Fixing health care: Tricky operation

I recently had a conversation with a fellow physician who leads a team trying to diagnose and treat a sick patient with complex problems.

This doctor is troubled. Many who know his patient are upset. It's an expensive, high-pressure case. A host of consultants are offering advice to the doctor and his team — much of it contradictory.

The physician is Scott Jensen, and the patient is Minnesota's health care system. Jensen is a Republican state senator from Chaska who chairs the bipartisan Senate Select Committee on Health Care Consumer Access and Affordability. The committee has five GOP members and four DFL members, including another physician, Matt Klein of Mendota Heights.

Ominous fiscal vital signs demand intensive reform efforts.

Soaring premiums early last year in the individual insurance market — where Minnesotans buy insurance if they don't get it through an employer or a government program — set off a code blue in the Legislature. A bipartisan prescription wasn't possible, but Gov. Mark Dayton signed a Republican-designed infusion of $540 million to resuscitate insurance for 160,000 Minnesotans in the individual market.

However, this two-year insurance Band-Aid assists only 1 in 30 Minnesotans. Fundamental reform is needed for the whole system.

Adding to the complexity of the situation, the 2017 insurance rescue bill included a bitter pill that may produce uncertain side effects. A provision finally allowing for-profit HMO ownership in Minnesota could be therapeutic. Yet the $90 million transfer of funds Medica made to an out-of-state subsidiary worries the Star Tribune Editorial Board ("A hasty decision by Health Department," Nov. 26). And Allina's new Aetna (and now CVS) partnership raises fears about unleashing for-profit market forces in Minnesota.

At the other end of the policy spectrum, the desire for single-payer health care is strong among progressives in Minnesota, including many DFL gubernatorial candidates. DFL Sen. John Marty (Roseville) has long contended that "a civilized, humane society that takes care of its people with universal police and fire coverage needs to do the same with health and dental care."

On the surface it seems an appealing argument. But as much as we appreciate police and firefighter readiness, we don't expect (or want) to see them very often. The police and fire protection analogy actually bolsters an argument Jensen makes — for universal coverage limited to major injuries and catastrophic health problems.

The bipartisan nature of the Senate Select Committee is encouraging, since health care has become such a bitterly divisive issue. Many policy options are mutually exclusive; deep divisions won't disappear overnight. Constructive work toward a solution must get beyond misinformation, inflammatory rhetoric and ideological intransigence.

Some naive conservatives say that the government should just stay out of health care. But the government health care train left the station 53 years ago when Medicare and Medicaid were enacted.

Here are the numbers: Health care spending in Minnesota was some $41 billion in 2013, probably close to $50 billion last year. Half of it is public spending, and three-quarters of that comes from federal funding — all of Medicare and more than half of Medicaid spending.

But the naiveté is bipartisan. Many on the left act as if Medicare and Medicaid dollars flow from a magical federal fountain providing an ever-increasing flow that will never run dry. This explains the opposition to a GOP congressional proposal to limit future spending growth by using state Medicaid block grants.

Reform efforts here in Minnesota occur within a fraught national context. Many Americans are unsatisfied with the current system. They increasingly worry about accessing and affording necessary care. The public angst makes sense with a yearly national health care bill of $3.2 trillion. That is almost $10,000 per person.

Many efforts at national health care reform have been made over the last 25 years. Hillary Clinton led a comprehensive 1993 effort that failed politically. Sixteen years later, President Barack Obama's Affordable Care Act (ACA) passed on the narrowest of party-line votes. Its partisan conception, its complexity and its costs led to the Tea Party political uprising and GOP wins in a series of elections.

Now, with the health care hot potato in the GOP's lap, Congress and President Donald Trump are discovering that health care is "really hard."

The ACA is still the law of the land, despite the GOP tax bill's repeal of the federal individual mandate. Gridlock requires states to act and consider all options, even partisan lightning rods like the state mandate bravely raised by Jensen in recent commentaries on these pages ("Why we should start talking about a state mandate," Dec. 28; "Actually, let's not talk about a 'mandate,' but about incentives," Jan. 11).

So what should we hope for from Jensen and his eight Senate colleagues as they write a prescription for Minnesota that will be considered by the 2018 Legislature and the governor?

It is crucial to get good advice — and not just from physicians, insurance executives and hospital CEOs. Their perspectives are valuable but not sufficient. They are certainly not unbiased. The general public must also have input. And what about health care economists and "policy experts"? They've been at the center of planning previous reform efforts, often with mixed results.

Two erstwhile influentials come to mind. Jonathan Gruber, an MIT professor and important Obamacare architect, had an embarrassing flash of candor in 2015. In unguarded comments before health care economists and other policy wonks, he admitted that the ACA's passage relied on "the stupidity of American voters." (Oops.)

Then, Tom Price, a physician and congressman with health care policy experience looked like he could be a good secretary of the U.S. Department of Health and Human Services until … he was involuntarily bumped from his flight on Air HHS when he booked air-travel upgrades that embarrassed his boss in the White House.

But a couple of clunkers don't disqualify all expert opinions. Three experts and the important concepts each developed are worth considering. As a conservative, I am chagrined that these three experts are all Democrats who supported the ACA. But insight is where you find it.

The Senate Select Health Care Committee should consider the following three concepts — the Triple Aim, the Iron Triangle and "fracking" the health care system to release value.

First, Don Berwick — a pediatrician and administrator of the Centers for Medicare and Medicaid Services (CMS) in the Obama administration. Berwick helped develop the Triple Aim for health care. Woven into every mission statement and health policy discussion, this ubiquitous formulation includes: (1) Improving the patient experience, including quality and satisfaction, (2) improving the health of populations, and (3) decreasing the per capita cost of care.

Berwick was the focus of GOP ire during his brief stint at CMS, mostly because he is a big fan of the United Kingdom's National Health Service (NHS). In fact, he is now a consultant to the NHS. The Triple Aim and Berwick's views on reform are worthy of attention. He is very optimistic about the feasibility of a U.S. version of the NHS and the likelihood that experts and managers can make things better.

Next is the late William Kissick, a physician who helped design Medicare in 1965. Kissick's concept, a stern predecessor to the Triple Aim, is called the Iron Triangle of Medicine. This rigid formula asserts that health care is provided within a closed system balancing (1) cost, (2) quality and (3) access. Improvement in any one area comes at the expense of one or both of the others. In essence, health care policy in the Iron Triangle is a zero-sum game.

Kissick, like Berwick, believed the NHS was the best system in the world. But unlike Berwick, he believed the NHS could never be implemented here because of the political, economic and social diversity of the U.S. He favored pushing control down to the states. That strategy would "constitute 50 natural laboratories for health care reform. Let the states individually devise innovations, struggle to implement them, learn from the experience, and then export the lessons to society at large."

These two policy experts have enthusiastic adherents, but their solutions can be at odds. Democrats and progressives seem sold on Berwick's view that health care is too complex to be left to nonexperts, and that optimistic pursuit of the Triple Aim is the path to a solution — hopefully a U.S. NHS.

On the other hand, Republicans and conservatives seem persuaded by Kissick's Iron Triangle — a pessimistic closed system demanding hard trade-offs. They also like his concept of decentralized state-led innovation.

Is there a workable escape route from this impasse? Bill Sage's ideas are worth a listen. Sage is a physician/attorney who describes himself as a liberal Democrat supporter of the ACA, but he says it needs to be recovered and repurposed. Sage recommends recovering trapped value by "fracking" our health care economy. This strategy blends some of Berwick's and Kissick's views. Sage recognizes that his fracking analogy has unsettling connotations, but disruption is necessary, he believes, for true reform that delivers the Triple Aim within the fiscal reality of the Iron Triangle.

Sage believes that regulatory reform and innovative efficiency gains can free at least $800 billion yearly (one-quarter of current health care spending) to be used for health enhancing infrastructure, education and social-service spending. His arguments are very persuasive, and his suggestions are applicable in Minnesota.

Sage envisions a system that delivers episodes and periods of care as warrantied products for a single price — rather than as separately billed, disjointed steps in a process. To make the change, he recommends "demedicalizing" the system by altering the role of physicians, enabling tech-savvy self-help, making insurance subsidies and medical care prices transparent, and redefining the role of hospitals.

With the 2018 session approaching, Jensen says: "Last session we took some important steps forward, but there is still much to do. The committee will take ideas and options from the public health sector, private businesses, the governor, Democrats and Republicans. I'm confident that when session begins in February we'll be able to propose solid legislation that will make health care better and more affordable for Minnesotans."

Heeding Sage's outside-the-box advice will increase the chances for success. The committee should get fracking.

Steve Calvin is a Minneapolis physician and medical director of the Minnesota Birth Center.