Sunday, September 23, 2012

Consumers have "no meaningful information about the quality of care," but the same can't be said for Leslie Michelson

Why do consumers have "no meaningful information about the quality of care"? Because businesses are the ones buying the insurance, not the patients. And insurers have no stake in long-term results.

September 21, 2012
Leslie Michelson: Doctor to the 1% (and Maybe Someday to You)
Wall Street Journal

The rich are different than you and me. Not only—yes, yes—do they have more money, but they've also heard of, and many have hired, Leslie Michelson.

...So the health-care delivery system, to the extent it qualifies as a system, "has no quality control, no integration, no coordination." Doctors "tend to operate in an independent and isolated way, and even specialists who've been treating the same patient for years and years typically never, ever speak to one another."

Private Health is designed to backfill these gaps whenever one of its patients has a medical emergency or complex condition, say, a traumatic brain injury or newly diagnosed cancer. A personal-care team parachutes in, led by a clinician employed by the company, and compiles a brief on the patient. They centralize and digitize the patient's medical records, usually dog-eared paper piles that can run to thousands of pages. Research scientists immerse themselves in the latest findings and treatment regimens for the particular condition involved.

Tests are double-checked—biopsy tissues are sent to an outside pathologist, MRIs to another radiologist. For an era of targeted therapies, Private Health runs a full battery of molecular diagnostics "to sequence the entire three billion base pairs of somebody's DNA in a couple of hours," Mr. Michelson marvels.

The goal is to ensure an accurate diagnosis and lay out all the treatment options. Private Health functions as a kind of running, independent second opinion. It operates in the twilight zone where there isn't a "best practice" for when and how to treat, but a continuum of risks and benefits that vary from patient to patient.

The clinician helps locate the right experts, Mr. Michelson says, and then works to "fuse together all these multiple specialists in a single team with a single objective." There are "no redos, no lost scans, no ambling around going from specialist to specialist, trying to figure out what's going on." The most frequent reaction is: "This is how medicine was always supposed to be practiced."

The idea for Private Health came to Mr. Michelson when he was running the Prostate Cancer Foundation, the multibillion-dollar philanthropy Michael Milken set up in 1993. Prostate cancer is a common disease but treatment isn't straightforward. Surgeons end up recommending surgery, radiation specialists radiation, still others "watchful waiting," etc.

Mr. Michelson says people started asking him for advice, which led to the prototype for Private Health. Eventually he decided to improve his process across more diseases and help more people.

One irony is that for all its white-glove extras (a research department, genetic profiling), a lot of what Private Health does are core functions that patients would value and providers or insurers ought to be doing but rarely do (case management, using computers). Why is that?

Cost is part of it. "It's too expensive for us to do it for everybody right now," Mr. Michelson says. Another part, he thinks, is that "the incentives are attenuated because of the structure of insurance," namely, job-based coverage.

Since businesses are the customers, not the individuals who change jobs every three years on average, insurers "act rationally" and don't invest in services with "short-term costs and long-term payback." Mr. Michelson thinks the better option is for businesses to convert to cash vouchers so their workers can buy portable policies. Right now, there is "no meaningful information about the quality of care, virtually no information about price, and no sensitivity to price," but that would change if the insurance industry built "an enduring relationship with consumers," he says.

"I understand that it is woven into the fabric of our society that employers can and should continue to pay for health insurance for their employees," Mr. Michelson declares. "But why, circa 2012, should HR departments be selecting and administering one or two or three plans for a thousand or a hundred thousand workers and their dependents? You don't need a Ph.D. in economics to understand that you will guarantee suboptimization."

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