Lois A. Bowers, MA

Charles J. Lockwood, MD, MHCM, dean of the College of Medicine and vice president for health sciences at Ohio State University, talks about comparative effectiveness research, cost control, and accountable care organizations with Medical Economics Editor-in-Chief Lois A. Bowers, MA.

Things like comparative effectiveness research are good in the sense that they'll support and encourage evidence-based medicine and best practices, but they really are a stop gap between what we have today and real-market solutions where healthcare systems are competing for better and better outcomes, higher and higher patient satisfaction, and lower and lower costs. 

Tort reform and ensuring that there's a minimum of lost data in the system. 

In the most conservative conceivable assessments sponsored by trial lawyers, tort reform reduced costs by about 4%. In the most liberal, optimistic views by physicians, some estimates have been that defensive medicine increases our costs by 30%. So probably 10% is the correct number, but 10% of $3.1 trillion is a lot of dollars. So we've got to have national tort reform, and it's got to be meaningful.  

The second key would be to ensure that we have reduced waste in the system to an absolute minimum. That's going to require not only that we have greater than 80% utilization of electronic health records [EHRs] but that those EHRs communicate through health information exchanges, so that if someone gets care in one health system and they switch to get care in another one, emergently or not, their records, their lab reports, and so forth are all available to them. And so we've reduced the repetition of tests and so forth. 

Those are very simple expedients that could be implemented pretty quickly. 

The problem we have, of course, is that some of the best solutions to healthcare problems are Republican solutions, and some are Democratic solutions, but they should be bipartisan solutions. There are elements of both parties' health plans that would greatly improve this country, and it's a shame that a real, meaningful dialogue and meaningful compromise to allow us to have both have not occurred. 

Q: What role do you see accountable care organizations playing in the healthcare system? 

Not much. As currently construed, basically, you get to keep a little bit of the money you lose by achieving efficiencies. That's not a really good incentive for doctors. 

A better incentive would come from vertical global fees or from capitation, where you get your money and now it's your job to figure out how to maximize patient outcomes and patient satisfaction and minimize cost. But to incentivize people by saying, "We're going to give you less money, and you get to keep some of the savings"-that's not a very attractive alternative.  

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A conversation with Charles J. Lockwood, MD, MHCM, about the challenges facing tort reform, reducing healthcare costs, and the role of accountable care organizations.

A doctor's view of tort reform and accountable care organizations in healthcare

 Charles J. Lockwood, MD, MHCM, dean of the College of Medicine and vice president for health sciences at Ohio State University, recently shared his thoughts on the challenges and possible solutions to healthcare delivery with Editor-in-Chief Lois A. Bowers, MA. 

Q: What are the major challenges facing the U.S. healthcare system?

I think that the fourth aspect to the healthcare cost crisis is discounted fee-for-service payments. We have an irrational system. The payers are neither the receivers of care nor the providers of care. As long as that crazy disconnect exists, we will create a lack of financial incentives to provide the best outcomes for the lowest cost, which is what value really is all about. We can't fix healthcare unless we remedy that. 

 There are two possible remedies. The very conservative one would be that patients buy insurance with very high copays and deductibles. So consumers of healthcare suddenly become price-aware and very thoughtful about every drug they take, what care they get, and so forth.The problem is, that kind of behavior will lead to self-rationing. Patients won't get preventive care. They'll delay treatment, and that behavior actually may exacerbate long-term costs. There's evidence of this effect in the literature, and it's been found in direct-to-consumer health plans. 

The other, more liberal strategy to fix the problem, would be to move to health systems with capitation. There, the physician-providers are constrained by costs, because they're getting a global fee or they're getting capitated. So they now need to exert control over the cost of care. The risk there is that they may ration care, and I think the way to prevent that behavior is with public reporting of patient satisfaction and outcomes. 

I suspect we'll ultimately move in the latter direction, with a very strong public reporting component. Either way, we can't continue along the current path, because we're going to bankrupt the federal government, and we're going to make American companies entirely noncompetitive. 

Q: What about the current system should be maintained in any kind of reform efforts going forward?

 If you have money and insurance, you can get the best care in the world, pretty quickly. That's important. 

It's also important that we don't lose our commitment to primary and basic biomedical research funded by the federal government, or the robust and vibrant pharmaceutical and medical device industry that's coming up with better and better therapies. But we have to create the kind of competitive environment and markets that exist in other parts of the economy so that the latest devices and drugs improve outcomes and reduce costs in a vigorous way. That kind of productivity has been missing from healthcare in this country.  

Medical Economics Editor-in-Chief Lois A. Bowers, MA, discusses with Charles J. Lockwood, MD, MHCM, the challenges facing the healthcare system, improving outcomes, and lowering costs.

System needs to include incentives to improve outcomes, lower costs

What exactly the future holds remains to be seen, of course. Most likely, you have an opinion, and so do some of the other experts we consulted for articles that appear in this issue. Among those visions: 

Whatever your view of the future, if you're like the doctors described in a recent report by the Physicians Foundation, right now you may be experiencing low morale because of your practice finance situation and the lack of progress that has been made under healthcare reform. 

Or maybe you're transitioning from a paper-based practice to an electronic one and are trying to find a way to maintain practice productivity-and revenues-in the process. 

And your practice most likely is discussing moving to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision-ICD-10-a crucial link to receiving payment for the services you provide in the future. 

While you're planning for that conversion, government efforts to crack down on fraud may have you on edge as you try to avoid making an honest error in your current system. 

And if you're a new physician, you may be facing personal financial issues in the form of medical school debt the size of a home mortgage. 

It's a challenging time to be a doctor. But there's hope for those PCPs who can hang on just a little while longer-even those who want to remain independent. On the horizon is the growing use of the PCMH, which favor PCPs because they are experienced in managing patients' overall health, and direct-pay models, which have the potential to free you from public and private payer reimbursement concerns. 

So what should you do between the present and the future? Lockwood and Goodman call for increased physician advocacy in the areas of healthcare system and tort reform as well as reimbursement. Also needed, they say, is increased flexibility as a new system emerges with improved quality and outcomes, increased patient satisfaction, decreased waste, and more efficiencies. 

It's time to take a look at the state of healthcare.

Viewpoint: What will healthcare look like in the future?

Charles J. Lockwood, MD, MHCM, dean of the College of Medicine andvice president for health sciences at Ohio State University, recentlyshared his thoughts on healthcare reform and the future of medicine withEditor-in-Chief Lois A. Bowers, MA.

In states that have a greater percentage of uninsured patients, there's going to be a lot more spending, and that's going to drive healthcare delivery reform, almost certainly in the form of some kind of global fee or capitation. I see rapid consolidation of health systems across the country. They'll be competing for those capititated lives and either offering their own insurance products, partnering with insurance companies, or being bought by insurance companies. There will be kind of a brave new world of healthcare delivery. Health systems will begin to focus on prevention, community health, and general wellness approaches. 

To accommodate primary care, we'll develop a multi-tiered system. The first tier will be retail clinics and midlevel providers providing basic vaccinations, point-of-care testing, anything that can be algorithm-driven, where you really don't need a physician. That currently takes up about 30% to 40% of primary care practice time, and it's one of the reasons why PCPs would have to work 18 hours a day if they really did everything they were supposed to do for an average panel in terms of prevention and acute care treatments. Tier two would be family physicians, general ob/gyns, pediatricians, and general surgeons who would provide preventive care and some urgent care. They would focus on wellness and on the initial management of diseases such as diabetes and thyroid disease. At the heart of the third tier would be comprehensivists who would coordinate the care for patients with more complex conditions. Most importantly, they would focus on the patients-almost all of whom have lots of co-morbidities-who account for much of the costs. They would leverage electronic health records and social networks to keep them out of the hospitals, keep them as healthy as possible, and make sure that there's no replication of testing and treatment. This activity will really drive down errors, drive down costs. I call them multispecialty patient homes. But the key with any complex health system is simple rules. And the simple rule that I think will change healthcare delivery will be to move from fee-for-service to global fees. 

Q: What can doctors do to be part of the solution to what ails the system? 

We need to advocate for ourselves in the sense of tort reform and ensuring that we continue to be reimbursed at an appropriate level given the quality of care that we provide. But we also need to be willing to adapt, with the constant focus being that we need to provide value to our patients, which means better and better outcomes, higher and higher quality care, higher and higher patient satisfaction, for lower and lower cost. We have to wring out the wastes and expenses of the system while improving efficiency.  

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Charles J. Lockwood, MD, MHCM, discusses the Affordable Care Act, primary care, and the state of the healthcare system with Medical Economics Editor-in-Chief Lois A. Bowers, MA.

Author | Lois A. Bowers, MA

Articles

A doctor's view of tort reform and accountable care organizations in healthcare

System needs to include incentives to improve outcomes, lower costs

Viewpoint: What will healthcare look like in the future?

Perspective: Healthcare reform and the future of medicine: a med school dean shares his views