Tag Archives: reform

Universities: are they as smart as we all hope they are?


News item in the UK: The sector’s funding body, the Higher Education Funding Council for England (HEFCE), announced (on 1 February 2010) that budgets are to be cut by £449 million for 2010/11.  This includes:

* A 1.6 per cent reduction (£215 million) in teaching funding;

* Research budgets will remain the same as last year;

* A 16.9 per cent cut in capital funding;

* A 7 per cent reduction for funding of special programmes and initiatives.

In a letter to vice-chancellors setting out the budgets, HEFCE said it recognised that the reductions will be “challenging” to institutions.

Now what is to be done? Predictably, the higher education sector in the UK is arguing that this will affect perhaps 200,000 students who won’t be able to get a university education. A few weeks ago, the sector argued that the UK’s place as a top tier home of higher learning was at risk — but that came from the elite Russell Group, which represents perhaps the top of the top universities in the UK.

There are a number of possible ways of thinking about this. A few:

  1. Universities already get a lot of money, and they perhaps could reduce their running costs — think of the disorganised structure of the academic year, think of teaching loads or confused performance management (is it teaching quality, research or publications??), and pretty good employment contracts. (I had one once.)
  2. There are too many universities trying to do too much, and perhaps it would not be a bad thing if some either closed or merged with another institution. The loss of the old polytechnics deprived the higher education system of a sensible alternative. Since comparisons to the US are frequently made, it is worth noting that some of the US’s top institutions are not called “university”, anyway, but ‘institute’ and indeed ‘polytechnic’. One could also look for new innovative institutions to emerge to challenge much that universities do. For instance, research institutions without university links, or which are focused on compelling issues — check out the Santa Fe Institute, for instance. Universities are not the only fruit!
  3. Cutting capital funding is not such a bad thing, given the horrendous financing of a state-sponsored capital funding body. Better universities learn how to build collaborative relationships with sources of capital, than expect their funding automatically to come from the state.
  4. Perhaps too much inadequate research is done, poor deployment of intellectual effort at reaching wider learning communities, responding to new ways of structuring learning beyond the rather tired full or part time dichotomy, and so on.

But of course, the key dilemma remains, what is to be done?

I take an optimistic view, but I would put the challenge at the door-step of the universities.

Rather than complain, prove that 800 years of public and private investment hasn’t been wasted, and come up with sensible solutions that would establish a sustainable approach going forward.  I doubt 200,000 or 200 students would be disenfranchised as a result, new ideas would emerge.

A recent book review in the Financial Times of Louis Menand’s The Marketplace of Ideas, would be a good place to begin some fresh thinking. The reviewer, Christopher Caldwell, notes:

Starting in the 1970s, professors, newly alert to injustices in society at large, took aim at credentialism and departmentalisation in every nook and cranny of American life – except, Mr Menand notes pointedly, their own. The professorial hierarchy continued to rest on a system of arduous PhDs (raising high barriers to entry), “disciplinarity” (denying the authority of the non-credentialed to teach or even discuss academic subject matter), and tenure (jobs for life). It was a system well-suited to monopolising bureaucratic power, but less well-suited to the free flow of ideas. Menand cites a 2007 study to show that, in the 2004 presidential elections, 95 per cent of the social science and humanities professors at elite US universities voted for John Kerry and 0 per cent (statistically speaking) for George W. Bush. Monopolies produce smugness and sameness in universities, just as they do anywhere else.

The title of this blog entry takes from a line in the film Independence Day, where the President says to the Geoff Goldblum character, ” And we’ll see if you’re as smart as we all hope you are” It is now time for the universities with their massive subsidised top-tier braintrust put on their thinking caps, stop playing victim and take responsibility for the solution.  The university-based economists let us down quite badly with failing models of our economies, and we are all paying for it in one way or other. Let’s not see two in a row.

Policy and failure: learning from Copenhagen

20 Bonus 2 MW wind turbines at the Middelgrund...
fanning the ineffectiveness of Copenhagen

The whatever they are called talks in Copenhagen on climate demonstrate the broken nature of our approach to achieving consensus amongst a diversity of nations, views, and wishes. The circus will soon close and we may have very little to show for it, despite everyone’s hopes and wishes. A room with THAT many people in it could hardly agree what to put on a pizza, let alone work through a complex drafting of such an important document.

A few points are worth noting:

  1. Trying to achieve an agreement by having the negotiations stretch throughout the night, so no one gets any sleep is bull-headed, and is hardly evidence of clear and coherent thoughts at 3 in the morning.  Early morning tweets from politicians who have stayed up all night just adds to the impression that these people don’t know what they are doing.
  2. The notion that the backroom gang do all the heavy lifting and then the leaders swan in to sign the final draft is well-past its sell-by date. Clearly, neither works.

Savvy negotiators know that getting your opponent to go without sleep is one way to ensure both delay and achievement of your objectives. Tiredness doesn’t just kill on the road, but is a well-established brinkmanship tactic. It is particularly helpful when there is a hard deadline, and great expectations of results; the closer to the deadline with a lack of agreement, the more likely sleep will be deprived and decision-making and clear-thinking begin to fail. Better to add days than nights to negotiations, and drop this adolescent behaviour.

Setting expectations high also creates an opportunity for nay-sayers to bargain their way to a lower level of agreement, giving the impression of failure whereas they may actually have found the spot at which agreement is most likely, but having failed to establish a Plan B, meant that it was Plan A or failure. An existence of a Plan B, though, would have infuriated some advocates for agreement, as it would identify prima facie where compromise would be likely.  The problem in part was that compromise is often seen as failure, rather than agreement by other means. Perhaps it is better to under-promise and over-deliver.

The use of backroom staff is important, but it is evident from Copenhagen that a lot of fundamental bluesky disagreements remained and where solutions lay above the pay grades of the staff involved.  Better than leaders learn to do their own work, and have the backroom staff refine the language, than the other way round.

The problem with Copenhagen appears to be faltering over accountability; this is a re-run of the nuclear arms treaties. One could argue that objections may be well-founded, but we haven’t seen the basis for that. Agreements do need mechanisms to ensure they do what they are intended to do, but we don’t have sufficient vocabulary for what we need as in the past, most agreements were either treaties with broadly equal partners (e.g. Treaty of Rome) or were imposed by victors over vanquished (take your pick here). This seems more like a communitarian process, with considerable inequality. Perhaps some lessons from community development models would have been helpful.

Of course, this is all quite apart from whether a deal is pulled out of the hat, and whether it is a deal or just a political fix.

Who owns a health profession?

Florence Nightingale, pioneer of modern nursin...
What would Florence do?

Who owns a profession and who should take responsibility for its development?

In the UK, the Prime Minister’s Commission on the Future of Nursing and Midwifery has been working away for awhile to determine the future of these two professions, so lets reflect on this question and look at what this Commission appears to be thinking.

The most obvious observation is that it appears to be thinking of nursing and midwifery within an NHS context. Many nurses work outside of the state-sponsored NHS, such in prisons, nursing homes, private and independent settings and workplaces. The Commission’s focus, therefore, on defining the future role of the profession suffers from a dilemma and in resolving this dilemma in a particular way, may further limit these professions to what the NHS defines as its role. This is particularly worrisome given the dire need for fresh and innovative thinking particularly from such a broad and diverse profession as nurses and midwifes which may indeed need to challenge current political and policy thinking.

I wonder whether, too, it is indeed appropriate for the ‘state’ to sponsor this type of work in the first place. The selection of those on the Commission is probably subject to various criteria — one can only hope that these folk are able to address the work of these professions in non-NHS settings in the first place, and secondly can address the dire need for fresh thinking about future demands and innovative approaches to service delivery, however and wherever.

The other concern is the tendency of these sorts of activities to become a restatement of warm words of praise, and in the end fail to move beyond that to address the underlying interconnectedness of clinical work, the interprofessional relationships and clinical responsibility and indeed to more disruptive and potentially more professionally satisfying professional development itself. Regretfully, the so-called “summary vision” is a weak and predictable statement.

There is nothing inherently wrong with addressing the needs of the NHS, but to address it to the exclusion of the legitimacy of the wider and likely future roles is a mistake.  Indeed, the NHS is a stakeholder in the development of these professions, but should not be given too much authority or control over how the professions develop. When the state steps in, as it has in this case, it should do so with the assurance of fairness to the widest possible range of interests, and not just those that fits its current, and probably ideological, preferences.

In the end, the professions own themselves (in an important relationship with their regulator) and should act to ensure that they confront these issues responsibly. Is it a sign of weakness perhaps that this Commission was even needed? Perhaps therein lies a clue to the future of these professions: take responsibility for your profession, as if you don’t others will.

What’s a finance minister to do?

With public finances in most countries looking pretty challenged these days, what steps can central jurisdictions take to achieve two key health policy goals:

  1. reduce the overall healthcare expenditure by bending the cost curve down,
  2. improve productivity, value-for-money, health outcomes.

Few in government have much experience with reducing healthcare expenditures.  And ministers are rightfully fearful of voter wrath, so one must wonder where the political courage will come from in the first place. Perhaps the key thing is denial is not an option, neither is blame-fixing. The first rule, therefore, is to fix the problem, not the blame.  True statesmanship is now needed, more so than party political rhetoric; that is, of course if we are right that things are in a really bad way.

Few, too, in healthcare management have the necessary experience with substantial changes needed in healthcare delivery systems especially where resource constraints will need to similarly deliver productivity gains.  We’ve had tremendous growth in healthcare expenditure matched with uptake of new technologies, complex treatments, and greater clinical specialisation. We can simply do more, and it costs. But along with this rise in capability, there has been much less reform of the way healthcare is done. Clinical workflows continue to be clogged with unneeded activity; we still use expensive hospitals when less expensive polyclinics or primary care settings would do. We fail to exploit the full potential of the other health professions, such as nurses and pharmacists. The second rule, is that you cannot continue to fund an unreforming health system.

Reform must be a constant feature of healthcare, since it is so dynamic as an area of innovation. If we want to bend the cost curve down, we need to persist in reform, indeed, disruptive reform, creative destruction in healthcare service delivery.  It is not about being nasty as a finance minister, it is all about using the money to unleash creativity to the benefit of all.

The challenge is less how to do that though, than wondering why what is there about healthcare today that seems to keep that from happening in the first place. Now that is really something to wonder about.

Speaking truth to power

Stained glass window of St. Thomas Becket in C...
Thomas Beckett spoke Truth to Power

Professor David Nutt, chairman of the UK’s Advisory Council on the Misuse of Drugs, is now a former chairman. He has joined by other scientists (2 so far) resigning in protest as the government’s heavy handed dismissal of Professor Nutt.  The minister, Alan Johnson, has said he had ‘lost confidence’ in the scientist for something he wrote in a scientific article.

The thought police are out in force once again.  But more important is the apparent abuse by this government minister of the whole point of advisors.  They must speak truth to power. In the absence of the speaking of truth, we will have self-censorship, political correctness, and general bowing and scraping to the political powers.  What the politicians don’t get, and Alan Johnson in particular, is that a candid and often challenging relationship is part of this delicate balancing of truth and power.

Indeed, there is clear abuse of power in silencing critics. There is a candle that burns in Canterbury Cathedral, testimony to this very issue (referring to St Thomas Beckett).  Truth is the first casualty of ministerial hubris.

In the end, we, that is taxpayers, and the general well-being of society, suffer when ministers can be so cavalier in dismissing people they don’t agree with.

Distinguishing between giving advice based on science, and political commentary is difficult navigation, as both scientists hold political views, which ministers may not like, while ministers may express scientific commentary with little grasp of its meaning.  Both can get it wrong, and much nonsense has come out of the mouths of both scientists and politicians.  But rather than shoot the messenger, politicians need to remember that they are in the main wholly dependent on right-minded scientists for advice, ones who will often hold dissenting views from the ‘spin’ that ministers seek to put on science itself. Einstein and colleagues understood this when they wrote to Roosevelt about atomic energy in 1939. It is worth noting that the US government dragged its feet on this letter until at least 1941, and it was not until 1942 that the Manhatten project began.

It is worth listening, even if you don’t like what you are being told. If scientists and advisors must speak truth to power, so power must listen to truth.

Such is the politician’s duty. Pity such duty is so poorly observed.

When it pays to be second best: English NHS “preferred providers”

For all the reform and protestations that the public deserves a health system for the 21st century, the ongoing saga of health reform in Britain continues to amaze.  The Secretary of State for Health for England, Andy Burnham, has decided that NHS providers get to try twice to prove they are worthy of continuing public confidence.  As he has put it, the NHS is the “preferred provider”, apparently for itself.

Those not familiar with the reform of the NHS, and indeed those who are, must be wondering why mediocrity should be rewarded, and in these difficult times, why the taxpayer or the government should countenance circumstances that public public money at risk.

The NHS commissioners (purchasers in real world speak) are the surrogates for consumer choice, as while NHS patients do have some choice, commissioners in the end are deciding in which directions that choice can be exercised.  A bit like Henry Ford’s model T car: you can have it in any colour as long as it is black.

Why should this matter? The Minister has said that the NHS should not be agnostic about who provides healthcare service delivery but instead favour NHS providers.  But as a monopoly supplier of services, the NHS and the English Department of Health must be mindful of abuse of a dominant position and in particular favouring institutions that are in effect emanations of the state, on the one hand, and forcing the public to experience second-rate service on the other.

Favouring a failing provider strikes me as looking a lot like state aid.  It also does not appear to be a service contract either, as the reason for awarding the contract seems to depend on the ownership of the provider (and protecting their status) and not whether they can deliver the service to a quality standard (which is the purpose of the contract).  The clue that this is a policy fudge is that a failing provider gets another chance to be a preferred provider over a potentially more competent and higher quality provider.  Can you legally enter into a contract for a service to a quality standard, knowing in advance that the provider is unlikely to be able to deliver to the terms of the contract?

Hmm. So much for value for money and healthcare fit for the 21st century.  Do I hear the auditors stirring?

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Disruption: the new word for reform

A swarm of robots in the Open-source micro-rob...
Robot Swarm: planning a revolution?

We have had years of reform efforts in healthcare, and despite what country one picks, the themes are depressingly familiar: cost-containment, more health professionals, patient empowerment, more primary care, value for money, and so on.  These types of reforms are rarely revolutionary, despite the claims, and the benefits not as readily forthcoming as forecast. For instance, we have had perhaps 20 years of integrated care pathways, yet such simple knitting together of care is still elusive.  What is clear, though, is that you can’t continue to spend good taxpayers’ money on unreformed health systems.

Reform models reflect the history of our healthcare (and other) systems, deriving from organisational and service delivery models of the industrial age.  Hospitals are really just 1030s conglomerates, and the claims that vertical integration likely to improve care and drive down costs, are simply copying the corporate models of General Motors, General Electric, GEC, Westinghouse, some of which are no more.  We don’t really live in that sort of world anymore, and despite the vast amount of money spent on healthcare, it is still the least information-enabled of all sectors of our economy, even though healthcare floats on an ever-changing sea of knowledge and clinical/patient information.  Our current notion of healthcare is wedded to the brains of individuals (i.e. health professionals), not the collective intelligence of many people working together (dare I call this cloud cognition, hive minds, or distributed cognitive systems…?).

I think we need to take a different look at reform models, and embrace a new terminology, one built on disruption.  Disruptive technologies in particular are game-changing, they alter our modes of interaction with other people, change how we manage information, make decisions, perhaps even think. They, of course, produce winners and losers, as these sorts of changes often are zero-sum. Keep in mind that health reform has tended to be non-zero-sum; there has been a fear of creating losers while at the same time trying to reward winners, so-called protection of legacy providers, and we see this in the most recent UK Department of Health plans to allow failing NHS providers two tries to improve performance before alternative providers will be allowed to take over the work. Disruption says enough is enough, and we must do things differently.

We don’t know that much about disruption except by what its effect is on us, but there are efforts to understand  disruption.  But this work has been weakly connected to both the policy space in which these insights can achieve some measure of meaning, and the real-world.  Healthcare systems can go to great lengths to frustrate innovation and change.  It is, therefore, timely and pleasing to see efforts of understand disruption, and the forthcoming report on disruptive forecasting from the US Committee on Forecasting Disruptive Technologies, National Research Council, may offer a renewed impetus not just to the forecasting work, but to its utility.

I like disruptive technologies for their ability to shift our thinking away from industrial age paradigms to information age paradigms.  In this way, we break the logic of physicality that defines, for instance, hospitals, and leads to new approaches anchored around the health information value chain, which unites patients and all actors in health systems (payers, providers, industry, academe).  Ehealth is one of these potentially disruptive technologies, as it achieves a couple of key disruptions, in terms of decoupling patients from physical location, and of the potential pooling of knowledge in distributed cognitive systems with machine intelligences through smart/remote diagnostics, predictive modelling and in time physical models of disease.

But disruptions are a much harder sell, but it seems to me that difficult public finances does offer an opportunity for rethinking: one should not waste a perfectly good crisis as it is an opportunity to evolve. (with apologies to Rahm Emanual who said “never waste a good crisis”.

READ an interview I gave on ehealth here: [LINK to Euractiv ehealth interview]

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Why the UK’s NHS may be an easy target in the US health debate

In an earlier post, I raised the ideological differences that may underpin much of the political rhetoric.

Of course, many informed commentators understand the problems and challenges facing US healthcare, which can be the best in the world.  And much good learning about how to make a health system better come from the US.  The NHS has learned much from the US, too.

But the NHS is like any system, built on assumptions and reflects a view of healthcare delivery that may not be shared by everyone.  However, many do share the underlying principles of universal healthcare, just not the organising principles that the UK used in designing the NHS.  There are other systems of healthcare organisation, and there is evidence that Bismarckian systems (non tax-funded systems) may actually produce better outcomes and care.  On that basis, the NHS is vulnerable to structural criticism, but not for trying to deliver a universal healthcare system that decouples the need for healthcare from the ability to pay.  The Americans in particular would not argue that people need healthcare, but they would debate how best to pay for it.  Hence the debate.

But the NHS does have vulnerabilities.  Let’s summarise a few:

1. NICE is seen by many as establishing a value for a human life based on quality adjusted life years, general affordability of a medicine based on a blend of clinical effectiveness and cost.  While NICE lacks statutory authority to enforce its decisions, its role from a US perspective would support the conclusion that within the NHS is a decision process that indeed does value human lives.

2. Overseas observers may be forgiven for not following the daily reform of the NHS, and on that basis, cursory searches of the health literature will produce historical documentation that supports the view that the NHS has been known to cause considerable personal suffering through the persistence of waiting lists.  For many US commentators, this equates to a form of rationing, which in their view is unacceptable.  Granted that people wait in all health systems; but in the past, the NHS can be accused of having used administrative procedures, like waiting lists, to queue patient care on the basis of clinical need, but with fewer deployed resources per capita than other countries, patients did in fact  suffer health consequences from waiting.

3. As a cash-limited system, the NHS is open to greater criticism from American commentators, who are more comfortable with co-payment systems, and systems which in effect enable people to buy their way to the front of the queue.  Since it is deemed unacceptable to use co-payment as a mainstream payment mechanism in the NHS (unlike the health systems in other European countries such as France, where co-payments are the norm, coupled with supplementary insurance), other commentators would naturally wonder why resource constraints that penalise people seeking greater healthcare cannot be overcome through personal discretionary payments.  The Canadian healthcare system comes under very similar US criticisms here.  That the NHS as a purchaser fails to fully integrate the provider infrastructure would seem odd to Americans and many Europeans, more accustomed to receiving care from a system that is largely agnostic over who owns the provider (public, private, voluntary, profit, not-for-profit).  More generally, the ability to pay more would be seen by some as not necessarily penalising others who might pay less or nothing — there is no moral contradiction for some here — as both types of patients will in the end get seen; the consumption of healthcare by the rich does not necessarily reduce the availability of healthcare for the poor, some would argue.  But it is important to keep in mind Titmus’s point, that a welfare system that only services the poor will lack support of the middle class, and in the end fail in its social welfare objectives, and also be financially unviable.  This is one argument for community risk rating and pooling.

4. The NHS can be criticised for confusing the politics of the NHS and the politics of healthcare, itself.  To external commentators, this mixes the essential relationship between the doctor and patient, with a state-mandated intermediary.  US commentary in part is predicated on avoiding any government intermediary between doctor and patient.  The NHS is a system for delivering care, while healthcare itself is essentially a private matter between doctor and patient, as many would argue.  You can always change the system, but the relationship remains.  Tinkering with the former in ways that alters the latter for many is unacceptable.

It is worth keeping in mind that the UK is not the only health system that American critics could attack; it is probably one of the easier to learn about and which offers an extreme view from their perspective.  Critics for years have attacked Canada’s health system as ‘socialised’, but have failed to target Italy’s.  They have generally ignored insurance-based or Bismarckian systems perhaps because of the insurance approach, which is closer to their view of how risk should be managed — buy insurance, don’t buy the risk itself.

The NHS itself, is a particular way of organising and paying for a universal health system, and there are separate debates in the UK about whether the NHS should become an insurance-based model, and so and so forth.  But in the end, few Americans are actually inconvenienced by their healthcare system, and perhaps think very little about it, in much the same way as UK citizens enjoy the benefits of the NHS, without necessarily being concerned exactly how it is financed.

Universal health systems do work well and apportion risk across the whole population in most cases without a lot of public hand-wringing.  UK politics is perhaps overly sensitive given the past problems with NHS waiting lists and apparent rationing, and dysfunctional separation of public and private providers adding delay to access to treatment.  These problems are largely absent from Bismarckian health systems of France, Germany etc, and so there is always the general public accountability to be had about whether the UK is making appropriate evidence-based decisions about the financing system it uses.  But that is quite apart from the fact of universal coverage.

In the end, the US doesn’t want an NHS style healthcare system.  In fact, very few countries actually copy the form the NHS form of financing (tax funded), preferring to use insurance, and of those that are tax funded they tend not to copy the organisational style of the NHS (state-run/owned hospitals for instance). This is keeping in mind that there are four NHS’s — one in each UK country, with the English NHS being the most progressively reformed (with some US ideas, too).

There is much to learn from looking at other health systems, and the US clearly isn’t having that sort of reform debate.  Something perhaps for the US to think about again.

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Why is the US having trouble with health reform?

So various US publications have waded into the health reform debate with comparing the US with the UK’s NHS.  These commentary, as many other bloggers and those on Twitter, are of varying degrees of stupidity, ignorance and general lack of insight.

It is worth keeping in mind that for decades, there have been comparisons between Canada’s healthcare system (very similar to the UK’s NHS, but there are very important differences, too) and the US.  The Americans have these debates constantly and the various lobby groups are well-equipped to flood the ether with their rhetoric. There is a deep-seated concern about ‘socialised’ medicine, about the role the state usurping individual responsibility, and about power and control.

And the spirited defence of the NHS will no doubt continue apace.

But underlying the debate is the unanswered question of why does the US have so much trouble with reforming its healthcare system in the first place.

One reasons is that Americans seem have a lot of trouble with what are called free-riders.  Because their system is insurance based, those who do not take out/cannot afford health insurance, get a ‘free ride’ on the taxpayer, through the federally funded Medicare/Medicaid programmes for instance.

By and large, Americans philosophically are liberal in their outlook, and believe that individuals should make the most of their gifts, so the system rewards, and celebrates success, and while not necessarily punishing failure, ignores it as long you pick yourself up and get on with improving your life.  Ideologically, that means that it is hard to grasp that everyone may have an interest in the general welfare of individuals, AND that the responsibility for the general welfare is the responsibility of government. Practically that translates into a political ideological debate about the role of the state.

Why does that matter?

The US politically is a different system from parliamentary democracies. In the latter, political parties stake out ideological territory (left, right, socialist, whatever) and the electorate chooses.  In the US, the United States itself IS the ideology.  The political parties are interpreters of this founding ideology and the electorate chooses within that ideology from the political parties.  That explains in part why there is a narrow range of political choice on offer in US elections, and why, under the skin, all political beliefs flow back to the founding ideology of the US Constitution, and its revolutionary roots.  The US believes it is the definition of democracy, so why would one have varying degrees of political persuasion if you’ve already solved the hard problem.

That means that the health reform debate is predicated on historical consensus about the political objectives of the US as a democratic entity. One of these principles challenges the role of government, another principle addresses individual liberty and third focuses on how the US interprets the public interest and general welfare.  The third principle is NOT interpreted by the state (as in the US, the state is a creation of the people), as it is parliamentary systems (where the state exists independently of the people — read Hobbes).  In the US, the resolution of a political debate amongst competing interests determines the public interest as the state does not have an independent existence and so cannot have its own guiding principles.

Why should this matter?

Because in the US, these debates nourish the democracy itself. The discussion is not esoteric but fundamental to the concept that Americans have of their country.  Such debate in UK, France, Germany, Canada, etc, with universal health systems, will invariably invoke principles to resolve the issue, that can not work in the US political arena.  The difference, of course, is that while the Americans will have the debate, other countries will sit complacently by while their governments pursue reform policies which should be challenged and debated outside the government.  The differences are subtle, but important.

Obama and Health Reform in the USA

A statue of Asclepius. The Glypotek, Copenhagen.
In whose name do we reform healthcare?

President Obama’s comments today to the American Medical Association in Chicago represent the slow, but certain, turning off the health reform supertanker that is the US healthcare system.  Despite evidence of the need for improved clinical working practices, use of guidelines, better use of evidence, powerful groups have resisted over the years opportunities for root and branch change.  Speaking to the AMA, Obama identified a few key barriers he sees as crucial to change:

  • eliminate the notion of pre-existing conditions
  • find alternatives to fee-for-service reimbursement
  • share best practice better.

Of course, there are many other moving parts within each of these, and others he mentioned (e.g. generic medicines, clinical IT, etc.).  But these three offer opportunities for substantial realignment with the US.  In turn, and briefly, by eliminating the insurance barrier of pre-existing conditions means adopting population-based health risk.  That moves the US to social insurance models familiar to Europeans.  The problem will be overcoming the problem of free-riders, which be-devil some US policy commentary, but free-riders in automobile insurance claims are not quite the same thing as someone who is poor and in ill-health getting access to healthcare.  Alternatives to fee-for-service opens the door to outcomes-based payment systems, enables better bundling of care across clinical pathways and more closely aligning payment to what actually happens to patients.  By integrating care, financial incentives move closer to actual clinical and hospital work patterns; similarly, with innovative thinking about how to structure reimbursement based on outcomes, payers can more effectively encourage reform with hospitals, to move them away from fragmented care.  Sharing better practice should seem the natural thing to do, given that everyone in the end does benefit when good practices are shared.  But sharing better practice can undermine competitive advantage in market-driven health economies; by shifting to alternative payment systems, sharing practice will make more sense, especially if payers act together.  However, ever mindful of potential for collusion, payment systems and information sharing must enable consumer and payer choice, rather than close down options, in an anti-competitive spirit.

This president is compelling in his expression of the anxiety so many Americans feel about what is wrong with their healthcare system, and he is to be commended for taking this challenge into the heart of the medical community.  In that respect, I am optimistic that some sort of change will come in the US.  More importantly for other countries’ healthcare systems, we see a lesson in a way to conduct health reform.  His big-tent approach is a lesson for other countries that feel health policy and reform comes from aligning the interests of narrow interests, of specialist commentators, academics and civil servants.

One lesson to take away is that health reform is something that must be conducted within the society, with all the key participants engaged.  It is not just the culmination of a rational research study, using contracted experts, who more often than not breathe each others’ air.  No longer, I think, can international observers be critical of US reform intentions.  Indeed, for some countries who think they have a pretty good and publicly funded system, US reform may show them to be small, mean-spirited systems, narrow in focus and costly overall.

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