Proceedings of the 4th National Conference on Primary Health Care Access: April 2, 1993 – First Plenary Panel – Reweaving the Safety Net, Part 3 (Ramsey)

The archiving and publishing of the introductory remarks and the proceedings of the first plenary session of the Fourth National Conference  on Primary Health Care Access (April 2-4, 1993) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.

This presentation follows: Proceedings of the 4th National Conference on Primary Health Care Access: April 2, 1993 – First Plenary Panel – Reweaving the Safety Net, Part 2 (A. J. Henley)

 

John E. Midtling, MD, MS (Moderator):  Our final presenter this morning is a good personal friend and colleague, Dr Chris Ramsey, who is Professor and Chair of the Department of Family Medicine at the University of Oklahoma.

Chris is currently President of the Association of Departments of Family Medicine, our national department chairs organization. He has been a representative to the Council of Academic Societies of the American Association of Medical Colleges.

What I have admired most about Chris is his ability to identify mega-trends and his ability to perceive change and make thoughtful analyses of that change. So at this time I would like to turn things over to Chris.

Christian Ramsey, MD; University of Oklahoma; Oklahoma City
Christian Ramsey, MD; University of Oklahoma; Oklahoma City

Christian N. Ramsey, MD, University of Oklahoma, Oklahoma City: It’s a real pleasure for me to be here this morning.. We started off with the title of “Curing the Crisis” as far as health care reform goes. I think that a more appropriate subtitle would be “Can Health Care Reform Escape the Emperor’s Tailor?” I hope that when I have finished this morning that you will understand what I mean by that.

The Health Care Systems Paradigm

What I want to do in the next few minutes is to talk about a subject that is absolutely incredibly complex. I want to talk about  the new emerging paradigm of health care systems, because this is useful framework  to evaluate policy options and policy changes. At the end we can talk about some specific policy impacts, especially the proposed reforms from the Clinton administration.

I have basically three hypothesis. The first one is that a new science paradigm for medicine is emerging. I call that “the info medical paradigm” which basically is a self-organizing systems model that operates with causal feedback, both positive and negative.

In this paradigm the final state of the system cannot be determined, nor it can it be reduced as in reductionism. It is very different from the science paradigm on which the current health care system is built, which is the bio-medical reductionist paradigm.

The importance of this hypothesis is that it is the science paradigm of medicine that in so many ways determines the structure of the health care system. That, of course, drives costs and it drives access. It drives a number of other aspects of the system as you will see. But at any rate that is this key difference.

The second hypothesis is that, in fact, not only is a new science paradigm emerging but that is driving a new health care systems paradigm. We are going to talk for a few minutes about that.

My third hypothesis proposition you have already heard, in fact, from one of our other speakers, that is that the system is already transforming itself from a provider and reductionist driven system to a patient and info-medical driven system.

In fact, we have today two systems – one emerging, one dying – operating next to each other. That has a lot to do with what we call the health care crisis.

The Current System

Let’s talk about this crisis and how the paradigms figure into it. If you will, I want you to think about the health care system as being composed of four different layers. I am going to start with the current system, so we are going to work from the top down. If we were doing the new system, we would work from the bottom up.

In our current system there are four different layers. The uppermost layer is comprised of the regulatory institutions, the government, the bureaucracy, the policy bodies, groups like the professional associations, such as the American Medical Association, and groups {like the National Conferences on Primary Health Care Access) who control the national policy and give the major franchises.

The second layer is the organized health care delivery market economy. That consists of provider organizations, hospitals, physician groups, insurance companies, academic health centers and research institutions.

The third layer is probably the most important. It is what I call the health and medical production layer. It is undefined, but there is an enormous amount of continuous and constant activity bartering back and forth between providers and recipients of care.

This goes on in many different ways in an enormously complex mosaic of our ethnicity and our culture across the United States.

Finally, underneath it all are the patients, their families, their genes, their diseases, and their behaviors.

What has happened is two big reactions in this overall system. First, the production costs which are dictated by the bio-medical paradigm have gotten higher and higher and, in fact, demand has increased. The reason is that if you develop a system on a reductionist paradigm, all you ever do is solve one problem and create a whole group of new problems to be solved. So the demand is unending. There is never an end to the demand.

If anybody has ever had a basic economics course you know exactly what is going to happen. The price is going to rise, and and rise because every time you solve a problem, you create new problems to be solved.

We have all heard this. Think about what has happened with our treatment of kidney disease and the need to create new bio-technology. The problems that you create are just absolutely endless.

The second thing is that it is very clear that the science paradigm under which we operate does not solve all the problems and people know this.

What has happened is that the science leaders in medicine get very defensive about the foundation of the bio-medical reductionist paradigm. It becomes more apparent to people that the paradigm does not really solve their problems, because it does not account for the meaning of illness in people’s lives –  for instance. how people react to being sick – or for all of the things that we understand and know to be “soft areas” that are very important in the whole medical paradigm.

 Reactions against certain medical interventions

What has happened is that as the system based on the old paradigm cannot solve enough of the problems, people at this lower level – at this level here and this level – start to find other ways to deal with things. That has been going on for a number of years in our society and some very interesting things have been done. For instance, we have seen people begin to say, “You’re not going to put me in the intensive care unit and hook me up to all those things. I am going to make it legally impossible for you to do it.”

You see employers getting organized into business purchasing cooperatives. You see providers being organized in different ways. We see patients now taking things very much into their own hands. A. J. Henley talked about this – some of the programs that they are doing to help activate patients to take a more active role to provide their own care and not turn everything over to the scientists.

We have seen the growth of alternative treatments, an enormous market that even now the National Institutes of Health (NIH) is having to acknowledge that it has to be looked at. As many of you read in U.S.A. Today, in fact today they are taking some applications for their first round of projects, although they made it very clear that the scientists are going to evaluate them, however.

Then you see the reorganization of the provider system into a whole different confluence than the old model that we have at the current time.

 Patients changing their behaviors creates problems for the biomedical models

What has happened is that as these lower levels in this model begin to change their behavior – guess what? It creates problems up here at the top because the job at the top layer is to control the bottom layer to give the franchises in to control the behavior. Things are out of control right now.

So what you see is, for instance, who in the world does the American Medical Association speak for today? Which group of physicians? There are now many groups of physicians taking about health policy on the national level.

You have the same thing going on at all levels of hospitals, within NIH, and all of the difficulty or the crisis is because of millions of tiny individual actions that are getting picked up down here and are resonating through this entire system. What is happening is, as I say, there is a brand new paradigm emerging.

Let’s go over here -and talk for just a minute about that. The things that are driving the health care system paradigm are a change in the science paradigm of medicine, medical mega-trends which we are going to talk about for just a minute, changes in the provider market and organization, and patient actions of various sorts.

Information technology is transforming medicine

Some of the trends are, for instance, someone talked a minute ago about the change in morbidity from a more biologic morbidity to a behavioral or lifestyle morbidity. I think that A. J. Henley mentioned that. There are a number of other trends that are very important. The one that I have here – information technology – is very, very important because of the law of the microcosm is coming into play not only in our lay organizations but in medicine also.

As many of you know, the law of the microcosm says that as the transistors have gotten smaller and smaller and the efficiency of computers has gotten greater that the intelligence that any organization gets pushed out to the fringes of the network and it is impossible for the central part of the organization to control the organization in a hierarchal fashion.

That is, in fact, happening in my very own medical school, the University of Oklahoma. It is absolutely impossible now for our administration to control what is going on in our departments. We have people that are all plugged in sharing information with each other over our campus networks. We have access to information from the administration. We can dial the National Library of Medicine to our patient care statistics, etc.

The administrators can sit over and dictate all that they want about what we ought to be doing. But the fact of the matter is that we are not a hierarchal organization any more. We are a networking kind of organization. So that is a very major trend that is going on there.

Incidentally, I can talk for hours about some of these things. System characteristics – there are some fascinating things there. We have had a health care system in the old paradigm really characterized by random interactions. Now we have a whole value change developing because we are coordinating and managing the interactions that people have.

We don’t just have random interactions. As A. J. was saying, you can now tell how many prescriptions a person has had, where they have them, who gave them to them, etc. It is now possible to basically add value to each stage of the production process, or you can calculate the value of an early non-invasive intervention to either immunize someone to change behavior that will basically be a much lower cost, much less invasive intervention than something that happens earlier on.

Intuitive (old) vs Evidence-based (new) systems

This is all the kind of characteristic that is going on as the system is emerging. You can look at the differences between the old system and the new system. The model of illness in the old system is a reductionist model and this information model is new. The clinical method in the old system is intuitive. In the new system it is a whole different thing. Some of you have read the articles about evidence-based decision making. It is a whole brand new way of looking at patients.

The basic sciences in the old method are all physical and natural sciences for the most part. In the new method they are information sciences. They are social. They are management sciences.

The driving force in the old system is the provider. It is a very physician and provider-driven model. Clearly, the new system is a much more patient-centered system. The patient is passive versus empowered.

The basis for competition in the old system is tertiary products and services and technology. You have it and you see it being accreted all around you.

In the new system the basis for competition is outcomes. What can you do with the resources? How can you organize the resources that you have to produce an outcome that is specified?

The physician manpower that is critical in the old system is the scientist-specialist. In the new system it is the generalist. There are changes in a number of different of these kinds of areas.

One of the other factors that drives this new paradigm is the move from a market in which the patient has to assemble the components of care to a market in which the patient joins a system and the system assembles the components of care in order to produce an outcome. That is one of the things that I mean when I say that there are fundamental changes in the market organization that are driving the system.

 Can Washington DC “reform” health care?

If the question of the day is – “What is going on in health care reform?”, we mean “What is going on in Washington?” Will it make any difference?

The context that we have to ask that question is – This changing science paradigm of medicine, these trends that are going on out there that I have just shown very highly over, the market diversity that has to be dealt with, that is the incredible diversity of the health care market in this country.

There is a tendency if you live in Washington to think of things in very monolithic terms and not to recognize that diversity and the fact that there is this transformation, in my opinion, that is already under way.

What does all this mean? At any rate, I think the question is – “What is the optimal role of the federal government?” I guess where I am is that first of all the primary role ought to be to do no harm.

I think there is a lot of potential for the federal government to do a lot of harm with what is going on out here right now. I think what is going on is moving in the right direction.

I am very impatient with it. But I am very encouraged by a lot of what I see going on. It is an enormous change in a very complex and exquisitely difficult to understand system. Some of the things that I think could be done that should be a very high priority is that the federal government ought to develop policies to ensure that we start to produce the right kinds of physicians.

That feeds very much into a number of these trends and changes that are all underway and no one here would have any problem with that. One of the things that I think ought to be considered is maybe there should be a “G. I.” plan of some sort.

We have educated an awful lot of people to do things that we don’t need them to do any more. I think it would be very much in our interest to go ahead and develop some ways to pay them to get trained to do things that, in fact, many of them went into medicine to do to begin with.

There are lots of people, I think, who could do very good general medicine who are now specialists. I think that we probably – I haven’t worked out the economics for this – but I think we could probably afford to subsidize their income while they became trained to do what we need for them to do. They would be very much happier to go along with what needed to be done if we were doing that instead of putting them out of business, in my opinion.

Need for practice-based research

We have to have some funding to study the common and ordinary problems that create most of the morbidity and mortality in our health care system – the problems that we deal with in general medicine that are not funded right now. That is practice-based research and all of you have heard me talk about that for a long, long time. That is very important.

Need to reform bases for federal payments to medical providers

Finally, the federal government in its role as payer should not do any harm. To me that means that RBRVS ought to be implemented using not these historic charge schedules that they are using as the basis for determining costs, but the actual cost.

That is the thing that has skewed RBRVS so terribly, as I understand it. It has not been implemented on the basis of actual cost data. They used charge data. All that has done is just perpetuate the inequities of the current system and to continue to overpay specialists. I think the federal government ought to change its behavior as a payer and that would be one thing that it could do.

Certainly the idea of doing some things like paying organizations that are doing things that you want them to do more so they could do more things, whether it is a managed Medicaid program or other forms of managed care, it would be another good thing that could be done.

Most people are getting care in some way. It is just being paid for in ways that are not acceptable to everybody. That is kind of my opinion about that. We are all paying it through cost-shifting or through subsidies of one sort. We just don’t like the way the accounting works out right now. That isn’t to say that people aren’t getting care, but I think we need to go ahead and hand it off to the states.

Concluding Remarks

I like the idea of giving some people accountability. I like the concept of having health accounts kind of like IRAs so that people have funds in these accounts. Their ability to find good deals and to purchase them would allow them to accumulate funds for a rainy day or to purchase additional benefits, etc.

I think the idea of the purchasing cooperatives is very good. I do agree that the market is not sophisticated and that there needs to be some help but I am not sure that the federal government can do much more than stimulate and encourage some initiative at much lower levels in this area.

I like the idea of experimentation and pilot testing so that we don’t have to bet the whole bank in one wave. I am very worried about taking this transformation that I see already happening off course. I think that ill-advised monolithic programs could do that.

There is one more thing that I want to say. I do think the idea of re-engineering social programs to bring them into the health network which is very much in line with what A.J. was saying is worth pursuing. I agree.

We are not the solution to these problems, but I think that they are the solution to lots of things that we are all interested in. We have examples in Oklahoma of programs that are doing the same things for the same populations that don’t even talk to each other. It is just as bad as the way General Motors or other big companies were run before they found quality management. So I think we need to do some things to deal with bringing our focus into including the non-medical determinants of health into the scope of our programs.

I think I have said enough. I hope I haven’t left everybody behind. This is a lot of material to cover quickly. Thanks.

Midtling: Thanks a lot, Chris.