The New Health Dialogue

We hosted an "Alternative Town Hall" at City Hall in Los Angeles this week. Like the town halls of last summer, it was packed to the gills. Unlike last summer's, however, speakers and attendees were not only civil but deeply engaged in thinking about "Putting the Care in 'Obamacare'."  Representing very different perspectives and roles in the state, they looked ahead to the opportunities that health reform creates to improve the quality of care that Californians receive and the value they get for their medical spending.

The speakers were three "L.A. health care rock stars," Thomas Priselac, the CEO of the Cedars-Sinai Medical System (one of the most prestigious hospitals in the country), Cástulo de la Rocha, the president and CEO of Alta Med Health Services Corp. (the largest Federally Qualified Health Center in the state) and Dr. Bill Chin, the executive medical director of HealthCare Partner Medical Group (a multi-specialty practice that cares for over half a million patients).

After an overview of the quality-enhancing provisions of the federal health reform law delivered by Leif Wellington Haase, director of the New America California Program, the panelists highlighted several different issues that they were dealing with across their organizations as they work on improving care coordination and integration to improve quality and bring down cost. The similarities across settings were striking, and suggested a common agenda for reform implementation. (These priorities dovetailed with the recommendations of the California Task Force on Affordable Care.)

Three themes emerged in the discussion that I moderated, all relating to the "unfinished business of healthcare reform," which may require state-specific solutions here in California and elsewhere.

1) Personnel flexibility. Each health care leader acknowledged the need for the state to think about preparing for its workforce shortages by training more doctors, nurses, and allied health professionals and agreed that the provisions in federal reform designed to increase the proportion of primary care physicians should help to a certain extent. But they also highlighted how they have succeeded in creatively using their medical personnel even though California (ironically) has among the most conservative laws related to these issues. To reorganize the structure and financing of medical care and expand access in the ways envisioned in health care reform, health personnel will have to be able to operate to their full potential while caring for patients -- yet the federal legislation may not adequately allow for this flexibility.

2) Evidence-based medicine. All of the speakers addressed the need for a greater respect for evidence in medicine to permeate the political processes, doctors' attitudes and patients' preferences. In spite of the efforts of organizations such as the Campaign for Effective Patient Care and others who have drawn attention to the fact that as little as half of all medical care has a solid evidence-base, changing these attitudes can be extremely difficult. In spite of downpayments on comparative effectiveness research both in the stimulus and healthcare reform, California may have to take a more active role. It will be impossible to pay for a lasting coverage expansion unless we make significant progress on bringing down the overall cost of medical care (or at least restraining the growth of those costs). Pursuing medical care with a solid basis in science is one of the best ways to improve the quality of care while controlling its cost.

3) Demographic trends. Federal health care reform put a downpayment -- but did not solve -- the challenges of long-term care and chronic disease management that we will face as the population of the nation, and the state, ages. A good starting point, as highlighted by Lisa Shugarman of the SCAN Foundation, one of the many healthcare leaders who attended the meeting, would be to raise awareness of provisions such as the CLASS Act, that could provide additional funding for long-term care. But ultimately, making institutions accountable, financially and otherwise, for the care of seniors over a long period of time is the most promising approach to ensuring that the care they receive is both efficient and effective. Quite a lot rides, therefore, on the pilot programs in Medicare and Medicaid, as well as the new Center for Innovation and the office for the "dual eligible" population. All will seek to find ways of improving coordination and changing the organization and incentives in medicine.

Though quite a lot of energy and attention was focused on the birth of health care reform, the consensus of the group was that this was a baby that we have just brought home. "Raising" it will require a great deal of energy and attention. In addition to intelligently implementing the provisions of federal reform, there are additional steps that states may have to take to make this legislation work as intended.