Professor Donald Light responds to yesterday’s message on Intermountain Healthcare’s success in improving quality while reducing costs (https://pnhp.org/news/2011/may/achieving-aco-goals-without-the-aco):
Hi Don,
Thanks for sending out your excellent synopsis of the new article about how Intermountain Healthcare has saved money while maintaining high quality. As an adviser to the NHS since 1991 who has published critical policy analyses in the BMJ since then of its pro-competition reforms to create a market internal to its single-payer frame, I took advantage of your free link and read the article. Let me share some thoughts with you and colleagues.
From the first page, it becomes clear that Intermountain is much more like a single-payer health care system than the NHS, back to at least 1986, because of its integrated and constantly improved data systems measuring costs and clinical processes that form the basis for all of its achievements. I pointed out in 1991 that it was folly for Mrs. Thatcher to allow competing hospitals to choose what they measured and how, and in 1997 I recommended to new leaders at Richmond House who were keen on integrated data that they adapt one of two fully developed integrated data systems available free on the web, one from the VHA (Veterans Health Administration) and the other from Finland. No interest was shown, and the NHS continued to pour large sums each year into contracting with international companies to develop a fresh integrated data system. Fourteen years later none yet exists, and observers have wondered if this is a boondoggle from the government to those corporations? Intended or not, that has been the result.
Intermountain’s account also exhibits, as does the case of the VHA, strong, consistent leadership over many years dedicated to improving quality and reducing costs. NHS results have been mixed, with some achievements of improved quality but not as part of a “single-payer,” integrated plan to hold down costs while improving quality by reducing large clinical variations. Most important, Intermountain treats its hospital services as integrated with all services outside hospitals, as does the reformed VHA, Kaiser, Marshfield, and others. By contrast, the NHS has sharpened the divides between hospital and community or ambulatory services, and the new reforms led by Langley will entrench them further. This lies at the centre of my new critique of the single-payer NHS reforms, published in Social Science & Medicine [Social Science & Medicine 72 (2011) 821-822]. Note that we recommend the NHS turn to US examples of integrated care like Intermountain, an irony your readers will appreciate.
A key point of the Intermountain article is that reviewing “the entire continuum that patients experience,” such as “home-based, clinic-based or inpatient care” leads to a focus on population-level health rather than on health care services. Marketing shifts from selling the latest procedure to selling health gain. This becomes the key point of the article’s conclusion as it describes how the current US payment system by procedure led Intermountain to lose more than it saved as it lowered costs for high quality, and how this needs to change if the US is going to move forward. Sadly, the NHS reforms now feature pay for performance or “payment by results,” which are really payment by procedures, with little systematic measure of results. The NHS is not the only single-payer system enamoured by market-based competition as the way to make its services more cost-effective, as students learn in the course I teach at Stanford on health care systems in advanced capitalist countries. (See http://www.kaiseredu.org/~/media/Files/EDU/Syllabus%20Library%20Files/Light_Fall2010.pdf.) The evidence shows that usually competition raises costs, fragments care as providers focus on more profitable patients or procedures, and increases administrative overhead. In my opinion, this is what has happened in the English NHS. One might think a single-payer national system would focus upstream on health and prevention, and the NHS does in some meaningful ways; but its reforms of medical services work against that goal and draw money away from it towards more costly “payment by results” specialty procedures once patients get seriously ill.
Finally, Michael Dixon, a national leader of GPs, and I have urged since 2004 that the NHS reorganize clinical leadership in an integrated way, and a key sentence in the Intermountain article states that “Physicians led almost all of the changes themselves.” So far, leaders of the English NHS have shown no interest in this idea, which has been critical to the success of Kaiser, Intermountain, and the VHA. I hope these experiences over the past 20 years enable your readers to refine their thoughts about what “single-payer” means and how it works. We need a more deeply textured and fully developed of that concept than reference to how a health care system is funded.
With best regards,
DonDonald W. Light
Lokey Visiting Professor, Stanford University
Professor, UMDNJ
http://www.med.upenn.edu/apps/faculty/index.php/g358/p31974
(See our book, The Risks of Prescription Drugs)
References for Donald Light’s message
Donald Light’s message today included this link to a syllabus for a course he teaches at Stanford on health care systems in advanced capitalist countries; it contains a large number of invaluable references:
http://www.kaiseredu.org/~/media/Files/EDU/Syllabus%20Library%20Files/Light_Fall2010.pdf
These are other references that relate more specifically to today’s message:
“Observations on the NHS reforms: an American perspective.” British Medical Journal 1991;303: 568-570.
“Betrayal by the Surgeons.” Lancet 1996;347: 812-3.
“Managed Care in a New Key: Britain’s Strategies for the 1990s.” International Journal of Health Services 1998;28:427-44.
“Is NHS Purchasing Serious? An American Perspective.” BMJ 1998;316:217-20.
“From Managed Competition to Managed Cooperation: Theory and Lessons from the British Experience.” The Milbank Quarterly 1997; 75:297-341 (Lead article)
“The real ethics of rationing.” BMJ (British Medical Journal) 1997;315:112-15.
“Managed Competition: Theory and Lessons from the British Experience.” Pp. 322-56 in Competitive Managed Care: The Emerging Health Care System. Edited by John Wilkerson, Kelly Devers and Ruth Given. SanFrancisco: Jossey-Bass, 1997.
“How Waiting Lists Work and their Hidden Agenda,” Consumer Policy Review (UK) 2000;10(4):126-132
“Here We Go Again: Repeating Implementation Errors.” BMJ (British Medical Journal) 1999;319:616-8.
“Managed Competition, Governmentality and Institutional Response in the United Kingdom,” Social Science and Medicine 2001;52(8): 1167-82.