Acknowledgments xiii
Introduction xv
Chapter 1 Health Care Won't Reform Itself 1
Many Treat-Few Prevent 3
Studies Prove the Inconsistency of Care 3
Care Linkage Deficiencies Abound 4
No Money, No Tools, No Accountability for Linkages 5
Paper Records Are Entirely and Almost Criminally Inadequate 6
Providers Don't Create the Economics Reality 7
Is Care Too Complex to Coordinate Anyway? 7
In Other Industries, Lower Prices Increase Sales 9
Screw-Ups Can Be Profitable 10
Screw-Ups Aren't Deliberate 11
We Need the Courage to Reform Care 11
We Need Universal Coverage 12
Tools Need a Use or They Are Useless 13
Strategic Modifications Are Needed 14
Chapter 2 Why Are Health Care Costs Going Up? 17
Normal Inflation Is the Bottom Line, First Level, and Basic Cost Driver for Health Care Cost Inflation 18
Worker Shortages Add to Cost Increases for Care 18
New Technology, New Treatments, and New Drugs Increase Costs 21
Few Standards of Value Exist 23
Other Countries Use Screening Programs for "New" Care 24
Untested, Purely Experimental, Unproven Care 25
The Dilemma-For Some Patients, There Is No Other Hope 25
Caregivers Sometimes Own the Businesses 26
Only in America Does "It Might Work" Work 26
Let's Require Disclosure of Effectiveness Research 29
Massive Care Coordination Deficiencies Add Expenses 29
Multiple Caregivers Don't Link Well 30
Perverse Financial Incentives Also Increase Costs 31
Problematic Insurance Benefit Design 32
Changes in Fee Payment Approaches Face Resistance 34
We Are Getting Older and More Expensive 36
Inflation, Technology, Inefficiency, Perverse Incentives, and Getting Old Are an Expensive Package 38
As aPure, Self-Serving System-Health Care Is Winning 38
Consumers Pay the Price for More Expensive Care 39
Care Costs Create Premium Costs 39
"Pass through" to the Customer 40
The Answer Is "Right Care" 41
Chapter 3 Set Goals and Improve Care 43
Data Isn't Shared 45
Random Tools Create Random Results 47
Begin with Goals 47
We Don't Need a Thousand Goals 48
Work Backward from the Goal to the Strategy 48
Asthma Care Needs Computerized Data 52
We Need Computerized Asthma Care Data 53
Universal Coverage for Children Can Improve Asthma Care 54
Being Insured Creates a Database 55
Care Won't Get Better without Goals 55
Goals for Key Diseases 56
The Tool Kits Look a Lot Alike 57
EMRs Need Support Tools 57
Patient-Focused EMRs Are Key 58
Benefit Packages Channel Cash 58
We Don't Need to Change the Entire Payment System 59
Data Is the Secret Sauce 60
Health Care Can Do This Kind of Work 61
Three Provider Payment Changes Are Needed 61
We Need Goals 62
Chapter 4 Connectors Are Magic 65
Older Patients Often Have Major Connection Problems 66
Medical Home and Packages of Care 67
A New Generation of Connectors 68
Connectors Come in Various Versions 68
Virtual Integration Can Mimic Vertical Integration 70
EMR Plus Care Support Tools 71
Denver Improved Outcomes 71
The Death Rate Dropped 72
Triple Co-Morbidities in Hawaii 72
Preventing ER Visits Is a Very Good Things to Do 73
Care Registry Worked for "Safety Net" Patients 73
Hospital Admissions Were Reduced by 70 Percent 74
We Need to Connect Everyone Who Needs to Be Connected 75
Buyers Need to Change the Cash Flow 75
Buyers Should Specify the Context for Care 76
The Point of Connectors Is to Connect 76
Claims Data Can Be Used 77
Chapter 7 The Perfect System 79
All, All, and Then All 79
Information Security Is Essential 80
CQI Is Needed-And CQI Needs Data 80
American Health Care Needs a Culture of Continuous Learning 82
Most of Health Care Is Splintered 82
One-Third Reduction in Broken Bones 85
Make the Right Thing Easy to Do 86
The Patient Should Be the Focus of Care Data 87
Ten Criteria for Ultimate System Design 87
Six Million E-Visits 87
All New Systems Should Be Connectable 88
The Perfect System Is Possible 89
Personal Health Records Can Fill Part of the Gap 90
Hub and Spoke Connectivity Can Be Computer Supported 91
Virtual Care in Remote Sites 91
Next Step - Connectivity 92
Chapter 6 We Need Universal Coverage, Care System Reform, and Care System Competition 95
Intermittent Coverage Disrupts Care 96
Care Improvement Needs Coverage Continuity 97
Data Should Be Longitudinal 97
What Kinds of Health Plans Should Compete? 98
No One Is Accountable if No One Is Accountable 99
"Insurance Exchanges" Should Offer Care Team Options 100
Chapter 7 Risk Sharing Works Quite Well, Thank You 103
Risk Pooling Is the Key 104
Co-Ops Set Quotas 104
Ugandans Understand the Cost/Premium Connection 105
Blame Your Fever on Your Thermometer 105
The Basic Business Model of Insurances 106
The Key Is Spreading/Sharing Risk 106
Swiss Rejected Canadian Model 107
The Double Mandate 108
Why Do American Insurers Screen Risk? 108
Large Numbers Are Not Magic 110
Risk Pools Don't Cure Cancer 111
Pooling Small Groups Isn't Magic, Either 112
95 Percent Defines the Business Model 112
Five Percent of Privately Insured People Had Health Screens 113
Hassles and Disagreements Are Minimized with Inclusion 115
Individual Enrollees Have Individual Motivations 115
Using Someone Else's Money Is Often Attractive 116
Expensive New Members Increase Average Costs 116
Death Spirals Can Be Unfortunate 117
A Single Mandate Can Destroy Risk Pools 118
The Best Approach Is to Cover Everyone 118
People Who Need Heart Transplants Should Get Heart Transplants 118
Chapter 8 Focus, Tools, and Better Health 119
Begin with Chronic Care 120
Chronic Care Is the First Priority 121
The Low-Hanging Fruit Is to Bite the Bullet 122
Focus, Tools, Health 123
Money Talks 124
Choices Should Affect Premiums 124
Registries Should Not Dictate Care 125
Science Changes 126
Chapter 9 Health May Be the Highest Priority 127
The Girth of America Is Expanding 127
Americans Are Also Inert 129
We Need a Culture of Health 129
Eliminate, Label, Reduce, and Persuade 130
We Need Half as Many People to Become Diabetic 131
We Need an Agenda of Health Improvement 132
Chapter 10 We Also Need to Set Goals to Directly Reduce Costs 133
We Need a National Forum for Cost Reduction 135
We Need a Commission 136
We Need Complete Data about Cost Drivers for Care 137
The Goal Should Be to "Bend the Trend" 138
Health Care Could Be Moving to a Golden Age 138
Endnotes 141
Index 149
About the Author 159
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