The 83 people who turned out last month for a daylong summit in Indianapolis on community-based health reform embodied
the reality emerging at the end of the national health care debate.
The legislation set to come out of Washington will not change the most fundamental problems of the health care system, leaving it up to states, cities and companies to figure out what to do about it.
“Whatever form national health insurance reform takes, it will not be enough,” Les Zwirn, executive director of Better Healthcare for Indiana, the Indianapolis-based not-for-profit that organized the summit, told the crowd gathered in a room at the Christian Theological Seminary. But, he added, “You can’t just sit back and wait for Washington to fix it.”
Zwirn and just about every other health reform advocate around the country had far higher hopes when Congress took up the issue in early June. President Obama and his top aides were talking not only about extending health insurance coverage, but also about creating incentives for doctors and hospitals to follow the best health care practices, which they said could cut out $700 billion a year in waste and improve quality.
Obama called for comprehensive health care reform in a September speech to a joint session of Congress.
“I am not the first president to take up this cause,” he said, “but I am determined to be the last.”
But that, quite frankly, was “crazy talk,” said Dr. Aaron Carroll, director of the Center for Health Policy and Professionalism Research at the Indiana University School of Medicine.
The bill coming out
of Washington will make major changes. It will extend health insurance coverage to 30 million Americans,
raising to 94 percent the portion of people with coverage. The bill will place significant new restrictions
on health insurers, requiring them to accept all comers no matter their health status. It will also require
all individuals to have health insurance and make most businesses provide it for their workers.
But the efforts to reform the way health care is delivered—which all agree is key for reducing its costs and raising its quality—are relegated in the bills to modest pilot programs and the votes of future Congresses. Proponents say that sets up the mechanisms for cost reductions, but critics point to the long history of fizzled pilot programs and Congress’ reluctance to cut health care spending.
“We are not done. We’re not even close to done,” Carroll said. “At some point, we are going to have to have a real conversation about how to handle the cost.”
The silver lining for Better Healthcare for Indiana is that the narrowed scope of health reform legislation leaves plenty of room for the kind of local reform efforts the group has been promoting the past two years. It wants local leaders to elevate community health status and spending to the same level of importance as economic development.
“We don’t need to wait for something to happen in Washington,” said Dr. David Cook, a board member of Better Healthcare, “because there are communities doing this already.”
The December meeting included presentations from leaders in Grand Junction, Colo., and Lacrosse, Wis., which have used collaborative efforts among doctors, hospitals, businesses and civic leaders to achieve some of the highest-quality and lowest-cost care in the nation.
If all communities in Indiana had costs as low as LaCrosse, the federal Medicare program would spend $2.5 billion less each year here. And private employers and insurers would save even more, said Cook, citing data from the Dartmouth Atlas of Health Care.
In Indiana, the two communities chasing hardest after Grand Junction and LaCrosse are Bloomington and Logansport.
They have costs, according to Cook’s analysis, that are 13 percent below the state average.
In Bloomington, a committee of health, business and political leaders has formed to better coordinate the various efforts to improve public health already being tried by local government, hospitals, doctors, employers, schools and not-for-profits.
Those efforts include a free clinic started next to the local hospital emergency room to treat the non-emergency medical needs of poor and uninsured residents. The area has also launched an electronic network for the easy exchange of medical records and a coalition of 30 agencies to promote walking as a remedy to obesity.
In addition, Bloomington Hospital is forging agreements with physicians that reward them for managing patients’ health, not just for doing lots of procedures. And Indiana University is working with area schools to collect body-mass index data on grade-schoolers, hoping to celebrate successes and intervene when problems arise.
“Setting the priority topics for the community is really our new frontier,” said Mark Moore, CEO of Bloomington Hospital, and a member of the community health committee.
In Logansport, local schools launched a program to measure students’ body-mass index scores, which led to changes in food choices and curriculum to emphasize better eating. Logansport Memorial Hospital gives $10,000 each year to the school with the best BMI scores.
The city built a public running and walking trail (now used by 4,000 people a year), and worked to get a fitness club open. Now community leaders have moved their meetings to the offices of the area economic development foundation, in order to get more businesses involved.
“You hit kids at school, you hit adults at work,” said Brian Shockney, CEO of the Logansport hospital.
The challenge for local reform efforts is that so much of the health care system operates in response to financial incentives set in Washington and various state capitals. Government-funded insurance programs, such as Medicare and Medicaid, pay nearly 50 percent of all health care in the United States.
On top of that, most private insurance plans follow the payment model used by government plans, which pays doctors for the volume of services they perform, not for managing their patients’ health.
A further challenge is that medical habits are generally set by the medical schools where doctors learn their craft. The Indiana University School of Medicine trains most Hoosier doctors, and politicians and civic leaders may feel in no position to inject a second opinion.
But doctors aren’t opposed to Better Healthcare’s approach. Mike Rinebold, a lobbyist for the Indiana State Medical Association, attended the meeting at the Christian Theological Seminary, and came away with a positive outlook.
“It can start from the bottom up,” he said about changing health care delivery to improve quality and reduce costs. “Physicians each try to do it in their own way and in their own practice. They would be better served if we could come to some kind of organized effort on a community level.”
Getting businesses on board has been a bigger challenge, Zwirn acknowledged. He’s encouraged that in Terre Haute, the local chamber of commerce is taking the lead on community collaboration around health reform and not leaving it to the local hospital. But he’s pushing for more employers to join in by the time Better Healthcare hosts its next reform summit in late 2010.
“Local businesses play the pivotal role,” Zwirn said, adding, “They have to stop thinking in silos, that a single institution is going to solve the problem. They have to collaborate to change the local institutions.”•