As Charlie Baker is sworn in as governor of Massachusetts, among the many public policy issues clamoring for his attention is health care. In the last eight years, three major health care reform proposals have rattled and banged their way through Massachusetts: first, Romneycare, which morphed into Obamacare, and then Gov. Deval Patrick’s health care cost containment bill. Despite these reforms, there remains a fundamental disconnect between the way health care should be and the way it is.
If a healthy Massachusetts is our goal, we must reorient our health care system to prioritize keeping people healthy rather than simply profiting when they are sick.
In Massachusetts, health care is both a major employer and a source of great regional pride. As a business, hospitals and health care systems are mostly focused on finding sick patients and serving them in the same way that other businesses find and serve customers. The problem is that health care is not about “health,” but illness.
If a healthy Massachusetts is our goal, we must reorient our health care system to prioritize keeping people healthy, rather than simply profiting — handsomely — when they are sick. A reorientation like this is simple to conceive of but difficult to implement. Money and power resist change that threatens money and power.
In 2001, the New England Journal of Medicine revisited "The Ecology of Medical Care," an article it originally published 40 years earlier, and which, since its publication, has “provided a framework for thinking about the organization of health care, medical education, and research.” Researchers in 2001 found that only 43 of 1,000 people in a given area used a hospital service. Even so, the health care system is organized according to the financial needs of influential hospitals and large health systems.
Overtreatment of patients is rampant, and it’s costing Americans billions of dollars in unnecessary medical expenses. Meanwhile, scarce public funds are increasingly allocated to covering health care services that serve the business interests of hospitals, medical specialists and pharmaceutical manufacturers, not sick people. In China, Maine (off-season population, 4,500), officials cannot afford to repair potholes or hire more teachers because the costs of health care for town employees consume such a large percentage of the town budget.
But how to shift the health care business model away from one that incentivizes providing more care to one that incentivizes providing better care? Accountable Care Organizations (ACOs), under which providers earn more if they keep their patients healthy, are a good start. But before ACOs can devote money to the kinds of services that create healthy communities, they will have to root out the services that are overused and unnecessary. To do this, they will need the support and input of the community they serve.
Many health care CEOs have embraced population health strategies, which aim to improve the overall health of the community and keep people out of the hospital. Success will require executives to make tough choices, scouring their hospitals for tests, treatments and procedures that they shouldn’t be doing. This means that success will mean losing money. It would be an especially courageous CEO that deliberately pursues a strategy that could imperil the bottom line (explain that to your board of directors). What could make the difference? A community (or “service area,” in hospital speak) that demands those hard choices.
Managing a hospital is like managing any other business; it is hard to change what you offer unless your customers tell you they want something different.
I suspect that a few hospital executives would welcome such input. Managing a hospital is like managing any other business: It is hard to change what you offer unless your customers tell you they want something different. The good news is that people are starting to make such demands of their health care leaders. As healthy and sick alike have recognized that our health care system is broken, they have been demanding better. Inside health care, doctors, nurses — lots of nurses! — physician assistants and other clinicians have started meeting and talking about how to improve the system. It’s a start.
We deserve a health care system that does not profit off illness. The priority should be on keeping patients well through primary care, preventative care and public health, not tests and procedures that benefit, most of all, the health care system. As the newly inaugurated Governor Baker and his team meet with healthcare executives during the first weeks of his administration, he should ask them what they will do to empower healthy communities and promote real health. Because it’s just a matter of time before people, healthy and sick alike, will demand the same thing.