Health Care in the Next Curve: Transforming a Dysfunctional Industry

Contents
Foreword …………………………………………………………………… xi
Preface ……………………………………………………………………… xv
Author …………………………………………………………………….. xix
SECTION I INDUSTRY DYSFUNCTION: ITS ROOT
CAUSES AND EFFECTS
1 It’s Not the Future We Used to Have ……………………3
The Old Future …………………………………………………………. 4
The Curves of Health Care …………………………………………. 6
The Root Causes of Industry Dysfunction ……………………. 7
The Economic Human and the Next Curve …………………10
Fast Forward: A New Future ………………………………………12
This Book: A Look Ahead ………………………………………….13
References ………………………………………………………………..15
2 Health Care’s Perfect Storm ……………………………..17
The Gathering Forces ………………………………………………..18
What’s Wrong with This Picture? …………………………………20
Costs on an Upward Trajectory …………………………………..22
Heading toward a Spending Ceiling ……………………………23
Is Rationing the Default Scenario? ……………………………….24
References ………………………………………………………………..25
3 What Happened to Health Insurance? ……………….27
A Perfectly Dysfunctional Model ……………………………….. 28
Affordable Access: Still No Fix ……………………………………30
Mandates Mean Fewer Products, Higher Prices …………….32
Employer Health Plans: Not What They’re Cracked
Up to Be …………………………………………………………………..33
Medicare Trouble Ahead …………………………………………….36
Medicaid Also Facing an Uncertain Future …………………..38
One Size Doesn’t Fit All ……………………………………………..39
References ………………………………………………………………..40
4 Follow the Money: A Broken Payment Model ………41
Why Not \"Food Insurance?\" ……………………………………….42
Fee-for-Service an Incentive for Utilization …………………. 44
Impact on Care Coordination ……………………………………..45
A Recipe for Waste, Fraud, and Abuse ……………………….. 46
Moving toward Value ……………………………………………….. 48
Problems Measuring Value …………………………………………51
References ………………………………………………………………..53
5 Silos, Everywhere …………………………………………..55
Automobiles Get Pretty Good Health Care… ……………….56
Where’s the \"System\" in Health Care? ………………………….58
The Problems of Service Fragmentation ………………………60
Information Silos: Part of the Problem …………………………62
Geographic Silos, Too ………………………………………………. 64
Population Health: More Teamwork Needed ………………. 64
Silo Culture Part of the Industry’s DNA ……………………….65
References ………………………………………………………………..69
6 The Real Costs of Regulation ………………………….71
The Perils of Regulatory Overreach …………………………….72
The Computer Will See You Now ……………………………….73
The Price of Regulating Prices…………………………………….76
Certificate of Need a CON Job ……………………………………78
More Regulation, Less Innovation ……………………………… 80
Frozen in Time ………………………………………………………….82
Tort Reform, a Critical Need ……………………………………….83
The Real Costs of Regulation ……………………………………. 84
References ………………………………………………………………..85
7 Where’s the Competition? ……………………………….87
Competition and Value …………………………………………….. 88
More Government, Less Competition …………………………..89
Independent Physicians: An Endangered Species …………92
Eroding Competition in the Insurance Market ……………..93
Conflicting Market Signals ………………………………………….94
Narrow Networks, Narrower Choices ………………………… 96
Consumers Caught in the Middle ………………………………..97
References ………………………………………………………………..97
8 Why Government Health Care Isn’t the Answer …..99
\"It’s the Government: They Know Best….\" …………………100
Medicare for None? ………………………………………………….103
Single Payer Means Higher Costs ………………………………106
Rationing Is an Inevitable Outcome …………………………..108
Impacts on Education, Research, and Innovation ……….109
Administrative Costs Aren’t Necessarily Lower …………… 110
Single Payer Very Popular—Until People
Understand What It Is ……………………………………………… 111
Americans Don’t Do Socialism Very Well ………………….. 114
References ……………………………………………………………… 115
9 Market Disruptors and Transformers ……………… 117
Big Data and a New World of Precision Medicine ……… 118
The Patient Is in ………………………………………………………120
A Fusion of Segments ………………………………………………122
Employers/Health Care …………………………………………123
Big Pharma/Insurance/Health Care ……………………….125
Providers/Health Plans ………………………………………….126
Providers/Suppliers ……………………………………………….126
Is the Community Hospital Becoming Obsolete? ………..126
Collective Consciousness and an Empowered Market ……129
References ………………………………………………………………130
SECTION II HEALTH CARE IN THE NEXT CURVE:
A ROADMAP TO INDUSTRY TRANSFORMATION
10 Destinations of the Next Curve ………………………135
Access, Choice, and Value ………………………………………..136
Access …………………………………………………………………136
Choice …………………………………………………………………137
Value …………………………………………………………………..138
A Roadmap to Industry Transformation ……………………..139
11 First, the Safety Nets …………………………………….143
Facing the Realities of Safety Net Needs …………………….144
I-1 Provide Universal Catastrophic Coverage ………….. 145
I-2 Put Invisible Reinsurance Safety Nets in Place
for Those with Pre-Existing Conditions ………………….146
I-3 Assure Guaranteed Issue, but with Incentives
for Continuous Coverage ………………………………………148
I-4 Overhaul Medicaid: Make It a True Safety
Net for the Chronically Ill and Disabled, and
a Transitional Program for the Able-Bodied …………… 149
I-5 Restructure Medicare to Ensure Long-Term
Solvency ……………………………………………………………… 152
I-6 Give Military Veterans Choices, Too …………………. 155
References ……………………………………………………………… 156
12 Insurance and Choice, Once Again …………………. 157
Restoring the Concept of Insurance ………………………….. 158
II-1 Promote the Growth of Consumer-Directed
Health Plans and Health Savings Accounts …………….. 158
II-2 Get Rid of the Employer Tax Exclusion; Give
Employees Options ………………………………………………160
II-3 Repeal Anti-Trust Exemptions; Energize
Competition in the Insurance Market ……………………..162
II-4 Eliminate Regulations That Standardize
Insurance Product Design ……………………………………..162
II-5 Revise IRS Rules to Make Preventive and
Health Maintenance Care Pre-Deductible ……………….164
II-6 Promote Interstate Insurance \"Regulatory
Competition\" and Sales …………………………………………165
13 From Production to Value ……………………………… 167
Value in the Next Curve …………………………………………..168
III-1 Complete the Transition to Value-Based
Payment Methodologies ………………………………………..169
III-2 Make the Patient-Centered Medical Home the
Standard for Primary Care ……………………………………. 170
III-3 Apply Bundled Payment Approaches to
Chronic Diseases and Conditions ………………………….. 171
III-4 Design Multi-Provider Payment Methodologies
to Support Inter-Disciplinary Care …………………………. 172
III-5 Pay Providers for High-Value Services and for
Virtual Care ………………………………………………………… 172
III-6 Make the Shift to Transparent, Market-Based
Reference Pricing …………………………………………………. 173
References ……………………………………………………………… 175
14 No More Silos: Patient-Centered Care in the
Next Curve …………………………………………………..177
A Team of Teams ……………………………………………………. 178
IV-1 Target High-Risk Patient Populations for
Early-Stage Intervention ……………………………………….. 179
IV-2 Organize and Coordinate Health Services
Delivery Around the Patient ………………………………….181
Develop Coordinated Disease Management
Centers …………………………………………………………….182
Integrate Behavioral and Social Services into the
Coordinated Disease Management Center Model …..184
Align Addiction Treatment with Medical Care ……..185
Develop Specialized Acute Care Units for
Elderly Patients …………………………………………………186
Manage Post-Acute Care Transitions and
Processes ……………………………………………………… 186
IV-3 Rationalize Delivery Platforms for Optimal
Access, Effectiveness, and Efficiency ………………………188
IV-4 Make the Home the New Health Care Center ….190
IV-5 Remove the Barriers to IT Interoperability ………192
IV-6 Track the Measures That Matter ……………………..193
References ………………………………………………………………194
15 Less Regulation, Better Health Care ………………..195
Putting the Economic Human to Work ………………………196
V-1 Get Rid of the Laws That Restrict Competition …….197
V-2 Remove Barriers to Market Pricing …………………. 200
V-3 Eliminate Restrictions That Discourage Care
Integration; Repeal the Stark Law ………………………….201
V-4 Change Laws to Make Drugs More Available,
Less Expensive …………………………………………………….203
Remove the Artificial Protective Barriers to
Market Competition …………………………………………..203
Streamline the Approval Processes for
Generic Drugs ………………………………………………….204
Enact \"Right-to-Try\" Legislation for Terminally
Ill Patients ………………………………………………………..205
V-5 Modify Rules in Order to Ease the
Administrative Burden on Physicians ……………………..206
V-6 Reform Medical Malpractice Laws ……………………207
References ………………………………………………………………209
16 Positioning Strategies for the New Future ……….211
A New Market Ecosystem …………………………………………212
Consumers Will Define Value ………………………………….. 214
Category 1: The Routine Stuff ……………………………….. 215
Category 2: Disease- and Condition-Related Care ……216
Category 3: Health and Wellness—Engaged
Partnership …………………………………………………………. 217
Positioning for the Next Curve …………………………………. 219
Unleashing the Spirit of Health Care………………………….222
Appendix: How We Got Here—A Brief History of
Health Care in the U.S. ………………………………………..225
Index ………………………………………………………………..239