A Principled and Pragmatic Approach to Healthcare Reform

On 8/13/09, Paul Begala's Washington Post article titled Progress Over Perfection made the case that our country needs the "right blend of principle and pragmatism" and we ought not to prefer "glorious defeat to an incremental victory." The primary issue, imo, is how to take an approach stressed by John in the past, i.e., (1) define what we have to (ought to, should, must) do in order for our healthcare reform strategy be judged as principled and, at the same time, (2) define what we can do in order for it to be judged as pragmatic. Following is how I see it.


To be principled, we ought to ensure that our strategy be guided by empathy ("putting yourself in others' shoes" to understand what they are going through) and compassion (caring what others are going through and doing what we reasonably can do to help those in distress). Failure to do so makes the strategy inhumane, fosters civil unrest, and causes cognitive dissonance that is often resolved by heartless, selfish, ignorant rationalizations (e.g., blaming the victim or believing that you are somehow more worthy than those less fortunate). As I have written in my blog, many humans are short on empathy and compassion, and our pathologically mutated form of capitalism breeds this disgusting tendency. When it comes to healthcare reform, a humanely principled strategy, therefore, means giving all Americans ready access to affordable top quality (high value, cost effective) care. Hence, we must have some sort of universal coverage and the means to continually improve the quality and lower the cost of treating persons with biomedical and psychological problems, as well as enabling people to take good care of themselves to prevent and effectively manage those problems.


To be pragmatic, we ought to find fair and effective ways to pay for the tactics aimed at realizing the two main objectives of a principled strategy: (1) providing universal coverage and (2) continually improving care effectiveness and efficiency leading to ever-better and more affordable approaches to care. The methods for financing these tactics must be sustainable over the long term, and there must be ample reliable oversight and transparency to assure no one is gaming the system for their own unprincipled selfish gains at other expense. These requirements are not easy to satisfy, especially since our society tends to focus on short-sighted, quick-fix solutions that are short on empathy and compassion for the public good, and also fail to promote self discipline and personal responsibility & accountability. This points to the need for substantial governmental reform aimed at minimizing lobbyists' influence, quid pro quo favors to party benefactors, operational inefficiencies, etc.

Some of the major healthcare reform tactics being discussed include the public option vs. co-ops, tort reform, and price gouging by pharmaceutical companies. These tactics are all important considerations for a healthcare reform strategy, but they do not explicitly address how they will help achieve the two main objectives of a principled strategy, i.e., prevent healthcare costs from continuously rising and promote ever-greater care quality. That is, these tactics fail to explain how they will to bring ever-increasing value (cost-effectiveness) to the consumer. As a result, it doesn't matter if the government (public option) or private insurers (co-ops) provides insurance coverage, malpractice insurance expenditures drops, and costs medication prices drop because expenditures will continue to climb and quality will not show much improvement unless we can answer these two unaddressed questions:


What is the most cost-effective ways to prevent, diagnose, treat and manage health problems for each person?

How can healthcare providers and consumers be enabled and encouraged to make decisions and take actions that implement those cost-effective ways of avoiding, understanding, and treating/managing health problems?
Answering these two questions requires that we focus extensively on (a) implementing coordinated international scientific research, (b) disseminating ever-evolving evidence-based guidelines emerging from that research, and (c) incentivizing everyone to act accordingly. Any strategy that fails to include the methods and means for achieving these tactics cannot possibly answer to the two questions above, which means it is an inferior unsustainable solution that is neither principled nor pragmatic because:

Consumers will never know how to take care of themselves in the most effective and least costly manner. This ignorance leaves all sorts of opportunities for the promulgation of ineffective and overly expensive self-management approaches.

Healthcare clinicians/providers will never know how to take care of their patients effectively for the least cost. This leaves all sorts of opportunities for ineffective and overly expensive testing/diagnostic and treatment procedures to promulgate due to widespread ignorance. The result is continuing escalation of costs due to over-treatment and over-testing; prescriptions for new and costly procedures, medications and medical devices that offer insignificant gains compared lower cost alternatives; gaming the system through fraudulent and unethical practices aimed at personal financial gains; etc.

The best way to curb malpractice expenditures has less to do with tort reform and more to do with (a) giving everyone the information they need to know the most cost-effective way to diagnose and treat each particular patient and (b) promoting clinicians' competence and willingness to deliver such cost effective care.

The best way to curb prices charged by pharmaceutical companies and medical device manufacturers, and for consumers not to overpay, is for widespread cost-effectiveness and comparative-effectiveness research to be done, including post-market surveillance.
As far as the public option versus co-ops is concerned, I suggest that if co-ops can provide high-value care via affordable coverage for everyone in a way that cost the taxpayer less than a comparable public option plan, then we don't need the public option. I reject arguments by the insurance industry that they are better able to manage universal coverage because they have more experience and patient data by which to make decisions since the data they have are "claims/administrative" data, which is grossly inadequate for answering the two questions above; what's needed are comprehensive clinical outcomes data (see this link). Nevertheless, the problem is that it is impossible to validly determine if co-ops are superior unless the public plan is also implemented, so we can compare the two.

Here's an idea: Since it will take some time to establish and initiate a public plan, how about starting by instituting a nation-wide co-op system immediately and having it run for a year while the public plan is being created. The cost, quality, and access data depicting the co-op's performance would be analyzed at the end of the year, the results would be made transparent o the public, and this information would serve as a baseline by which to rate the performance of the public plan and subsequent versions of the co-op system. I suppose we can start by estimating the cost of the public option by extrapolating expansion of the current Medicare system, and then compare it to the co-op option supported by government subsidies. Anyway, both options must include the price of implementing the necessary cost-effectiveness research and incentives, as well as providing a justifiable game plan about how it will all be done in a sustainable way. In addition, there must be transparency of cost and quality for both options, so consumers can make an informed decision. No matter the method used, there must be a valid way to clearly compare the two options.


Lots of details to be worked out, of which cost of coverage is only one factor. Other factors required for continuous increase in the value (cost-effectiveness) of care to the consumer--in addition to the need for universal coverage, knowledge of cost-effectiveness, incentives for delivering high-value care, tort reform, and cost controls on pharmaceuticals—include the need for (a) care coordination (e.g., through patient-centered medical homes), (b) well-care/sick-care integration, (c) serious consideration of complementary and alternative (CAM) approaches to care in addition to conventional Western allopathic approaches, (d) serious consideration of the mind-body connection, and (e) development and use of next-generation health information technology that provides clinical decision support through implementation of patient-centered cognitive support methods.


Being overly focused on the immediate cost and management of universal coverage, without a balanced focus on the urgent need to continuously increase care value to the consumer, will never result in a better healthcare system and, most likely, will cause further deterioration of care quality and substantial rise of costs over time!


I conclude, therefore, that we certainly do need a principled and pragmatic approach to healthcare reform. Unfortunately, the current debate in our country is grossly imbalanced as we focus on ways to pay for and administer universal coverage, without due consideration for how we will pay for and administer ways to continually increase value to the consumer in ways that reduce healthcare expenditures and improve care quality over the long haul. The bottom line: I contend that the ONLY principled and pragmatic way to minimize cost while maximizing care quality (i.e., optimizing cost-effectiveness/value) is by assuring everyone get all the personalized care they need—and only the care they need—which is delivered in the most efficient and effect way possible. We are literally in the dark ages, however, when it comes having such evidence-based knowledge! This means that we much commit the resources necessary to (a) obtain and evolve such knowledge through international collaboration focused on ongoing clinical outcomes research, and (b) use such knowledge to support the decisions and actions taken by clinicians and consumers. This should be a top priority equal in importance to universal coverage!