Reforming the Reform Debate

Over the past few months, literally millions of words have been written or spoken about health, healthcare, the healthcare system, what we need to do to address the serious issues related to each, and why.

The White House has undertaken an unprecedented process to gather input from every stakeholder, resulting in a degree of alignment never before seen. With the imminent confirmation of Health and Human Services Secretary-designate Kathleen Sebelius and the recent appointment of healthcare veteran Nancy-Ann DeParle, the critical focus of Director of the Office of Management and Budget Peter Orszag and the President's own commitment that healthcare reform "cannot wait, must not wait, and will not wait another year," significant changes to America's healthcare landscape are almost a surety. However, even a cursory review of everything that's been written and said to date reveals a striking omission. Nowhere can we find a simple, clear, unambiguous statement of what it is that we want the reformed system to actually accomplish. This is not a minor oversight. If we don't have a common objective and a single measure to determine whether or not we're achieving it, the likelihood of our reformed system producing outcomes—clinical or financial—that are markedly different than those of the current system is small.

The requirement that a system have a purpose was clearly expressed by W. Edwards Deming, who helped Japan develop into an economic power after World War II: "A system is a network of interdependent components that work together to try to accomplish the aim of the system. A system must have an aim. Without the aim, there is no system." President Dwight Eisenhower conveyed essentially the same thought: "We succeed only as we identify in life, or in war, or in anything else, a single overriding objective, and make all other considerations bend to that one objective."

Absent that aim, absent that single overriding objective, we are left only to debate how to fix what we don't like about how the current system functions, how it's organized, and how it's paid for. And, unfortunately, that's exactly the debate we're having.

A variety of factors are driving the current discussion, not least of which is the critically unchallenged assumption that in reform, we must preserve as much of the present system as we can. But the truth is we don't have a system. We never have.

Rather, what passes for America's healthcare system is a patchwork quilt of services, modified over time by governmental or private-sector changes—often in conflict—in payment, coverage, facilities, and manpower policies, in response to the critical need of the day.

Consider, for example, the conflicting policy perspectives that led first to Hill-Burton and then, a mere 20 years later to Certificate of Need. Look at any element and similar reaction responses can be found. Unlike the weekly successes we see in the TV show House, we have an historically poor record of curing the problem by treating its symptoms.

But that's the path on which we seem to be embarking again. While well-intentioned and replete with phrases that have become iconic in the debate—quality, accessible, universal, transparent, affordable—we apparently have not realized that those terms describe principles of how we want the system to work; they lend little clarity to the question of what we want it to do. And neither does blaming any of the candidates historically held responsible for getting us into this mess in the first place. (Government, health plans, hospitals, doctors, lawyers, consumers, and virtually every other stakeholder in health and healthcare have, at one time or another, been the whipping boy for our broken system.)

History makes it pretty clear that another round of incremental "adjustments" is unlikely to yield a solution that, at the end of the day, both improves health and is sustainably affordable. As the Center for Health Transformation puts it, "Small changes or reactionary fixes to separate pieces of the current system have not and will not work. We need a system-wide transformation."

By any assessment, America's health and healthcare are poor. The last World Health Organization ranking put us at #37, despite the fact that we spend a greater percentage of GDP on health than any other developed nation.

So, what should our aim be? Over the next decade, we progress to #1, we design a system that keeps Americans as healthy as possible for as long as possible, and we create a system that all other considerations bend to that one objective.

In setting that objective—and why would we accept anything less—we need to recognize that we will not achieve it by continuing to focus on or enhance our current sick care processes or by tinkering with other elements on the supply side of the health equation. Rather, we need to be focused on assuring that the reformed system is enabled to do three things:

1. Keep healthy people healthy
2. Mitigate or eliminate health risks associated with modifiable lifestyle behavior choices
3. Assure optimized, evidence-based care for those who require it

If we don't address all three areas, the apparently inexorable demand for services, fueled principally by both an aging population and the epidemic-level incidence of avoidable chronic disease, will quickly overrun the system's ability to respond.

With one goal and three clear initiatives, the opportunity exists to actually structure a true system, in which each of the interdependent components do, in fact, work together to further achieving the goal. Without that goal, true reform will elude us . . . again.