March 3, 2007

On Sunday, March 3 Jim Hinton shared Presbyterian's vision for transforming healthcare in New Mexico through a guest column in the Albuquerque Sunday Journal. As New Mexico engages in the debate over universal healthcare coverage, the State Legislature will consider three universal coverage models in 2008.

Presbyterian's perspective for universal healthcare coverage is that it is not an end to improve healthcare in New Mexico, but it is a key component in driving positive change. Presbyterian also believes that paying for quality and investing in technology will create a better healthcare system for everyone.

Here is Jim's guest column:

Computer Chips and Healthcare

Forty-one years ago, Gordon Moore, co-founder of Intel, predicted that the circuit capacity on a computer chip would double every two years. At the time, Dr. Moore was projecting the promise of a young computer industry over the next 10 years. It turns out Dr. Moore was right about everything but how long the computer industry would sustain this progress. It's held true not for 10 years but for the last four decades, and today we commonly call this phenomenon "Moore's Law." The world's computing capacity has doubled every two years; all the while the cost of chip technology to consumers has continued to steadily decrease.

The quality and capacity of computers have grown rapidly while the costs have shrunk; unfortunately, just the opposite is true in health care. Our quality is improving but not consistently. Our capacity is straining. And our costs are steadily increasing.

Patients and health plan members know this. The physicians, nurses and caregivers who work in our crowded emergency rooms and hospitals know this. And employers who struggle to afford the cost of providing health benefits to employees know this. In fact, fast forward 40 years and today's Chairman of Intel, Craig Barrett, is spending a great deal of his energy not on building better chip technology, but worrying about the cost of health care. Last September, Dr. Barrett said, "The current healthcare system is economically unsustainable and negatively impacting our nation's ability to compete globally."

These are tough words for many of us in health care to read. But they're true. Of course, improving health and saving lives is an invaluable service, but we need to be honest about the fact that too many of our patients and health plan members can't afford the care we give.

It's time for health care to create our own "Moore's Law." A transformation of health care in which the quality of and access to care accelerate while costs stabilize and ultimately decrease. I believe New Mexico is the perfect place to begin.

Transforming health care will hinge on two fundamental changes. First, we must provide healthcare coverage for every New Mexican. But we should provide coverage for every New Mexican not as an end, but as a means to better health care for everyone. Once every New Mexican is "in" the healthcare system, the second change will be to reward performance, quality and the use of technology in health care to dramatically improve our health.

One in Four New Mexicans

One in four New Mexicans has no health insurance, no insured access to care. Four hundred and two thousand New Mexicans. Because those of us in health care have seen these numbers so often, I wonder if they still register. But we have to understand the number of uninsured for what it is - a catastrophe.

It's a catastrophe because people without health insurance are less likely to have a relationship with a doctor, less likely to receive preventive care like mammograms or immunizations; people without insurance are more likely to be poorly managing a chronic illness. While the uninsured have access to hospital emergency rooms and a patchwork of providers, they are fundamentally on the outside looking in when it comes to health care in New Mexico and in the United States.

And having one in four New Mexicans uninsured is a catastrophe because the costs of providing care to the uninsured are continually shifted to those who buy health insurance. The problem is that people with insurance are finding it harder and harder to pay for it, making those with insurance ever more vulnerable to joining the ranks of the uninsured.

We need to treat health coverage as a right - and a requirement. As long as some people can choose to opt out of, or never find a way into, the healthcare system and shift the burden onto those with insurance, our healthcare system will struggle to balance quality, cost and access. With hospitals and doctors in New Mexico today providing tens of millions of dollars in uncompensated care each year, the system is saddled with cost pressures. Providers are in a defensive posture instead of being poised for innovation. That is why getting everyone in the system is the critical first step to transforming health care.

Our state is fortunate to have a Governor and a Legislature committed to addressing our uninsured crisis. Over the last four years our state has been creative in building new programs and expanding current ones in order to give more New Mexicans consistent access to health care. Currently, our state policy-makers are going through a rigorous process to define the costs of three different models of universal coverage, providing health coverage for every New Mexican. I am very optimistic about this study and look forward to the action it will spur in the months ahead.

Without prejudging the study results, I am hopeful our state will look to a universal coverage model in which government is the facilitator but not the single payer. We need only look to the great success of our state's innovative Salud! program to see the power of the public-private partnership. Salud has delivered nationally-excellent standards of health for Medicaid members at costs substantially lower than traditional Medicaid. With a similar model for our state's uninsured, we can combine the best efficiencies and innovation of the private insurance market with the government's ability to bring everyone together.

How does universal coverage connect to our new Moore's Law? When we get every New Mexican in the system, we can start to eliminate a huge portion of the inefficiency - people seeking crisis care that could have been avoided, straining hospital ER's; people lurching from insurance to no insurance and back again. We will stop shifting the cost of inefficiency onto employers and employees purchasing health insurance. We can bring rationality to our healthcare system and then set about the hard work of transforming the quality of our health care.

U2 and Your Health

When I go to Amazon.com and purchase the most recent U2 cd, here's what it tells me, "Customers who bought this item also bought Coldplay and Green Day." That's pretty good information. (If I knew who these bands were, I might even be tempted to buy their cd's.)

But what if you logged onto your individualized healthcare web portal and you received a message that said, "Patients like you who visited the emergency room with an asthma attack twice in one month find themselves hospitalized for their condition. We have scheduled an appointment for you to review your asthma medications"? That would be really good information.

And I believe this is clearly possible in our vision of a transforming healthcare system.

When we talk about a lack of quality in health care today, it is not an indictment of the people who deliver our health care. I have worked in health care for 24 years and I have the greatest respect and appreciation for the hundreds of physicians, nurses, technicians and other providers of care in New Mexico. I firmly believe that healthcare providers want very much to deliver the best care possible, every time. Our job then is to give them the tools and the technology to do just that.

There's no question, though, that the healthcare system provides inconsistent quality. There are the obvious quality problems, like preventable medication errors. But just as concerning, and less apparent to the patient, is the inability of the healthcare system to provide the same standard of care for every patient every time. For example, we know that one of the standards of care for diabetes patients is regular blood sugar tests to measure whether the patient is in good control of his disease. If you looked at all of the providers, though, you would see some getting excellent results where every patient's diabetes is being managed in good control. You would see others where the patients aren't even getting their blood sugar regularly tested. We shouldn't accept that kind of variation. In any other service or product we pay for, we would call it a defect.

Our system is not set up to reward consistent quality. One of the biggest reasons for this is that hospitals, doctors and providers are paid for the service they provide, not whether or not the service has been shown to improve the health of the patient.

Providers will benefit greatly from a rational system in which every patient is covered. They will no longer have the burden of uncompensated care. In return, our transforming system will ask providers to be paid for the quality of work they deliver. Where medicine has created evidence-based standards of care, we should pay for providers who give that care. If it is accepted medical knowledge that four evidence-based interventions upon hospital admission can lessen the impact of a heart attack, we should expect hospitals to provide those four steps each and every time - or why would we pay them the same reimbursement as the hospital that is delivering that standard of care?

This surely will have an initial financial impact on providers, but in the long run, we will create a healthcare system that wrings out its defects, adopts best practices and continually ratchets up the quality of its care. Doesn't that sound a lot like Moore's Law, where the chip capacity doubled every two years?

In addition to paying for quality, we should use the advantages of a rational system where everyone is insured to make the technology investments that will transform health care. Like the Amazon.com example earlier, technology should give patients and health plan members unprecedented access to information about their health. From the digital MRI that allows two doctors to consult on a patient at the same time while miles apart, to internet appointments with your doctor, the possibilities are wide open. These technology investments are happening in isolated places today, but if we invest in a system that values technology, it has the power to radically transform health care as we know it.

Of course, with excellent access to health information comes a strong dose of personal responsibility. If we ask providers to be paid for the quality of the service they provide, it is right to ask patients to be accountable for the choices they make that affect their health. Just as life insurance companies do not have the same policies for individuals who take up hang gliding, we should ask patients who smoke or make similar poor health decisions to accept the consequences of those choices.

A transformed healthcare system will benefit everyone in New Mexico, but it will ask more of everyone as well.

310 Days of Sunshine

This "Moore's Law" for health care is our vision of what is possible, of how we can change our healthcare system to get the care we deserve every time. Health care is extraordinarily complex, so this is not our attempt to "fix" every problem. We are focused on a few critical principles that have the ability to transform health care today - universal coverage and rewarding performance, quality and technology.

Other states like Massachusetts and California are making progress on parts of this healthcare challenge. They are looking at creative ways of solving their uninsured crisis. I believe covering every New Mexican is only the first part of the puzzle - we should cover every New Mexican so that we can improve the health of everyone in the system.

We are blessed to live in a land with 310 days of sunshine a year. I think that's one of the reasons New Mexicans are so optimistic. We know we can do this. We can tackle big problems and improve the quality of our health care and the quality of our lives.

And when we succeed, maybe someday people will ask how they can make their computers work as well as their health care.