David C. Lewis, M.D.Professor Emeritus of Community Health

and MedicineDonald G. Millar Distinguished emeritus

Professor of Alcohol and Addiction Studies

Brown UniversityDavid_Lewis@brown.edu

IndividualismIndividualism

FederalismFederalism

PluralismPluralism

IncrementalismIncrementalism

American Political American Political CharacterCharacter

The ProblemThe Problem

“ “The American health care system is the The American health care system is the poster child for underachievement…The poster child for underachievement…The largest limiting factor is not lack of money, largest limiting factor is not lack of money, technology, information, or even people technology, information, or even people but rather a lack of an organizing principle but rather a lack of an organizing principle that can link money, people, technology, that can link money, people, technology, and ideas into a system that delivers more and ideas into a system that delivers more cost-effective care (in other words, more cost-effective care (in other words, more value) than current arrangements.” value) than current arrangements.”

Source: Stephen M. Shortell and Julie Schmittdiel, in Source: Stephen M. Shortell and Julie Schmittdiel, in Toward a Toward a 2121stst Century Health System Century Health System, edited by Alain C. Enthoven an , edited by Alain C. Enthoven an dLaura Tollen, 2004.dLaura Tollen, 2004.

HealthcaHealthcare re ReformReform

Reform is Reform is NecessaryNecessary47 million are uninsured47 million are uninsured50 million are underinsured50 million are underinsured79 million struggle with medical debt79 million struggle with medical debtLack of coordinated careLack of coordinated careHigh cost, low value for the dollarHigh cost, low value for the dollarInconsistent qualityInconsistent qualityInefficient use of resourcesInefficient use of resourcesCare is not patient-centeredCare is not patient-centeredProfessional judgment challengedProfessional judgment challenged

BIGGEST COSTSBIGGEST COSTS

HOSPITAL READMISSIONSHOSPITAL READMISSIONS

SPECIALIST SERVICES SPECIALIST SERVICES

Patient-Centered Patient-Centered Medical HomeMedical Home

Personal physicianPersonal physicianWhole Person OrientationWhole Person OrientationPhysician Directed Medical PracticePhysician Directed Medical PracticeCare is Coordinated and/or IntegratedCare is Coordinated and/or IntegratedQuality and SafetyQuality and SafetyEnhanced AccessEnhanced AccessPayment ReformPayment Reform

INSURANCE REFORM INSURANCE REFORM WILL BE INFLUENCED WILL BE INFLUENCED

BYBY

STATE BASED DECISIONS ABOUT DESIGN OF STATE BASED DECISIONS ABOUT DESIGN OF EXCHANGESEXCHANGES

VIABILITY OF EMPLOYER BASED COVERAGEVIABILITY OF EMPLOYER BASED COVERAGE

COMPARATIVE EFFECTIVENESS RESEARCHCOMPARATIVE EFFECTIVENESS RESEARCH

Ensure that governing boards Ensure that governing boards and other advisory bodies and other advisory bodies tasked with developing and tasked with developing and administering the Exchanges administering the Exchanges include individuals with include individuals with expertise regarding the expertise regarding the unique needs of individuals unique needs of individuals with mental health and/or with mental health and/or substance use disorders.  substance use disorders.  

Recognize and enforce the Recognize and enforce the essential health benefits essential health benefits requirements of the Exchanges.  requirements of the Exchanges.  This includes the requirement This includes the requirement that comprehensive mental that comprehensive mental health and substance use health and substance use disorder benefits, at parity with disorder benefits, at parity with medical/surgical benefits, be medical/surgical benefits, be covered by all plans covered by all plans participating in the Exchanges. participating in the Exchanges. 

Ensure a strong outreach and Ensure a strong outreach and education component, targeted to the education component, targeted to the public, eligible employers, and service public, eligible employers, and service providers to ensure sufficient access to providers to ensure sufficient access to coverage and benefits. coverage and benefits. 

Determinations about Determinations about who needs what services, who needs what services, levels of care, and lengths levels of care, and lengths of stay must be made by of stay must be made by professionals treating the professionals treating the patient, and medical patient, and medical management tools cannot management tools cannot be used inappropriately be used inappropriately to deny needed care. to deny needed care.