2008 Dorsey Hughes Symposium Blog

2009 Symposium

The Colorado Health Foundation President and CEO, Anne Warhover, announced that next year’s symposium will be held at the Keystone Resort and Conference Center, from July 30 to August 1st, under a new name: The Colorado Health Symposium.

Coordinating Health Care - Denis A. Cortese, MD

Denis A. Cortese, MD (Bio)
President and CEO, Mayo Clinic

Health care and health are totally separate concepts, says Cortese. Health care is complex, and to deal with complexity, you need a shared vision. In the United States, do we have a health care system? No. If you think we have a system and we can fix it, you’re doomed to failure. To have a system you need two things: a shared mission and a shared vision. We have neither.

In this country there is a lack of leadership at the senior levels. The needs of the patient come last, after insurance companies, physicians, drug companies and politicians. I always ask people three questions:

1. Would you like to be hospitalized tomorrow, even at best hospital in the country?
2. Would you want to be sick tomorrow?
3. Would you like to be a patient (which is defined as someone who suffers or endures)

…and very few people answer yes to any of them.

The main problem with the current health care delivery system is we’re not getting what we pay for. What about value? Value is function of quality divided by the cost. So the bad news is, we’re getting exactly what we’re paying for. We need to get to the point where we’re paying for value. Coordinated care can deliver the goods. We need to reward the best performing hospitals—not by giving them more money, but by not cutting the amount they’re already getting. And we don’t need to look at other countries to solve our problems. All we have to do is look at the five U.S. states that already outperforming European countries. And we’ve got to get people to view health care as a fundamental human right.

How would you weigh in on these questions?

• Should we get Congress out of the health care business?
• Can current resources be redistributed to integrate care?
• How can we turn dissatisfied consumers into health care reform campaigners?

Coordinating Health Care - Katherine Baicker, PhD

Katherine Baicker, PhD (Bio)
Professor of Health Economics, Harvard School of Public Health

Health care reform is playing a predominant role in the presidential debates, says Baicker, largely because of rising costs. There is an artificial divide in America: expanding coverage and controlling costs. For the most part, higher costs means more uninsured, and more uninsured means higher costs. Rising health insurance premiums have eroded about 25% of the wage growth employees would have otherwise seen.

People want to eliminate waste, fraud and abuse, but that’s only a small part of problem. People are receiving very uncoordinated care, particularly the uninsured. They wait to get treated in an emergency department, which is a very inefficient way to deliver care. But even if all the uninsured were insured, it wouldn’t necessarily reduce spending. We have to figure out a way to finance health care reform without relying on gains in efficiency.

A lot of our health care spending brings negative returns. We’re not getting high value out of the health care system. Some evidence suggests that lack of coordinated care drives high spending and low quality. But there are many causes. Medicare, for example, reimburses for quantity of care, not quality. We must focus on system-wide interventions. There is a lot of evidence of a spillover effect: if one hospital in a county improves care and lowers the rate of preventable deaths, the next year other hospitals in the county also improve.

Wouldn’t be that shocking if we felt we’re getting our money’s worth. If care was coordinated, it would be worth it. If we got better health for dollars spent, we might want to spend more dollars.

How would you weigh in on these questions?

• What would be the optimal health care financing system?
• What are the initial steps toward coordinated care?
• How can The Colorado Health Foundation bring leaders into the process?

Coordinating Health Care - Donald Berwick, MD

Donald Berwick, MD (Bio)
President and CEO, Institute for Healthcare Improvement

Places in the United States with the highest Medicare spending also have the worst quality of care and poorest outcomes. This, Berwick says, is one of the biggest problems of the current health care system. The dollars are spent in unstable ways. What we need is a new system. At the Institute for Healthcare Improvement, they created the “100,000 lives campaign” for preventing deaths in hospitalized heart attack patients. It consisted of six simple changes, such as preventing infections and delivering reliable, evidence-based care.

It was so successful that the hospitals came back and asked for more, leading to the “5 million lives campaign,” which added another six changes. Unfortunately, it’s more difficult to make changes at the population level. To tackle this task, Berwick proposes the “Triple Aim”:

• Improve the health of the population, not just individual patients
• Improve the patient’s experience of care
• Lower the per-capita cost

This goes beyond coordinated care. The problem is, the current business models of all health care organizations are based on keeping these triple aims separate. No one takes responsibility. To reach these triple aims, we must focus on individuals and families, have strong primary care services and structures, manage the health of the population (e.g., identify segments at risk), establish a cost-control platform (with a cap to create discipline), integrate the delivery system and put an “integrator” in place who takes responsibility for what happens.

He has three simple tests for proving that we have achieved the triple aims:

1. Hospitals seek to be empty, not full
2. Supply-driven care is no longer the market dynamic
3. Patients feel remembered by those who cared for them

How would you weigh in on these questions?

• Can we reach the “triple aim?”
• Can Medicare be fixed?
• Can simple changes be successful?

Coordinating Health Care – Susan Dentzer

Moderator
Susan Dentzer (Bio)
Editor-in-Chief, Health Affairs

The current health care system is becoming increasingly complex, Dentzer says. It has been referred to as an “Ad-Hoc-Racy, a term coined by David Lawrence, former chairman and CEO of Kaiser Permanente, who once wrote about the current fragmented system after his 88-year-old mother had broken her hip. Over the course of her treatment and rehabilitation, she saw more than 80 different direct care providers. “When was the last time you knew 80 people who were on the same page about anything?”

Dentzer says we are getting suboptimal care and suboptimal communication. At times it seems like a pick-up soccer game, in which the players don’t know each other and are all wearing earmuffs so they can’t communicate. Coordination underlies everything we’re trying to achieve in 21st century health system. The lack of coordination is particularly problematic for the 60 million Americans with chronic disease. “More Americans have chronic disease than voted in the last presidential election,” Dentzer notes.

She lists several possible solutions to the current fragmented system, beginning with more integrated care, based on the chronic care model. Other solutions include:

• A paperless health system via health information technology
• Creating a “national prevention initiative”
• Forming a best practices institution
• Sharing decision-making with the patient
• Combining the medical model with the social model (home and community-based services)
• Having patient-centered medical homes

How would you weigh in on these questions?

• Can care be integrated under the current payment system?
• Should we take incremental steps toward integrated care?
• Does everyone need integrated care?

Vision for the Future - Anne Warhover, President and CEO, The Colorado Health Foundation

The Colorado Health Foundation’s vision is that Colorado will be healthiest state in nation. Warhover admits that we’re not there yet. We do pretty good in terms of obesity (although that trend is going the wrong way), but we’re doing terrible in terms of children with health insurance, the number of older adults with a regular primary care provider and the number of pregnant women receiving prenatal care.

Our three key strategies are to provide all Coloradans with access to healthy living opportunities and to ensure that everyone has health coverage and high-quality, coordinated care.  How do we get there? Overhauling vending machines in schools seems like an obvious place to start. Philadelphia has done it in every school in their city, replacing sodas and other sugary drinks in school vending machines with water and low-fat milk. But there are still people who stand up in public meetings and say, “This isn’t right. We have to offer our kids Coke.”

We’re not alone. At this symposium, Dr. Kenneth Cooper from Texas issued a challenge to Gov. Ritter of Colorado to see which state could have the healthiest children. Wouldn’t that be terrific: A nationwide challenge among states. But we have a long way to go as a country. We have to start taking responsibility. We need leaders who can stand up to the special interest groups who are in the business of maintaining the status quo.

How would you weigh in on these questions?

• How can we encourage health care reform leadership?
• What is the greatest health challenge facing Colorado?

Coordinating Health Care: Questions of the Day

How would you weigh in on these questions?

1. What incentives could be implemented to encourage more coordinated care practices?

2. What do you think of Dr. Berwick’s idea that hospitals should seek to have more empty beds?

3. What can The Colorado Health Foundation do to encourage the adoption of coordinated care?

Screening Room – "Frontline: Sick Around the World"

Examines health care systems in five capitalist democracies – Taiwan, Japan, Germany, Switzerland and the United Kingdom – to determine if the United States can learn anything from health care systems in other countries. The documentary is reported by T.R. Reid, long-time foreign correspondent and Rocky Mountain bureau chief for The Washington Post.

Learn more about Frontline: Sick Around the World.

Please weigh in with your views about Frontline: Sick Around the World.

Keynote - Encouraging Healthy Living

T.R. Reid
Author, documentary producer and Rocky Mountain Bureau Chief for The Washington Post

Reid describes the distinction between medical care and public health -- “If you save one life you save a human being. If you save millions, it’s a statistic.” The prestige of a medical specialty appears to be inversely proportional to the size of the population it addresses. There were two great scientific discoveries in 1953. Those behind the identification of DNA got the Nobel prize and a book deal, despite the fact that DNA and genomics have yet to have a great impact on the prevention and treatment of disease. The guy who found the indisputable link between tobacco and lung cancer in 1953 is largely unknown—despite saving millions of lives and billions of dollars.

Since preventive health care costs money, you need incentives that will drive society to offer it. Incentives in our current health care system are often the reverse. Insurers will refuse to pay $150 for a diabetic to see a podiatrist for preventive foot care, but nearly all insurers will cover $30,000 for an amputation.

One of the biggest problems is that consumers change insurance companies every six years. So what incentive does one company have to keep you healthy if you’re going to get sick in six years when it’s another insurance provider’s problem? In countries that have a single payer, such as Great Britain, your doctor wants to keep you healthy because you’re going to be his patient “from the instant the line turns blue on your mother’s pregnancy test till the minute you die 90 years later. Considering our many assets, “If we can fix our health care system and get our incentives right, we can and will have the best health care system in the world.”

How would you weigh in on these questions?

• Do people in other countries have better lifestyles or better health care systems?
• How do you convince insurers that preventive care is cost-effective?
• What can The Colorado Health Foundation do to encourage preventive care?

Panel Discussion - Fighting Obesity in Our Schools: What Policies Work?

Moderator: Joseph Thompson, MD, MPH

Panelists:
Elaine Gantz Berman, member, Colorado Board of Education

Ned Calonge, MD, MPH, Chief Medical Officer, Colorado Department of Public Health and Environment

Dr. John Lange, Superintendent, Adams County School District 14

Schools seem like the perfect places to tackle the childhood obesity epidemic since children spend so many waking hours there nine months a year. But taking fitness and nutritional messages to the classrooms is not easy, panelists said.

Calonge noted parents and school officials may object to mandating physical education because they feel pressure from the No Child Left Behind Act and want the time spent on academics. School districts may balk at pulling vending machines from schools because they receive lucrative payments from snack and beverage companies, Berman observed. Colorado does not mandate physical or comprehensive health education, she added. Parents may tell well-meaning nutritionists to butt out when offered advice about preparing healthier foods, Lange said. Because 80 percent of Adams 14’s students qualify for reduced-cost or free lunches, families don’t have the means to buy healthier foods either, he added.

Meanwhile, obesity statistics – even in Colorado, the nation’s leanest state – remain shocking. New federal estimates for 2007 show that 114,000 Colorado children ages 2 to 14 are obese and another 113,000 are overweight. Adding to those numbers, nearly 26 percent of Colorado children are heavier than desired. All the panelists stressed that health and education must work together, with the community, to counter this epidemic.

How would you weigh in on these questions?

• There’s strong evidence that a healthy, active child learns better. How do you change the discussion around childhood obesity from a health issue to an education issue?
• Is there any way to increase the amount of fresh foods prepared in school cafeterias?
• Can the “lean” movement learn lessons from the highly successful “green” movement to better convey fitness and nutrition messages?
• What more can The Colorado Health Foundation do to combat childhood obesity?