What Is Health Care Reform About
Really? Hint: It’s Not About Health Care


Leonard Zwelling

         For the past 5 years or so, I have been living and breathing
the politics of health care reform. And, the economics of health care reform.
And, the regulation of health care reform. Surprisingly perhaps, I have not
been living with the actual provision of health care and neither have most of
the people making all the decisions on the politics, economics and regulation
of this industry—what I call the health care-industrial complex.

         Three weeks ago, my life changed when I shifted my employer
from a tertiary, highly specialized cancer care facility in which I have not
had a real role in patient care for over 20 years, to a federally qualified
health clinic whose major foci are primary care, pediatrics, pre-natal care and
mental health. I am now heavily involved in helping those providing health care
to many people who might have a difficult time gaining access to care at my
past employer.

         I have been living in the reality of the people who actually
provide health care. As is so often the case, I have learned that what I
thought was true and what is really true are not exactly the same. I think
that’s because health care reform, the focus of my attention for the past five
years, has nothing to do with health care provision, but rather with how to pay
for it.

care reform is about money or as my friend Norman Ornstein of the American
Enterprise Institute has said: “Everyone’s idea of health care reform is the
same. I pay less!”

         Understanding the realities of health care reform AND health
care itself allows for better planning on the part of huge institutions like MD
Anderson and much smaller ones like my current employer, Legacy Community
Health. So in an effort to clear the air that has become hopelessly filled with
hogwash about health care reform and confused reform with real patient care (Memo
to Barack Obama: a health insurance card is NOT health care even if you get
your clunky website to work), I will try to outline what I have learned in
Washington and Houston. I hope this helps you in your thinking about our

Health care is an
act that takes place between a consumer known typically as a patient and a
supplier, usually a doctor or other provider of services. It is not an act requiring
the involvement of insurance companies, coders, billers, schedulers, etc. Those
other ancillary people are supposed to support the doctor-patient interaction.

This tends to get
lost in some organizations in which the support structures begin to believe
that health care and the resources it generates are to benefit the support
staff. They are not. It is the other way around.

It is important
to know what business you are in. Whether it is MD Anderson or a primary care
clinic, the business is the provision of care by one human for another. That
care, however, can vary a great deal in type and in quality.

If you want to
alter the way health care is delivered, it would be best to know what it is you
are delivering and then develop an appropriate business model to deliver it. Is
it primary care? Prevention? Screening? High intensity diagnostics and
experimental therapeutics? Proton therapy? Choose one or two. You cannot do
them all and do them all well.

For now, we are
still on the fee for service model. Whether accountable care organizations
(ACO) and patient-centered medical homes (PCMH) change this remains to be seen.
This is because ACOs and PCMHs are really 1994’s capitation with lipstick.

In our dominant fee
for service system, the more you do the more you make and the unit of business
is the “encounter”. The operations folks thus correctly push for doctors to see
more patients so that the organization makes more money. That’s the goal of the
operations and finance folks, maximize income. 

In the ACO or
PCMH systems, the less you do the more you keep (you are paid a lump sum to
care for a lot of “covered lives”). The unit of care is the “patient panel”. The
goal, rather than to care for the sick is to maintain the health of those in
the panel. For now we are still fee for service but this is likely to change
and shift the financial risk from the insurer to the provider.

Once you choose a
care delivery model, you should be able to create an environment in which the
providers of health care can be optimally supported to provide the type,
intensity and quality of the care chosen in the business model du jour. In
other words, let the providers do their jobs. Even better, help them do their
jobs. Don’t stand in their way with electronic systems that don’t work or
double the work load because the support systems designed by operations people
are inconsistent with the practice of medicine and don’t support what a doctor
does. Support staff managed like an assembly line instead of in teams, and
process managers who have no idea what it means to care for a patient let alone
30 or 40 a day will struggle in improving the quality of care and struggle with
the providers they purport to support.

It also would be
wise to measure what it is you are doing and identify targets of success. This
involves both deciding what you are measuring and setting goals of success. Is
it money? Is it outcomes? Is it volumes? Is it payer mix? Decide and make sure
everyone involved knows what are the goals, the strategies, the tactics and the
metrics so that they can fully buy in to these or decide to do something else
if their view is not that of the organization.        

things should all seem obvious, but I assure you they are not. Ask any clinical
leader at Anderson whether he or she really controls the processes by which
patient care is delivered (like it or not bean counters, care is the product!) and
you will likely get a good laugh if not tears. 

are a group of people called various things– operations, nursing, quality
assurance, quality control, logistics, lawyers, etc–who really control the
resources by which the real product of a health care system is delivered. It is
rarely in the hands of physicians. AND THAT’S OUR FAULT!

the coin of the realm in health care is the COIN of the realm (money) not
really health or health care, the oversight of the coin has been given over to
financial and administrative people, not doctors. The eventual outcome may be a
healthy balance sheet, but not necessarily a healthy population.

shift the balance back to health care and not its “efficient” (I love that word
because I have no idea what it means in our business), and high “quality” (or
the meaning of this one either) care delivery, doctors need to reassert
themselves into the management of the processes by which their care is

more excuses. If you have to go to business or law school to represent yourself
and your colleagues, do so, but stop stepping away from your responsibility. And
for goodness sakes stop whining that life isn’t fair. We know that. If life
were fair, no one would get cancer, but they do. FAIR, as George Will has said,
is the four letter F word

you deliver care is every bit as important as the care itself. We need to take
both back—for the sake of our patients. It would also clear our minds and return
us to our rightful position in society—ethical leaders fighting for the rights
of the ill at their time of greatest need.

remember that. It’s why you went into this business in the first place! How
much more fun would your work be (FUN=Pleasure+Engagement+Meaning) if doctors
ran the zoo?

Leonard Zwelling