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OurBlook interview with Matt Modleski, vice president of Stovall Grainger Modleski, Inc., healthcare consultants
(Editor's Note: When Mr. Modleski mentioned to us that he and his wife Dianne lived in England and Dianne worked as a nurse in the British medical system ... and thus they experienced first-hand some of the issues now being debated in America, we wanted to hear Matt's views ... and here they are.)
 From your point of view as a consultant to providers in the industry, is there really such a big problem or number of big problems with health care in America that a revolutionary overhaul is needed? If so, what are these problems that you see first-hand?
MM: I do believe a complete overhaul of the health care system is required based on two facts alone. First, if we don’t do anything, by 2075 our current government-run health care business (Medicare) will consume 90 percent of all federal revenue (David Walker formerly of the GAO). Second, today, in our current system, we kill between 4,000 and 8,000 people per month due to mistakes and errors (To Err is Human, IOM 1999). Those facts alone mean what we’re currently doing isn’t working. The first place we should start in health care reform is with a SMART objective. Until we know our objective in terms that are Specific, Measurable, Actionable, Realistic and Timebound, it will be impossible to have a comprehensive reform strategy and the tactics that support it. Everyone having everything that everyone else has and wanting someone else to pay for it isn’t reasonable. Meaningful reform without a serious discussion about personal accountability for one’s own lifestyle choices is also impossible but it is not a topic politicians seem willing to tackle.
Do you think there's much fraud or misuse of the system in health care from users, practitioners and third parties? If so, what's the most frequent thing you see?
MM: There is fraud in the system by users of the system, some intentional and some unintentional. What’s much more perverse and expensive is the reimbursement system itself. The only thing that gets reimbursed in the health care system is “activities or procedures.” The activities are reimbursed whether or not they work and whether or not there was a less expensive option available. We need to overhaul the reimbursement system to one that measures value for the patient in terms of quality and cost over a period of time. The best book I’ve read with meaningful insights into this concept is “Redefining Healthcare” by Porter and Teisberg.
Proponents of the so-called Kennedy plan the Democrats are trying to push through insist strong federal government controls are necessary to broaden coverage and stop the skyrocketing costs of health generated in the current market-based system. Opponents say it would be a radical expansion of government power, and that a government program would balloon out of control. Your thoughts? Are there any provisions in the bill you especially like or dislike?
MM: When Medicare was established, there were all sorts of promises made and then summarily broken over time. Right now, if the one government program we have is unsustainable, common sense would say without a complete overhaul of both the delivery and reimbursement systems that a second government program that pays for additional access to the system will also be unsustainable.
If we go back just a few months to the way the TARP money was “sold” to America, we should be able to learn a quick lesson. TARP legislation was rushed, overpromised and now has significantly underdelivered on those promises. Meaningful overhaul of the health care system in America cannot be achieved in three months.
I would suggest a SMART objective in the 5-10 year range that actually permits all the broken pieces to be identified, a clear strategy put in place and then the tactical elements executed in support of that strategy. If we do something other than that, we will get enormous new costs and the same dysfunction we have now.
The one area I think anyone in health care would agree is necessary is a meaningful way to connect the different systems in health care and then collect, aggregate and share information. The devil is in the details but let me give you a quick example of why information must be made available to consumers if we are to become better purchasers of our own care (also key to any meaningful reform). Today, if you “buy” a procedure in health care, it’s difficult to know whether you’re buying the best, mediocre, or the worst care. It’s difficult to know whether you should pay for the best test available or simply one that’s sufficient 97 percent of the time for half the cost.
Information will power the way to meaningful change in health care ... that’s one “tactical” element I agree with ... but since the objective of the reform isn’t in SMART terms, it’s tough for me to know whether or not the resource allocation to IT is too little, too big, or just right.
Do you feel a public plan is necessary if reforms include mandated health coverage?
MM: No, I do not, see my earlier comments on Medicare and TARP. I believe mandated coverage is necessary and some ownership/financial liability by everyone is required.
While Medicaid is frequently derided as an out-of-control failure, Medicare doesn't seem to get much criticism. Do you think it is a success, and would any of its features be good for carrying over into any broader medical plan reforms? What if anything should be done with Medicaid?
MM: Medicare is wonderful as long as we don’t have to pay for it, but we do. I believe there will be a role for the government to play in support of the poor through subsidies to purchase insurance, but I also believe a system that gives free care should expect that freebie to continue to get more expensive because it incents the wrong behavior.
Rationing has been a problem with Canada's system. Do you think there’s any reform that could increase the number of Americans covered without rationing?
MM: I think we need to be careful with the word rationing because one person’s “rationing” is another’s prudent choice of therapeutic options. For example, if I have a sore shoulder and “want an MRI,” should I be able to get that MRI on demand? Or, should my primary care doctor prescribe two weeks of physical therapy, shoulder exercises and four days of Advil before ordering the MRI? If he does the latter first because 75 percent of the time it solves the problem without the cost of an MRI, have I been rationed? To answer your question more directly, without sweeping reform of the reimbursement system as well as the care delivery system, I see no way to add more access to the current system without some form of what people would see as rationing. The one possibility is that we do what we’ve done so far with Medicare and forget about the real costs and simply run up a huge debt ... I hope we don’t do that.
The major players so far in the health care reform debate represent powerful interests such as drug companies, doctors and those who wish a big expansion of federal power, but small business plays a vital economic role in any discussion of costs to employers. What role do you see small business owners playing in the debate?
MM: As a small business owner myself, I think we need two things. First, we need to be better educated on how broken the system is and begin to demand “information” that permits us to make better choices. The second thing we need is access to larger risk pools whether regional or national. The argument for regional risk pooling makes sense based on regional demographics but the bottom line is this .. there is no reason that a company of 15 people located next door to a company of 3,000 people using the same insurer should pay double or triple the cost for the same coverage as the 3,000 person company. Making that adjustment alone would take a huge burden off of small employers ... temporarily. Small businesses create most of the jobs in America. If ever there was a time when our bargaining power was on the rise, this should be it … one would think.
How do you see the debate playing out in Congress this year? Do you think we will see sweeping reform at the end of the day or minor tweaks? Do you see any Republicans crossing the aisle to support a public plan? Do you see any Democrats crossing the aisle to oppose it?
MM: I believe you’re seeing cracks in the plans being circulated because they are shy on cost details and almost non-existent in terms of a true strategic plan. I hope we don’t have “TARP-2” that’s called health care reform in October 2009. It is absolutely impossible to address all of the issues in health care in three months, especially when most of America isn’t even aware of the facts I laid out in my answer to your first question.
Health care reform is of course an enormous topic. Is there anything else you'd like to say about any aspect of it?
MM: I would be happy to continue to ramble on about a whole host of other elements of health care reform, (like an overhaul of malpractice laws) but we’ll save that for another day. Thanks for bringing meaningful dialogue to the issue of health care reform.
(More about Matt ... he was an Air Force pilot and in fact the 355th Wing Instructor Pilot of the Year and a member of the Thunderbirds.)
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