Eventually, Flower does estimate the actual financial impact of specific initiatives, while repeatedly using a single metric for significance — the estimated US$100 billion needed to extend healthcare coverage to people in the U.S. who are uninsured today. Any strategy or program that has the potential to make a significant dent in that number through savings and reinvestment jumps to the top of his priorities for action.
Amid this year’s bumper crop of healthcare books, Flower has a thesis that is more causally straightforward and far less high-and-mighty than most. He has two rules for understanding economic behavior: (1) “People do what you pay them to do,” and (2) “People do exactly what you pay them to do.” So, while acknowledging the usual list of unintended and undesirable consequences in the U.S. business model for healthcare, Flower spares us the unproductive indictment and prosecution of the usual suspects (such as greedy doctors, heartless insurance companies, and overpaid executives).
Instead, Flower puts the emphasis in the right places. The biggest savings, he concludes, will come from addressing “inappropriate therapies; ‘heroic’ end-of-life treatment; pharmaceutical waste; [and] the acute results of untreated, preventable chronic disease.” Making major strides in these areas won’t be easy, but he sees the ACA as having many of the structural and financial features needed to move forward. For instance, everyone needs to have coverage, not just to spread the actuarial risk across entire lifetimes, but to enable access to the right level and type of services. The ACA gives the previously uninsured an alternative to the hospital emergency room, which is a terrible, and terribly expensive, setting for primary care.
The major thrust of the book’s delivery-side prescription can be summarized as an endorsement of intensive, targeted, and proactive primary care under the umbrella of a close-knit provider system whose members’ pay is based on health status and results, not volume and transactions. Flower cites research showing that some of the oldest and most respected health systems, including the Mayo Clinic, Cleveland Clinic, and Kaiser-Permanente, have used this approach with outstanding results and demonstrably lower cost per covered patient.
Can the U.S. healthcare system cut its costs by 50 percent, as suggested in the title? Probably not, but 20 percent looks achievable. The book’s framework and recommended priorities for action are the most attractive options available, and the good news, as Flower points out, is that many leading organizations are moving dramatically in the right direction. For these reasons, I commend Healthcare beyond Reform as the best healthcare business book of the year.
Evidence-based medicine and the standardization of treatment protocols are pillars of both the ACA and Flower’s recommended approach. Although there is a lot to be gained by vetting and standardizing fairly noncontroversial screenings, interventions, and treatments, it is a complex and nuanced subject. None of this year’s books on healthcare speak to the subject as eloquently and engagingly as Otis Webb Brawley’s How We Do Harm: A Doctor Breaks Ranks about Being Sick in America.
The title suggests a tell-all memoir, but the top clinician and executive at the American Cancer Society gives us much more. Brawley, who is also an oncologist and professor at Emory University, relates his inspiring personal journey — from poverty in Detroit to his life as a prominent scientist, physician, and leader — using sometimes moving, sometimes disturbing, and often cautionary and self-questioning stories from his career and patients. Each story not only illustrates structural and moral failures in the healthcare system (without preachiness), but also digs into the science underlying some of the thorniest issues in medicine and healthcare.