January 22, 2007

Personalized Health Care Services

I strongly oppose the so-called single-payer health care model. I have previously articulated my reasons for doing so in this earlier post. One of those reasons is that cost-effective health care is highly-personalized and, by necessity, highly tailored and non-standardized in terms of processes and approaches, but highly-rigorous and standardized in the measurement of results.

Everywhere in the world in which government has operated or regulated health care, including this country, it has tended to create exactly the opposite: a highly-politicized and highly-rigid regulation of processes and approaches, and almost no standardization or regulation of results. The American College of Physicians recently released a relevant position paper “Achieving a High-Performance Health Care System with Universal Access”, which evaluates the condition of the US health care system in comparison to other countries.

Consider Medicare, for example. Today, some 40 years into the program, Medicare is now finally beginning to look at medical outcomes and create quality-measurement processes. Nevertheless, Medicare still primarily regulates what is paid for a particular medical interaction and the details of how someone is treated, and it does not generally alter reimbursement based on results. In fact, far more effort goes into detecting small financial frauds than large-impact treatment incompetence. If poor quality medical care is addressed, it tends to be the aberrational, dramatic incident extensively covered by the news media, as opposed to the widespread, non-dramatic health care practices not covered by the media.

But the bigger issue is standardization vs. customized, tailored health care communications and treatment. We have extremely effective smoking cessation programs in our on-site clinics. The reasons they are so effective certainly include highly-competent, highly-trained health care professionals who care deeply about the people they serve, and work tirelessly to succeed in getting individuals who come to them to stop smoking.

However, one major reason they succeed is that the therapists have a highly-personalized face-to-face dialogue with the individuals, and understand the specific drivers for their smoking habit. They devise customized strategies for removing smokers from high-risk smoking situations, give them targeted strategies for coping with their particular barriers for quitting smoking, and deliver key messages in highly-individualized ways to maximize the chance that these individuals will change their behaviors. They also recognize that some individuals need more time to absorb their advice than others, and that smoking sometimes is accompanied by other health-related conditions, such as excessive alcohol consumption, stress, clinical depression, or weight management issues, and they help address those conditions as well. This recent post from the World Health Care Blog cites the growing interest in these types of personalized health care treatments and insurance programs.

By contrast, Medicare dictates uniform guidelines for the number and length of interventions, and typically dictates treating one medical condition at a time, and a highly-standardized approach to that treatment. Medicare also assumes that an individual will visit specialist health care professionals one at a time in specific sequences. It does not tend to allow health care professionals to intervene in teams with individuals, or to vary their routines by what works.

Medicare has a laudable record in delivering broad-based health care to the broad elderly population, and it has saved countless millions of individuals and families from financial ruin over the last 40 years. But it is dysfunctional in terms of optimal delivery of health care. The per-visit reimbursement model, coupled with the highly-rigid treatment regulations, need to be overhauled to allow non-standardized treatment, reimbursement based on success, and rigorous measurements for that success.

Government-based systems do not tend to get overhauled the way Medicare needs overhaul, for a variety of reasons:

  • Government employees will react most aggressively to aberrational, dramatic stories, not broad compelling, non-dramatic examples of systemic failure.
  • Too many people are comfortable regulating and standardizing reimbursement schedules and treatment processes, because it is easier to formulate rules around them, than around results.
  • Politicians do not want to be accountable for medical outcomes, because they mistakenly believe they cannot influence them, so they regulate inputs, which they can control, but which, as regulated, are ineffective in achieving better medical outcomes.
  • We spend hundreds of billions of dollars on the dysfunctional aspects of Medicare. Too many businesses and individuals are benefiting from the current system to make it feasible to dismantle it all at once.

We need to drive our elected officials toward a performance-based system, not the current system, which is heavily process and rules-driven.