Who Should Be Accountable for Bringing About Change?

"Every system is perfectly designed to get the results it gets."

Reminiscent of Confucius or one of Yogi Berra's infamous isms, this quote offers us wisdom beyond just simple word play. In the case of system performance, especially when thinking about a particularly complex system such as U.S. health care, the above statement provides us with insight to explain why we're getting the results we're getting (which as we saw, in begging the question of "...How m'I Doing??", are not all that great) - and it isn't by happenstance. Rather the opposite, our health care system can be thought of as being finely tuned to get the results it's getting. The "tuning" in this case could come in the form of efforts to reform health care, but it need not be so deliberate, as our system of health is constantly having its dials turned by a countless number of shifts in processes that directly or indirectly link to our health. To help us get a handle on what matters in the world of health and what doesn't, health experts have created the term "determinants of health" to capture this comprehensive network of interactions associated with our health.

If you haven't already done so, before looking closely at the contents of the image below, try to come up with as many factors of health as you can on your own (write them all down if you'd like!) - after we'll gauge how closely our intuitive senses match the real thing.

The Institute for Healthcare Improvement provides us with this useful depiction of our health hemisphere. 
So how'd you fare? Did you account for all of the factors mentioned above? - leave me a comment with your thoughts!

As we see depicted in the above diagram, there's much more to our health than what we traditionally might have thought. "Health care", which receives an overwhelming majority of the funding for health matters in the U.S. (upwards of 90% of the $2.6 trillion dollars spent on health annually), comprises only one piece of the schematic's hemispherical puzzle. The rest of the amphitheater is occupied by our genetics, behavior, social environment and physical environment as well as interventions made on the part of society to promote or deter healthy living, much of which are the subjects of our attention in public health (which mind you, gets less than 5% of our financial attention in the form of funding). When we think about making changes to our system of health, we're going to need to think big picture about how any number of these factors could have an effect on our health outcomes.

Continuing on this matter, we find that significant improvements to our system of health tend not to arise spontaneously. A principle from the field of system performance sums up this notion succinctly in stating that "change can happen without improvement, but improvement cannot happen without change". A two-liner of which even JFK would be proud, and, I imagine, not just for its rhetoric, as we are able to unearth from it the concept that improvement never arrives unaccompanied by intervention (otherwise known on this blog as a "wedge"!). While observing properties of the natural world some centuries ago, Isaac Newton was coming around to a similar realization that culminated in his monumental laws of motion, which still stand true. Following a similar rhyme to the aforementioned adage of systems, his first law states that "an object at rest will stay at rest and an object in motion will stay in motion at a constant velocity, unless acted on by an external force." A concept cutting across historical and disciplinary divides has retained its relevance from the founding of classical physics all the way to the health care reform efforts of today.

Since we've seen that the U.S. healthcare system has significant room for improvement across the board (with a few exceptions like emergency care), we're now left with devising a means to change our ways as we've come to the realization that business as usual, i.e. no change, will not cut it. So what will we do? At present, much of our answer to this question can be found in the federal legislation as key decisions regarding domestic healthcare reform have already been drafted into law with the passing of the Affordable Care Act in 2010 - so at this time, the more appropriate question then, is not what are the changes that we are looking to make, but instead, HOW will we make them and WHO will be responsible or held accountable for carrying them out?

*Yearning for further coverage on how Congress came to the "what"? Refer to the perspectives offered in "Massachusetts: America's Next Top Model...".

"Who Accountable???", the healthcare reform spin-off of the classic "Who Done It??"

Are you ready to give it a whirl??

Massachusetts: America's Next Top Model, Many Years Running...

The double take is probably warranted, but rest assured, you're in the right place. No, you haven't mistakenly ended up in the opinion pages for the CW Television Network's top performing show, nor is there even an inkling of a chance in this blog taking a runway-style turn into discussing the ins and outs of high fashion (sorry to disappoint!). In rounding out the analogy though, let's for a moment imagine the following scenario: What if the Miss America pageant, the competition that pits model-citizens (not to be confused with model citizens) from each state against one another, alternatively focused its sights on identifying the state leading the way in social policy in a given year?

In this fantasy competition, I would wager that historically Massachusetts would have come out on top, donning the winner's sash and tiara, more than any other state since the colonies came into being some 400 years ago.

To see how I came to such a conclusion, let me share a quick list of national social milestones that took place in the beloved Bay State (click on the year to view sources):

1630 - First self-governing colony, with the General Court housed in the colony instead of in London, U.K. This landmark feature set the stage for Massachusetts to catalyze many of the significant movements of that time period (think the original Tea Party!), eventually leading up to the colonies' independence from Britain in 1776. Not only of national significance, the Massachusetts General Court happens to be the oldest continually operating governing body in the world!
1798 - First public hospital was erected in Boston following passage of the Act for the Relief of Sick and Disabled Seamen (our nation's first law to mandate the purchasing of health insurance).
1799 - First public health department is created in Boston and Paul Revere is named its first leader. To find the noteworthy department in its present form, look no further than the Boston Public Health Commission.
1820 - Boston's English High School is founded as the country's first public high school.
1848 - Boston Public Library is established, the first to be publicly funded and open to the public, even allowing patrons to borrow books for free.
2004 - First state to legalize gay marriage.
2013 - First state to attain universal healthcare (> 98% coverage).

In addressing the crowd that gathered for the 71st Citizens' Legislative Seminar at the Massachusetts State House a few weeks ago, Senate Majority Leader Stanley Rosenberg spoke of the state's history as a "bellwether" for innovative policy, a history that is apparently congruent with the present as Massachusetts continues to construct original frameworks for social policies that eventually spread nationwide, not the least of which being the Affordable Care Act (ACA or "Obamacare") of 2010. Now that's what I call a model state!

Inching our way toward the onset of the ACA at the start of 2014, let's take a look back at the Massachusetts' legislative decisions on health care of the past decade to see exactly how the state shaped the national debate that lead to the corresponding landmark law.

Interestingly enough, it all began with then Governor Mitt Romney signing into law Chapter 58 of the Acts of 2006, at the time known as "Romneycare" (and without a bit of irony).

Boston's Faneuil Hall plays host as legislators gather around to witness Governor Romney ink his approval, effectively chiseling this groundbreaking piece of legislation into law. NPR captures the photo op!

Since policy by nature is comprehensive in its form, providing no shortage of words; what follows is an attempt to ease your exhausted eyes with my version of what I'll call legislative "sparknotes", as I highlight the key provisions in Massachusetts' healthcare policy of recent history, starting from the ancestral legislation of 2006 that set the state in motion toward its universal healthcare model and leading up to today. Those well-versed in the proceedings of the ACA (and you all should be considering you've now memorized the entirety of "Walk with Me..."!) should begin to notice the resemblances without breaking a brow sweat.

With All That Said...How m'I Doing??

Since we have all now read and slept on (literally under your pillows, right?) the points discussed in "Walk With Me, We've Got a lot to Talk About", I'll boldly (foolishly) assume that we've all been brought up to speed on some of the more pressing matters in national health care reform pending implementation of the Patient Protection & Affordable Care Act (ACA) and proceed with taking us to our next stop; in what I will call a more "empirical dimension". By empirical here, I am referring to a process that disregards opinion or how we may feel about our efforts and instead focuses our objective lenses toward direct observation and statistical analysis.

Regardless of your natural inclination toward numbers of all kind, it's hard to ignore the importance of statistics in our society. In our fast-paced present day, it seems like the world is becoming increasingly more bloated with information thanks to the advent of the internet and "Big Data". To make sense of all that swirls around us, we must enlist a myriad of quantitative metrics to test our findings collected through observation. This process of basic scientific inquiry, when calibrated appropriately, can yield impressively accurate and useful results.

On the Leading (w)Edge, we stress and much prefer this sort of scientific approach using statistics to measure complex systems (in increasingly complex ways, thanks to computers and human ingenuity!), placing our valiant attempts toward improving quality of life under the microscope to be checked and verified/rejected. In other words, for the case of health care, we ask and objectively test the following question: Is our country doing a sufficient job of caring for our population's ailments/needs while simultaneously promoting healthy living standards and behavior?

One question, in one sense being so easy to ask is in another sense incredibly difficult to test with accuracy. Our battalion of public health experts call on an army of metrics to attempt to get to the question's root and uncover a comprehensive sense of our performance (so how m'I doing??). A few of the chief measures, that you'll likely see cited time and again in public health studies and articles covering the matter, and as a result are worth familiarizing yourself with, include: life expectancy, disability-adjusted life expectancy (DALE), health-adjusted life expectancy (HALE), infant mortality, percentage covered by insurance, equitable distribution of resources, cost of health care (% of GDP or per capita), preventable deaths, death due to various illnesses...the list literally goes on, and as you can tell it's a pretty morbid list.

Not all metrics get so technical however. Can you recall having seen this image before at your doctor's office?

If only it were this easy to measure our population's health...image courtesy of NPR

The above image, however amusing, serves to remind us of how difficult it can be to remain objective when measuring a qualitative thing like health or pain. Even though the "pain scale" uses numbers (0-10), it's ultimately up to the patient to decide how much pain they're truly in at that moment. With no universal way of determining our own pain (being it a sample size of one), we resort to pictures and quick descriptions in an effort to attain a true universal scale for pain. Similar to pain, health and quality of life are equally as difficult to measure objectively, though you should note it's not for a lack of trying- as we've seen, unlike pain, we have many metrics at our disposal.

In that same vein, one thing that I will encourage we keep in mind when looking at the following reports on health care performance/outcomes, is that these measures should not to be confused with the actual aim of the measure(!). In other words, the metric is arbitrary (we created it), whereas the actual condition of the system is implicit or independent of our measure. In our case, we could say we're using these metrics to try to quantify the extent to which our people suffer from health complications, the extent to which our health care network helps or hurts (the latter known as quaternary prevention) and the extent to which our people tend to live lives of high quality.

Numerous attempts have been made to measure the quality of health care systems- below I have cherry picked a few of the more widely cited and useful. Since all rankings are not created equal, please be mindful while you peruse.

AND NOW FOR THE UNVEILING OF THE RANKINGS!

Walk with Me, We've Got a lot to Talk About

Several important developments in health care have taken place in the U.S. within the past week as the stage is being set for the implementation of the Affordable Care Act (ACA) at the start of the new year. On October 1, our nation witnessed the red carpet rollout of the state-based health insurance marketplace, which marked the beginning of open enrollment, a period during which people on the market for insurance coverage- either previously uninsured or looking to change plans in hopes of securing a better deal- can shop for health insurance using their state's database of coverage options (a period which runs through March 2014). This innovation in the process through which we purchase health insurance, allowing for a choice of plans and competition between payers (which as we will see tends to drive prices down), is vital for the progression of our system toward a more equitable model; one that has at its core what Dr. Donald Berwick would call the Triple Aim- the goal of improving population health while increasing quality of care and reducing costs.

"Improving health and care quality while reducing/containing costs."

As Dr. Berwick and the Institute for Healthcare Improvement (IHI), the Cambridge-based think tank that he helped found, would stress, the three principles consisting of population health, quality of care, and cost, symbolized by the vertices of the triangle, need not be at odds with one another. To take this point (ha-ha!) further, the aims are connected with bisecting lines, which meet in the center at a single intersection that signifies the common ground between the three aims. Bearing resemblance to a target, by no means a coincidence, we are able to utilize this comprehensive metric to set our standard for success with any reform or quality improvement effort moving forward.

In addition to the innovations we're experiencing with the newly formed insurance exchanges, we’re also seeing more people eligible for health insurance coverage than ever before, though we'll still be left with some ways to go to attain universal coverage. As the numbers would suggest, an additional 16 million will likely remain uninsured after the expansion, meaning the country will lie at about 95% coverage. That said, some states are getting close to full coverage with Massachusetts leading the way at 98% (fellow northern states Vermont, Minnesota and Wisconsin are also above 90%).

Data based on 2009 U.S. Census. Thanks to Wikipedia for use of their map and legend!

In later posts, I’ll discuss how other countries have performed with relation to universal health care - Spoiler alert: we’ll see that the U.S. isn’t exactly pioneering in this regard.

It truly is an exciting time, and yet, it is also a time of mass confusion and near hysteria- see any of the many news articles on the government shutdown. As much remains uncertain, there is a tendency to fear the worst. But, we must refrain from getting caught up in the hoopla and trust in the process that has gotten us to this point. The ACA was written into law over three-and-a-half years ago having passed through the House and Senate and finally receiving the signature of President Obama, showing us that the consensus amongst legislators at that time was that this bill has a potential for doing good. Now when we open the paper (or pull up our favorite news vendor's website), we're liable to see chatter about Federal budget constraints and the debt ceiling- money, money, money! These are real concerns for sure and there is some element of uncertainty to all of this. But, we must keep in mind what this is all for: that these types of legislation impact the lives of real people. 

I think it’s fair to say that health care reform is a complex beast. This is true everywhere in the world, but especially true in America where our melting pot of a society seeks care from an intricate network of providers and payers who sometimes cover the cost of procedures, and other times do not. This system leaves many not being able to afford the care that they seek and provokes a psychological stress unseen anywhere else in the developed world when one is left to decide between seeking or avoiding care for fear of going bankrupt. To make matters worse, our health insurance has long been tied to our employer, so that if we happen to lose employment, we also lose coverage (affordable coverage, that is, since we can all agree that COBRA is not!)...Only in America, right??

Far from profound, the expansion no doubt will have the greatest impact on those who had been previously denied or unable to afford coverage and now are eligible to have their care at least partially (at most entirely) subsidized. This is a monumental step toward a more equitable system: one where the rich, the poor, the black, the white, the old, the young, (male, female, third sex, heterosexual, homosexual, metrosexual, whatever!) from state to state have equal access to care of quality and reasonable cost - a system that truly nurtures the growth of healthier communities. That’s the goal. That’s the culmination of the Triple Aim - or should I say Aim'en!

I’ll end end with a video that serves as a great introduction into this realm of thinking, constituting what we'll call the "Leading (w)Edge" philosophy (if you're already familiar, feel free to brush up!). Professor John McDonough of Harvard School of Public Health, a key player in the drafting of the ACA, hosts the aforementioned Dr. Donald Berwick, a pediatrician by training, founder and President Emeritus of IHI, most recently having served a 17-month recess appointment as Administrator of the Centers for Medicare and Medicaid Services (CMS) in Washington, D.C, which ended in December 2011, for an enlightening discussion on healthcare reform and more. At present, Dr. Berwick is contemplating a position in public office, having recently thrown his hat into the ring for a possible run for Governor of Massachusetts in 2014. If that’s the case and the Triple Aim has taught us anything, you may want to seriously consider giving him your vote. Please, take a look.