Hey, Dems, best to fix health-care delivery first

Afew things have changed in the health-care debate since the Great Health Care Wars of 2007-2013. For one thing, advocating a government-run, singlepayer system was a distinctly minority view a decade ago. This time around, two of the three top Democratic presidential contenders have committed to Medicare-for-all, by which they mean a universal system that would functionally outlaw private insurance.

But the more interesting difference between then and now is less ideological than technocratic: The entire Democratic debate seems mostly focused on how to finance health care, not on how to deliver it. Possibly because their proposals on the finance side are so radical, Sens. Elizabeth Warren, D-Mass., and Bernie Sanders, I-Vt. — and by extension, everyone else in the race — have spent a great deal of time reassuring everyone that nothing about their health care will change except for the cost. That’s a pretty significant shift from the Obama era, when we heard how government would make care not just cheaper but better, too.

After attending the Democratic presidential debate in Westerville, Ohio, last Tuesday, I drove from Columbus to Cleveland, where I spent a day at the Cleveland Clinic, which served as one of the models for Obamacare’s reforms. Founded in 1921 by doctors who thought medical experts should work as a team, the Cleveland Clinic has kept true to that mission for nearly a century. Its doctors are salaried and get no reward for doing more procedures; its administration pursues both innovation and integration of care.

Almost all the things that are broken about the U.S. health-care system actually work at the Cleveland Clinic. The doctors focus narrowly on one thing; in the kidney and urology institute, for example, one specialist will handle just prostate cancer, another incontinence, a third kidney disease. Research has shown that this type of specialization produces better outcomes than a broader practice. The specialists work closely in teams with other equally specialized experts, in institutes organized around diseases — and thus the affected patients — rather than in departments organized around the kind of specialists who work in them.

But that’s just one example of the ways in which Cleveland’s integrated-care model differs from what’s available to most Americans. Health-care IT is usually startlingly inept and hard to use; the Cleveland

Clinic’s is user-friendly and offers patients easy access to high-tech features such as virtual office visits. The clinic’s very buildings are designed to make the system easy for patients to navigate, to minimize the number of visits and the number of buildings visited, and to speed up the time between diagnosis and treatment.

These things are possible only because of Cleveland’s highly integrated model. Two years ago, I switched from the traditional fee-for-service system into Kaiser Permanente, which takes Cleveland’s salaried-doctor-and-integrated-facility model one step further by also functioning as your health insurer. Choosing Kaiser over a traditional insurer was a deliberate experiment by someone who often writes about health care and knew quite a bit about their model — and even so, I was stunned when I experienced firsthand how much easier such systems make life for patients.

If you offered sick people a choice between reforming the payment side of the system so that everything functions more like Medicare, or reforming the delivery side so that all hospitals function more like the Cleveland Clinic or Kaiser, they might well choose to reform the delivery side. Medical bills are scary, of course, but so is navigating through the fractured mazes of different systems that most very sick people end up caught between. So it’s worth asking why Democratic politicians — like too many health systems — seem so relentlessly focused on the money rather than the patients.

One answer is that reforming delivery systems is hard. The government can’t command other health systems to replicate the cultural values, or the institutional expertise, of a Kaiser Permanente or a Cleveland Clinic or a Mayo Clinic. All the government can do is alter payment schedules. And when the Obama administration tried to use that financial lever, it turned out that in the absence of a better institutional culture, patients saw, at best, marginal improvements. At worst, the results were perverse: New Medicare rules that penalized hospital readmissions seem to have resulted in the deaths of some patients.

Unfortunately, if Democrats aren’t going to reform the delivery system, then they probably can’t reform the payment system, either. Because unless America gets a handle on how patients are cared for, we can’t care for millions more of them at a price the American taxpayer will accept.