1 conversation exposed 2 health care imperatives

A single conversation this past weekend with a cousin, who is a president at a Boston area college, revealed two imperatives about health care — that we need both universal coverage and a universal payment system.

Consider this: The cost to provide health services to students at small colleges like this pushes up against the $1 million mark annually. That cost is not for total coverage — it's for "gap care," clinic style, that essentially triages the students and provides minimal care before the student's own insurance kicks in.

What happens is the college is solving its problem (how to provide health services for its students) by contracting with a health system (in this case a large not-for-profit with its own hospitals and doctors) that sets up an on-campus clinic and directs students to its own ambulatory clinic for after-hours care.

The health system wins because it is funneling a new population of patients into its system — to the hospital, of course, but increasingly to its own physicians.

The college pays a fee to the health system to administer the service. The health system's providers then deliver the care, which often is billed to the students' own health insurance (remember, every student is required to have health insurance or buy it from the college).

It's a system built on fragmentation.

Instead, if our system had universal coverage for everyone — and a single universal payment system where providers were paid fairly and adequately — we could likely solve both the access and cost dilemmas. 

We remain far away from a single payor system in the U.S., instead encouraging health systems to jockey for business by setting up competing Accountable Care Organizations (ACOs) that cover discreet populations, such as seniors on Medicare or low-income people on Medicaid. Perhaps all the students at a particular college are another possible ACO population!

Indeed, ACOs are a great step forward. They hold the promise of a true continuum of care where quality, experience and cost can be "controlled."

But, using our example of these students, which ACO are they part of? The one that might exist with their health insurance (in most cases their parents' health insurance) or the system they get placed in by the college's arrangement with the health system?

Either way, it's fragmented care. What we really need is truly integrated care — care that is accessible anywhere, uses technology and data to inform clinical decisions and is actually affordable. 

That's a hope and a dream worth pursuing. 

Medical care is intended to help people …

There's no denying health care is big business. But the big payoff should be focused on patients.

In a July 4 op-ed in the New York Times, H. Gilbert Welch, MD, MPH, professor of medicine at Dartmouth's Geisel School of Medicine and an author on health care ethics, posited whether health care's current business model borders on "criminal."

"Medical care is intended to help people, not enrich providers. But the way prices are rising, it’s beginning to look less like help than like highway robbery. And the providers — hospitals, doctors, universities, pharmaceutical companies and device manufacturers — are the ones benefiting."

Dr. Welch points to recent media coverage, such as Time magazine's 36-page cover story "Bitter Pill" (March 4, 2013), that shows pricing disparities and how consolidation has increased costs, notably to those who can least afford to pay them.

One area of concern is the acquisition of physician practices by hospitals and health systems. Is this motivated by money (hospital-owned physician practices get higher reimbursements) or achieving the Triple Aim (higher quality, lower cost and better patient experience)?

Probably both.

There are growing examples that show the acquisition of physician practices by hospitals has resulted in more tests and higher costs (Dr. Welch gives a few examples). There is also plenty of promise of better coordinated medical care through disease management and improved patient engagement.

But what is clearly evident — especially in areas where "integrated" health systems are truly integrated (think Kaiser Permanente) — is that care can improve when everyone is working collaboratively toward the patient's well-being.

Dr. Welch had another poignant line:

"… what happened to the word 'community' next to the word 'hospital?'"

By building a truly integrated system — from physicians to hospitals to community wellness programs — we can again focus on improving the health and well-being of our communities and reserve the medical part of the system to take care of those who genuinely need it.

That's accountable care — being accountable to the community you serve and the patients who put their trust in you.