By Adam L. Logeman, MS, Oscar Ponce, MD, Neri Álvarez-Villalobos, MD, Victor M. Montori, MD, MSc
Mayo Clinic Proceedings, November 2019
The health care system in the United States is capable of both health care excellence and pricing people out of care. Key individuals can exert influence on public and private discourse, policies, and actions that are responsible for health care’s current state and envision a path forward. Since 2003, the periodical Modern Healthcare has published a yearly ranking of the 100 most influential people in US health care. The list is compiled with readership input and vetted by the periodical’s editorial board using proprietary criteria; the selection is also opaque as to what (ie, health care or clinical policy and the practice or the business of care) or who (ie, policymakers, employers, payers, clinicians, and patients) is subject to their influence. Because it receives wide reporting and limited critique, this list stands as a useful longitudinal account of who others perceive to be in a position to influence health care.
Using the published yearly list and the reported characteristics of the persons listed, we sought to determine the relative ranking over time, covering the period 2002 to 2018, of executives and administrators, academics and frontline advocates, and government officials.
There were 1700 persons named from 2002 to 2018, a minority of them women (range over the period, 17% to 28%). Most influencers are top executives from nonprofit health care provider organizations; their proportion has increased from 23% in 2002 to 72% in 2018, with an apparent substantial upward inflection in this trend since 2009. This predominance appears to be at the expense of academics, advocates, and government officials.
We found that the perceived influence over US health care of chief executives of health systems is increasing. To the extent that the ranking validly reflects influence, the sharp rise in the influence of chief executive officers at the expense of representatives of patients or health professionals may underscore the increasing industrialization of health care. It is not possible to find patients, patient advocates, clinicians, or clinician advocates at the top of this list. This trend placing health care influencers within C-suites, accountable to boards mostly comprising other corporate leaders, may explain the rise of business language and thinking—for example, high-value health care.
Our findings suggest that patients and clinicians are neither defining what health care is nor deciding how it should evolve. Urgently, they must find and use their collective voices to turn away from industrial health care and move decidedly toward careful and kind patient care for all.
To Control Costs Expand Managed Care and Managed Competition
By Alain Enthoven, PhD; Victor R. Fuchs, PhD; Stephen M. Shortell, PhD, MPH, MBA
JAMA, November 7, 2019
The US health care financing and delivery system serves the public poorly. It costs far more than in any other country, does not produce better health outcomes, and leaves millions uninsured.
Over the years, managed care, defined as patient-centered coordinated care provided under payment incentives that reward achieving cost and quality measures, and managed competition, a market designed to create incentives for managed care organizations (MCOs) to reduce cost and improve quality and patient satisfaction, have demonstrated a potential to control costs without any sacrifice of quality.
Managed care increases efficiency of care delivery within individual health plans. Managed competition creates a structure within which health care plans compete with one another. The 2 are complementary and synergistic, and have several advantages over reforms that require government-initiated transformation of all medical care. These models offer the possibility of controlling costs without government price controls.
Managed care, a concept that addresses both payment and delivery, has a long history, beginning with Kaiser Permanente in the 1940s and including passage of the Health Maintenance Organization Act of 1973 and current interest in risk bearing ACOs. Managed care, fully or partially implemented, is now a widespread form of health care in most parts of the country.
2019 data suggest that more physician organizations are owned or strongly affiliated with a specific hospital/health system, reducing to some extent the overlap of physician networks.
The competitors are health care financing and delivery plans based on managed care or traditional open-ended fee-for-service systems.
For managed competition to succeed, it must lead to the transformation of US health care from traditional, open-ended, uncoordinated fee-for-service systems to efficient MCOs.
From the Conclusions
When an economic or health care crisis comes, cost control will have priority, but crisis solutions are rarely the wisest. Managed care and managed competition are not panaceas. As is true of all types of medical care interventions, clinical or organizational, not every individual attempt will succeed; however, managed care and managed competition have a good record of success in controlling costs and maintaining quality without resorting to price controls, the principal alternative.
By Don McCanne, M.D.
The most influential people in U.S. health care? It’s not the patients. It’s not the clinicians. It is not the academics, advocates, nor government officials. According to the Modern Healthcare survey, it’s the top executives of health care provider organizations, or leaders of “industrial health care” (forget about “medical”).
And what about the managed care revolution that failed to adequately control high health care spending and left in place the health care injustices that are so prevalent today? The deafening echo perpetuated through recent decades is intensifying in its call for yet more managed care, now often labeled as ACOs or value-based care. And what do we hear from the health care academics? Net savings performance still varies widely and quality performance is still highly variable (Health Affairs Blog, October 25, 2019). It is not working.
And just to confirm that not much has changed, the Old Guard (Enthoven et al) tell us that we need to continue to expand this model to control costs in order to avoid government price controls. What? Costs have continued their upward spiral in the private commercial insurance market (in spite of transient brief slowing) yet have been much better controlled under the government-run Medicare program. Tens of millions remain uninsured and many more remain underinsured while patients are losing their choices of physicians and hospitals. Again, managed care is not serving us well.
The private sector is not going to voluntarily bring most people under the safe umbrella of health care. When the private industry has already tapped those backed by adequate resources, only government policies can pull the rest in. Only the government can ensure that absolutely everyone is included, that financial and other barriers to access are removed, that all essential services are covered, and that the system is affordable for each of us through a universal financing system funded through equitable taxes. None of these are functions of managed care.
We need to discharge the private managed care managers and replace the system with our own public stewards. As the authors of the Mayo Clinic Proceedings article state, “patients and clinicians must find and use their collective voices to turn away from industrial health care and move decidedly toward careful and kind patient care for all.”
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