Broadly speaking, health-care reform encompasses three big issues: insurance reform, payment reform, and reform of our delivery system. For me, these are three separate but related conversations, clearly not independent of each other. Most of the conversation has been about insurance: how we pay for it and how we ensure that even more Americans are insured and that more are even better insured.
Very little of the debate, so far, has been about how to organize the delivery of care. Instead, the debate takes the care delivery system we have at the moment as a given, though there has been a little discussion on the optimal design of IT systems for delivery.
In my opinion, there is another important set of discussions to be had around how we actually organize care. Many of these issues are managerial in nature, rather than policy issues. Questions we need to answer include:
- What is the best way of configuring and managing services?
- Who are the professionals we need?
- What is the optimal setting and context in which they should be delivering care?
- What processes should they use?
There are all sorts of operating managerial and strategic decisions that we haven’t even talked about at a policy level and national level. Yet at ground zero, lots of interesting experiments are underway with professionals trying different ways of configuring and managing services. On that list I include experiments with disease management programs, substituting nurse practitioners for physicians in certain circumstances, the in-store clinic model for treatment of simple diseases, as well as experiments with IT to enable precise electronic communication between patients and doctors so that real medical discussions can be had at a distance.
At the national level we don’t hear much about these innovations—yet they present an equally important set of issues. We need to make a distinction between debating how it will be paid for and what the “it” is that is paid for.
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