Just like the rest of America, health care on Martha’s Vineyard is in trouble — too often fragmented, unsafe, variable, hard to access and far too costly. Poor system designs are the cause, designs sustained by a fee-for-service payment system that pays for volume (how much you do), not value (how well the patient does). Doctors, nurses, other clinicians, staff, and managers do their very best to help, but they are often fighting upstream against systems that make their work harder.
Across the country, at long last, things are starting to change. The Affordable Care Act moves the nation toward health care as a human right, assuring health care coverage for up to 30 million more Americans, and it also makes changes in Medicare, Medicaid and private insurance that will increase transparency, focus measurements and incentives on the quality of care, and pay doctors and hospitals differently, so they can devote energy to coordinating care. That’s the best way to reduce both human suffering and costs.
But the Vineyard has challenges that most of the rest of the nation doesn’t. The health care needs of the Island are chimeric. The Island needs not one care system, but two. The year-round population needs seamless, coordinated, health-oriented care — with a big dose of prevention — in which primary care, not hospital care, is the foundation. The summer population — transient, with off-Island sources of continuity and primary care — needs mostly an episodic care system, excellent at handling acute illnesses, trauma, and walk-in needs. Therein lies potential confusion and misplaced investment — when the latter system tries to meet the former need.
Take the new hospital as iconic of the dilemma. It is beautiful, technically state-of-the-art, a source of pride to the community and of reassurance to anyone who imagines a severe, acute illness, a surgical intervention, or sudden worsening of chronic illness — such as an asthma attack or a diabetic crisis. I come here in the summer and I feel lucky that if I need it, the hospital is there. Its business model is the classic one for U.S. hospitals – make money on volume, stay full and busy, charge the prices that the market will bear, and ask donors for more.
The problem is that system of care — centered on the hospital, relying on volume to stay afloat, and inevitably underinvested in prevention, wellness and alternatives to acute care — is the very system that our nation needs to learn to navigate away from — towards health, healing, home and eliminating waste. We need a care system invested in reducing the use of hospital beds and high-tech services by keeping people at home, well and supported.
Waste in U.S. health care is enormous. It takes many forms, such as visits, medicines, surgery, tests and procedures that we don’t need and that don’t help us, administrative hassles, poor coordination and avoidable complications of care. In an article in the Journal of the American Medical Association this spring, my colleague, Andy Hackbarth and I reviewed the vast evidence on waste in U.S. health care, and found the lowest estimate of its magnitude to be 20 per cent of the total spent; the median estimate was 34 per cent.
We are lucky to live in the only state in the nation that is unequivocally committed to making health care a human right and, with over 98 per cent coverage now, we have basically done just that. Last week’s state health care reform bill is a crucial next step — setting limits to growth of the state’s total health care costs, and supporting the changes in payment and organization that can reduce costs the right way — by making care better for patients, families and communities.
Martha’s Vineyard can lead the way. With its defined population, community resources, community spirit and basic infrastructure, the Vineyard — more than most other communities — can, if it chooses, craft a fully integrated, cooperative, prevention-oriented, health-oriented care system for the Island, at a price the Island can afford and sustain. Key steps for building such a system follow:
• Develop a shared vision of the care system that the year-round population needs, wants and has a right to. That vision should include goals for Island health improvement, total cost and (uncompromising) quality of care.
• Draw Island physicians, to the extent they are willing, into a single, team-oriented, cooperative group, with the explicit intent of making the systemic vision a reality.
• Systemically reduce waste in the health care system on the Island, especially in the form of tests, treatments, procedures and hospital bed days that do not help the patient. In effect, the goal of the change is to keep the hospital as empty as possible (by helping people stay well and at home).
• Emphasize health-giving and health-sustaining supports, professions and interventions. Focus on the upstream causes of illness, such as poor diet, inactive lifestyle, unsafe behaviors, substance abuse, accidents and injuries, poverty and isolation of ethnic minorities. Start with the kids, but don’t give up on the adults. This will involve changes in the payment system to support these investments, and the faster the Island can move from perverse fee-for-service payment toward global budgets and population-based payment, the sooner this can happen.
Achieving this vision will require major changes in the Vineyard health care system. The hospital’s business model will have to evolve to one not dependent on staying busy and full, a painful, but essential dilemma that is facing hospitals all across the nation. Doctors, nurses and other clinicians will have to see themselves even more as a team, and as stewards of the overall system of care. The population will need to realize that more care is not always better care, and that their health is largely in their own hands through the choices they make in their lives and behaviors. The Island will need to self-consciously craft its chimeric plan — one configuration for the heavy load of episodic summer demand, and quite another one for the needs of the resident population.
Call me crazy, but I cannot stop feeling that Martha’s Vineyard could show the rest of America how health care should be organized and delivered. It wouldn’t be easy, but it is possible.
Dr. Donald Berwick is the former president and CEO of the Institute for Healthcare Improvement, a nonprofit organization with a worldwide mission, and former professor of pediatrics and health care policy and management at the Harvard Medical School and Harvard School of Public Health. President Obama appointed him as administrator of the Centers for Medicare and Medicaid Services, where he served from July 2010 to December 2011. He summers in Chilmark and appears in the documentary film, Escape Fire, which screens at the Chilmark Community Center on August 15 and at the Harbor View Hotel on August 16.