The dust is quickly settling on the collapsed nomination of Tom Daschle to head both HHS and the White House Office of Health Reform. Apart from the pervasive chatter about Daschle’s problematic tax and business dealings, and about the President’s appointments process - what does Daschle’s departure mean for those of us focused on improving the health care system?
Let’s keep our eyes on the prize – transforming an inefficient and ineffectual health care enterprise into a dynamic, responsive, and effective one. Tom Daschle’s insights really did make him well-suited to the leadership role. We should do well to keep these at the forefront in forging ahead to address health care’s shortfalls.
First, Daschle understood the nature of the interlocking drivers that maintain our system as-is. His book, Critical, underscores that there are many forces that shape our health care and these same forces — aka “special interests” — reinforce and perpetuate each other. There’s not one glaring culprit to point the finger at.
Second, it Daschle rightly noted that it is more important to address the leadership and governance problems than to tinker with the individual cogs of the vast machine. Every one of those cogs – how we pay primary care doctors, how NIH spends its money, how we invest public dollars into health IT, whether to let Medicare negotiate drug prices, and literally thousands of others – will involve a constant balancing of private and public interests and lots of technical analysis. Daschle said the key is to take the most important policymaking processes out of the political swamp where the loudest and richest stakeholder groups, often acting in their short-term interest, can sometimes overwhelm the long-term public interest. To do that, he advocated creation of an independent Federal Health Board.
Third, the most powerful drivers of “value” in a reformed health care system are exactly the levers most subject to political and business pressures – and least easily resolved through a public interest lens if left strictly to market forces. In the simplest terms, if the market were the right forum to adjudicate our cost, quality, and safety challenges, it would have done so by now. Instead, Daschle argued that a Federal Health Board could “promote ‘high-value’ medical care by recommending coverage of those drugs and procedures backed by solid evidence. It would exert influence by ranking services and therapies by their health and cost impacts.” (p. 172) The Health Board would “help create the right incentives by paying providers based on health outcomes, rather than on services delivered,” (p. 175) by “making the health care system more transparent” with cost and quality information provided to the public, and by guiding our national health IT investments. (p. 177-9) All of these goals are spot on…employers and others need to be at the table to make sure the a Federal Health Board (or, Senator Baucus’ Independent Health Coverage Council) drives value and fosters market innovation.
Those of us who are committed to improving the quality and affordability of our health care system will need to keep talking about the elements that Tom Daschle argued for – comparative effectiveness that addresses costs, accountable investments in IT, payment for outcomes rather than services and new mechanisms of policy-setting that put the public interest above those of the many system stakeholders. We will have to ask whoever comes next not to miss this once-in-a-generation opportunity to introduce discipline and science into our health policy process. We want to let loose the talents and compassion of many thousands of health care professionals to advance our national commitment to safe, effective, available, and affordable health care. But to do that, we will need to employ a small but carefully targeted bit of public policy that sets the public interest ground rules for a more open and competitive health care marketplace.
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