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