The Four Pillars of Health Care Reform: Legislation Falls Short

March 30, 2010

The recent signing of health reform legislation signals a watershed event in the delivery of health care in our country. It is the culmination of a tangled legislative battle, but it ignores 3 of the 4 pillars of health reform. In this article, I describe these pillars, and then outline how recent legislation falls short.

The recent signing of health reform legislation signals a watershed event in the delivery of health care in our country. It is the culmination of a tangled legislative battle, but it ignores 3 of the 4 pillars of health reform. In this article, I describe these pillars, and then outline how recent legislation falls short.

The 4 pillars of health reform are creation of value in the system, coverage for everyone, coordination of care, and promotion of prevention and wellness. The recent legislation addresses only the second pillar. 

Creation of value. We must recognize that despite spending more for health care than any other society in the developed world, we do not achieve value for the money we spend. We must implement a program that recognizes no outcome, no income.

Namely, we should have more widespread pay for performance programs, bundled payments, and related mechanisms that emphasize payment will only be received when care is based on solid evidence and achieves appropriate outcomes. The current legislation does continue to fund nearly a dozen Centers for Medicare & Medicaid Services demonstration projects, which take a small step toward determining value.

Coordination of care. This is ignored in the insurance reform legislation that was passed. There is an excess of 16,000 Current Procedural Terminology (CPT) codes-and not a single code for care coordination. Ample published evidence recognizes that only through the coordination of care will we be able to reduce waste and thus decrease cost.

A small percentage of chronically ill persons consume a very disproportionate share of resources for health care. Through improved care coordination, we could go a long way toward improving outcomes, improving safety, decreasing waste, and decreasing overall cost to the system.

Care coordination must be based on an improved electronic medical record infrastructure that goes beyond current “meaningful use” criteria. Care coordination should be a fundamental part of the primary care medical home or the accountable care organization.

Promotion of prevention and wellness. This also gets short shrift in the current legislation. It is true that the stimulus bill and related spending has sent modest resources to organizations such as the CDC and elsewhere, but there remains no nationally coordinated attack on prevention and wellness.

Our health care system is a disease-based system, not a wellness system. I see employers playing a much greater role in implementing this critical tier because they have the most economic gain in the short term by reducing absenteeism and presenteeism in the workforce.

We need a nationally coordinated effort to recognize that for every dollar spent on prevention, we can achieve a 2.5% return on our investment. Also, the medial training model must be redesigned to promote practitioners who participate in prevention and wellness activities. There is no greater investment that a society can make than in prevention and wellness for its citizens.
Reforming the system. Achieving the 4 pillars of health reform will take political courage. It is easy to malign the insurance industry, the pharmaceutical industry, and other “culprits” rather than create fundamental changes in a broken system.

While I applaud the President for his leadership in making this first step toward system reform, it is simply not enough. In the coming months, we will witness the release of pent up demand for health care services as millions of Americans enter an already broken system, which will potentially cripple it fatally for the future.