Five innovative health-care leaders assess the challenges in costs, technology, and prevention
From left: Ralph de la Torre, Gregory Curfman, Gail Wilensky, Ronald Williams, Jonathan Bush Photograph by Henry Leutwyler
Pearlstine: Is it possible, given the culture of the U.S., to change the way we implement health care and impose some things that have worked well overseas?
Williams: In Europe, there’s a notion of solidarity. If you’re 80 years old and you do not qualify for a hip replacement, it’s OK as long as your neighbor does not qualify for a hip replacement. In the U.S., [it's] “I’m going to get mine or you’re going to hear from my attorney.” We have to have a thoughtful, mature debate recognizing there are limits to the country’s resources and care should be delivered based on the physician’s judgment.
Wilensky: The horse has left the barn when it comes to using what other countries have done. A lot of what they do is not only to have a [central] budget, where there is a decision by the national government how much should be allocated for the national program of health care, but they have direct controls on all the stuff that costs money. We have a plethora of everything that costs money—specialists, freestanding MRI centers, many freestanding ambulatory centers. That’s going to be very hard to rein in. God help the politician who tries.
De la Torre: At this point it’s hard to tell whether the culture created the structure or the structure enabled the culture. But we do have a problem in both. What we’ve done is create a system that has 2,600 physicians intertwined with our 12 community hospitals who completely share risk upside and downside and share quality upside and downside. And so we begin to align incentives to provide the appropriate care.
Wilensky: The problem in health care that you don’t have in other industries is that you’re mostly using somebody else’s money. It’s not that you can’t have market-based incentives, but it makes it much more difficult. Even if you have high-deductible plans, anybody who has any serious medical problem, i.e., enters a hospital for any reason, is going to blow through any threshold you set up. Which means you’re either using third-party payment in the private sector or you’re using government parties. And that’s why the notion of trying to have people with aligned incentives is so important.
Williams: I do believe this is where the private sector will move much faster than the federal government. We don’t need Congress. We can enter into a relationship with a hospital system, and before I left Aetna we had signed up with 12 different systems to collaborate and share data with the notion that the hospital can do well by moving people down the spectrum of care and improve the quality with reduced costs. The problem we have is in alignment. If a hospital has a CAT scanner, and it can reduce the use of that CAT scanner but not generate enough revenue, it’s a self-defeating activity.