When three preeminent thought leaders like Elliott Fisher, Donald Berwick, and Karen Davis submit a joint proposal for healthcare reform, attention must be paid. Fisher, a professor at Dartmouth Medical School, has coauthored seminal papers about practice variations across the U.S.; Berwick is the president of the Institute for Healthcare Improvement and a coauthor of the Institute of Medicine's epochal report Crossing The Quality Chasm; and Karen Davis, a health economist, is president of The Commonwealth Fund.
Their joint paper in the current issue of The New England Journal of Medicine urges physicians to take the lead in national efforts to reform the delivery of health care. According to the authors, physicians should do everything they can to guarantee a better experience of care, better population health, and lower costs. "However, neither physicians nor anyone else on the front lines can improve care much on their own," they write. To achieve that goal, they say, "integrated delivery systems" must become the norm. By that, they don't necessarily mean vertical organizations owned by hospitals. "Networks of independent physicians" sharing electronic health records and a common infrastructure could also achieve these aims. So could large multispecialty groups or group-model HMOs.
The authors point out that these "accountable care organizations" won't thrive "unless payment systems encourage their development and unless we change the laws and regulations--including proscriptions of gainsharing and anti-kickback rules--that prevent cooperation among health care professionals and organizations."
They would like to shift the reform debate away from public vs. private insurance plans. Instead, they say, all health plans should be required to focus on the development of integrated delivery systems. This is where their argument starts to get wavy. After all, HMOs tried this back in the '90s, and they failed miserably. Moreover, most of the existing integrated delivery systems are led by hospitals--which are dedicated to bashing each other's brains out.
The authors ask physicians not to be afraid that this kind of reform would "impose a hardship on patients or providers." They assume that their approach could easily decrease health spending growth by 1.5 percentage points, as promised recently by health care industry associations. "A 1.5 percentage point reduction would still allow spending--and thus the total incomes of providers--to rise from $2.6 trillion in 2010--to $4.3 trillion in 2020."
So how would physicians start to cut back on spending in the absence of accountable health organizations? The experts suggest that they reduce their overuse of certain clinical services. "Ideally, providers would also agree to slow fee increases for private payers further, allowing Medicare to catch up."
Without admitting that this is unlikely to happen, the authors acknowledge that the Congressional Budget Office might be skeptical about the efficacy of voluntary efforts. Therefore, they note, Congress might have to set a target for spending growth and empower Medicare to reduce provider payment updates if the target is exceeded. They also suggest that the physician-guaranteed reduction in cost growth be linked to universal health insurance, "comprehensive reform of the delivery and payment systems," and government subsidies for EHRs.
There are many good ideas in this proposal, some of which Congress is already considering. But the authors' persistent idealism doesn't square well with the realities of healthcare today. Aside from the obvious fact that people tend to act in their own self-interest, there are other issues, such as defensive medicine and patient demands for unlimited choice, that pose challenges to their approach. The question is, if these experts can't come up with a workable solution, who can?