New Book Hits Stores Oct. 12
Tennessee Gov. Phil Bredesen's broad government and healthcare experience and expertise are brought to bear in his first book, a thought-provoking examination of why America's healthcare system can't be reformed if government and the industry don't change course. Fresh Medicine: How to Fix, Reform and Build a Sustainable Health Care System will hit bookstores on Oct. 12, offering the governor's insight into a model that he calls "hypercomplex" and "obsolete."
Bredesen is wrapping up his eight years as governor, which were preceded by two terms as Nashville's mayor. In 1980, he founded HealthAmerica Corp., a Nashville-based healthcare management company that grew to more than 6,000 employees and traded on the New York Stock Exchange. He sold that business in 1986.
In the book, you call President Obama's healthcare reform "a stunning disappointment." Why?
I thought the opportunity was there. The planets were aligned to really start tackling some of these underlying problems with healthcare. We cannot go on with growth in healthcare at twice the growth of the economy. There are certainly issues of the system's organization – too many silos. I think everybody understands that this insurance paradigm is worn out. There was an opportunity – a new president, an attentive nation – to really begin to deal with some of these issues. What happened, I think, was that he turned it over to the Congress. They handled it in predictable ways and turned it very quickly into a partisan issue. It's only once in a generation when these things line up so you can really do some of these difficult things. It was a great disappointment to me that we didn't do that. We added 32 to 34 million new, very deserving people [to the system], and that is a good thing, but we stopped there. ... And I'm not sure when the next opportunity will be to tackle this.
You mention health insurance as "a fundamental source" of what ails the system, but how do we move away from something that's so entrenched?
Obviously, that's a very hard thing to do. I spent a lot of time in the book saying that you have to bring economic tension back into this. You really can't do it at the level of an individual practitioner ... so you have to look for a level of organization. In economic terms, that's when I talked about these systems of care. At the Mayo Clinic, you basically have in one organizational unit everything from primary care to extremely sophisticated hospital and specialist care and everything in-between. That's the piece that has to be integrated.
Integrated in what way?
There are other ways of compensating people. You pay people salaries. You pay people bonuses. You do what the rest of the world does. If we continue to think that healthcare is just a bunch of independent people turning in slips of paper to get paid, we're never going to improve the quality. We're always going to have these cost problems going forward. Now, that is hardly an original observation. Almost everyone who thinks about healthcare long-term would agree that this insurance paradigm worked in the 1930s, 1940s and 1950s, but it just does not work anymore and creates all sorts of bad incentives and excessive overhead.
You mentioned earlier the tension between buyer and seller that makes economics work, but in healthcare?
The way in which we create value, which is what we want in healthcare, is that there has to be some economic tension. When you buy a car, you decide whether you want a $20,000, $30,000 or $40,000 car. As I mentioned in the book, if you want to buy a cup of coffee, you make a decision whether it's $1 at the quick mart or $2 at Starbucks. Finding a way to reestablish that in healthcare seems to me right at the core of what we need to do to create value. That seems to be the missing piece, where people are trying to balance the amount of money being spent with how high the quality can be. Then you'll generate the tension, and healthcare will improve dramatically.
Is that, at least in part, what you mean in the book when you talk about setting healthcare on "a new foundation"?
Especially when we talk about this [healthcare reform] act, things have gotten very baroque, just adding things and adding things and adding things. So I talked about just going back to some basics here. First, we want America's healthcare system to be the best in the world. It's not today – let's stop fooling ourselves. We want it to be the best in the world, so let's figure out how to do that. Second, we want the cost of it to be under control in some realistic way. It's 17 percent now of GDP, and it's on its way to 25 and 30. It will be 30 in my lifetime, and I'm relatively old. It makes no sense for this nation to be spending so much more than any other country does on healthcare. Third of all, we have to pay for it. Medicare is generating these huge, huge unfunded liabilities for our kids and grandkids to deal with, and it's wrong. We've never had a "reset" with healthcare. Because we never went to a fully nationalized system like most other countries have, there was never a time in which we redesigned things. We need to step back and say, "OK. What stuff is really important?"
In the book, you describe the system as "hypercomplex."
What I was talking about in that chapter is that healthcare is so big today – it's a sixth of the economy, and it involves millions of people – that the notion of managing it by passing some laws in Washington I just think is naïve. ... Let's figure out how to bring this thing back down to a more human scale where the tools that we use to manage other kinds of organizations can be brought to play, such as systems of care and quality audits. ... First of all, we've got to have some accepted standards for what is evidence-based medicine. We need to leave plenty of room for professionals to modify these things; I always want my doctor to figure out what's best for me.
No "cookbook medicine."
No cookbook medicine, but there are lots of areas out there where there is consensus, and lots of other areas where we need to build some consensus, such as lower back pain and some mental health diagnoses. Second of all, we need to audit that stuff, look at medical records and measure whether or not these organizations are adhering to those. The essence of what I'm trying to say in this book is that if you go back to what medical care ought to be about, which is quality of care defined as doing the best job we know how with the state of science today, and make that the centerpiece, that would make a lot of things fall into place.
Certainly, the quality of the medicine is key, but you also touch several times in the book on care with dignity.
First of all, when patients are seeking care, I think everybody ought to seek it under the same basis. I don't think if you're a Medicaid member, you ought to have to go to certain doctors and clinics. You should be able to access healthcare without going to the human services offices and telling them your income and everything else. The only way you can do that is to have some sort of universal care, and I'm for that. Second of all, when it comes to decisions about your health, I think we ought to incorporate in our quality measures patient participation in that decision when it makes sense. We can give patients in many circumstances far more information and control over the decisions that are really important to them than we do today.