KFF/HRET) data - see Figure 3.6 in their Employer Health Benefits 2007 Annual Survey report - which estimates that 65% of American workers currently have coverage from their employers.)

I have always found it difficult to reconcile the fact that, while a large portion of American workers apparently don't receive health coverage through their employer, we "only" have 50 million uninsureds. In the 20 years I've worked on or around this issue, this has made no sense to me, and I've never been able to get anyone to explain the discrepancy satisfactorily. So while I nod at the official uninsurance numbers, I suspect they're actually much bigger.

Over the last several decades, we have come to understand a great deal about the relationship between health and productivity. If the employer-based system is now only capable of delivering coverage to half its workers, then that has immense implications for our national ability to be productive and competitive in the global marketplace.

Focus On Fixing The System, Not The Problems Of The Uninsured
More importantly, while, yes, our uninsurance problem looms large, in the end, it pales in comparison with this fact: Mainstream Americans, who historically have had coverage over the last 40 years, are now losing it. So it is a mistake to frame health care reform against the context of the uninsured, at least as we have traditionally understood that population. That approach suggests that health care's problems are isolated to a currently disenfranchised minority rather than directly affecting all of us. Worse, it distracts us from the more pernicious problem, which is the severe operational dysfunction that pervades the whole of the American health care enterprise, one-seventh of the current US economy, one-eleventh of its jobs, as well as quality-of-life and financial impacts for virtually all the American people.

One deficit in the study is a description of the uninsurance problem. While many workers and families have lost coverage, those who still possess it have much skinnier benefits and higher out-of-pocket requirements than in the past. (Which means that when health coverage premium inflation is understood in the context of cost per unit of benefit, the actual cost growth rate is MUCH higher than the 5 times general inflation number I cited earlier.) A recent Watson Wyatt study showed that nearly half (47%) of all employers now offer a High Deductible Health Plan (HDHP), with or without Health Savings Accounts (HSAs). Now consider a recent EBRI/Commonwealth study that found a lower penetration of HDHPs in the market, but also learned that employers were 5.5 times as likely to provide HDHPs WITHOUT HSAs as they were to provide a HDHP and fund an HSA. In other words, most of us are paying a lot more for much less coverage than in the past, and that gradual degrading of benefits makes it increasingly difficult to come financially intact out of any significant health event.

So if the news is that rank and file Americans now face losing health coverage or going personally bankrupt if they get sick or are hurt, then our focus now should NOT be on the uninsured, but on reconstituting the adequacy and availability of coverage. It should emphasize the balance between what care should cost in a rational marketplace, and what most of us are able to pay on our own or through some collective mechanism. In the process of making coverage whole and available again, any moral society that is also devoted to its own self-interest would re-enfranchise those who had been disenfranchised by the failings of the previous system.

Despite the most fervent hopes of the American people, it is extremely unlikely that, when a new Administration takes office next year, health care policy reforms can be brought to fruition that make care in this country more affordable and accessible. Achieving that would require overwhelming the special interests who, as a new study from the Center for Responsive Politics again makes clear, now bring the cash to bear - $445 million in 2007 - to dominate Congressional health policy, and to continue the spectacular unwarranted variation and waste - half of all health care dollars - that lies at the heart of the crisis.

Even so, as progress in the market continues to accelerate, many of health care's cost issues could begin to subside and resolve. We're seeing tremendous movement toward transparency, decision-support and accountability throughout the continuum in the rapidly evolving Health 2.0 market. Access to better and ever-cheaper tools is facilitating information exchange and ultimately, more effective population and personalized health management. New attention to the medical home is revitalizing primary care and promises to curtail unnecessary downstream services.

The market can make care and coverage less expensive and more available. But getting to a system that assures appropriate care to everyone within our borders must be facilitated through policy. It will require political will, backed by a national understanding already firmly in place within our largest corporations, that without secure access to health care, our people cannot be highly productive or continue to lead on the global stage.

I doubt this important new, cautionary study about the character of America's employer-sponsored coverage system will get much visibility or traction within health care reform circles. But it should. Building the will to address what's actually wrong with the system - rather than developing a patch-quilt of half-measures built on ideology - demands looking at and thinking hard about the realities of how our health system functions.

Employer-sponsored coverage has many positive attributes. While it may have emerged out of less-than-perfect circumstances, over time it has come to correctly link the value of health with productivity and competitiveness, giving the employer a clear (though not the only) stake in ensuring that workers and their families are secure.

That system is increasingly in shambles. It can be fixed or replaced. But we must do one or the other. The status quo isn't working or good for Americans, our employers, or the future of the nation.

Deep thanks to Synthia "Hawkeye" Molina of health care technology intelligence firm Central IQ, for sending the Bernstein/Shierholz article my way.

Brian Klepper is an analyst, commentator and Principal of Healthcare Performance, Inc, a health care business development practice based in beautiful, balmy Atlantic Beach, FL.

By Dov Michaeli MD, Ph.D

I am not a health care policy wonk, or a wonk of anything, to tell the truth. But having observed the heated arguments, the indecipherable terms and acronyms, and the general sense of helplessness in breaking the political logjam, I asked a naїve question: how do others deal with the issue?

 I looked at the British system, which I know quite well. I also looked at the Japanese system, which I knew from my visits to the country and contacts with Japanese doctors, professors, drug companies, and just plain folks. Finally, I looked at the Taiwanese system, which I think is an unsung hero that deserves more recognition.

The British system

The Brits are very much like us economically, politically and culturally. They have a much more cynical attitude toward government than we do, if you can imagine that.

So here are, in general outline, the salient facts about their system.

· The “macro economic” aspect: the percentage of gross domestic product (GDP) spent on health care: 8.3

· Average family premium: None; funded by taxation.

· Co-payments: None for most services; some co-pays for dental care, eyeglasses and 5 percent of prescriptions. Young people and the elderly are exempt from all drug co-pays.

· The British system is "socialized medicine" because the government both provides and pays for health care. Britons pay taxes for health care, and the government-run National Health Service (NHS) distributes those funds to health care providers. Hospital doctors are paid salaries. General practitioners (GPs), who run private practices, are paid based on the number of patients they see. A small number of specialists work outside the NHS and see private-pay patients.

· How does it work? Because the system is funded through taxes, administrative costs are low; there are no bills to collect or claims to review. Patients have a "medical home" in their GP, who also serves as a gatekeeper to the rest of the system; patients must see their GP before going to a specialist. GPs, who are paid extra for keeping their patients healthy, are instrumental in preventive care, an area in which Britain is a world leader.

· What are the concerns? The stereotype of socialized medicine -- long waits and limited choice -- still has some truth. In response, the British government has instituted reforms to help make care more competitive and give patients more choice. Hospitals now compete for NHS funds distributed by local Primary Care Trusts, and starting in April 2008 patients are able to choose where they want to be treated for many procedures.

Finally, The brits love to gripe about everything: traffic, the schools, the weather, and yes--the NHS. But try to suggest  that health care should be privatized and you will be met with hostility, as I witnessed personally, and as the Conservatives found out to their dismay in the following election.

The Japanese system

· Percentage of GDP spent on health care: 8

· Average family premium: $280 per month, with employers paying more than half.

· Co-payments: 30 percent of the cost of a procedure, but the total amount paid in a month is capped according to income.

· Japan uses a "social insurance" system in which all citizens are required to have health insurance, either through their work or purchased from a nonprofit, community-based plan. Are you listening Barack? Those who can't afford the premiums receive public assistance. Most health insurance is private; doctors and almost all hospitals are in the private sector. Take that, free market zealots.

· Japan boasts some of the best health statistics in the world, no doubt due in part to the Japanese diet and lifestyle. But also due to superbly trained physicians and surgeons. And due to almost fanatical emphasis on preventive medicine. To wit: Japan has  the highest rates of stomach cancer in the world. But almost every Japanese undrgoes an annual gastroscopic examination. Consequently, most stomach cancers are detected at stages 0 and 1 (in other words, very early). This results in a low, and decreasing mortality rate. On the other hand, in the U.S gastric cancer is detected mostly in stage 4, sometimes in stage 3--either way too late for curative surgery. Mortality rate--close to 100%.

Unlike the U.K., there are no gatekeepers; the Japanese can go to any specialist when and as often as they like. Every two years the Ministry of Health negotiates with physicians to set the price for every procedure. I have been privy to some aspects of these negotiations. The government gets into the minutest detail of the charges for procedures and drugs. Because Japanese culture abhors confrontation and fosters consensus, these negotiations are long, arduous, but at the end of the day everybody signs on. This helps keep the cost down.

· What are the concerns? In fact, Japan has been so successful at keeping costs down that Japan now spends too little on health care; half of the hospitals in Japan are operating in the red. Having no gatekeepers means there's no check on how often the Japanese use health care, and patients may lack a medical home. These are of course policy concerns. But I had the occasion to ask several colleagues and some regular people I met, what their concerns were.  Almost universally the answer was: none. Not a scientific poll, but telling nontheless.

The Taiwanese system

· Percentage GDP spent on health care: 6.3! This should be music to the ears of liberals and conservatives, Democrats and Republicans alike.

· Average family premium: $650 per year for a family for four.

· Co-payments: 20 percent of the cost of drugs, up to $6.50; up to $7 for outpatient care; $1.80 for dental and traditional Chinese medicine. There are exemptions for major diseases, childbirth, preventive services, and for the poor, veterans, and children.

· Taiwan adopted a "National Health Insurance" model in 1995 after studying other countries' systems. Like Japan and Germany, all citizens must have insurance, but there is only one, government-run insurer. Working people pay premiums split with their employers; others pay flat rates with government help; and some groups, like the poor and veterans, are fully subsidized. The resulting system is similar to Canada's -- and the U.S. Medicare program.

· Taiwan's new health system extended insurance to the 40 percent of the population that lacked it (sounds familiar?) while actually decreasing the growth of health care spending. The Taiwanese can see any doctor without a referral. Every citizen has a smart card, which is used to store his or her medical history and bill the national insurer. The system also helps public health officials monitor standards and effect policy changes nationwide. Thanks to this use of technology and the country's single insurer, Taiwan's health care system has the lowest administrative costs in the world.

· What are the concerns? Like Japan, Taiwan's system is not taking in enough money to cover the medical care it provides. The problem is compounded by politics, because it is up to Taiwan's parliament to approve an increase in insurance premiums, which it has only done once since the program was enacted.

Some naїve questions

· Why don’t we hear more about the Japanese and Taiwanese systems in the media, in the political debates, in congress, in health care forums debating ad nauseam how to fix the system?

· Are we so hopelessly captive to commercial and political forces that have a stake in the status quo, that nothing can be done to change it?

· Why can’t we do it? Are the Taiwanese so different from us? Are they smarter? Are we so dumb?

So please, all you policy mavens: please enlighten this naїve layman; why do we need to reinvent the wheel? It has already been invented in Japan and Taiwan. And it works!

Lynn Jennings

On blogs like this, people like me write analytically about issues which are often, at best, conceptual to us.

Not so to the guys in the rough and tumble world of health care finance. I remember that the first time I went to dinner with Lynn Jennings, I only knew that he was CEO of Alliance Underwriters, working in reinsurance, and that he is a former President and a current Board member of the Self-Insurance Institute of America (SIIA). SIIA is the national association of third party administration firms, the organizations that administer health plans for self-funded employer health plans. As we were walking into the restaurant, he turned to me and said, "In reinsurance you make a very sizable bet and find out three years later how things turned out."

Over time, though, as I've come to know Lynn better, I've found he has a profoundly practical view of the world, supported by a belief that careful management makes it possible for health care to work far better than it usually does.

Here is his advice to employers on managing employer-sponsored health plans. Whatever your philosophical orientation, these are sound recommendations for employers who must grapple with the difficult choices associated with employee health benefits.

Brian Klepper

For 40 years, I have worked in the complicated world of self-insured group health plans. I have led a third party administrator (TPA), underwritten stop-loss coverage and, with my wife Judy, overseen a utilization management firm. Now I’m also building employer-based clinics.

Over time I’ve been struck that most interests in the health care equation want care to cost more, not less, and that it is difficult for the responsible employer to navigate through this system. Some employers don’t believe that they can control costs, and have simply lost faith in their power to impact how the care delivery and administrative processes work.

I strongly believe otherwise. Here are some principles that I think can help any employer gain control of health plan quality and costs.

1. Make your plan affordable!
Design your benefit plan – including the required contributions and the deductibles – to work for your least compensated employees. If your company has a wide compensation range, consider a tiered plan that ties contributions and benefits to one’s ability to pay. 

Cover ancillary benefits only if the basic package remains affordable.  Adding dental coverage isn’t helpful if it results in contributions that are unaffordable to your rank and file employees.

2. Dollars paid through benefits are dollars unavailable for salary!
Strive for balance in your health plan. While “frequent flyers” may appreciate a “top drawer” benefit structure, most employees will see no benefit. Money saved can be applied to better pay.

3. Don’t insure what you can self-insure!
The cost of self-insuring predictable risks is nearly always less than insuring that risk. Budget internally for known losses and insure the unpredictable and unaffordable. This is true in auto, homeowners and health care insurance.

4. If your vendors’ interests aren’t aligned with yours, don’t expect them to reduce your health care costs!
Understand the motivations of your health plan partners and suppliers. How will your insurance company (health plan administrator), hospital and doctor be affected if your costs dropped 25 percent? If your broker is paid by the insurance company, what will his/her reaction be? 

A rate increase to you is a raise for everyone else.  Only the employer, your employees and the consultants you pay directly have a vested interest in lower health care costs.

5. Pay your brokers & consultants directly!
Your advisors work for whoever pays them, so if you don’t pay them directly, they don’t work for you!

Insist that you – and only you – pay them. Only then can you be assured of how much they are receiving and whom they are loyal to. Ask all health plan related vendors – e.g., your administrator, insurance company, health management company, network, pharmacy benefit manager – for compensation disclosures.

6. Let vendors know that you expect and will measure results!
Set meaningful, attainable and measurable goals for your plan, like a specific reduction in ER visits, inpatient admissions per 1,000 members, or participation in health risk appraisals. Then communicate them to vendors so they understand what you expect and are motivated to find solutions that will help achieve them.

7. Control your data, externally!
Health care is expensive. If you self-fund your health plan, the risk and cost are yours, and the claims data that result are yours too!

Many independent data warehouses can collect the data from your administrator monthly or even daily, and then store it in a standard format. Your administrator should willingly and, at no additional cost to you, transmit your data to your warehouse. Make sure the transmissions include all relevant data: enrollment, medical, PBM, dental and vision claims.  By having ready access to your own data, you can always know your actual numbers. The ability to measure is the ability to manage.

8. Audit your vendors!
You spend significant dollars on health care. At least every two years, engage an independent auditor to review your health plan’s performance. If your administrator will not agree, change.

9. Don’t be held hostage by vendors!
Doctors and hospitals whose fees are excessive, or who insist on referring outside your network, do not need to be included in your plan.

Take charge. Refuse to include providers who would hold your plan hostage. Let providers know that abusive practices won’t be tolerated.

10. Be wary of a health plan’s “packaged” services!
Health plans are typically built on an array of specific functions: administrators, stop-loss carriers, provider network, utilization management programs. Sometimes plans require that you use arrangements that bundle one service with another. Seek best-in-class products and services whenever possible. Every service and product should stand on it’s own.

11. You’ll get what you accept!
You have the right and obligation to insist on excellence.

Penalize vendors – e.g., health plan administrators consistently unable to pay claims accurately the first time, or disease management programs that cannot prove savings and other programs – if they don’t perform as promised.

12. You can’t please everyone all the time!
No matter what you offer, some employees still won’t like it.  Get over it.  Do what is right and what you can afford.  Most will appreciate it.

13. Innovate! Experiment!
Try new things.  The definition of insanity is doing the same thing, over and over again and expecting a different result. Not everything works for everyone and the “tried and true” may be obsolete!

Brian Klepper 

A wonderful meeting (Full disclosure: They brought me in to blog my impressions.), The Families USA conference that ended Saturday brought together some impressive Congressional politicians - Nancy Pelosi, Tom Daschle, Ken Salazar, Blanche Lincoln - and true health care experts - Don Berwick, Tony Fauci - with "consumer advocates" from around the country.

I thoroughly enjoyed the people at the conference. They were, for the most part, knowledgeable about health care and committed to driving a better system. (My favorites were a group of California Gray Panthers, all of whom were VERY up on the issues). There were also bright young people relatively early in their careers, and representatives from community health advocacy organizations around the country, all fervently dedicated to a better, more equitable health system.

My concern was that I believe this group under-appreciates the influence of health care lobbies over Congress and the policy process. They WANT things to change for the better, and they advocate for approaches they KNOW are more logical and reasonable than the way health care is currently done. So why WOULDN'T we do it that way?

The answer, of course, is because it would damage Congress' largest contributors. Almost every politician I heard speak patronized this crowd, making a point to tell them that their input was vital. Would that it were so. If it were, Congress wouldn't take the money it does from health care interests throughout the continuum, and shape policy for their benefit rather than ours. And, please note, the lobbying rules didn't change substantially when the Democrats retook control.

Families USA's leader is a warm, brilliant, articulate guy (and great dancer!) named Ron Pollack, who has guided this organization for years and made it into the health care consumer advocacy powerhouse it is today. He has a clear, unifying, noble vision for how American health care ought to be delivered and financed, evidenced by the caliber of speakers who agreed to talk at this conference.

Unfortunately I don't believe we can get there by relying on consumer advocates. Ardent and well-intentioned as they may be, they lack a power base, and simply cannot compete with large corporations for the attentions of Congress. I hope I'm wrong about this, but this is why I doubt that meaningful reform will take place after the elections. Even if we get a President who is disposed to real change, getting there will require that Congress go along, and they're beholden to the health care industry.

Families USA has built a formidable platform. There's no reason why, quietly, discretely, this group couldn't reach out to certain non-health care business leaders and groups, explain how their interests align with those of non-HC business - we all seek a more stable and sustainable health system that allows the nation to be healthier and more economically competitive - and facilitate a new coalition that could overwhelm the power wielded by the health care sector. After all, they're 1/7th of the economy. Non-Health Care business is 6/7ths.

They're just looking for someone with a compelling reason and a plan to come together, and help us all resolve this issue so we can get on with other equally pressing matters that face the nation.

Brian Klepper

Several events and trends emerged over the last year that will reverberate throughout the health care marketplace in 2008 and going forward. While none of these dominated the trade press like some other issues - electronic and personal health records, RHIOs, the evolving labor shortage, pay-for-performance reimbursement - these manifestations of change are occurring in the marketplace as well as through policy, and are moving health care forward in fundamentally positive and far-reaching ways.

Health 2.0
The most significant for the long term in terms of its capacity to change how health care works is the Health 2.0 movement, which Matthew Holt and Indu Sabaiya have played a central role in facilitating and explaining. In some ways, Health 2.0 is simply a continuation of what has come before: companies creating new value through information and connecting with customers over the Web. Health 2.0 takes this approach into every area of health care data, often driven by companies outside of or at the margins of health care, who have no financial stake in perpetuating inappropriateness and waste, and who see an opportunity to make money by rationalizing the system.

We've already seen big, established IT companies like Microsoft and Google announce forays into this space, as well as a slew of startups, most of whom have staked out interesting niches. But there are other players who haven't made themselves known yet: health IT companies who are positioned to aggregate data and feed it back to their clients; companies who already have established health care data streams and have large repositories; analytics firms; organizations from financial services and other areas that see an opportunity to leverage their own data strengths and expand into health care; and established health care organizations that, as the competitive market intensifies in health care, will use their strength to enter the data space and use it to advantage.

In the process, health care data will move beyond simple transparency - public availability of pricing and performance information, which is often inscrutable, especially to consumers - to decision support. The creation of easy-to-use data-driven decision assistance tools that can help consumers, clinicians, designers and purchasers of all kinds will change everything.

My bet is that business and the health care sector, more than consumers, will first fully take advantage of offerings that will gradually come online, and use this new information to make better clinical decisions, to better purchasing decisions and to understand their own performance relative to the market. Ultimately, as payments are tied to results, this information will constitute incentives for performance and disincentives for waste.

Consumer Checkbook v HHS
Last August 22, the consumer advocacy organization Consumers' Checkbook won a Freedom of Information lawsuit against the US Department of Health and Human Services (HHS). As a result, CMS was ordered to release Medicare physician data for 4 states and DC.

HHS had argued that physicians are entitled to a right of privacy, a particularly curious position given this Administration's generally progressive stance on health care pricing/performance transparency and keeping in mind the fact that physicians paid by Medicare are vendors taking public dollars. On October 19th, HHS filed an appeal, indicating they would fight to keep the data secret. The case is still unresolved. Even so, Checkbook has filed suit for the release of Medicare physician data in all other states.

As I noted in writing about this previously, the AMA's fingerprints seemed to be all over this, but I had no direct knowledge that this was so. Then, a December 10th the AMA publication American Medical News article reported, "The Association is pleased that HHS is taking its advice, said AMA Board of Trustees Chair Edward L. Langston, MD." I'll bet it is.

The Checkbook case is a watershed moment for physician transparency. Until now, despite all the calls from supposed "market-advocates" for informed consumerism in health care, the public has had no way to really tell how a doctor compares to his/her peers in terms of resource consumption or results. If the data were released, evaluated and publicly reported, one important part of health care could begin working like a competitive market. Whatever the outcome of this case, kudos to Consumers' Checkbook for taking the initiative and, in the process, betraying the lie of those who call for consumerism but, to protect their current market advantages, want to hold back the information that makes markets work.

Stopping the Payments for Hospitals' Mistakes
August must have been a big month, because that was also when CMS threw down the gauntlet and announced that, starting October 1, 2008, it would no longer pay for preventable errors. Until this change, hospitals were paid for the mistake and for the care of rectifying it, a no-lose proposition.

As Medicare goes, so go the commercial payers, so this is momentous. Come October for Medicare but sooner for private health plans, hospitals will be on the financial hook for making sure they get it right the first time, a significant change from the past and potentially damaging when they fail, especially for organizations that have had average margins nationally of only five percent.

In a sense, this event is less important than the important quality and safety work underway at health systems around the country. (For a wonderful 5 minute articulation of the value of these efforts, see this short interview with Gary Kaplan MD, the CEO of Seattle's Virginia Mason Health System, recorded in April 2007.) But for those who are not yet focused on getting quality under control, CMS' action leads the marketplace and constitutes a major incentive.

Moving Toward A National Center for Comparative Effectiveness and National EBM Guidelines
American medicine is gradually, grudgingly acknowledging that using evidence to identify best practice, and then applying that best practice, typically results in improved outcomes and reductions in variation. The refinement process is unending, of course, and the number of different clinical approaches that must be evaluated vast.

In November 2006, economist and former HCFA (now CMS) Secretary Gail Wilensky published a Health Affairs paper that described the background and laid out the arguments for the establishment of a national agency that would sift available data to support better clinical decision-making. Another long-overdue idea that has private sector precedents in efforts like the Blue Cross and Blue Shield Association's Technology Evaluation Center (TEC), the concept of a national Comparative Effectiveness Center is finally beginning to get traction.

In September, when Senator Clinton released her proposed health plan, a Comparative Effectiveness Center was featured prominently as a key element of her policy reforms. More recently, in December, the Congressional Budget Office published a paper called "Research on the Comparative Effectiveness of Medical Treatments," that argues for the value of a governmental role in identifying best practice, the need for tying identified best practice to financial incentives in the marketplace, and the difficulties of creating these changes in a policy environment so highly susceptible to private interest influence.

It is hard to accept how long it takes to effect changes that the system desperately needs. Each of the trends I've described will take years to actually impact the ways that care supplied, delivered and financed, but they're moving us in the right direction. Equally important, change is accelerating and spreading to more areas in health care, primarily because technology continues to create opportunities that the marketplace can leverage. To those of us consigned to take the long view, this is great news and important perspective while we're also focused on health care's persistent, moment-to-moment problems.

by Pat Salber

How many times have you heard health professionals, politicians, and others say: “Here in the US, we are fortunate to have the best health care in the world.” I still occasionally hear someone say this, but certainly not as often as in the past. The proponents of this myth generally follow the “best care” statement by noting that Canadians come to the US to get procedures they have to queue for in their own country. These same people scoff at “socialized medicine” in the UK believing that we are must be getting better care than those poor Brits subjected to “government medicine.”

Well, gang, it just isn’t so. The November issue of Health Affairs reports on the results of a 2007 survey of adults in seven countries, including the US, that asked about their health care experiences. The survey and resulting paper, “Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007,” are the work of researchers at the Commonwealth Fund.

Here is a summary of some of their findings:

• 42% of people in the Netherlands feel that their health care system works well and that only minor changes are needed. In contrast, only 16% of Americans feel that way about our “system” and 34% feel it needs to be completely rebuilt.

• 35% of Americans are “very confident” that they get high-quality, safe care. This is similar to Australians perception of their system and better than the 28% of Canadians and Germans who feel that way. In the Netherlands, 59% are very confident and only 5% are not confident (compared to 21% in the US) about the quality and safety of their care.

• More people in the US and Germany had short waits for elective surgery compared to the other countries, but more people in the US reported not visiting a doctor when sick, skipping tests, treatment, or follow up, and not filling prescriptions or skipping doses of medications because of cost than people in any of the other countries.

• Only Canada (22%) was below the US (30%) in the percent of patients who reported being able to be seen on the same day they called.

• 36% of adults in the US had visited an emergency department in the past 2 years. About 40% of those said the visit was for a condition that could have been treated by a primary care physician is one had been readily available. The figures were similar for Canada, but far lower in Germany and the Netherlands.

Hmmm. According to this report, it appears that you can get stuff you don’t need very badly (e.g., elective surgery) pretty quickly in the US, but more than a few of us are shut out altogether when it comes to getting needed care for acute and/or chronic illness.

When it comes to health care costs, it is remarkable that US per capita spending is about double of the next most expensive care (Canada). These figures are worth looking at in black and white:

Not only are we the most expensive health care in the world, we don’t even cover everyone. 16% of Americans are uninsured at any given point of time (25% are uninsured at some time). Compare that 0% to <2% in the other 6 countries.

So we pay more, some of us get much less and others get nothing compared to the other countries in this study. Best health care in the world? Unless you are rich enough to buy whatever you want, whenever you want it, you might be better off in the Netherlands!

Brian Klepper 

Now that health care reform is once again an active, visible issue in state governments and the presidential campaigns, the ideas are flying fast and furious. Predictably, some ideas are better than others.

Over at Health Care Policy and Marketplace Review, Bob Laszewski asks an important, practical but vexing question for universal coverage advocates: Can you really mandate people to buy health insurance?

Mandated health insurance is a plank in the Clinton campaign's health care reform plan and is a key way that Ms. Clinton and Mr. Obama differ on that issue. (I don't know why Presidential candidates should provide this level of operational specificity at this point in the game - there are lots of different ways to skin the universal coverage cat - but they have.) Under Ms. Clinton's plan, all citizens would be required to prove that health coverage has been provided to them or that they have purchased it.

To illustrate the difficulties in actually using a mandate, Bob points us to the penalties being developed by the Massachusetts Department of Revenue for citizens who fail to buy health insurance. The 2008 proposal would tie the penalty to the lowest coverage cost offered through that state's health care program, and would be $912/year for a person older than 26 years. As he points out, the burden would fall most heavily on the group that makes just too much money to receive subsidies.

I recently described nearly the same problem in California's health care reform proposal, where a couple with a household income of $54,000 would have to fork over $12,000 for coverage. It's difficult to see how this can work.

There are two issues here. First, most of these state efforts assume that whatever universal health coverage is achieved must be comprehensive, an extremely expensive proposition. (Yesterday's news that US health care in 2006 had crossed three different annual financial thresholds - $2 trillion, 16% of Gross Domestic Product and $7,000 per person - ought to be sufficient evidence of that.)

But as a practical matter in getting a program underway, it may make far more sense to shoot for universal coverage of basic care services. Of course, defining "basic" is the trick here, for several reasons. (This is a terrifically complicated problem. Does basic include three liver transplants? Is it the same for healthy person and one with spina bifida, or does it change with health status? How can we define it?) While social justice is an undeniably compelling reason to implement universal coverage, there's a lot more to the universal coverage issue than simply that. Without universal coverage for at least basic health services that associate dollars for every patient who presents, the nation's safety net hospitals will gradually be overwhelmed by the demand for uncompensated care. (Today's NY Times article on Atlanta's Grady Hospital's financial dilemma does a pretty good job describing the reality of this problem throughout the country. A few weeks ago, I also wrote about Grady's problems and how they're at the edge of the much larger looming health care crisis.)  A "basic" program would be far less expensive and easier to finance than a comprehensive program. And it should be possible to create a basic program for all Americans, and then let insurance companies build market-based supplemental programs on top of them.

Second, a mandate effectively caters to the insurance industry, suggesting that the only way that universal coverage can be achieved is for people to buy coverage (and let the insurance companies take a profit). But universal coverage could be built in other ways as well. For example, there is no reason why we couldn't establish next generation community care clinics around the country, and designate a range of primary care providers who would "take assignment" for any care delivered through the program. Anyone in America could show up at a clinic or a designated provider and receive the basic care they need without paying much or anything. The care would be detailed in the EHR and a bill submitted to the Feds or their intermediary.

A mandate would also create extremely complex and expensive administrative issues. If we required everyone to buy coverage - including all those who aren't subsidized but who would have trouble affording it - then we'd have to establish a monitoring/tracking function that could make sure that everyone did what they were supposed to do, and then punish the offenders.

But the deeper problem with the state and national reform efforts currently on the table is that they finance reform upfront by requiring a lot more money from the people paying the bills, while talking in vague platitudes about cost containment. All the real concessions come from the purchasers, and virtually none come from a health care sector where we KNOW that care and cost are extraordinarily variable between providers, and that between a third and half of all care and cost are unnecessary or inappropriate.

After 25 years of managing the care process, its not like there's any mystery about what health care actions save money and get better outcomes.

We know, for example, that paying doctors salaries and not letting them make money on the procedures they prescribe, drives down cost significantly.

We know that, in any market, if you compare the resource consumption of all doctors within a given specialty for a particular condition, and hold the outcomes constant, that there will be a 6x-8x difference between the least and most expensive practitioners. You can save a lot of money if you look for the physicians who consistently get the best outcomes at the lowest costs, and steer your patients to them. And if you make your findings known publicly, it creates a competitive market for the doctors, and the quality and cost of the care will likely improve across the market.

We know that, for routine conditions, doctors who have modern tools and follow evidence-based best practice guidelines generally have lower costs and better outcomes.

We know that generic drugs perform just as well, in most cases, as brand drugs, and are a lot cheaper.

We know that, to the degree you can open up access with zero or very low co-pays, particularly for low-income populations, that you'll nip exacerbated care in the bud.

We know that, if you can identify patients with chronic diseases, and then intervene with face-to-face lifestyle, education and behavioral counseling, you have the best chance of lowering that population's costs, which typically account for half or more of any credible population.

We know that, if you can tie payment to outcomes, you'll change reimbursement incentives from rewarding more care to rewarding only the right care, and the total use of services and cost will be reduced.

We know that team-based medicine, where doctors collaborate, is more effective and efficient than siloed medicine.

We know that if we can obtain pricing/performance transparency information, we can identify the top vendors, and then we can use that information to make better purchasing decisions. We also know that, at this point, the information that's become available is mostly too complicated and arcane for most consumers to use. But in the future analytical results will flow into decision support tools that will make objective purchasing decisions much easier.

We know that, until the pricing and performance of ALL health care players, services and products - doctors, hospitals, health plans, suppliers, particular treatments, drugs, devices - are made transparent, it will be impossible to really get costs under control. For example, I'm a big proponent of carefully constructed Pay-for-Performance programs, but until health plan performance is just as transparent as the plans have demanded that providers be, the gains would simply accrue to the plans. In other words, change the incentives and you'll likely change the way care is delivered. But if the health plans aren't transparent, how will we know how much waste and money was actually eliminated, and what happened to it. Was it shared with the providers who produced the efficiencies? Was it returned to purchasers in the form of reduced premiums? Or did it simply bolster the earnings of the health plans.

The real issues of health care reform have to do with universal coverage and cost. Universal coverage can only be achieved through policy change, because at a societal level, there must be a governmental assurance of payment for the services.

But its unlikely that real cost-containment can take place through policy reforms, because the most powerful lobby, the health care industry, has the advantage of a Congressional system that is highly susceptible to influence. Facing the possibility that their revenues could drop dramatically, the industry would use all its sway to prevent meaningful reforms. Even so, there are tremendous changes afoot in the marketplace - Health 2.0 is the best example - that will over the next few years infuse unprecedented levels of transparency and decision support into health care, and begin to rationalize the waste that has had a grip on the throat of purchasers and patients for decades.

Unless we can convince America's non-health care business community to come together and roll over the health industry's lobby, in terms of the policy-based reforms, we should resign ourselves to these realities and shoot more modestly, for universal coverage of basic care. That would be a critical foothold to build on, and would pave the way for much more progress.

We need to abandon lofty and impractical approaches that are constructed by dreamers, and develop practical solutions that are based on actions we already know work. Any other approach will almost certainly produce coverage at an unsustainable cost, and simply postpone and intensify the crisis.

About a year ago, the Executive Director of a very prominent business association called and asked me to define the list of reforms that any reform proposal must include if it hopes to be effective. That list is up on my site under the Reform section. Before it was posted it was reviewed and found acceptable by about 30 colleagues. Please feel free to take a look and offer comments.

Brian Klepper 

I was reading through some other peoples' blog posts yesterday and came across this straightforward statement by Paul Levy, the CEO of Beth Israel Deaconess Medical Center in Boston. Paul made news by establishing a blog called Running a Hospital.

I think he's probably taken some good-natured ribbing by his more straightlaced colleagues. But I admire that fact that he's broken the bounds of decorum and speaks openly about the many tremendously difficult issues that face hospital executives.

While many many hospitals (and doctors and health plans and...) are still doing everything possible to hold back the transparency tide, here's his take, published yesterday on Matthew Holt's Health Care Blog:

The main value of transparency is not necessarily to enable easier consumer choice or to give a hospital a competitive edge. It is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care. So, even if we can't compare hospital to hospital on several types of surgical procedures, we can still commend hospitals that publish their results as a sign that they are serious about self-improvement.

 Nothing could be truer, or more central to the mission of fixing American health care.

In yesterday's New York Times , the economics columnist David Leonhardt wrote a nice tribute to Shannon Brownlee's Overtreated, an explanation of how and why American health care is out of control. Ms. Brownlee, a Fellow at the New America Foundation, wrote me that she wrote this book for her mother. (Can there be a better motivation? I'm reminded here of JD Salinger's Raise High The Roof Beams, Carpenters and its tribute to the hero's librarian, Ms. Overman.) Leonhardt suggests that Overtreated should win the award for "economics book of the year."

Shannon sent me her book, and it is as deeply interesting and important as Leonhardt claims it is. For those of you genuinely interested in health care, its a worthwhile expenditure of your time. Take a leap, buy it and immerse yourself in it. You won't be disappointed. 

Brian Klepper

In an extraordinary move earlier this week, the politically-appointed Fulton-DeKalb Hospital Authority, the governing body over Atlanta's Grady Health System, unanimously and voluntary stepped aside, to be replaced by a new non-profit corporation. Projecting a $55 million deficit this year, the hospital had just three weeks of cash on hand. It needs $300 million immediately for sorely needed renovations, and must deal with $63 million in accumulated debt to its biggest creditors, Emory University Medical School and Morehouse School of Medicine. New oversight was the predicate for a hoped-for financial bailout from business, philanthropies and financial institutions.

Other Atlanta hospitals are undoubtedly concerned that Grady will fail, and will probably do everything possible to support a bailout. The last thing they want is for Grady's patients to come to their facilities. Now would be a good time to rally business leaders and legislators, who nearly always go to fancier hospitals, which of course has been a big part of the problem.

Grady’s turmoil should be recognized as the first small shock of much larger seismic event, long in the making, a concrete sign of America's relentlessly intensifying health care crisis. The wrath falls on our most vulnerable - those with health problems or with few financial resources - as well as on the institutions and professionals that care for them.

Nearly every large and mid-sized city has a Grady that struggles with similar issues. In addition to being the health care resource to the poor, they are often academic centers - clinicians-in-training need SOMEBODY to learn on. They can be home to a region's highest expertise, particularly related to crisis care. Many house their community’s neonatal intensive care unit and burn unit, as well as the level 1 trauma center, which brings with it disaster preparedness responsibilities. These are precious services that we somehow EXPECT will be there when we need them. So if a safety net hospital closes, the loss to the community and the replacement resources required are immense.

Grady, like other safety nets around the country, isn't failing due to mismanagement, although some of that almost certainly plays a role. Instead, it is the slowly-boiled frog, its financial base eroded over decades as it increasingly became the hospital of the inner city, the center for care for Atlanta's low-income and uninsured residents. As governmental support steadily dwindled, demand for its services rose. Fully 75 percent of Grady's patients are on Medicaid, which pays less than the cost of care. Only 7 percent have commercial insurance.

Safety net hospitals are famous for struggling through, but presumably there's a calculus here. As small businesses are increasingly priced out of the coverage market, and as state government, facing budget crisis, cut back on publicly funded coverage, the burden on the safety nets will continue to rise and the resources will continue to decline. At some point the demand-resource mismatch will give way, and some will topple. Their patients will seek care at other hospitals, which will simply transfer the burden elsewhere.

We can keep the safety nets afloat. The most logical solution would establish universal coverage for "basic" care services - we have to define what "basic" means - which would associate dollars with each presenting patient. We could also update the EMTALA laws that govern how emergency patients are seen, so those seeking minor care can be managed in less expensive settings.

But these answers don't seem likely at the moment. Despite current rhetoric, universal coverage legislation is doubtful unless we can find ways to significantly drive down cost. Legislation that drives out unnecessary health care spending would reduce health industry revenues, though, an unlikely prospect so long as lobbyists drive Congressional policy.

Still, we should think deeply about what Grady's troubles really mean, and consider this case not in isolation, but as possibly representative of systemic forces. Without significant system change, we could see more safety nets falter in the next few years. Each community where a failure occurs will gradually appreciate the importance of its loss. As the poor turn to the remaining hospitals for care, the cascading impacts on the larger system could severely test America's commitment to care that is independent of an ability to pay.

And that would challenge our core values as a nation.

By Dov Michaeli MD, Ph.D

Just returned from a dinner gala put on by the American Diabetes Association, to honor people and organizations who passionately work day in and day out in the cause of diabetes prevention and cure. I must say, this was truly an eye-opening experience.

But first, some statistics on the extent of the problem we are having, and the disastrous trajectory in which the disease is progressing:

• 21 million Americans have diabetes, and 54 million have pre-diabetes, or metabolic syndrome. Add the two figures, and we have 75 million Americans, or about 25% of the population suffering from the disease or its precursor.
• 1 in 3 children born this year will suffer from diabetes during their lifetime. Think of it, in a few short years one third of the population will have diabetes. I recall reading somewhere that physicians and advocates are overstating the problem; that  the appellation of “epidemic” is alarmist. I must say, to me a jump from a relativly minor disease about 30 years ago to 25% today, to 33% in a few short years meets all the criteria of an epidemic. And if you consider the spread of diabetes in Europe , China , India , and even Africa —this is a true pandemic.
• Diabetes is not an equal opportunity disease: 1 in 2 Latino, African American, and Asian American children will develop the disease.
• African Americans are 1.5 times more likely to develop diabetes than their Caucasian counterparts. Hispanic/Latino Americans have 1.8 times the risk. Asian Americans/Pacific Islanders have 2.0 times the risk. Native Americans have 2.2 times the risk. And these are the populations that suffer the most from our broken health care system.
• For the fiscally-inclined among us: the annual cost of diabetes in the U.S. is $132 billion. Consider that a proposed budget of $35 billion to cover all poor children (1 in 2 of them will develop diabetes), was just vetoed because it was “too expensive”. Were our ‘decider’ and his cohorts left behind when they taught arithmetic at school?
• 1 in 10 health care dollars spent in the U.S. are for diabetes and its complications.
• 1 in 6 Americans between the ages of 12-19 have pre-diabetes. So brace yourselves: a wave of young adults is threatening to “mature” into full fledged diabetics. If this is not an epidemic, I don’t know what is.

A ray of light

It was truly heartwarming to realize that there are heroes who are fighting the bleak reality. They don’t whine, complain or just disengage in disgust: they fight. They are there in the proverbial trenches, day in and day out, at great financial and personal sacrifice. Am I talking about doctors, or nurses? No, although I am sure there are plenty of them who deserve accolades. Believe it or not, I am talking about lawyers. Yes, lawyers! The ADA gala was to honor six lawyers of the Reed Smith law firm, who worked thousands of hours pro bono to mitigate the harsh reality our diabetics have to face.

 Here are but two examples of their work. They forced the city of Philadelphia to reverse their hiring ban on police officers with diabetes. Young children with diabetes in public schools in California had to call 911 if they needed insulin. Nobody was authorized to administer it to them. Can you imagine a 5 year old afraid that she might need insulin at school and would have to wait for an ambulance to come to her aid? And what if the ambulance arrives a few minutes late? The lawyers of Reed Smith, working on behalf of the ADA and parents of children with diabetes, won the arduous legal fight for the children; School personnel will be trained to administer insulin to the children if the school nurse is unavailable. To the Nurses Association’s shame, it is now suing the ADA to reverse the settlement. I used to believe their pious propaganda about their concerns for patients, first and foremost.

I never thought that I’d find myself praising lawyers when it comes to Medicine. But my hat is off to these lawyers—they are true heroes .

Dov Michaeli MD, Ph.D is in the biotech industry

Laptop-attached ultrasound units that produce startlingly clear internal images for five dollars in the field. Organs that re-generate inside scaffolds.  Drugs tailored to an individual’s biology. Micro-images of cancerous cells lit up by bio-chemical markers. Decision support tools that scan the physiological values in electronic health records for patterns too complex to be detected by an unaided clinician.

The advances available from dramatic improvements in computational capabilities were a recurring theme at the Aspen Health Forum, with experts from each discipline describing where the technology was leading us. I attended two sessions featuring Star Trek clips that predicted realities now within at least theoretical reach. (Prescient and corny, audiences nodded nostalgically.) Sessions on biotechnology, imaging, electronic health records (EHRs) and the hospital of the future highlighted the power that is being leveraged to improve care.

The deeper point is that biological mechanisms are built on incredibly complex metabolic webs. The information we depend on has also become overwhelming in scope but fragmented. We’re only now beginning to have the computational power required to model, integrate and manage the many processes contained in each of these arenas. The power we access through digital analytics allows us to extend and broaden our reach.

A simple example was the argument, made long ago by David Eddy, a pioneering giant in the application of information technology to care, that the explosion of new knowledge has outrun the capacity of even the best human minds to appreciate and incorporate it. Tens of thousands of new articles are added to the medical literature every month, far more than any professional can evaluate and absorb. But information technology can store all that updated knowledge in formats available at moments of decisions, when we need it most.

Dr. Eddy described the promise of cognitive processing, in which software routines would scan and compare dozens or hundreds of physiologic measures within a patient’s health record for patterns a clinician could never identify. A quick analysis might show, for instance, that when 19 of the variables present appear in combination with the values detected, there’s a 62 percent probability of a particular condition. The tool would then describe possible next steps in the care pathway.

The horizon is receding across technologies. In a session on the future of diagnostic imaging, GE Healthcare’s Medical Director Robert Honigberg thrilled the audience by showing decade-old and new ultrasound images. He then ticked off ways that, combined with broader advances in information technology, greater macro- and micro-imaging clarity would improve our abilities to effectively address issues: screening for stroke, Alzheimers and cancer; strengthening the power of primary care physicians in rural settings; virtual identification of pathologies; global disease registries; image-guided radiation treatments; and on and on.

Finding ways to help patients, clinicians and purchasers leverage the vastness of health information for their own purposes falls into the larger realm of Health 2.0. Still in its formative stages but gathering steam quickly, this sector of health informatics could create the pricing/performance transparencies and decision support that can positively improve clinical quality and finally make health care markets work, lowering cost. But one of Health 2.0’s real appeals is its business model which, as Google has learned, leverages the utility of information to create communities and markets that have commercial value. That, in turn, makes it low cost to the end user, and therefore highly accessible.

Some developments offer more accessible (i.e., lower cost) value propositions than others. In an everyday context, those, like Health 2.0, that depend almost strictly on data analysis and reformulation into decision-support will likely be far less costly, with far greater potential for population-level impact than, say, those that involve biologics. That relationship might be reversed, though, in situations like pandemics, when the biologics are the only recourse for populations. How does one work through these dilemmas?

It is difficult to not be dazzled by these possibilities. Who wouldn’t long for progress that can replace a child’s defective heart or kidney or eye, and make a compromised life whole again? But as with virtually all progress, developments raise profound conflicts between what we want and what we can afford. In a system being crushed by cost – while the average American family’s health care costs $14,500 in 2007, one third of households make less than $35,000 – where do we invest and how should investors be rewarded? Is there a reasonable limit to the price of even great progress?

One thing was clear. The advances that have made these miracles possible will continue to accelerate and become less expensive, making the technologies that are now available but out of reach accessible as well.

So the promise is breathtaking. Only our resources, our imaginations and our judgment will limit us.

Brian Klepper is a health care analyst based in Atlantic Beach, FL. He was a Fellow at the recent Aspen Health Forum. 

Brian Klepper

Three weeks ago Pat and I attended a fascinating conference in San Francisco on Health 2.0, an emerging industry that promises to change the ways patients manage their own health, and the ways that clinicians and purchasers of all types make clinical and management decisions. The term Health 2.0 refers to Web 2.0, the idea that, in social networking, people will use Web-based platforms to reformulate data for their own purposes.

Jane Sarasohn-Kahn is a highly-respected health economist and commentator working at the intersection points of health care and technology. Jane and I worked together to describe the elements and functions we believe will be integrated to constitute Health 2.0's real value. We've posted this narrative and an accompanying image - its an animated PowerPoint slide that lets you watch the elements build - on several sites, including Jane's site,  Matthew Holt's The Health Care Blog and the Health 2.0 wiki.

We have invited readers to download the image and read through the narrative, and provide then feedback on this model. Please join us. Understanding how information can be leveraged to promote better, less costly care is a critical step toward getting us there.

Aggregate, Analyze and Advise

Scott Shreve MD, an Emergency Physician who has been a prominent theorist in this exciting new area, summarizes Health 2.0's primary data management functions as Aggregate, Analyze and Advise. It's a good way to think about it, and is very consistent with the description that Jane and I came up with. A short version is described below.

Aggregate

Keep in mind that the companies chasing the big, comprehensive vision that is at the end of the Health 2.0 rainbow - Microsoft, Google, Yahoo, WebMD, Revolution Health - hope to make money. They'll directly get fees for the services they provide or capture the traffic and profit from the ad revenues, as Google does. (It's worth mentioning that Health 2.0 represents an incredibly powerful development in health care technology, which has a very accessible (relatively low cost to each end-user) value proposition in terms of its ability to impact the health of large populations. This stands in stark contrast to some of other health care technologies, like bio-technology, that often have a very inaccessible (i.e., expensive) value proposition.) To get the ball rolling, though, and deliver on the promise of Health 2.0, the companies in this game first have to develop ways to aggregate patient data of all types: claims, clinic, drug, lab and image, and then map these data elements - they're from different sources and often in different formats - to a common format, like the increasingly well-recognized and accepted Continuity of Care Record.

Once aggregated and stored in centralized data repositories, they'll route that individualized information into Patient Health Records (PHRs), which help patients monitor and manage their health, to Electronic Health Records (EHRs), which help clinicans monitor and manage patients' health, and Health Management tools, which help health care professionals in non-clinical settings (like wellness specialists, case managers and disease managers) monitor and manage patients' health.

Analyze 

In addition to routing the identified patient data to its proper destinations, the stored information in the CDR will be analyzed to identify patients with health risks (like people with chronic health conditions, or people who are likely to have an acute event in the future), and to identify best practice guidelines (i.e., the treatment approaches that consistently get  best outcomes at the lowest cost). The evaluations will also allow comparison of the relative pricing/performance of providers (e.g., doctors by specialty and hospitals by service) health plans, products (drug, device, equipment and supplies by class), and interventions/treatments.

Advise 

The results of these analyses can be used to create public transparency reports on health care products and services - like a Consumer Reports for health care - and can also be used to create decision support tools that advise patients, clinicians, and purchasers of all types about how they might better manage health care quality and cost. 

The patient advice tools will also include expert information like medical encyclopedias, and user-generated information like patient or caregiver advice to other patients.

This flow and reformulation of information in Health 2.0 efforts will give every health care decision-maker far better information. This is a market-based approach that holds promise for profoundly transforming the health care marketplace for the better. Go over to one of the sites listed above, and give our graphic and the narrative a look. Then let us know how we can make it better.

Brian Klepper is a health care analyst based in Atlantic Beach, FL.