Shattuck Lecture: Some Heat, Some Light, Some Answers

The New England Journal of Medicine's 118th annual Shattuck Lecture this morning approached a familiar topic - improving health coverage for Americans - in an unconventional, and sometimes exhilarating fashion.

NYU Law Professor Arthur Miller led 13 nationwide experts in a Socratic-style dialog on many of big issues dogging the health care system. To my eyes, the biggest winner from the dialog was the nearly unanimous support for the advanced medical home payment model, developed by several primary care specialty societies. Several speakers today said that the medical home model could save primary care as a medical specialty, as well as improve the care provided to Americans.

Reed Tuckson, chief medical officer at the parent company for United Healthcare, hailed the medical home payment model as a "rational model" that will help medicine "do the right thing the right way."

Charles Baker, CEO of Harvard Pilgrim Health Care, said, "Primary care needs to be treated with more respect by the payers, especially Medicare, which sets the rules for everyone."

William Frist, heart and lung transplant surgeon, former U.S. Senator and a former Shattuck Lecturer (2005), warned however, that any payment reform must deal with the inexorable rise of health care spending. With long-term prremium increases outpacing wage hikes by a factor of three, he said, the "internal costs" of health care must be addressed.

Information technology as a solution to the problems won only muted support. Baker said that technology companies "over-promised" the financial benefits and the ease of installation and use. He said that health care a far more complex enterprise than any other industry (such as financial services) that has transformed itself through information technology. "This problem is real," he said. No one in the room disagreed, and others pointed out the sharp productivity loss that many practices experience for the first year after installing an electronic health record.

By far, the most criticism was reserved for the health policy platforms offered by the three remaining presidential candidates. No candidate escaped unscathed.

Susan Denzter, editor in chief of Health Affairs, said "All of these plans have a substantial element of unreality about them." She said that they suffer from a "fantasy" rooted in a deep lack of knowledge of health care, and an adherence to the "holy writs" of each party's ideology.

Baker said real reform will only come when there is authentic political commitment to reform. He said, "I don't believe currently that any of the candidates seem prepared to stake their presidency on this. And until this happens, it's not going to happen." Tuckson added, "It will require multiple stakeholders prepared to go with their second choice." Were these comments a reference to the formula that led to health reform in Massachusetts? No one said so explicitly, but I wonder if they were thinking about it.

Is business willing to join the reform effort? Robert Galvin, MD, director of global health care for General Electric, said there's more appetite for change than ever. But he said that unless the issues of access and costs are addressed adequately, "it will be difficult to sway business that what's on the other side won't be worse than what we have now."

As with all Shattuck Lectures, the Journal plans to publish a summary of the proceedings. It will also post a condensed version of the video of the discussion on its website.

- Frank Fortin