Very intrigued to see where this discussion goes.

Thanks for the post, Anthony!

Burrell (Bo) Clawson I propose that better outcomes need to have a predecessors; proper health education and true risk based insurance rates, where smokers and overweight pre-diabetics pay more.

Better outcomes in the end must have better earliest diagnosis, so people get corrections before they have a chronic lifelong illness. If people get tested early and choose to change when they can do so to prevent a lifestyle based illness, they can keep the low insurance rates.

Unfortunately, I do NOT see our Congress of Democrat Progressives and Republican "Followers of Progressives" doing anything substantive … yet.

Perhaps the employers in the US with wellness programs can start to make a carrot and stick improvement with their employees.

Human health trends often get set in grade school years from seeing & following what their family members do, so there is a long way to go on education of people to think about long term health.

On the temptation side, we have huge psychological and marketing expertise & $s devoted to convincing the public to buy the wrong type of foods and drinks. Those companies know full well what they are doing in enticing people to buy less healthy preprepared foods that people don't need.

Education is the only thing I see as solving the "better outcomes" end results and it is going to be a long process. I don't know if it can be done.

Wow. That's a tough one, Anthony. I'm sure we have some actuaries out there who could answer this a lot better than me. Behavior doesn't often shift until people feel the impact of not changing behavior. If I am 27 and a smoker and you tell me that I will have 10 years lopped off my life (or whatever the number is), I am not going to be motivated to change. But if you tell me that my premium is going to be double because I'm a smoker, maybe I will change. Maybe. If 20% of all Medicare patients end up back in the hospital within 30 days after discharge, and hospitals are penalized for that number, they will go to work on it (as most of them are, by the way). If we did not know that we were experiencing that outcome, how would we even know we should go to work on it? Because it's difficult, does not mean we shouldn't do it. Outcomes are very important, IMHO. Awareness + incentives (+ and -) can create change.

I'm already over my head and realize I should have sidestepped this as adroitly as Joe did.
Gary

Burrell (Bo) Clawson The numbers for illness demographics in the US are depressing:

120-140 million people with chronic illness from CDC & Milken Inst. (& many with multiple chronic illnesses.) Not all chronic illness can be avoided, but a lot surely can.

4-5% of patients eat up 50% of a hospital's costs.

50% of hospital admissions are due to self-induced problems.

Measuring the changes that lead to a number of key chronic illness problems can be done. It remains to be seen if we can motivate people before major problems reach the surface of recognition. Miniaturized health monitor devices people wear may possibly help.

Anthony Wunsh Let me try and explain my point better.
As we are dying in the real problem facing healthcare, cost, cost to deliver care, cost to receive care, cost to insure for access to care too many are trying to solve problems that will have no effect on cost for decades. And "better outcomes" while a noble idea is one of those that frustrate me. Everyone wants everyone else to eat better, learn more about health, change bad behavior and such, no sane person would say this is not a good and noble idea. But it has zero effect on a system today that is crashing around us. While people talk about theory and long-term solutions, more and more are being priced out of even having the ability to get the most basic of care.

And I just can't get away from the fact that when HMO was forced on the vertical, the very same rhetoric was used to sell it, preventive medicine and more access to free care and more education due to more visits was going to lower costs and make us all healthier. Well it in fact raised costs due to over consumption, raised insurance rates due to changes in risk and added free services (maintenance instead of catastrophic protection), and we certainly did not become healthier the opposite in that measure as well.

There are real things that can be done today to reduce costs and we do none of them and some folks in Ivory Towers or political positions or agendas keep doing more harm than good.

Fix what we can today, and work on the long-term after we can afford it.

And by the way, cost is relative whether you are the employer, the employee, self insured, self pay, tax payer or provider.

Anthony Wunsh Bo, yet again the point I made in the post, 70 million smokers still, obesity at epidemic levels, and certainly we are not to believe these folks do not know it is a bad decision, yet they make it anyway.

In what world is government going to force the behavior changes on 325 million people of all different situation, gender, ethnicity, environment, demographic and income levels. And then do we want to live in a country that allows government to force those decisions on us.

The societal ramifications of fixing this are far reaching, but there are immediate cost fixes available to us. Like getting a third party out of the financial and healthcare transaction, like allowing insurance across state lines, like changing tort laws, streamlining drugs to market and easing governmental regulation, all would have immediate impact on access to care thus should also generate better outcomes.

Are we not backwards in how we are approaching this?

Burrell (Bo) Clawson Maybe we should look at the 2 components of a person's health as needing attention at the same time to drive change: Immediate care and mandatory monitoring in order to receive care.

Right now in airplanes and increasingly in automobiles computers are monitoring all sorts of measurements, so that early problems are fixed before a crash occurs.

Finding when a chronic condition is getting slightly out of control and doing something in conjunction with physician input (maybe via email) is way far cheaper than letting a patient wait until a crisis requiring an ambulance and hospital visit.

Anthony Wunsh Bo, great idea, but again it addresses a fix to the long-term cost of care. The 120 million or so you quoted are likely not going to be cured, so the cost to maintain them will remain constant, perhaps eliminating some of the events that drive that cost.

But here are numbers to digest.

The way we get paid costs the industry and thus the system 1.2 trillion dollars a year, in hard costs to process the billing and remittance processes, 400 billion unpaid each year of claim request dollars from insurers and another 400 billion uncollected in patient responsibility. And I don't mean charity or inability to pay, these are the dollars from insured patients who don't pay the deductible, co-insurance and co-pay dollars.All of this is passed on in higher charges to those who do pay.

Tort causes us to order 400 billion a year in added tests and malpractice insurance is a top five expense in the vertical, again all passed on to the consumers of care one way or another.

Cost to bring a drug to market now at 2.9 billion, any question as to why drugs are so expensive in the USA. Why, not so in Europe and other countries.

Government short reimbursement from Medicare and Medicaid means all in the private sector pay more, and the amount of regulation required forces healthcare to employ staff that has nothing to do with delivery of care. Untold billions annually lost to this.

Pick one and fix it and what impact would it have, fix them all and the cost of care would be 60% less than it is right now, and then how many more would be able to afford more care?

Guys,

It's not always a cost of care. There are cases where an improved quality of life warrants incremental expense.

Even still, I find myself agreeing for the most part with the comments above. In the U.S. we've had a more rigorous regulatory environment than Europe and a more tortious environment. The revenue opportunity was sufficient to absorb those costs. As our government tries to move us more towards a European style of medical management, I am very concerned that neither tort reform nor regulatory hurdles will be addressed.

Burrell (Bo) Clawson Anthony, I appreciate that the overhead in the healthcare system is immense. We start somewhere fixing things or we eventually implode like the old USSR.

It seems like today, the only way to motivate patients is to get more personal interaction with their employers & doctors via email and monitoring/testing devices.

Measuring devices were super expensive in the past, but now they are built into mass produced chips, so these are now cost effective for many uses. The cost-benefit ratio for simple electronic devices is huge and companies are already jumping in.

I see personal body worn electronic monitoring as quickly becoming the norm. Apple is indeed betting on it and I would not be surprised to see a specific multi-functional medical monitoring device come from Apple at some point.

Jason Sanford We can start by simply addressing over-treatment of indolent diseases. ~ half of diagnosed cancers fall into this category and yet we cost the system billions through unnecessary, often radical treatments which cause lifelong morbidities in these patients. To me, these are bad outcomes that could easily be avoided, while saving billions through the process. Better outcomes are not "smoke and mirrors".

Burrell (Bo) Clawson Jason, I think we can all agree that over-treatment should stop.

Physicians who are unable to earn enough with low reimbursements to make a decent income, then are tempted to make the recommendation which gives them income to keep the office open.

I have already heard of 'under the table' pressure in Em. Depts. for the docs, nurses and PAs to mark down for extra billing codes to keep the income up. There are lots of articles on these problems.

Trying to design solutions is a tough, rough road.

Some politicians simply don't care if the system fails because they have already publicly stated that healthcare will quickly move to the US Govt. running everything as "Single Payer." Unfortunately, the US Govt. is even less efficient at running large projects, let alone mega-projects, than the private sector. Part of this is due to the congress and bureaucracy sticking their thumbs in the pie for goodies of various types.

I agree with Jason Sanford 100%

Anthony Wunsh Okay all a point to be made, here on this thread already we have heard and read various points, which differ greatly, many are personal causes or based on experiences.
It is a microcosm of why nothing ever gets done.
We have heard change the habits or behavior of 325 million people, we have heard, docs over treat, we have heard big pharma is the enemy, and more.

Yet I don't think we are paying attention to the big picture. If you read my post, have we not already tried behavior management, have we not tried better outcomes?

I can't seem to get the point across that everything is tied to the cost of care, all of it.

How we get paid directs behavior, so change it and you won't need to pad that bill, change tort laws and we won't need defensive medicine, eliminate a third party between doctor and patient and we won't have impersonal care.

How we get paid costs this industry 1.2 trillion dollars, that one thing is 40% of the cost of care and drives most of the additional other challenges presented in this thread, does it not. What would we be like if care cost 40% less?

Defensive medicine is 400 billion and malpractice insurance is in the tens of billions in premiums, change this and you save nearly 20% of the cost of care and docs would not have a reason to be defensive.

Fix the fundamental system issues and the outlying issues disappear, do they not.

If you take a bigger picture view it is easier to see how solving them solves many of the other concerns and wastes.

I for one believe we need to move to a public/private model, much like the rest of the first world countries do, not single payer, but direct delivery of care to the masses and allow those that want to buy up to do so. We have corrupted the health insurance product so much it is now the problem and obsolete.

If the goal is to treat the most people for the least cost and provide the best quality of care to achieve better outcomes you first have to find a way to afford to deliver the care, not insurance.

Burrell (Bo) Clawson Anthony noted "We have corrupted the health insurance product so much it is now the problem and obsolete."

Arguably it is the state and federal governments that essentially set & approve "health insurance" policies and procedures. Then the insurance companies "lobby" their overseers.

It seems like insurance companies are are now almost a government run institution as are Medicare and similar government programs.

Which government entity is going to relinquish its power over health insurance?

Is the government going to allow private persons to opt out of the ACA?

Leslie Wise First of all let's acknowledge that the current system requires no outcomes at all. FFS is a services rendered model with no requirement of clinical success. Success is that the visit occurred or the service was provided. To now require a patient focused clinical benefit for the economic value transferred to the provider is a "better outcome" from a clinical, economic and humanistic perspective.

With respect to the diverse points previously put forth with respect to tort reform, willingness to pay vs. ability to pay, insurance regulators and regulations and legislative inertia, etc....all of those issues play apart in a dysfunctional convoluted system that refuses to address whether healthcare is a fundamental right. Countries with the political will to declare healthcare a fundamental right provide health/wellness to its citizens in a much more rational pragmatic evidence based system with significantly better patient outcomes much cheaper than the U.S. This, of course, depends how one defines better. Better outcomes may mean improved compensation to healthcare providers. Better outcomes might be adoption of "innovative" products sooner. Better outcomes might mean hospital processes become more efficient. I could go on and on, which I believe is the point of the question. How do ever adequately quantify relative value?

Stephen Glassic An Estimated 60 billion a year is lost to Medicare Fraud.

http://www.aarp.org/money/scams-fraud/info-2014/fighting-medicare-fraud.1.html

http://www.aarp.org/money/scams-fraud/info-2014/medicare-fraudsters-worst-enemy.html

They are making some progress in fighting it but it might be a loosing battle.

Clifford Thornton This (better outcomes) will not be measurable until U.S. "healthcare" changes in significant ways (i.e. quantum shift) and becomes truly dedicated to making most patients healthy as opposed to well enough to be discharged or sent home (I'm not saying let's keep them for 2 months, I'm saying create a discharge plan that institutes an aggressive plan to overall "good health").

The current model is rigged to guarantee that patients eventually return to a facility/office. The pharma industry is also rigged (for the most part) to the current model, which is why they probably don't support preventive care more rigorously. We need to incentivize physicians, facilities and pharma to focus on preventive care, dramatically increased levels of health (mainly through encouraging healthy diets and regular exercise, and generally more healthy lifesyles -- we also need to find better ways to incentivize employers to support this), and the most difficult part -- strongly communicating to patients that they need to take more control and responsibility for their own health and that of their families. We also need to tax tobacco products in the equivalent that it incurs costs to our healthcare system.

Yes, this is tough to swallow, but it has to happen, sooner than later. We can not have a situation where 30, 40, 50% of GDP is derived from healthcare. That is not healthy for America. We need to allocate more resources to education, getting our publicly traded and private U.S. owned and operated businesses more competitive on the International stage, national defense, and cutting our national deficit.

There has to be a balance between the future (economic & geopolitical) health of America and caring for our population's health. If the financial stability of our country and that of our population are at risk, then we have to collectively ask, where is this all leading? And when do we say it's time to strike a balance.

Yes, this line of thinking will upset many, but I've got to point it out because I love the United States of America. And I care about our country's future.

Healthcare should strengthen our population and allow its population to flourish. When it becomes such a burden that it, in some ways, does the opposite, then you need to start asking tough questions. When Healthcare becomes an organism that functions more for its own sustainability, that is not a good thing. You have to look at the overall picture; how healthcare overall falls into national goals and national goals are determined by our elected officials who are placed into office by voters. My point is, we need more integrated policies. The way things are now, I don't see alignment between healthcare and other sectors of the economy and key government functions.

We all have to think more rationally about these issues and see the reality. As an educated American citizen I am taking a stand on this issue.

Clifford Thornton Mr. Wunsch -- respectfully, you are overlooking the key point here. You have to dramatically reduce what is causing/driving the cost. That is the only real way to solve this puzzle, no matter how hard, no matter how politically sensitive, this is the only REAL way. Yes, we have to change behaviors. And for those who refuse (to change), they will have to deal with those ramifications, same as if you decide to do illegal drugs, decide not to work (when you physically can), decide not to pay your income tax (when you are legally obligated to under current laws), or fail to live up to basic civil obligations as an adult.

If, you have let's say tractor trailers that keep causing very harsh damage to the roadways they travel on, do you make the payment system from trucking companies to local municipalities and companies which operate toll roadways/highways more efficient? Or do you either make roads stronger/more robust or tractor trailers lighter or some other engineering design that reduces 90-95% of the damage? Yes, you fix what is driving the cost. This is simple logic and there is no way around it. You have to fix the key driver of the cost.

I know there are many complexities here, but when you boil it down, this is what it comes down to -- changing the cost drivers. And bad personal health decisions are what's driving the majority of the cost. I'm convinced. I've seen it first hand.

Ian Newington Anthony made the key point in his last post. Essentially he said that what we are measured and rewarded on drives behaviour. The problem is that if the measure is wrong, the behaviour it drives will likely not be desired. And most measures, especially those put in place by politicians, it seems, are the easy to measures and not the right measure to drive the right behaviour.

Short term it might work - so in the UK waiting times for surgery dropped significantly when targeted but now the same approach may be driving counter-productive and inefficient (read costly) behaviour.

No simple answers but it does require a long-term vision of where we want to be that gets it out of the 4-5 yr political cycle.

Clifford Thornton Please see link to related book, "Quantum Leadership" By Tim Porter-O'Grady, Kathy Malloch:

https://books.google.com/books?id=Em9yAwAAQBAJ&pg=PA100&lpg=PA100&dq=u.s.+healthcare+quantum+shift+outcomes&source=bl&ots=WwtFEVucs2&sig=-WTs0VM0yQ8SmQTPEQxFpx_k3nA&hl=en&sa=X&ei=BcqjVNyhFoKqggTgpITgCQ&ved=0CDgQ6AEwAQ#v=onepage&q=u.s.+healthcare+quantum+shift+outcomes&f=false

An example that I am not the only one thinking along the lines that I am (please see comments above). See related sections address the U.S. Healthcare system.

Clifford Thornton Ian -- we are clinging to fishtank thinking. Forget the metrics, look at what is going on out there and driving the cost. If you are being bombarded with artillery shells and getting annihilated, you don't need metrics, you need a counter-strategy. We can't seem to get our minds out-of-the box. Mr. Clawson's approach is rational and a real solution.

This is a problem that needs to be attacked at the root and directly. This is about making tough leadership decisions and making decisions and at the core of our nation's ethics, priorities, and meeting national objectives to create a better America.

We can go on all day about what is driving the politicians to make what decision or what government metrics are driving hospital administration decisions. While these have to be taken into account -- the heart of the problem lies in the root cause of the majority of admissions, which we all know, some of the most prominent one's are heart disease and stroke. And the majority of these cases are lifestyle related. So, then that leads us to how we change behaviors to dramatically reduce admissions for these diseases or better identify, treat and combat them before they require very expensive care.

You make good points, but I just think we're getting caught up in an endless whirlwind if we don't address the key matter at hand and basically it comes down to too many people smoking, not exercising, eating garbage, too much stress. So, the discussion has to lead to how do we change this in a positive and significant way? For example, why has China seen sudden and dramatic increases in cardiovascular disease over the past two decades? Just research and you will see the answer. Then correlate.

Barry Musikant This is a wonderful and needed discussion. It inevitably leads to the economic system we live under. Capitalism seeks profit above all else and the winners in capitalism become larger and larger entitites that have the ability to skew legislation to their own continued concentration of power and money. None of us want to replace capitalism because it so tightly relates to our notion of democracy. Yet, unfettered capitalism leads to encroachments on a functioning democracy. These are the big issues that will prevent policies that would help the majority of people. To help the many, regulations must at a minimum be in place to limit the powerful corporations from creating an environment that maximizes their profits at the expense of the rest of us. Until this happens, all the rational arguments in the world will be defeated because they are not the priority for those making the rules.

Regards, Barry

Richard Schrenker This is one of the better threads I've read in a while, but even it ignores what I consider to be the elephant in the room that no one wishes to acknowledge - mental and emotional health, along with their very direct connection with and impact on behavior. It is easy enough to point to "lifestyle related" choices as the root cause, but as anyone who is familiar with recent risk management research is aware, root cause analyses very often fail to describe failure modes in complex systems (e.g., check out Nancy Leveson's home page in general and her book "Engineering a Safer World" in particular).

At this point I would ask all of you to share your perspectives on if and how you see the relationship between physical and emotional health in the context of the topic of this thread. I will step a little further out on the ice and suggest you consider what you might consider to be "spiritual health" as well, for those of you who feel that component in your life. I would also ask you to share your thoughts on whether two or three components can be compartmentalized, i.e., treated as independent concerns. Taking the above into account, how does that inform your thinking on what "better outcomes" means, and how to approach them?

If you infer that my line of thinking is the current system draws its boundaries in too closely around applying technology reactively and usually too late for chronic conditions, you're right. I see plenty of opportunity for communities of faith as well as community-based secular organizations to not only more actively participate in health care but on a continuous, ongoing basis. I also see health as being more than just the absence of disease, physical or emotional. And I see technology as being a powerful enabler of community health systems. But only in the context of a more intentionally designed system focused on serving and supporting the points where health care, as broadly defined, is delivered.

This vision may not be workable, but then neither is the one currently in place. If insanity is doing the same thing over and over and expecting different results, then I don't believe tweaking the current system will make a damn bit of difference. Other ideas?

Mike Sturdevant At least one institution has changed policies over the past few years to try and 'change outcomes' of their employees - The Cleveland Clinic. Pre-employment nicotine testing, ban on trans-fats in the complex, extra inducements for employees to take control of their health, etc. However, I can find nothing showing that the outcome of all these changes has been measured. Has the Clinic lower the cost of insuring it's employees? Have the employees enjoyed better health? Does anybody have data?

Burrell (Bo) Clawson MIke, I've had some contact with Cleveland Clinic through their Innovation dept. and their yearly Innovation Summit, seek better solutions across the board from their hospitals and clinics to the staff and to their patients at home or in care facilities.

Cleveland Clinic with a dozen hospitals, works with both internal innovations from their staff and external sources of innovation to come up with better solutions for both stabilizing &/or stopping medical issues and preventing them in the first place with early diagnosis.

Hopefully, I'll have some more direct results to mention in the near future.

Anthony Wunsh Let me approach this in a different manner and contributors please respond how it effects your idea of the problems. Great discussion all, and note we have avoided the ideological ranting and raving, thank goodness.

In my mind this is a public/private model. Before though let me set the stage.
In the US today we spend 1.5 trillion dollars on Medicare, Medicaid and VA Care, when you add in the state costs to the numbers. For this we treat about 50% of the population. In these costs are the expense in how they get paid and the management and existence of these agencies. It adds up to about 40% of the 1.2 trillion dollars.

I propose for the same money we could eliminate all three agencies and simply provide the care at no cost to the patient. Don't panic, I can cost justify and spend not one penny more in doing so and treat 70% of the people. Buy, build and add all publicly owned facilities, where all staff are employees and the budget is based solely on the number of patients treated. Now bear with me please, there are no billing costs, no reason to do more than is necessary, no cost other than the actual cost to deliver the care, we own the labs, imaging centers, surgery centers, hospitals and doctors offices as the public.

Then allow the private sector, the other 30% to buy up to what they may perceive as better care. This could be insurance or direct pay, their choice and the private sector would have to compete against the public sector to entice that 30% to step out. They would have to control cost and innovate new services.

Then pay for the education of new docs under a contract they work in the public sector for five years at reduced salary, this would solve the doctor shortage as well.

Would this system, which is employed by most first world countries not solve most of the above stated issues with care, outcomes, cost and access?

Jason Sanford @Bo Burrell - There are two sides to that coin. The "better outcomes" movement is being driven by the private, commercial payor industry. These companies practically penned the ACA themselves. And as much as mass-media fear-mongrels might suggest, we will never have a single payor, "government run" system in this country. The federal government does very little on it's own, as nearly every "government run" entity is really a government/private partnership. This is true for Medicare, as pretty much every function of that system is administered by various private companies. Fortunately, for every future patient in this country, the interests of these entities are currently aligned, and it's time for physicians to take responsibility by doing the right things for their patients. They will have to, because payors will essentially mandate it through value-based contracting. Physicians will be viewed as individual cost units, and evaluated on the matrix of expenditures vs. outcomes. This has already begun in the private insurance sector with numerous state franchises moving to this model in various specialties . Post - human genome project medicine is really the biggest lynchpin in this development as it allows us to make decisions based on individual biology vs population based risk assessment. This will result in numerous disease states (including some cancers) being redefined as chronic conditions that do not require costly treatments. The implications of this are deep and wide, and it's potential for reigning in our healthcare costs is very real. So you tell me what sounds like the better outcome for, say...a prostate cancer patient - radical surgery, diapers, and no sex for the rest of your life - or a once per year visit to your physician to pee in a cup. Funny how the better of the two outcomes also happens to be the right one for the individual patient. And oh by the way, costs almost nothing compared to the first scenario. So in this sense I agree with the originator of this thread. It's unrealistic to think that Americans will take broader control of their individual habits that ultimately result in these diseases. (Although this is a worthwhile endeavor) But we can, and should make smarter decisions about how we treat them, which will result in "better outcomes" in every sense of the term.

Burrell (Bo) Clawson Jason, I agree with your long comment. The question is how we get there and it is going to be a big mess for awhile as far as I can see.

People in Wash. DC look at healthcare in terms of the "big population centers", but the healthcare system is distributed from small towns with a doctor or two all the way up and it is not easy to operate with mega system precision in all geographic areas.

Right now a great many changes are underway, while the boomers are starting to retire along with a lot of doctors retiring, whether because of age or they can't effectively deal with the new digital systems and the decreasing payments from various insurers.

For doctors who stay in the system, they are being pressured and some good % of them don't see enough income to operate their practices. Numerous hospitals are closing in rural areas over the last few years. How do we make a hospital viable in a town of 5, 10 or 20,000 people? It becomes impossible to supply all needed medical care when the small hospital can't possibly comply with the FDA, Medicare, Joint Commission, ICD-10 and all the computerization.

Jason Sanford Bo - It can only happen one patient at a time. And it is happening. I see it every day from numerous perspectives. And yes it's a big mess, but it's a mess that's long overdue. The status quo necessitates that we tear this rotting frame down to the studs before we rebuild it properly. At least two folks in this thread have jobs that have a direct impact on driving this paradigm shift. And it's a huge shift that requires payors, providers, and patients to all be on the same page. More hospitals will close, and more physicians will retire, and this will be the natural order of things going forward. Our bloated system is the unfortunate byproduct of practicing inefficient medicine for the better part of the last century. In fact, our healthcare system today more closely resembles a large cattle farming operation than one that puts compassionate care for the individual above all other things. In many cases it comes down to doing the right thing vs. putting dinner on the table. Luckily the current and future state of our payor infrastructure is aligned with the former.

Jason and Heather, reminds me of our recent conversation "Stayin' Alive: How much would you pay?"at http://bit.ly/pay-to-stay

Joe Camaratta The CDC recently reported deaths from stroke slipped from third place to fifth place as a leading cause of death in the U.S. since 2011. The per capita death rate from stoke (and heart disease) continues to decline due in part to program such as Get With The Guidelines from the American Heart Association, which help care providers apply evidence-based guidelines to improve patient outcomes. There are also examples from other non-profit groups to reduce (for example) hospital acquired infections. Measuring outcomes is important, and outcomes can be improved.

Most efforts to improve outcomes have focussed on acute care and care providers. The time period over which to measure these outcomes is well-defined, and the target group for outcome improvement (i.e. care providers) is easily identifiable. Improving outcomes through smoking cessation and weight management are an order of magnitude more difficult - and might require decades to demonstrate an impact on healthcare costs. So, our current efforts might be having an impact - its just too soon to tell.

I agree that changing the way we pay for healthcare in the U.S. is a requirement for sustainable improvement. Bundled payments with defined patient outcome and satisfaction metrics could be a good model for acute services or treatment of disease. Different models are needed to promote prevention and disease management. And, don'f forget the consumer! We also need (financial) incentives that engage consumers in healthier living. Government alone can't solve this problem.

Clifford Thornton First of all I would like to say sorry if I was very harsh in the earlier parts of this discussion. But, there's a reason for that -- going into healthcare (from the telecom sector) I was extremely dissapointed at how far behind healthcare was in terms of best-business practices when compared against other industries (being in the telecom sector you cross sectors with many different industries as everyone needs communication). I was also very dissapointed by the behavior -- not consumer driven (except in an elite suite at a Southwest Florida hospital). The attitude was more, well your stuck, we've got you and deal with it -- you'll get your care when we're good and ready and whenever we can get to you. I even heard a Doctor one time say, "you're not doing us any favors by being here." As an insightful commentor mentioned above, it's alike to a cattle farm; great analogy. So you get my gist.

If interested, please see a post I wrote on this a few years back, related to this topic:
http://www.mhealthtalk.com/new-healthcare-system/

At times working in that environment, I seriously felt like I was in a circus. Yes, there are a lot of very smart people, and many nurses really cared, but you could have the best pilots in the world, for examples the U.S. Navy's Blue Angels, but if they don't have a good flight plan and coordinated efforts, those pilot's individual talent's will not be properly demonstrated. We've got to get our health professionals working toward clearer, common goals.

In any case, I like how this discussion is progressing and I think we're making some positive progress. I think Mr. Wunsh has a very good idea in consolidating Government healthcare related agencies. It almost always helps to streamline things which is one more economical and two makes organizations more nimble to respond to changes and will make it more viable to transform to a new model based on better outcomes.

Also, Mr. Schrenker's post couldn't be more needed. We need to incorporate the mental well-being of patients and healthcare workers into account. I've seen many nurses in the ER where I had to perform Echoes on the STAFF. So, that has to be addressed. There is definitely worker burn-out and we should train supervisors and directors to IDENTIFY and address this earlier on. But, I firmly believe that addressing the mental component will be one of the keys to long-term success and I think a big part of this is changing the hospital environment to a more positive place and changing it from the "you're in jail model" and also change hospital staff attitude on this. And a big step to this is reducing volumes and let nurses actually be nurses again, giving patients the type of dedicated care that nurses got into healthcare for in the first place and why I got into echo in the first place and why I decided to leave it (I just couldn't operate the way I wanted to under the current model anymore).

Mr. Camaratta -- great to hear we are making progress on stroke. I am very happy to hear that as I've seen the devastating consequences of stroke first hand. It is good to see that something is working. But, we shouldn't take our foot off the gas pedal just yet.

It sounds like to me that we need to do two things. In the short-term (short-term I mean the next decade) change the healthcare delivery and payment model -- consolidation is one great approach and shifting behavior and attitudes of physicians, administrators, nurses and other allied health workers. Also remove the unecessary testing and reduce or eliminated over-treatment (as discussed earlier). This is the more practical, real-world stuff that needs to be accomplished.

In the longer term (two, three decades out) continue with "Get with the Guidelines" type programs, continue with educating patients on healthier lifestyles, keep pushing better diets exercise (make this a priority in primary education!).

Anthony Wunsh Clifford - Well written and thought out post, thank you for the insight. Much work to do, and part of it is agreeing on what that work should be.

Mike Sturdevant Check out this week's issue of Time magazine for a story about some primary physicians that are taking things into their own hands. Sorry I can't find a link to it that doesn't require subscription.

Burrell (Bo) Clawson As much as I hope any group could solve the problems, I realize it takes everyone looking at reality and working together to address a whole handful of large problems and then buckets full of smaller ones.

No matter what physicians as individual and groups do, it is the US government agencies that have the greatest impact on what happens with Medicare, Medicaid, HIPPA, FDA, CDC, etc. which can be adverse to doctors.

We as citizens need to be more active against a runaway US Congress that simply ignores the will of the people and goes ahead and enacts what in reality is a confiscation of private business by regulating it to death.

As older more aware people in business, we need to speak up to younger people about how governments wind up over regulating and thus strangling the very businesses that government is supposed to set a level playing field for all to compete upon.

Stephen Glassic Mike Sturdevant, I think the Time Magazine article you are referring to is the one that is linked to in this discussion on this group.

https://www.linkedin.com/groupItem?view=&gid=78665&type=member&item=5955777163184594946&trk=groups_items_see_more-0-b-ttl

The idea sounds good, but see the comment I made there. It used to be, that when many doctors owned their practices, they had more control over how they ran the practice and treated their patients. They no longer have that control because they are no longer independent and have to answer to administrators. Administrators, by nature of the position, are most concerned with regulatory, finances and public image. They have too many regulatory bodies they have to answer to which creates too much administrative burden. Not to mention the complicated billing issues (multiple payers for just about every patient visit and different pricing for each one). The consequence is that they can't devote enough resources to providing meaningful healthcare.

And now with the ACA, another complication has been added to income tax returns, which indirectly ads to the overall cost of healthcare.

As I was saying, what the physicians mentioned in the article are doing sounds good, but they might eventually become buried in in regulatory and administrative expenses which will have to be passed on as increased costs or reduced service. I just don't see that model as being sustainable without other changes to reduce wasted resources.

Good discussion with many relevant facets. I'm with Anthony that the best immediate intervention involves reducing and ultimately stopping the flow of wealth and resources to those who do not actually contribute to the delivery of quality health care, which would include many in the insurance, legal, and regulatory businesses. But for this to happen would require intelligent, meaningful legislation that doesn't appear likely considering the track record of the two ruling parties. Also, it is impossible to legislate away basic human greed...

Clifford Thornton cont'd: I don't know if a study exists where they study the outcomes for each model, but that would be very interesting and useful to see when those statistics/results are out in a few years. It will be hard to navigate or know if we are navigating in the right direction under the new model.

What do people think about care under a physician "employed" dominant model versus the model of the past -- "independent" dominated healthcare delivery system? What are the pros and cons? What is really better for the patient or just like anything else, it depends? Perhaps this should be another thread, but I think it related directly to the original point of the thread.

It's hard to find an analogy to the current situation outside of healthcare. In retail, I suppose you could say healthcare is moving to the "Walmart" model as they heavily dominate all retail sales -- I think around 80% now. Or imagine if around 70% of all Certified Public Accountants (CPAs) in the United States were employed by large accounting firms. What would these mean for consumers filing their income taxes -- would it be good or bad?

Going back to Mr. Glassic's point though -- given the current landscape/mix of operating environments for physicians -- the power is with the institutions and the legal implications of ACA and that is the reality.

Personally I've worked in both private practice and large hospitals and as I've touches on in other posts the differences are mostly obvious. Private practice gives individualized attention and care and their physicians are aware of the current status and changes, what is lacking is (usually) the best state-of-art equipment and if the physicians are more than two decades out of medical school, are not adjunct professors or closely involved with medical societies, they may not be as up-to-date on care strategies as opposed to physicians with larger institutions who may have more access to research resources and interaction with an array of physician specialists -- which they may encounter verbally or while reviewing paper or electronic charts. I'm not drawing a line in the sand here, on either side, because I've seen private practices with cutting edge equipment and very up-to-date physicians. But, I have encountered some private practices that were very out-of-the-loop and just seemed to be billing operations where patients just happen to "stop by". I'm giving my perspective here --- which I think is pretty broad since I have worked in healthcare in New Jersey, New York, North Carolina, Maryland, and Florida.

But, there is no doubt in my mind you lose the close personal relationship that a private practice setting can provide and I think concierge medicine is stepping in to fill this gap for those who demand it and can, to be honest, afford it. No matter how hard larger organizations try, they can not duplicate this in a meaningful way. In many cases, many official periodicals may fail to point out, in times past and perhaps and some cases now, physicians and patients were/are friends and hung-out in the same social circles -- country clubs, summer mountain resorts, yacht clubs, etc. So, obviously that was a very personal and delicate relationship. I've seen that also backfire. I've seen a situation where a dentist was close friends with an internist or cardiologist and failed to order adequate tests for the dentist's wife and I think it's attributable to perhaps the internist worried about putting his wife through all that for no reason or worried about the social ramifications if putting her through all that discomfort and then they all come back negative. She had a-fib and was in CHF and I think an echo ordered earlier could have found the physical heart changes earlier and perhaps led to an earlier, more aggressive care plan. In her case her heart atria were severily dilated (an almost guarantee for a-fib) and had significant mitral regurgitation (which only adds to the problem

Barry Musikant If not for the profit capitalists seek to gain via their investments, the natural order of care would be for the physicians to remain in control. That is happening with those wealthy enough to afford private care by those supplying the caring, but that leaves a huge market where costs can be cut, treatment diminished and outcomes at best difficult to fathom. In short where huge profits for the few can be made. Look at the Walmart model, taking money out of the community and giving the heirs of Walmart, a small number of individuals a fortune worth more than the bottom 40% of our entire population. So much for the concentration of power and access to care. What saves a few bucks for the individual is more than offset by the loss to the community.

Yet, these same large capital investors have all the protection of the central government when it comes to banking, industrial and farming subsidies. It is the misallocation of fundings due to crony capitalism, difficult to differentiate from any other form of functioning capitalism at the highest levels that concentrate fortunes for the few with extreme creativity in explaining why most people get the short end of the stick.

Solutions will be hard to come by when the purse strings are controlled by the wealthy and powerful (the same people).

Still sounds like an attempt to rearrange deck chairs on the Titanic.

Regards, Barry

Anthony Wunsh A couple of anecdotal points to make, and perhaps redundant but these are just bullet points.

The USA has the highest per capita in healthcare of any country in the world, while ranking poorly in outcomes based on what is currently used as the measure. So it begs one to question how are the others controlling costs with better outcomes and perhaps emulate them does it not?

While the cost to receive care was 2.9 trillion dollars in 2013, this does not take into account the nearly 2 trillion spent on insurance premiums, and the more than 500 billion lost to tax credits, (these are never part of the conversation)

We continue to ignore the past, we attempted to sway behavior in the past with negative results, yet here we are again making the same promises, again without someone saying what success looks like, how much it will cost and how long it will take to get to it.

Barry I am not sure I can agree with your analysis, capitalism is what financed innovation, it is why the USA is the research country of the world for drugs and procedures, it is why state of the art facilities are built and new technologies brought to market. The challenge is corruption of the capitalistic system by a select few, at least in my opinion. The Walmart example is just not fair, they are now the largest employer in the country and perhaps the world, surely this is spreading the wealth. They have proven in markets that were depressed to breath new life into them have they not. They remain a non union company yet their employees are ranked among the most satisfied, if they weren't they would vote a union in. And the wealth of the owners, has nothing to do with the community and everything to do with the price investors are willing to pay for the publicly traded stock which is probably owned by your retirement fund and in your portfolio of investments as well, which is what drives the wealth of the Walton children.

Anyway, we do have a challenge because the goal is not properly defined, those in power are not motivated to fix the problems and too many are feeding of the trough of healthcare revenue who bring no actual value to the delivery of care itself, and they are not going to leave without a fight.

Clifford Thornton Per Mr. Glassic's points, more and more we are moving to a model where U.S. based physicians are moving to an employment model vs. independent practice. An article published by Medical Economics (Infographic) on January 31, 2013 (please see link below) states that just 39% of (U.S.) physicians remain independent. And I read recently (within the past month) in The Wall Street Journal (I can't seem to find that article online right now) that that statistic is now down to 33%. The article stated that, given the healthcare landscape changes, it will be very difficult, nearly impossible, to go back to the previous model (i.e. more private practices/independent physicians.

Given this, Mr. Glassic's points are very valid as if the power shift is towards the large healthcare/hospital systems, then obviously those forces will dictate how care is carried out and financed.

Therefore, going back to the genesis of this discussion - "Are "better outcomes" smoke and mirrors?" -- we should ask this question under the current model mix of independent vs. employed physicians. I actually think that this is a very critical assumption to take into account given that the way in which medicine is practiced can have very serious implications for the patient under each type of care environment. Obviously, under the independent model physicians will have the ability to make quicker, unquestioned/unchallenged (other than insurers), and direct decisions for the patients and under the employment model more subject to their facility's operational rules, clinical department red tape (i.e. the cardiologist says their patient can continue with their normal routine but the orthopedist or neurologist says "no"), and medicaid/medicare rules pertaining to hospitals or clinics. The employer model will require more coordination across specialties, more approval processes, more layers in order to make a decision, another words more space between the physician and his or her patient.

One could argue that quicker decision making under the independent model (and I am not saying this is always the case as independent physicians can drag their feet or wait years, let's say until they recommend their patient to a cardiologist/EP (say they are an internist) for a pacemaker when they should have already) means better outcomes. And one could argue the same for the hospital model where "collaborative care" equates with better outcomes. And you could argue the opposite for both. I don't know if a study exists where they study the outcomes for each model, but that would be very interesting and useful cont'd.

Related articles:

The Physician's Foundation, "Survey of 20,000 U.S. Physicians Shows 80% of Doctors are Over-Extended or at Full Capacity"

http://www.physiciansfoundation.org/news/survey-of-20000-u.s.-physicians-shows-80-of-doctors-are-over-extended-or-at/

American College of Physicians, The ACP Advocate Blog
by Bob Doherty, "Is assimilation inevitable for independent physician practices?"

http://advocacyblog.acponline.org/2014/10/is-assimilation-inevitable-for.html

Pittsburgh Post-Gazette, "High-deductible insurance plans put pressure on independent physicians to collect bills"

http://www.post-gazette.com/business/healthcare-business/2014/11/23/High-deductible-insurance-plans-puts-pressure-on-independent-physicians-to-collect-bills/stories/201411230081

Medical Economics, "Just 39% of physicians remain independent (Infographic)"

http://medicaleconomics.modernmedicine.com/medical-economics/news/user-defined-tags/private-practice/just-39-physicians-remain-independent-info?page=full

Hoover Institution, "The Coming Two-Tier Health System"

http://www.hoover.org/research/coming-two-tier-health-system

The Wall Street Journal, "Doctors: Skeptical About Health Law, Optimistic About Future of Medicine"

http://www.wsj.com/articles/doctors-skeptical-about-health-law-optimistic-about-future-of-medicine-1410840302

Clifford Thornton I found some limited studies comparing care outcomes across care settings (i.e. private practice vs. hospital) -- so for it seems there is no measurable difference:
,
PubMed, "Implications of practice setting on clinical outcomes and efficiency of care in the delivery of physical therapy services."

http://www.ncbi.nlm.nih.gov/pubmed/25350133

Journal of the American Board of Family Medicine
by LA Civitarese - ‎1999, "Congestive Heart Failure Clinical Outcomes Study
in a Private Community Medical Group"

http://www.jabfm.org/content/12/6/467.full.pdf

Harvard Business Review --
"The Strategy That Will Fix Health Care" byMichael E. Porter and Thomas H. Lee FROM THE OCTOBER 2013 ISSUE

https://hbr.org/2013/10/the-strategy-that-will-fix-health-care/

* section on "multisite health care delivery organizations"

The Physicians Foundation -- "Health Reform and the Decline
of Physician Private Practice" Completed October 2010

http://www.physiciansfoundation.org/uploads/default/Health_Reform_and_the_Decline_of_Physician_Private_Practice.pdf

* case studies

FROM EXECUTIVE SUMMARY:

"A Continuing Erosion
Conducted in June, July and August of 2010 by Merrit Hawkins, a national physician search and consulting
firm, the survey offers a snapshot of how physicians responded to the health reform bill some three to four
months after it became law. As health reform is implemented, physician attitudes may change. However,
the survey suggests that physicians’ assessment of health reform in its early stages is predominantly negative,
perhaps in part because they do not believe they had sufficient input into the new law. A great majority of
physicians indicated that the physician’s perspective was not adequately
represented to policy makers during the run-up to health reform."

"• Only 10% of physicians said reform will improve the quality of patient care they are able to provide, while
* said reform will diminish the quality of care they are able to provide."

" About half of physicians (49%) said their attitude toward medicine was “somewhat negative” or “very
negative” before health reform was enacted. Since reform was enacted, about two-thirds (65%) said their
attitude toward medicine was “somewhat negative” or “very negative.” "

"• The great majority of physicians (89%) believe the traditional model of independent private practice is either
“on shaky ground” or “is a dinosaur soon to go extinct.” "

MedPage Today -- "Costly Care at Hospital Practices
The bigger the system, the bigger the bill." November 23, 2014 by J. Duncan Moore, Jr.

http://www.medpagetoday.com/PracticeManagement/PracticeManagement/48788

Key point:

* for hospital-owned physician practices were 10.3% higher than physician-owned practices, and those for multihospital system-owned practices were 19.8% higher in the period 2009-2012, according to the article in JAMA by James C. Robinson, PhD, MPH, a professor of economics at the University of California-Berkeley, and Kelly Miller, a program analyst at the Integrated Healthcare Association."

Centers for Disease Control and Prevention (CDC) -- "The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review" by Michael Stellefson, PhD; Krishna Dipnarine, MS; Christine Stopka, PhD

http://www.cdc.gov/pcd/issues/2013/12_0180.htm

* case examples and results by care delivery model/type of facility (see matrice at end) for diabetes care and management. See box entitled "study setting"

Interesting summary of Advanced Practice Nursing -- not so much focusing on setting -- but who will be delivering much healthcare going forward:

American Nurses Association -- "ADVANCED PRACTICE NURSING:
A NEW AGE IN HEALTH CARE" 2011

http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/MediaBackgrounders/APRN-A-New-Age-in-Health-Care.pdf

Clifford Thornton Well, I didn't want to have to say this, but I'll say it because it has to be said for change to happen.

This is basically the fundamental problem in healthcare -- Doctors are just NOT trained to cure patients. I have even heard them say, my (physician) Father told me not to cure patients (i.e. this will kill any future revenue streams from this patient). Medicine has become a business -- and the fundamental question is -- should this be the case (and I'll differentiate medical care carried out by a physician from medical devices, since medical devices being a physical product, I believe there needs to be some financial incentive for them to exist. But, fundamentally -- should Doctors be in this game for compensation or to cure patients -- because the two are mutually exclusive.

I'm calling the Doctors out on this issue because I'm tired of beating around the bush.

This is the reality. Let's face the music -- Now!

Do we want to find cures and cure patients or continue on as business as usual? We all know the current care model in the U.S. is not directed to cure patients. Period.

Bottom line. Medicine should exist to cure illness. Just like if my care keeps getting an engine indicator light to appear, I want that issue fixed and the warning to go away. Make the illness go aware to the best ability of modern medical science. This should be the ultimate goal of all clinicians.

This is not about capitalism, this is not about Government, this is not about Greed, this is simply about U.S. physicians deciding to actually attack disease with the vigor and resources in each case as if the patient were their wife, child, Mother, Father or other close relative or friend.

I pose this challenge to U.S.- based physicians. Start focusing your plan on actually curing disease as if this were your last chance to prove your worth, your last patient, pretend for each patient your treat your ability to cure them or not will determine if you make it through residency or licensing. Start taking each case as if it were your last. Start practicing medicine like Tom Brady plays Football.

If you're a physician and can't play the game right, then get out. Please! Start a real-estate company (like one physician did), invest in hedge funds, go build yachts, something if you want to get rich. But, if you seek to get rich off of patients and their lives, their livelihoods, their families, their assets -- then please do us all a favor and GET OUT OF MEDICINE!

This country is about individual freedom, not about bankrupting Americans for medical care. That is fundamentally flawed.

It's time to face the music. It's time for real change in this country! It's time to see the reality and issues for what they are. No, I'm not going to be quiet. No I'm not going to stop speaking my mind.

It's time for the American public to be treated in such a way that they deserve by the medical establishment and NOT used like an old, dirty mop. The American public does not exist to fleece the pockets of the medical system. The medical system should exist to enrich the lives of Americans and make them healthier and stronger to succeed and for older patients to support the efforts of the younger members of their families.

Stop over-charging, stop unecessary testing, stop defensive medicine.

U.S. physicans -- start standing up for your practice and the rights of patients. Stop waiting on the sidelines. Join or start patient advocacy groups. Vote for tort reform. Organize voting groups to target politicians who support changing legislation on payment models which takes the power away from insurers. You need to take back medicine! Where is your will to fight? Stop doing more than saying you're "Aghast" as did the head of the American College of Cardiology after the cuts in 2009. Instead, start acting. Writing to congress, going on TV news stations and stating your opinions.

Clifford Thornton Correction -- "Start doing more than saying you're "Aghast" as did the head of the American College of Cardiology after the cuts in 2009. Instead, start acting. Writing to congress, going on TV news stations and stating your opinions."

Do I sound a little angry? You bet! I'm angry because when I see my fellow Americans not treated honestly, respectfully and such a way that reflects the great people they by the Healthcare system, that is a major injustice.

I believe many people have given up and just accept it, especially when they are ill or at the mercy of the system, but I will not! Someone needs to fight for them.

Oh yeah, that's right a Democracy is where the good of the majority of people is taken into account.

If you need some reminders of the true meaning of a Democracy, see the following links:

http://faculty.frostburg.edu/phil/forum/PlatoRep.htm

http://plato.stanford.edu/entries/democracy/

Selected quote from link above:

"Many have noted with Mill and Rousseau that democracy tends to make people stand up for themselves more than other forms of rule do because it makes collective decisions depend on them more than monarchy or aristocracy do."

http://www.examiner.com/article/aristotle-and-plato-s-politics-and-democracy

Clifford Thornton Correction --

http://plato.stanford.edu/entries/democracy/

Selected quote from link above:

"Many have noted with Mill and Rousseau that democracy tends to make people stand up for themselves more than other forms of rule do because it makes collective decisions depend on them more than monarchy or aristocracy do."

Barry Musikant Anthony,

I think we are saying the same thing. Sure capitalism when applied to startups provides a basis for creativity. However, capitalism as it is practiced in the US today leads to winners who then have the resources to stifle competition and lobby for legislation that enhances their privileged positions. Think about the tax benefits that go to hedge funds. Their profits are taxed at capital gains rates while the rest of us pay higher ordinary income tax rates. As for research, much of what has been applied to product development came not from private industry, but from the NIH or DARPA or other government sources of research and then transferred to private industry. Those are government functions supported by the taxes of ordinary citizens. Yet, the profits generated are in no way mitigated given the source of funding.

In the same way, the fundamental desire to improve the health of our citizenry is not the goal of the investors. If it were, we would have open access to lower cost medications. This was denied in the new healthcare legislation. More people get health care insurance and it is not tied to employment, but overall 40 million more people now become customers for the private insurance industry. So crumbs go to the citizens and the creative lobbyists for the major industries get to rule the day attaining greater profits for their clients.

That's why I call it rearranging the deck chairs on the Titanic. I like capitalism in its early stages. I don't like it when I see the distortions that the eventual winners can and do impose on us.

Teddy Roosevelt didn't like it either, but in his day, he was capable of doing something about it. Let's see what we are capable of doing today.

Regards, Barry

Regards, Barry

Anthony Wunsh Good morning group. Clifford, let me say that the fundamental concept of cure versus treat, I don't know where I stand, not to say, I don't have thought on it, I just struggle with a couple of issues.

One: No matter what, under any circumstance each of us is going to require healthcare, even it is an end of life, we are all going to require it. And there is no cure and not sure there should be one.

Two: Cure versus treat, is not going to change motor vehicle, accident or many other issues that create encounters, again not against curing cancer, or finding a way to stop influenza, I hope it is not sounding that way

Three: do we not have to diagnose in order to cure? Confused about how this changes no matter how disease is handled

Four: I SIMPLY REFUSE TO BELIEVE THAT MY DOCTOR OR MOST DOCTORS LOOK AT ME AS A REVENUE STREAM AND DO NOT HAVE MY BEST INTEREST IN MIND WHEN TREATING ME. Tough for me to swallow as I deal with thousands of them in my day job. Do they see the insurer as something to be taken advantage of, probably since they feel they have to to get a fair shake.

Back to the original post, a shortened version as Joe wanted it in the thread and not directed to the article I wrote. But the whole notion of cure not treat, of preventive medicine, of changing behavior to live healthier, of all in the industry being noble and righteous in all endeavors, is to say the least a fantasy.

But there are key things that can be done, to make care, whatever you define that as more affordable and thus more accessible to more people, which in my opinion leads to the more altruistic goals stated above. Call me naive, but as I have said numerous times, this really comes down to the cost of care.

Stephen Glassic First of all, I have to say, this is the most riveting discussion I have seen anywhere on LinkedIn.

I believe that science and technological discovery is advancing much faster than development and capitalism can handle. One reason being, that once something makes it to market, it takes time to recoup investment and show a profit. This can be a problem in commercial and consumer markets but even more so in the medical market because of the extra costs and time it takes to get something to market (weather it is a device, a pharmaceutical or a combination).

Put on top of that, the cost to own for a hospital. When something better, significantly less expensive and more effective comes along it is hard to justify switching, even if the current technology has paid for itself. It would be like a salesman going from selling capital equipment to working in a retail store.

I have read about many discoveries and developments in areas of technology ( such as electronics, photonics and imaging, sensors, nanotechnology) and biology (in areas of genetics, molecular biology and chemistry) that have the potential to diagnose, prevent, cure or more effectively and/or less invasively treat various chronic illnesses or injuries. And in many cases, at a fraction of the cost of current methods. Sometimes it starts with a biological discovery where other technologies will have to be applied to effect diagnosis and/or treatment. Sometimes is is a new technology (or several used together) that make a biological discovery, a new therapy, a better diagnostic or a better treatment possible.

Many new developments are coming from those who don't have the capital to bring their ideas to realty. They have to rely on finding investors. Why would an investor, who's objective is to maximize return on investment, or a hospital be interested in something that will cure or prevent cancer over an expensive chemotherapy drug? Or why would an investor or a hospital be interested in a non invasive cure for pancreatitis or kidney disease over a treatment for it? Or why would an investor or a hospital be interested in a diagnostic test that uses a $0.10 test strip and a smart phone over one that uses a two million dollar piece of lab equipment and expensive disposables and reagents? Somehow their thinking and objectives need to be changed and the cost to get to market must be reduced and we also need payers to help drive that change.

Even thought it is known that change is needed, it is easier said than done and cannot happen overnight. I just hope that it happens in a truly progressive and meaningful way. More discussions like this can only help.

Burrell (Bo) Clawson Stephen Glassic asked "Why would an investor, who's objective is to maximize return on investment, or a hospital be interested in something that will cure or prevent cancer over an expensive chemotherapy drug?"

The short answer is profit … for the right entity. If a company provides a drug, Sovaldi, which cures Hepatitis C in 90% of the cases within weeks, versus just treating Liver failure for years, it is the insurers and patients who will want to PAY for the treatment.

Investors need to find new, simpler, better, less expensive products of all types which have a good market to invest in. The home medical device market is hot with startups.

For hospitals, from what I'm seeing, the ACA and its Accountable Care Organizations (ACOs) now must pay attention to home monitoring and testing to keep patients healthier.

Private insurers and corporate wellness programs all want to pay attention to patient's health once they leave the healthcare facility/office and go home. Insurers have less losses and the companies have healthier more productive employees.

Medicare already is effectively fining hospitals that discharge patients who get readmitted in less than a month, so hospitals are implementing home testing & monitoring on discharged patients.

Today, Kaiser's physicians have a 2 way email connection with a supermajority of patients at home to keep track of their health conditions. This lowers the cost of providing care and alerts doctors to changes earlier than before. Home testing and monitoring is becoming more prevalent as a means of controlling-limiting Kaiser's treatment costs.

Anthony Wunsh I think and Stephen please correct me if wrong, that Stephen's point is they have invested millions and billions as an industry in equipment and technology and procedures already and the changes, which all recognize are better, make those investments useless. Thus why switch and make your investments, already spent, mute.

They will have to adapt, but will have to be dragged kicking and screaming or others will enter the market, (if the government doesn't prevent them with regulation and over burden) and they will lose the investment regardless.

Burrell (Bo) Clawson Anthony, I suspect this is the price healthcare providers have to "pay" when the insurers, patients and possibly employers INSIST on more efficiencies of all types.

Those payers start moving insured members to the providers with more efficient services.

Am I wrong?

Stephen Glassic Yes Anthony.
Say for instance, they have one or more ORs with a Davinci robot and in one Davinci Suite, are performing a particular surgical procedure that brings in 80k per procedure at three per day. A non invasive procedure becomes available that can be performed for half the price, provides better outcome and faster recovery with shorter hospital stay for the patient. It does require an investment in equipment at a cost of 20% of the Davinci OR Suite original cost. The yearly cost to maintain the equipment is 10% of the Davinci maintenance costs, can be maintained by in-house Biomed tech and that includes training for the tech.

By switching to the newer procedure, they will be receiving 50% less per case. without an increase in the number of cases.

My guess is that as long as a competing hospital is not using it and they can still receive the same reimbursement from the payer for the current procedure, there will not be enough incentive to switch unless they can use the Davinci system for other procedures.

Clifford Thornton Links to Dr. Bove's comments (as referenced above) "shocked" "aghast"

* why didn't he and his members do something sooner; fight this earlier? As opposed to being reactionary?

http://www.medscape.com/viewarticle/705283

Dr. Bove's defense (of cuts):

http://content.onlinejacc.org/article.aspx?articleid=1140270

Here are some resources to begin planning actions to make change happen:

University of Pennsylvania, "The Mindsets of Political Compromise"

http://www.upenn.edu/president/meet-president/Mindsets-Political-Compromise

The Week, "Can we overcome our current political dysfunction?"

http://theweek.com/article/index/257710/can-we-overcome-our-current-political-dysfunction

The Famous People, "Political Leaders"

http://www.thefamouspeople.com/political-leaders.php

National History Day 2015
Theme: Leadership and
Legacy in History

http://www.nhdmo.org/uploads/1/6/8/8/16887220/leadership_and_legacy_theme_narrative.pdf

Clifford Thornton Mr. Wunsch, You're absolutely right, that "it's a fantasy to think that everyone will more But the whole notion of cure not treat, of preventive medicine, of changing behavior to live healthier, of all in the industry being noble and righteous in all endeavors, is to say the least a fantasy."

That's my problem with the entirety of healthcare. It has, to a large part forgotten why it exists.

I was thinking today, what if the whole healthcare system shut down today? All hospitals, all physician offices, everything. How bad would things really get? Yes, babies would be born at homes or even out in public -- and there would be difficult deliveries, people would die of heart attacks (but at what scale versus hospitals). But, also how many people would not get hospital borne infections? How many would not become addicted to pain killers? How many would not die of medical errors from a major medical procedure when they just had a minor (non-life threatening problem initially)? What would be the delta on society?

I know society would survive. I think citizens are more resourceful than what they are given credit for. My point is, what is the medical establishment doing for society and to what extent?

I just disagree with the current approach to medicine. It is still for the most part, about treating and that's where the money is. But, in 100 - 200 years I will be proven right I believe. We will see a dramatic shift to identifying and treating disease before it takes effect. And they will say (about things now -- we're all crazy) As an ancient Chinese doctor wrote, the best Doctors prevent disease.

"The superior doctor prevents sickness; The mediocre doctor attends to impending sickness; The inferior doctor treats actual sickness."
— Chinese Proverb
Chinese Proverb. In North Manchurian Plague Prevention Service Reports (1925-1926) (1926), 292, 305.

The whole idea of Western Medicine has become perverted in my opinion. We have moved so far away from what medicine and care should accomplish we don't even realize what has happened.

But, I suppose the demand of our population has enabled this. They have become accustomed to living whatever lifestyle they want and just taking the medicine to counter (i.e. mask) its effects. So, they want the current system.

I do realize things like congenital conditions are not lifestyle-related and I support care for those types of cases, but by and large our medical resources are directed at lifestyle incurred diseases.

I'd just be happy if medicine focused more on root-cause and see physicians then attack the disease much earlier on. But, I realize that's just not the state of things today.

Why do I feel so strongly about this quantum shift in care approach? Because it will save hundreds of billions of dollars and I'd like to see that go to other, more productive sectors of the economy and society. Solving education, poverty, improving public works, creating more parks or improving existing one's --- things that improve the quality of life in the USA.

Do most people like hospitals? Are people happy to go to the doctor? Does healthcare bring joy, happiness and fulfillment to people? I think for the most part the answer is No. So, it's only logical to limit the size of growth of something that most people don't derive satisfaction from.

Society as a whole must decide -- do we want to continue to feed this monster in healthcare or take a whole new approach and for the most part manage our health with physicians and nurses as "coaches". Yes, there will still need to be facilities for births, trauma surgery, congenital cases, and other emergent situations, but as we move more to preventative model over decades or even centuries we will see the healthcare landscape completely altered. I'd be very upset if I were to see the same model 50 years from now.

Stephen Glassic I thought I would share this post under the LinkedIn Pulse Healthcare topic because I think it is relevant.

https://www.linkedin.com/pulse/walgreens-innovating-again-hospitals-could-deep-krivich-fache-pcm?trk=nus-cha-roll-art-title

This makes me wonder if the Walgreens' venture into the healthcare delivery arena along with their partnership with Theranos will play a major roll in changing the landscape in healthcare delivery and the diagnostic testing market. Will companies like this be marked down in history as the catalysts of change? Are they causing nervousness among hospitals, clinical laboratories and the large clinical diagnostics systems manufacturers? Or are they working at competitive solutions? It will be interesting to see how this all plays out.

Robin Breslin Your post straddles the dangerous void between science and politics.

A scientific approach would say - define our goals, measure our progress, analyse and solve problems.
But I have repeatedly seen politicians ignore scientific advice .. particularly when it points to something that could never be popular ..

.. the simple fact that affordable and comprehensive healthcare is not affordable for all (unless we all downgrade our lifestyle expectations).