Several months have gone by since the passage of health care reform. It is clear that the reform legislation was designed to help patients by bringing health insurance to more than 32 million people who haven't had it, and making life easier for many who have. What hasn't been as clear is how dramatically the new law promises to transform the landscape for hospitals. Like many other health care leaders, the initial response of trustees is uncertainty.
Many of us have read Atul Gawande, M.D., a surgeon and health care quality and safety researcher. In a recent article in The New Yorker, he wrote: "The most interesting, underdiscussed and potentially revolutionary aspect of the law is that it doesn't pretend to have the answers.... In large part, it entrusts the task of devising cost-saving health care innovation to communities ... it counts on local communities and clinicians for success. We ... are the ones to determine whether costs are controlled ... and health care improves.
"We" means health care leaders: trustees, executives and physicians. There's no question that reform will bring change. As trustees, it is important to begin to understand the implications of this change for the future of our hospitals.
When I've talked about reform with colleagues around the country, I've seen confusion and frustration. But I've also seen a growing sense of opportunity—an opportunity to use reform legislation to remake health care for the better. The question is: Where and how might that happen?
We can start by focusing on the momentum we already have. Four years ago, the American Hospital Association convened a wide network to develop a national health care policy. The result was Health for Life, a policy framework organizing and communicating goals for the nation's health care. Its broad categories are:
- Coverage for all, paid for by all;
- Focus on wellness and prevention;
- Highest quality care;
- Efficient, affordable care; and
- Best information and communication.
In parallel, the AHA initiated Hospitals in Pursuit of Excellence, which focuses on finding and sharing examples of how hospitals are already improving quality and bringing down costs. It has now become the backbone of AHA's efforts to foster improvement in the field. These are improvements that don't require new laws or regulations, but instead are actions that are within hospitals' control.
Both Health for Life and Hospitals in Pursuit of Excellence served as guiding principles during the past year of advocacy work in the reform debate. Now, given the opportunity ahead of us, I believe they may be the best guide to shaping our future health care system.
Let's look at some examples of how that might happen.
Most hospitals have a mission statement that reads something like "to improve the health of our community." That's been a simple message; people come to our doors injured or sick, and we do all we can to make them better. Recently, though, in many hospitals, there are changes in what that statement means. We've begun to take on a broader and deeper mission, and now concepts like community health and population medicine motivate many of us around the country.
We already know that even though we are the providers of medical services, we have a limited impact on human health. In its Healthy People 2010 report, the Department of Health & Human Services shows a startling graphic: Lifestyles and behaviors as a group, and then social and environmental factors, dwarf medical care in determining how healthy we are. Socioeconomic factors such as education, poverty and geography are all more important in determining our health than how good our doctor or hospital is.
At the same time, we are entering a world where the volume-based approach to paying for care is likely to fade away. In the future, payments will be tied to the quality and safety of the care we deliver. Hospitals, doctors, post-acute caregivers and other providers would be paid once for an episode, or in fact, for a year, of patient care. Our goal will be not to increase admissions or medical interventions, but to shrink them. So, in a new era of accountability, we would be paid for results; that is, patient health.
Today's model of only providing medical care enables us to control just 10 to 20 percent of the factors that influence patient health. But under reform, we have no choice but to adopt a whole new meaning of "improving the health of the community" that goes far beyond simply taking sick and injured people and making them well. In the future, the health of our community will be measured in terms of low disease burden, high vaccination rates, controlled chronic disease rates, healthier lifestyles and a better educated public.
I believe that in order to prepare for this future, we need to do more to strengthen our boards. When you study high-performing health care organizations that have moved on their own to achieve performance improvements and efficiencies, you see boards that are engaged and committed. You see board members with deep knowledge of the field, and with the skill, know-how and experience to work effectively with the community.
As trustees, we have been living in a relatively familiar and constant environment for many years.Â Very soon, boards will be faced with an unprecedented level of change. Among the strategic decisions we're going to face in the near future are: reconfigurations to improve efficiency; new arrangements with our physicians; formalized relationships with other providers; and beyond that, a broader leadership role in our communities.
Boards that are not prepared for these decisions will not be able to effectively fulfill their missions. The most important way a board can prepare is by becoming better educated about these issues. Where there are educational resources available, we need to use them, and if there are areas not currently addressed by educational resources, we need to see that they are developed and disseminated.
I said at the outset that with health care reform, we do have a changed landscape. There's no question that it's filled with uncertainty, but in that uncertainty, we have a unique opportunity. As Gawande noted, we are the ones who will determine how health care improves and how to use the opportunity that's presented to us. The gains we've made in recent years and the strategies we've created to guide our future show that we have the vision and, more importantly, we have the will.
I believe that we will look back to this time as a turning point, a time when we accepted the challenge to take this nation's health care to the levels we've always envisioned. We can and should make it the best in the world.
Richard P. de Filippi is chairman of the board of trustees of the American Hospital Association, Washington, D.C.