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Peter Heywood wrote this on July 18, 2014 / no comments

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In July, the New York Times published a piece by Dr Aaron Carroll in its Upshot column. Dr Carroll is a professor of pediatrics at the Indiana University School of Medicine, and I suspect in his position he would be quite open to new ideas and aware of how innovative change actually unfolds.

So I was disappointed by his article http://nyti.ms/1jYFwoK suggesting that the Affordable Care Act was not going to deliver on its promise of achieving the Triple Aim. In it, he picks up on the old retailer bromide: “Price. Quality. Service. Pick two” by noting that if quality is going to increase, then costs may rise, or if access is going to get better, it will be at the expense of quality.

One of the examples he cites has to do with newly-insured consumers in Massachusetts using expensive hospital ERs more, because now they have coverage and, well, the ER is convenient. In the same vein, the incidence of invasive surgery increased by 9% in Mass because, again, people now had access to it.

He does slide in a reference to the fact that the ACA may reduce overall spending because of “other changes to the health care system” but doesn’t really dig into that point. Yet these “other changes” may well be the most important observation he makes, if somewhat dismissively, in his post.

I agree that the consumer facing side of the ACA is primarily about providing access, although you could argue that it’s really about encouraging people to access the system because now they’re covered. And if all that the ACA, and healthcare reform in general did was to open the doors of an existing system to more people, then, yes, the ACA will fail in its mission. Kind of like building high speed onramps to an existing narrow two lane road.

This is similar to the many articles written about how the first ACOs haven’t delivered on their promise, or the challenges of integrating EHRs into practice. Guess what? The first iterations didn’t work. Gee, that’s never happened in innovation before.

Change is not an event. It’s a process. Systems often try to apply innovations to existing structures or processes, Often the early results are less than satisfactory and it takes time for the full potential and scope for change to make itself evident. For instance, when television first appeared, it was essentially radio with cameras. It took a decade or more before the rudiments of an entirely new entertainment system finally appeared. Or when electricity first appeared in factories. It took a generation before the far more efficient linear assembly line innovation arose. Before that, people arrayed machinery around a central power plant, just like when (and as if) they were steam powered.

Back to access and the ACA. What can happen to the health care system when the impact of more access and more portable coverage is truly absorbed? I believe innovations will in fact let us choose access, lower costs and quality. A new system (and a pretty disruptive one to the established order) will, I am sure, evolve that is not confounded by Dr Carroll’s “trade-offs” but instead operates by new rules, expectations and behaviors. Some of these changes might include:

  1. Consumers understanding that “going to the doctor’s” means visiting a place, not a person. Not every visit or interaction requires a consult with a physician, although consumers (and in fact physicians) have so far been trained to view all of the ancillary staff as simply reactive support for the doctor, not experts in their own areas.
  2. Supporting that, pressure for a regulatory move to give skilled specialists (nurses, pharmacists, physical medicine providers and more) greater scope in managing or leading a patient’s care plan.
  3. The continued acceptance and rise of alternative care destinations, such as retail clinics, to address issues of convenience.
  4. The evolution of Accountable Care (the regulation driven initiatives) into accountable care, true outcomes based care practiced as the norm throughout the system, with the attendant care plans and evidence-based actions that obviate unnecessary interventions.
  5. The evolution of new technologies that far better utilize the potential of all the data out there than the glorified filing cabinets that are most of today’s EHRs, to give access to true evidence-based protocols.
  6. The equal rise of consumer technologies that simply and coherently link health actions, behavior change and provider communication so that consumers really start to take charge of their health.

The only thing you can really predict about the future is that it won’t look like you imagined it. Thus you can be critical but not make unalloyed declarations that something’s a failure this early in the game. We’ve only just started down the path of massive change in a system that, Lord knows, needs it. You can’t be Pollyanna-ish about the future – pitfalls, barriers and failures will be there, of course, but the ACA is not really about access. It’s about unleashing creativity by revealing entirely new needs. And the impact of that will take time and many wrong turns to realize.

Peter Heywood wrote this on July 18, 2014 / no comments

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