It is past time Americans developed a vision that provides a compass heading for the American medical system, to guide America through conflict, and to help us overcome resistance to change. Our vision must be compelling enough to inspire all stakeholders to action—now, and in 20 years from now.

In my home state of Arizona, 1.4 million non-elderly Arizonans spent more than 10 percent of their income on health care in 2008.

The situation in other states is no different. Although Americans have the most expensive health care system in the world, the system is not necessarily a good one. A recent Commonwealth Fund report on U.S. health care stated: “Despite having the most costly health care system in the world, the United States consistently under-performs on most dimensions of performance. An updated Fund report finds that the U.S. system ranks last compared with five other nations on measures of quality, access, efficiency, equity, and outcomes.”

Over the last decade our scholars and politicians have articulated a long list of health reform goals, including better cost control, more consistent quality of care, universal access to medical services, tort reform, equity in fee schedules, streamlined information management, and progress in disease prevention. The Institute of Medicine pulled these and other themes together in an exhaustive roadmap for health care quality improvement published SEVEN years ago: Crossing the Quality Chasm: A New Health System for the 21st Century.”

Why does American health care go from bad to worse even though we can so clearly and precisely state the goals we must achieve to save it?  It’s because, in the American healthcare economy, competition and revenue are not linked to generating better quality care at lower cost.

Competition within the healthcare industry occurs at the wrong level (between hospitals and among insurance plans), and over the wrong objectives (growing networks, negotiating lucrative contracts, filling hospital beds, selling pharmaceuticals), when competition should be over value: effective treatment of patients and diseases at the lowest possible cost.

In a 2004 Harvard Business Review article Michael Porter, the university’s Bishop William Lawrence Professor, wrote: “The most fundamental and unrecognized problem in U.S. healthcare today is that competition operates at the wrong level. It takes place at the level of health plans, networks, and hospital groups. It should occur in the prevention, diagnosis, and treatment of individual health conditions … it is at this level that true value is created--or destroyed—disease by disease and patient by patient.”

Prof. Porter characterizes competition in American health care as a zero-sum game, where innovation, improvement in quality, and global cost control are not necessary for success.

In fact, the interests of health care commerce are often in direct conflict with the interests of a sound public health policy. For example, in the American version of market-driven health care, we have created an economic monster, a completely backwards incentive, the paradox of American health care: the sicker Americans are, the wealthier the American health care industry becomes.  Disease prevention does not fill hospital beds or sell pharmaceuticals.

Furthermore, health insurance plans have devised means to profit and thrive in a zero-sum environment in a way that most certainly conflicts with good public health policy, destroys value, and stifles innovation. Health plans make money by refusing to pay for services, and by limiting subscribers’ and physicians’ choices.

Competition in the wrong arena manifests as misaligned financial incentives at the provider level. Thus, expensive treatment of illness has become more lucrative than accurate diagnosis or prevention; providers compete to offer the latest and “most advanced” treatment to attract business that pays the bills. As a result, we see academic and specialty private practices scrambling to become sexy “centers” and “institutes” offering full lines of sophisticated treatments and diagnostic services, even if these are already available elsewhere. The resulting duplication of services does not improve quality, drives up costs, and focuses on procedural and high-tech diagnostic services at the expense of investment in preventive care.

Consequently, increasingly fewer newly minted American medical school graduates aspire to a career in primary care medicine. Five years ago, in a 2003 issue of Money magazine devoted to health care issues, the authors concisely stated a compelling explanation for this phenomenon: “Surgery is where the money is in medicine. Doctors and hospitals get paid more by Medicare and private insurers for doing something—especially for cutting a patient open or doing some kind of invasive diagnostic procedure ...Way down at the bottom of the reimbursement ladder is the lowly general practitioner (the one who is supposed to be the gatekeeper) who practices medicine mainly with his wits, not a knife.”

Realigning the basis for competition will require substantial change in the entrenched and profitable system by which we pay for and deliver health care. Politically powerful stakeholders who benefit from the current system will not be quick to accept change. This is why the quality chasm has not been bridged, and why effective systemic change will be so difficult.

An honest, non-partisan, and comprehensive assessment of barriers to change would also acknowledge that health care information technology remains backward, and does not yet support the flow of information that doctors need in order to make good decisions; that exorbitant malpractice liability has stifled risk-taking in medical decision-making and has driven doctors to spend even less time with patients in order to see the number of patients needed to pay their malpractice insurance premium; and that training of medical professionals does not prepare us well enough to lead a change initiative (more on this later).

There is no villain in all this. We simply have a system that is fundamentally flawed. One can get rich doing things that have little impact, perhaps even harmful impact, on health care quality, yet a primary care physician can barely make a decent living by focusing only on providing real value to his or her patients.

This is not the sort of problem that a redesign of the reimbursement system, health savings plans, mandatory coverage, or tax breaks can fix. This is a massive, multi-headed massive beast. Cutting off limbs and heads will not work. Its only weakness is its heart of greed—and only with a carefully aimed stroke to that small, mean heart can we prevail. We can aim the stroke well only if we physicians can agree on and promulgate a clear vision for the future of health care, one that that promotes affordable high quality health care over commercial interests; that places value at the center stage; and that provides a framework for making difficult decisions about what we will and will not pay for.

We are currently working without a unifying vision for health care, and it’s the fatal flaw of the current approach to reform. I propose that we start here, then. Without the benefit of a guiding vision, incremental yet steady, purposeful and manageable change is not possible. Well-meaning and hard-working private citizens, philanthropists, academics, politicians, and government agencies must either confine their efforts to a limited short-term health care reform agenda, or contemplate the idea of triggering sweeping change and then hoping for the best.

It is time to stop where we are!

Our national pride is wounded, but the lesson is learned. It is time to re-focus the debate. Where do we want to be for the first half of this century? What do we want health care look like? What can we afford? How can we change the market incentives so that creating value provides competitive advantage? How do we do away with unhealthy types of competition between hospitals and insurance companies, competition that destroys value? Who can lead us? We must have the answers before we can move forward.

Conditions beg for a clear first step to energize and organize. Because change is not currently guided by deeply rooted principles to which all stakeholders are committed, reforms are vulnerable to manipulation by the potent special interests invested in health care commerce, and health care reform becomes a political football. The election year brought continuing debate about changing how we pay for health care, including talk of single-payer options. Whether one agrees or not is beside the point; we are not ready. It is not yet clear who will decide how dollars are spent within such a system, according to what principles, and what behaviors that system would reward.

Whose interests would a single-payer system serve if instituted this year? Yours, mine, and those of future generations of average Americans? Or, interests of the pharmaceutical companies, the health insurance industry, physician special-interest groups, and large hospital corporations?

We cannot enact reimbursement reform without a value-driven framework to guide decisions on those services we want to pay for. We must build into any new payment system simple principals that direct providers, hospitals and pharmaceutical companies to compete over providing value at the level of the individual patient and disease. If we do not, it will be industry and hospital corporations—the commercial interests—who benefit most.

Furthermore, without a clear vision of our long-term goal, well-meaning patchwork efforts such as a single-payer system will create unintended consequences. We have seen this before. Our government’s 30-year effort to create an innovative reimbursement system based on effort, time, risk, and overhead has practically destroyed Primary Care medicine by forcing the providers to see too many patients in too little time.

The first step would be to identify the core concept for our mission, our vision of the future, the “it’s so obvious why didn’t we think of it sooner” bedrock idea around which a cohesive vision of a better future can be built. There is only one a priori requirement: it must relentlessly drive us toward increases in value in all dimensions of health care.

Although the Bush administration demonstrated limited interest in the subject of health care, President Bush offered significant insight when he spoke on health care reform in 2007.  In one sentence, he focused our attention on medical decision-making as the central concept of health care in America. Then he took it a step further—he defined where decision-making leadership should come from. In the 2007 State of the Union Address the President of the United States said, “The best decisions are made by the patients and their physicians.”

Restore decision-making to the medical experts and their patients. This offers a concise, common sense, compelling imperative for health care, and it is in harmony with the broad range of health care reform ideas. It creates the framework needed for us to successfully address fundamental causes of our problems. Add a line from Dr. Porter and we have: “Restore decision-making to the medical experts and their patients; one patient, one disease at a time.”

Restoring decision-making to the medical experts and their patients—or if you prefer, restoring decision-making to the patients and their medical experts—goes right to the heart of Dr. Porter’s assessment. It is a statement that challenges health care professionals to perform at a very high level while keeping the patient and the disease at the center of the process. It suggests that health care providers and patients should be free to grapple with the tough questions of who gets what care.

It threatens to bring out the best in us all. We can build on such a rock.

By implying that the system does not work as it should, the President was also asking: Who, if not doctors and patients, is directing health care? The answer: Health insurance plans. They have co-opted medical decision-making for their own business purposes. They easily outmaneuvered the poorly organized and business-naïve physicians of the past and have cowed our up-and-coming generation of doctors. I recently overheard a medical intern standing outside of a patient’s hospital room say, “Will the insurance company allow us to order the CT scan?”

And as these new health care professionals mature into our doctors, we are simultaneously witnessing the exodus of older physicians who would fight back and lead health care reform if given the chance.

How is decision-making controlled?

ü      Through the confusing and idiosyncratic American system of pre-authorization and coverage exclusions, a system like no other on this planet.

ü      Through medical director review of your doctor’s decisions.

ü      Through pay-for-performance programs run by health plans.

ü      Through abuse of evidence-based medicine by selecting only the data that support the “deny coverage” decision.

These are the tools of decision-making control that culminate in the “We regret to inform you” denial letters of coverage for treatment.

Health plans assure that there is inadequate time budgeted for doctors to lay the foundation for good decisions; to do the listening, learning, and teaching required for a patient to make the right health care decision. In fact, we physicians often find ourselves spending more time interacting with health insurance companies—calling for authorizations and begging medical directors to pay for various therapies and medications—than we spend with patients. This cost shifting of the insurance plans’ internal authorization work, from the insurance company to the provider, is a time-sapping distraction—and surely no coincidence.

As I was thinking this subject over a few months back, an incident occurred in my family that illustrates the importance of time for health care professionals and patients to just talk. Perhaps it will sound familiar. My fit and healthy 80-year-old mother went to her doctor to tell him that she had two weeks of steady pain radiating around her chest since lifting a box of books; the pain was getting better and not causing any disability. Her doctor spent five minutes with her.

By uttering the two words “chest” and “pain” in the same sentence, my mother triggered a week of expensive and invasive heart tests and specialist visits, all negative. And that was it. No diagnosis. The pain was still there.  Perhaps $20,000 of Medicare funds spent; the bulk of it to the hospital and to the test/device/imaging/procedure industries involved in her workup of “chest pain”—not to health care providers.

My mother’s pain was not chest pain at all. It never was. I asked my mother if at any time during all this anyone had asked where it hurt the most ($30 medical history): “No darling, no one asked anything after I said my chest hurt (not in five minutes they didn’t!), they just put me through tests.” I asked if anyone had examined her ribs or spine by simply pressing to see if pain came from there ($60 medical exam): “No.” I asked if anyone had ordered an X-ray of her spine ($124 test): “No.” It became clear that the pain was primarily in her back, radiating to her chest. It was obvious in 10 minutes of doctor-patient interaction that she has a spine condition, not a heart problem.

This was not a difficult diagnosis; it merely required more questions that the average doctor is permitted time to ask. Thousands of dollars were spent on behalf of a problem that never existed. This happened because no one had the time to talk to my mother for more than five minutes because they had to see more patients that they could handle, and because the way money is made at the service delivery end of health care is to do tests and procedures.

Who will stand forth and engage in the work of supporting a rational approach to health care change? If the insurance industry has no incentive to initiate change, if we suspect that the major players on the field of health care commerce have compelling business reasons to resist the idea of handing control of decision-making over to health care professionals, and if we assume that physicians who have the will to effect change lack the time or the means to go it alone, who can we look to? Who has the desire and the muscle to successfully take up the cause, to hold our collective feet to the fire until we take positive steps toward a better future?

Neither the executive branch nor legislative branches of the federal government seem up to the task of effective reimbursement reform. Indeed, politicians’ consistent pursuit of consensus vision throughout election cycles is not a realistic expectation. We must look elsewhere.

American businesses and state and local government agencies have a keen interest in health insurance reform. They and their employees are all profoundly affected by overpriced, under-performing health benefits programs that allocate precious health care resources incorrectly.

The fundamental problems of American health care have to do with unhealthy competition and misaligned economic incentives. Short of nationalized health care, only our business leaders can change this. They are the “customer,” as they are the largest buyers of health plan products. They know that a healthy economy requires a healthy workforce, and that they cannot afford any further increase in health costs. Yet these are coming unless we try something different. As a group, they may be ready to give priority to sound long-range public health policy in their boardrooms. It has become plain that there is no alternative.

Business leaders have the leverage of the large group health insurance plan. Many businesses design their own health benefit plans. A coalition of business leaders could recruit expert help from health care economists and organized medicine, like the AMA, the state medical associations, and medical specialty societies, and together they could draw the outlines for the two most important items on the to-do list: begin reform of our health care reimbursement system designed to place health care professionals and patients back in charge of decision-making; and terminate intrusive insurance plan micromanagement of decision making and restrictions on employees access to services.

Along the way, business leaders should insist on transparency in pricing, provider experience, and outcomes reporting. Consumers need better information on who is doing what for which diseases, and on their results. Business leaders can require that insurance industry managers respond constructively, rather than seeking cheaper insurance products that will perpetuate the current problems. Who else could and would successfully challenge the health insurance industry to participate?

Is the health system is ready to manage care instead of leaving this to the health plans? No. A shift in how we deliver health care and how we train health care professionals is required to prepare physicians and other healthcare providers. In “Crossing the Quality Chasm: a New Health System for the 21^st Century,” the Institute of Medicine concluded that health care for the chronically ill needs to be a collaborative, multidisciplinary personalized process. We need to prepare all health care professionals in a manner congruent with the fact that Dr. Marcus Welby is no more. The days of one doctor calling all the shots are mostly over because health care is often just too complex for top-down, mono-disciplinary management to consistently produce the best outcomes.

The artistry, experience, and intuition that an expert physician, nurse, psychologist, or physical therapist brings to the process will always have a place.  However, health care delivery needs to move towards a team-based decision-making model that includes the patient, allied health care specialists, and often behavioral specialists. Physicians become more the expert managers, and less the solo decision-makers in this model.

For example, we know a lot of our health problems have their roots in unhealthy behaviors, but how often do you see a behavioral psychologist working on the primary care team in a large group practice? Team-oriented ways of handling complex systems, such as systems thinking, have been developed and pay dividends to businesses that use them. They are by no means new to businessmen.

I recently asked a group of senior medical students if they had ever heard of systems thinking, or any of its synonymous disciplines; if they had any specific training in how to create, deploy, or manage teams of health care professionals to manage the complex problems of the growing chronically ill population; or if they had any leadership skills training. Their answer was, No.

Our medical, nursing, and pharmacy schools would have to embrace the challenge of graduating health care professionals trained to lead the multidisciplinary teams if we want patients and their providers making the best decisions. This is worth paying for, but we cannot ask the health insurance industry to reimburse health care providers for services they are not trained to provide.

In light of that, the President’s State of the Union message is in need of revision. It must reflect the need for the team-based model of care by replacing the word “Physician” with “health care team”: “Restore decision-making to the patients and their health care teams.” There are many analogies. Think of the change in the space program, from the days of omnipotent test pilots whom few would ever challenge, to the thoughtful, humble, team builder-team member, engineer-astronaut. Not as glamorous as Chuck Yeager’s career, but by now proven to be a safer and more effective strategy in the face of complex and unstable machinery, systems, and plans that seem to hover at the border of chaos.

The physician as manager is a role that might make medical traditionalists uncomfortable. However, it is a role health care providers, in particular physicians, must assume if they want Americans to trust them to make the best decisions with their patients. To our credit, some related medical, nursing and pharmacy schools are starting to push their students into team environment class work and clinical training, such as the University of California at Irvine.

Effective change in medical training, and change in information management, financial incentives, and medical malpractice—all require clear vision about where we are going in order to stay on track with the goal we all want, which is an excellent yet affordable public health system. I am advocating that we must first have the kernel of an idea, an imperative that constantly reminds us of the path we have decided to take toward that excellent yet affordable public health system. Then we must build around this a vision that illuminates the way forward, inspires the undecided and the fatigued, and which will expose the insincere.

How about this: In 20 years we will have done away with the five-minute doctor visit. We will have doctors, nurses, and allied health care providers who are trained to build and to work within efficient problem solving teams that include the patient; these experts will take whatever time they need to make the important decisions in partnership with their patients because we will value that service above all others, and we will pay for it.

We will have revamped the reimbursement system to sustain these changes.  Health care providers will have society’s permission to openly share and learn from bad outcomes and mistakes. They will not suffer stifling administrative interference when ordering tests and treatments from health plans, for profit hospital systems, or government agencies.

There will be no restrictions on choice of provider or hospital. Instead, the major stakeholders will have cooperated in updating and disseminating reasonable evidence-based guidelines, developing information management, outcomes monitoring and reporting systems (not pay for performance, mind you, the real thing) that help to reduce illogical variation in medical practice.

Information about results of the care will be easily available. Our imperative will integrate all these ideas toward a health care culture in which patients and the expert health care team make the decisions, one patient at a time.

Just as one cannot pack for a trip before the destination is clear, we cannot sweat the details of health care reform until we know where we want to go.  Let us show that we are up to the challenge and together develop the vision for 21st Century American health care that will guide us through what promises to be a difficult next 20 years. 

Perhaps there is a better vision than the one articulated here, a more urgent and relevant imperative from which it will derive.   Let us discover it now.  Time is running out, Medicare will be insolvent in just 7 years.  America’s new president must help us articulate where to go with health care, what we see as the framework for change, be clear on who will make the important decisions along the way, and by what set of rules.  This will be a test of “Yes, we can”.  This will take courage at all levels.  Creating a national consensus will take exceptional leadership.  We have done it before, we can do it again.