MANAGED CARE June 2007. ©MediMedia USA
The United States' health care system needs consumer and market controls to succeed, but it can't rely on only those two factors
Jonathan Weiner wants you to know that, unlike some of his colleagues in public health circles, he doesn't see managed care as the enemy. He notes that he is one of only a handful of academics who teach a course in managed care, as he has for more than a decade. A widely known researcher, policy analyst, and lecturer on health care organization and financing, he advocates sharing applied research among health plans, physicians, academic medical centers, and public and private payers. A professor of health policy and management at Johns Hopkins University's Bloomberg School of Public Health, Weiner sees a glaring need to use population-based research to improve efficiency, quality, and equity and then to translate what's learned into practice. His areas of focus include primary and ambulatory care, risk adjustment, quality of care, health informatics, workforce planning, and international health systems. He was codeveloper of the widely used Johns Hopkins ACG risk-adjustment/predictive modeling methodology and now leads the ACG R&D team.
Weiner, a member of Managed Care's advisory board, holds a doctorate of public health from Johns Hopkins, a master's degree in health administration from the University of Massachusetts, and a bachelor's in human biology from the University of Pennsylvania. He spoke recently to Senior Contributing Editor Patrick Mullen.
MANAGED CARE: You've done consulting work across Europe and Asia. What are some essential differences in how other developed countries approach health care compared to how we do things here?
JONATHAN WEINER: Other developed countries have come to two realizations that we have not come to. One is that it is immoral — or at best, amoral — not to provide health care to everybody if we believe that basic health care is a sign of a developed country. Taiwan has moved very rapidly to universal health care. Even mainland China acknowledges that as it gets more developed, it will need to provide health care for everybody. Recently, while a colleague from Germany was here, a tractor-trailer truck rolled up with what I think is Johns Hopkins' 18th scanner. He asked how we can afford another MRI while people two blocks away don't have health care. I told him I don't know. The second realization is that other countries acknowledge that the collective — social insurance programs like the sickness funds of Germany, government agencies, or third parties that look very much like our insurance or managed care companies — cannot provide everything for everybody.
MC: So far, health care has been largely immune to global competition. Do you expect that to change?
WEINER: Yes, the health care system will become flat like the rest of the global economy. It's true that patients can't head overseas as readily as many jobs have. But increasingly, as things are digitized, American doctors, just like American corporations, will need to be careful. When it's feasible — in areas like laboratory, pathology, radiology, reading EKGs — care will be delivered at the lowest-price, highest-quality point, regardless of geography. Medical tourism is also showing signs of growth. At least two insurers, Blue Cross of South Carolina and one of the southern California Blues are starting to cover people traveling abroad to get health care. For elective surgeries, some patients will gladly go to another country where a procedure is a third or a quarter of the cost here and the quality is as good or better.
MC: Is there some shared trait among countries or organizations that have embraced health information technology?
WEINER: Every advanced HIT system I've studied — the British, Hong Kong, Kaiser Permanente, and Geisinger Health System in the U.S. — has a centralized rational entity that looks at the big picture and sees itself as being in this for the long haul. Hong Kong has probably the most sophisticated HIT system in the world. All of the nearly seven million Hong Kong residents have electronic medical records. We really are the laggards. Many well intentioned and ethical managed care executives from IPAs and PPOs just can't make a business case for investing to bring physician office systems up to speed.
MC: They can't justify buying equipment for independent physician offices that will reap most of the benefits?
WEINER: Exactly. Although corporations must behave ethically and legally, it's not their goal to solve social ills and collective issues. That's why we have government and elected officials. That's a microcosm for everything that's right and wrong about our health care system. Few organizations, including many good ethical managed care plans, are in it for the long haul. Integrated delivery systems take a longer-term view because they're also providers.
MC: What direction are organizations that are investing in HIT moving? How are electronic medical records evolving?
WEINER: The EMR is giving way to the EHR — electronic health record — as the preferred term for what's in the doctor's office. Also, organizations are giving up on doctors moving quickly, and are bypassing them and going to a personal health record, a PHR. It's an Internet-based, patient-oriented record that beneficiaries can take with them from doctor to doctor. Aetna has developed its own PHR because it's the right thing to do. It makes business sense and PR sense.
MC: Online banking has become the norm. Do enough people now have enough confidence in data security to have similar confidence that their health information will remain confidential?
WEINER: I don't think so. We have a ways to go. Ironically, I had $25,000 stolen electronically a couple of years ago and I got every penny back. If my medical records or those of my family are stolen, it's a little trickier.
MC: What's the best way to help physicians adopt EHRs?
WEINER: Provide incentives and make it easy. Learning a new system isn't something that can be done by a doctor in his or her spare time at 8 p.m. after having seen the twentieth patient. Physicians want to do the right thing, and many of them aren't good at or interested in administrative issues, so we need a support infrastructure. Not everybody can practice in an integrated system like Kaiser Permanente, but everybody could in theory practice with a virtual support infrastructure. It's going to be a huge change, and it will probably be generational. A team at Hopkins and the Park Nicollet Institute in Minnesota is working on what we call the e-Indicator project. We're collaborating with quality organizations like the NCQA, the National Quality Forum, and several leading-edge delivery systems that are already computerized. We're trying to see how EHRs can be used to measure and monitor quality and safety. We found that young doctors and residents coming out of medical school can often learn to use EHRs in three hours when older physicians sometimes need three weeks.
MC: How will technology change medicine?
WEINER: Within a generation or two, we'll see the positive side of health information technology. Health care will actually get more humane, with more human interaction and more communication, because the technical side of what doctors do now will be handled by the electronic box. Things like figuring out what tests should be ordered, what drugs should be used, looking at an EKG and comparing it to the evidence will all be done better by electronic systems, using algorithms developed by doctors at places like Cleveland Clinic and Johns Hopkins. Doctors will need to be communicators, facilitators, coordinators, and coaches. I believe that model will favor women doctors, because they happen to be better at those skills. I also think this is a real opening for nursing because they've historically had those skills. One big part of the consumer education movement is figuring out how to make sense of all of the clinical information that's emerging.
MC: How well is medical education adapting and producing doctors who have the skills you describe?
WEINER: There are pockets of innovation, but by and large the medical education system is not so much in touch with changes in health information technology, with population-based medicine, or with the need to be community oriented. As the health care system changes, how doctors are trained needs to change.
MC: You've talked about how "managed care is dead." What do you mean?
WEINER: I was talking about the effects of the managed care backlash. When managed care plans, working mainly as agents for employers and government, tried to make some necessary changes and do the right thing, nobody would let them. We shot the messenger. We're lousy at doing what's necessary in our health care system. Tightly controlled managed care as envisioned in the '90's in the Clinton reform plan is not managed care today. I'm a big supporter of good forward-thinking managed care on the part of executives and clinicians, and I definitely support the appropriate role of the market and consumerism. But we can't lose sight of population-based care and public policy issues that don't come naturally to managed care organizations facing pressure every quarter to make a profit and keep investors happy. We face a duality: We can't have good health care without a consumerist and market orientation but we also can't have good health care only with such an orientation. I'm not just blaming the managed care companies. Consumers in health care aren't always that smart either. But often managed care doesn't do the right thing.
MC: What would be an example?
WEINER: It doesn't take a lot of manipulation of a company's medical loss ratio to pad the bottom line. That's one reason my colleagues at Johns Hopkins and I developed the ACG Case-Mix System, which is widely used for risk adjustment across the United States by Medicaid and managed care plans, and in about eight other countries.
MC: How do ACGs differ from other tools for risk adjustment?
WEINER: ACGs were the first population-based method. They're based on research showing that clustering of broad morbidity types is a more reliable predictor of health services resource use than just the presence of specific diseases. ACG originally stood for ambulatory care groups, but now that the software is used for all types of care, we call it adjusted clinical groups or usually just ACGs for short. The system categorizes each of a patient's ambulatory and inpatient ICD diagnosis codes into one of 32 morbidity categories and one of over 200 disease groups. We can also use pharmacy information to assign risk categories. Using data from millions of patients, we've developed predictive models for all types of financial, administrative, and care management applications.
MC: Do you expect the United States to continue to have a private-public hybrid health system, even as employers' enthusiasm for managing health benefits wanes?
WEINER: Absolutely. In the early 1990s I consulted with both the Clinton health reform team and also the first President Bush's team. By the way their plans were almost identical. Both proposed a market orientation on a playing field regulated by government, which I felt was about right. Health care is a third rail for policy makers and business executives, and will be until we reconcile the major cost and access issues, but even if they don't maintain their pre-eminent role, employers will always be involved and will always be expected to pay into the system.
MC: Where should health plans, physician groups, and health systems be spending their research and development money?
WEINER: In health delivery, we first should stop doing R&D as an alternative to rational policy. Over and over, we do research that concludes that being uninsured is bad for you or that evidence-based practice is more efficient than non-evidence based. It's paralysis by analysis. We need more applied research. It is absolutely inexcusable to have databases that allow us to improve care and efficiency and not to fully exploit them. When EHRs come fully on line, the possibilities are endless. The ability to analyze the electronic medical records of 1.4 million Kaiser Permanente enrollees helped uncover some of the problems with Vioxx.
MC: Have we moved beyond the battle over cookbook medicine? Is there general agreement among physicians that for most diagnoses, common standards can and should be followed?
WEINER: Absolutely. The Institute for Clinical Systems Integration, at «www.icsi.org», is a case in point. Providers, doctors, and managed care organizations in Minnesota developed evidence-based guidelines that they all could follow. The original impetus came from employers working through the Buyers Health Care Action Group, the business coalition in Minnesota. They pushed hard for evidence-based care. It's a big part of why Minnesota practice patterns are much more efficient than almost everyplace else. We must do that nationally. Our health care system is the most expensive in the world by a factor of two, and the most inefficient probably by a factor of three. Yes, we pay our doctors and administrators more and patients who get care get a lot more, but a lot of the cost difference is due to waste. We need clinical research of the type funded by NIH, and we need more operational population-based research. The Agency for Health Care Research and Quality is terribly underfunded now, and once genomics come more fully on line, research into cost effectiveness will become even more important. Give credit to the pharmaceutical industry: I know they're controversial, but still, their R&D investments are relatively high.
MC: What needs to happen to more quickly and widely translate research into practice?
WEINER: We need partnerships among industry, academia, consumer organizations, and government. Existing databases have to be joined. EHRs have to be interoperable. Kudos to the Blues plans, which created Blue Health Intelligence, which brings together the claims experience of 79 million Blue Cross & Blue Shield members nationwide with all personal details removed. The managed care industry could follow the lead of other countries and set up a not-for-profit research institute. It would be at arm's length from health plans while representing their interests to academics and government. It would be guided by population-based principles of budgeting and benefits.
MC: What will wide adoption of evidence-based care mean for patients?
WEINER: Insurance coverage will be evidence-based and won't cover everything. Everybody in health care — Medicare, employers, managed care entities — must understand that they have a social responsibility to work within fixed limited resources. Below an agreed-upon line is the coverage that everybody gets. Beyond that, the patient pays. Over time, the coverage will improve as we get richer.
MC: How important are the provisions in the Medicare Modernization Act that opened the door for Medicare to make cost-benefit analyses?
WEINER: I serve on the Medicare Coverage Advisory Committee, an academic group, and I can tell you that Medicare has nowhere close to the authority it needs. There's a lot of good people at CMS trying to do a good job, but their hands are tied by legislation. In most cases, they are not allowed to look at cost-benefit issues.
MC: Who's persuading Congress to maintain the status quo?
WEINER: Device manufacturers, pharmaceutical companies, everybody and their mother. God bless Big Pharma for keeping the new technology coming out. We may all need it one day, but it doesn't all work equally well, and it certainly isn't all cost effective. We cannot as a society pay for everything for everybody. That is absolutely impossible and totally unethical as long as we have 18,000 people a year dying — the equivalent of fifty 747's going down — because they lack health insurance. My tone and tune will change once we have basic health care for all. We are a rich country and we absolutely can afford it, as long as we operate within a budget.
MC: What would be the optimum mix of primary care physicians, specialists, and other caregivers?
WEINER: An in-depth analysis I did with Kaiser Permanente and several other large prepaid group practices has been controversial because it shows that health care can readily be provided with far fewer doctors, far more nurse practitioners, and fewer specialists than we have today. The Association of American Medical Colleges says that type of practice is a pipe dream because while it may be the right thing, it's not what our system wants. They may be right. Patients like specialists and hospitals make more money by supporting specialists than generalists.
MC: Wouldn't changing what our system is willing to pay for change what our system wants?
WEINER: What we want, what we need, and what we can afford are three different things. As a public health professor, I spend a lot of time on what people need. We subsidize specialists more than we do primary care education. When a young doctor or medical school dean tells me that in this country the market does what the market should do, and government should keep out of it, I tell them that's fine, as long as they're willing to return the million and a half dollars in federal and state subsidies for each doctor trained. A plastic surgeon practicing in the fanciest suburb in any city gets more of a subsidy than the family doctor practicing in an inner city or rural area, and that's not right. Moreover, the plastic surgeon can make a half million dollars a year, while the inner city doctor is making a hundred thousand. We're the only country in the world where specialists generally make twice as much and can easily make ten times as much as what a primary care doc does. In Spain and the U.K., most family practitioners make more than specialists. A lot of physicians and people in public health — not to mention Michael Moore in his latest movie — blame all of our health care problems on managed care executives making millions of dollars. I remind them — and I've done the math — that when you look at U.S. doctors' salaries compared with physicians in places like Germany and Switzerland, the differential adds up to far more than what HMO execs make. So when we talk about profit in health care, there's enough blame to go around.
MC: Thank you.