Getting Doctors to Compete

I've been doing some guest blogging at WorldHealthCareBlog, which is affiliated with an all-star health care conference sponsored in part by the Wall Street Journal now underway at the Washington, DC Convention Center. I'm sitting in on a session each day to hear what some leading thinkers have to say about the evolving health care reform debate. On Sunday, I heard Harvard Business School professor Michael Porter, who has been stumping the country for five years touting competition as the solution to the nation's health care woes:

"Universal insurance is not enough to address the fundamental challenge facing our health care system," he told the 1,600 attendees. "The fundamental problem at the end of the day is the value of the health care we deliver."

And how would he reorganize health care to deliver better value? "Where we need to go is an integrated practice model," he said. His model entails patient-focused practice groups that knit together every specialty needed to treat an individual's medical condition. It's not that physicians will no longer specialize; it's that they're no longer going to practice in specialty silos divorced or only marginally connected to all the other people providing that particular patient's care.

Competition enters this new system by giving individuals information about the relative performance of these integrated practices. That way, consumers and payers will be able to use outcomes and price data to not just hold down health care costs, but choose those practices that deliver better outcomes.

It's a compelling vision, and one I'm somewhat sympathetic with. It also tracks very closely with another long-time observer's perspective on how the health care system has to change, one who has a very different political perspective from Porter.

Dr. Arnold Relman, the former editor of the New England Journal of Medicine, has a new book coming out called "A Second Opinion," where he, too, calls for the total reorganization of the practice of medicine around the integrated practice model in order to deliver patient-focused care to the chronically ill people who account for 75 percent of all health care expenditures.

However, where Porter would have various systems compete by making available pricing and outcomes data, Relman would simply have the state or non-profits employ all the specialists needed to deliver integrated care. He's also a backer of a single-payer national insurance model where Porter still sees a major role for both insurance companies and for-profit physician practices in the system.

Though he admitted that computerizing medical records is a tool, not a solution, Porter suggested at several points in his talk that this tool could resolve the fragmentation implicit in leaving the current structure of physician practices (with most doctors belonging to specialty groups) alone. That salutory view about the promise of health information technology was echoed by the two commentators the Congress lined up to respond to Porter's talk: Ron Williams, chief executive officer of Aetna Inc., and George C. Halvorson, chief executive officer of the Kaiser Foundation Health Plans and Hospitals, more commonly known as Kaiser Permanente.

"We need care connectivity and electronic databases," said Halvorson. "Only 8 percent of the diabetics in this country get the right care. We haveto move than to 80 percent. To get there, we have to create an architecture that requires people to be in registries."

Is Health IT really our savior? Thank goodness John Iglehart, the founder of Health Affairs and currently a national correspondent for the New England Journal of Medicine, asked the obvious question -- on that could just as easily be posed to Relman as to Porter: "What would force providers to restructure?"

Perhaps the organizers of the conference weren't interested in generating heat to go along with the light shed by Porter. But I would have loved to hear how the president of the American Medical Association, who speaks Monday, would respond to Porter's (or for that matter, Relman's) plans for reorganizing the practice of medicine. Moving physicians away from fee for service payment to paying them for integrated treatment for conditions (the Porter model) or to salaries in integrated practices (the Relman model) represents nothing less than a revolution in the practice of medicine, one that would entail significant income losses for thousands of doctors.

Yes, it's happening in many places. Yes, younger physicians are more open to computerization and working within integrated practice models. Yes, employers are no longer looking to beat up on the insurance companies for failing to hold down costs, but rather want value for the money they spend on employees' health care.

But until someone comes up with a concrete payment model that actually encourages the physicians we have (not the next generation coming along) to move into integrated practices, health care reform is going to stay a debate about insurance and not a debate about how to get better quality for the money we spend.

Posted by gooznews at April 24, 2007 01:43 AM