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Comes the revolution?


The state of the nation's health care system.


Washington Insight

Comes the revolution?

By Daniel B. Moskowitz, Contributing Editor

It's official: The nation's health care system is a mess. The prestigious Institute of Medicine said it was so last month in a report that was scathing but not particularly groundbreaking: Chronic health problems get too little attention; specialists treating the same patient do not coordinate their care; it takes too long for medical discoveries to be used by the average practitioner. But the IOM packaged these familiar findings in a politically savvy way that shows an understanding of how Washington works and a determination to pull the right levers. It just might work.

The report came from the same IOM committee that issued To Err Is Human, the 1999 paper that spotlighted widespread medical errors and energized the medical establishment, including the government officials who oversee providers and the flow of public funds into health care.

But the complex challenge of reducing errors is child's play beside the new mission of the IOM's Committee on Quality of Health Care in America. Chair-man William Richardson, president of the W.K. Kellogg Foundation, rightly calls it "the rest of the iceberg:" nothing less than completely revamping the delivery of health care in the United States over the next 10 years. "It's time for a new system," insists Harvard Medical School's Donald Berwick, a member of the committee.

The genius of the new report is that it combines human stories—a woman who had to wait nine weeks for a biopsy after a suspicious mammogram, medical records lost when a patient switches doctors—with a broad indictment that leaves no component of the system immune. The strategy is to get beyond finger-pointing and actually work on improvement. Committee member Molly Joel Coye, president of the Health Technology Center in San Francisco, went out of her way to say: "There's no reason to think that the quality problem we're discussing is attributable to managed care. This is an across-the-board problem."

Richardson says his panel isn't looking for a monolithic solution: "Indeed, innovation and pluralism at the local level should be nurtured." But it wants that pluralism to conform to certain national precepts, such as basing care on "continuous healing relationships" that harness the Internet and the old-fashioned telephone as adjuncts to office visits, tailoring that care to patient needs, giving patients more information and relying more on their treatment choices. "Health care organizations, clinicians and patients must work together to redesign how care is delivered," Richardson argues.

But the panel has a big role for employers, too. "Current payment methods do not adequately encourage or support the provision of quality health care," Richardson says bluntly. And it's worse than that: The committee found that too often payers were, even if inadvertently, actually discouraging innovations that could improve quality. The committee wants payers to stop the pretty talk and actually implement payment policies that reward providers who measure the quality of their care, make it public and work to improve the outcomes.

None of this private sector reform will happen without leadership—and a lot of money—from the federal government. The IOM recom-mends that Congress set up a Health Care Quality Innovation Fund and give it at least $1 billion to jump start the shift to a more patient-centered, innovation-welcoming, integrated health care system. The money would fund model projects that would stimulate private investment. At the same time, Health and Human Services would be charged with getting new scientific knowledge into the hands of doctors in ways that they can immediately apply to patient care.

One needn't be a cynic to predict that any change will be less rapid and less sweeping than the IOM committee members are demanding, but their attempt to foment a revolution may produce more than modest ad hoc proposals. Already such health policy powers in the Senate as Ted Kennedy (D-Mass.), James Jeffords (R-Vt.) and Bill Frist, MD, (R-Tenn.) have signed on and are trying to get pieces of the IOM recommendations into bills they are now drafting. This could be the start of something big.


Daniel Moskowitz. Comes the revolution?. Business and Health 2001;4:13.

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