Reform Requires Transformation

We all know that there is a great deal of conversation happening at the national level around health care reform.  We also know that many consider the current discussions not really about true health care reform, but rather health insurance reform.  There is significant attention being paid to the end result of a fractured health care system that is lacking in coordinated care, inadequate utilization of technology and costs that are out of control.  The end result is higher insurance premiums and escalating numbers of uninsured and underinsured individuals in this country.  Certainly, as we in health care have known for some time, it is often easier to treat the symptoms rather than take the time to address the root cause.

The Future of Family Medicine report clearly and succinctly stated in 2004 that BOTH the US Healthcare system and Family Medicine (I would suggest all of primary care) needed to change.  The health insurance industry is a major part of the equation, of course.  The ever-increasing administrative burden and misaligned incentives certainly create barriers to providing high quality care at an affordable price.  The focus on premiums, however, is again directing attention to the result not the cause.  In this environment of for-profit insurance companies, profit margins are going to be protected whether we like it or not.  Increased costs and increased risk lead to higher premiums.  That is the model the country has embraced and will continue to embrace.  But profits should not be excessive or unreasonable and services should not be denied -- and it is the responsibility of the government to protect its citizens, as it should do in banking, pharmaceutical and many other industries.  While the narrow focus on insurance premiums may reduce the cost (or quality) of private insurance, it will not reduce the cost or improve the quality of the care delivered to our patients.

Those that deliver the care are best positioned to lower the cost and improve quality of that care.  Many of us would argue that it is primary care that is best positioned to lower cost and improve quality.  The Future of Family Medicine report stated that not only did the system need to change but primary care itself needed to change.  I would suggest that the payment systems and administrative burdens need to be reformed, but primary care needs to transform.  Transformation is something we do and not something that is done to us. 

TransforMED is involved in many pilots across the country.  What we are learning is that in as little as 6 months, quality goes up, costs come down, and patients and providers are happier.  Several progressive payers are realizing that primary care providers can be paid more and incentives can be aligned with the savings from improved quality and efficiency as demonstrated in the TransforMED pilots.  The strongest testimony to this is that at the one year anniversary almost all of the TransforMED pilots are expanding by adding more practices and improving incentives.  Many payers and self-funded corporations are now thinking about moving PCMH past the pilot stage.  This is health care transformation not reform.

Healthcare can be "reformed" and/or it can "transform".  The private insurance system needs to be "reformed" to lower the administrative burden to providers, correctly align the incentives to take care of populations of patients based on outcomes, and guarantee that everyone has access to a basic level of health care. The real key to success, however, is that all primary care practices "transform" to patient centered, high performing practices within the framework of the Patient Centered Medical Home.  This successful transformation will be evidenced in a lower cost of care, a higher quality of care and an expanding primary care workforce with aligned incentives.

The bottom line is that successful reform cannot occur without meaningful transformation.  The forces are aligned, now the "dots need to be connected".