Building our next health system: Highlights from the Lown Conference

April 16th, 2018

This year’s Lown Annual Conference just wrapped up last week, and we are so excited to share all of the tweets, quotes, and photos from the two jam-packed days. The conference theme was Breaking the cycle of high cost and low value: America’s next health system and featured keynotes and panels with health policy experts, clinicians, researchers, journalists, and more! 

Here are our highlights from the meeting, with a lot more coming soon…

The single payer debate

There was a lot of talk about single-payer health care at the conference, but it wasn’t the usual debate of “single-payer or not” – it was about what kind of single-payer system we need. 

Yeah we know the speakers were great, but did you see that chandelier??

George HalvorsonFormer CEO of Kaiser Permanente, shared his vision for a universal health care system, centered around team-based care and capitation instead of fee-for-service. 

“Financial incentives matter, plain and simple,” said Halvorson. “As long as health care delivery systems get paid for solving crises, they’ll continue to focus only on fixing crises once they’ve happened – not on controlling chronic disease and preventing complications.”

Halvorson argued that “Medicare Advantage For All” should be the single-payer model for the next health system, considering the improvements in access and hospital care Medicare Advantage has provided for participants so far. However, other panelists disagreed.

Dean BakerSenior Economist at Center for Economic and Policy Research, pointed out that we need significant changes in our insurance providers before handing them the reins to a “Medicare Advantage For All” system – at the least changing them to non-profit insurers like in other countries. He also proposed more radical changes to bring down prices, like abolishing patent monopolies for new drugs.

“The way we pay for drugs now, it’s like paying firefighters to come to your house when your house is on fire,” said Baker.

Adam Gaffney and Danielle Martin both made the case for going to a “Medicare For All” system as soon as possible. Gaffney, an Instructor at Harvard Medical School and Board Member of Physicians for National Health Program, pointed out how far we still need to go even with the Affordable Care Act. 

“28 million people are still uninsured, and 40 million are underinsured,” said Gaffney. “We’re not going to get to universal coverage through patchwork programs.”

Canada is a cautionary tale in incrementalism,” said Martin, family physician and Vice-President Medical Affairs & Health System Solutions at Women’s College Hospital in Toronto. She explained how Canada ended up with gaps in coverage for pharmaceuticals, dental care, and mental health care because policymakers thought they would “get to that later” but never did.

Tackling low-value care

“Moving to universal coverage is important, but the system that incentivizes profit over quality, access, and affordability also needs to change,” said Dr. Vikas Saini, president of the Lown Institute, in his opening address.

Even in countries like Australia, which have universal coverage, there is still a significant problem with resources wasted on low-value care, that the whole country pays for (and can harm patients). In his keynote address, Dr. Adam Elshaug, co-director of the Menzies Centre for Health Policy in Sydney, explained how they are addressing this important issue. 

“We’ve found that variation exists at hospital level, it’s not about region or patient characteristics,” said Elshaug. “Even the same doctors are behaving differently at different hospitals.” Elshaug explained that private hospitals in Australia tend to have more low-value care procedures done, because they have capacity they need to fill, while public hospitals are more discerning with the procedures they do because they have more patients to take care of.

Evidence (or lack of evidence) plays a large role in the proliferation of harmful low-value care. Members of the panel on ORBITA, a recent trial that found stents ineffective for stable angina, pointed out the importance of high-quality evidence early in the approval process. 

People say, ‘It’s unethical to do a sham controlled trial.’ I think it’s unethical not to!” said Dr. Rita Redberg, professor of medicine at the University of California – San Francisco, and chief editor of JAMA Internal Medicine. “Placebo is a great healer but we shouldn’t be marketing and selling it.”

In her keynote, Jeanne Lenzer, journalist and author of The Danger Within Us: America’s Untested, Unregulated Medical Device Industry and One Man’s Battle to Survive Itdrew attention to the lack of evidence standards for approval of most medical devices, as well as lack of safety information post-approval. “We don’t even know how many people die from medical devices because no one’s keeping track,” she said. “And the more serious the event, the less likely it is to be reported. It’s a black hole.”

Lessons from the breakouts

Several research presentations and panels offered practices for reducing low-value care. In the “Measuring Overuse” breakout panel, health policy experts from Massachusetts, Washington, and Virginia shared how they’re evaluating and reducing overuse in their regions. Jodi Segal, Professor at the Johns Hopkins School of Medicine, helped create an “overuse index” to track the prevalence of low-value care across regions and time periods. 

Susanne Dade, Deputy Director at the Washington Health Alliance, and Beth Bortz, President & CEO of the Virginia Center for Health Innovation, both found that significant proportions of patients in their states were receiving low-value services, costing their states hundreds of millions. “There’s an inclination to say, ‘Just do the test, it’s cheap’ but when you add them together you get hundreds of millions of dollars in waste,” said Dade.

In the breakout panel, “Protecting patients: Let’s play it safe and NOT do that test,” panelists went into some of the deeper reasons behind overuse, including medical culture, financial incentives, and emotions.

Feelings inform our treatment decisions, but we don’t get a ‘bad feeling’ when we think about the harms of false positives in the same way we get a ‘bad feeling’ when we think about giving a patient radiation,” said Dr. Joseph Fraiman, an emergency medicine physician.

Hot Topics

We’d be remiss not to mention some highlights from our most popular breakout panels, one on overuse and underuse in the opioid crisis, and one on preventing gun violence. 

The gun violence panel brought together several trauma surgeons from cities struggling with high rates of gun violence – Philadelphia, Miami, and Washington, DC.

“Health disparities are driven by social inequities and the trauma of structural violence,” said trauma surgeon Dr. Rishi Rattan, trauma surgeon at Jackson Memorial Hospital in Miami. “Gun wounds can be healed, but it is much harder to heal patients of the chronic conditions brought on by the constant stress of insufficient income, poor education, and substandard housing.”

Panelists did not shy away from talking about the racism in our culture that perpetuates violence, and the lack of action to solve the violence. “There is a false narrative of ‘drug dealers killing drug users’ but for the overwhelming majority of people in my trauma unit, the only crime is that they’re being raised in an environment that is poor and has more crime,” said Dr. Carrie Sims, trauma surgeon at the University Of Pennsylvania.

Dr. Mallory Williams, Chief of the Division of Trauma & Critical Care at Howard University Hospital, discussed the link between state-sanctioned law enforcement and violence in communities of color. “Black men are three times for likely than white men to die at the hands of police, even though white people commit more violent crime,” he said.

In the breakout panel, “Overlooked: Two takes on doing better with opioids,” Dr. Stefan Kertesz, associate professor at the University of Alabama at Birmingham, discussed the negative impacts of the way our health institutions have responded to the opioid crisis. No one denies the significance of the problem of widespread opioid addiction, but proposed rules that force patients on high doses of opioids to taper may cause more harm than benefit, said Kertesz. He pointed out that the vast majority of overdoses occur in patients on low doses of opioids, yet the proposed rules target those on high doses.

“Insurers want to show they’re ‘doing something’ about the opioid crisis – and the most ‘efficient’ way they can reduce doses is to focus on people taking high doses,” said Kertesz. “But we don’t have evidence that this works.”

The last word…

Dr. Victor Montori blew the audience away with his emotional and thought-provoking closing keynote. Montori, an endocrinologist at the Mayo Clinic and author of Why We Revolt, challenged the language we use to talk about health care.

“We shouldn’t talk about care as a product, delivered by providers to consumers who are activated, ” he said. “We’re making a significant cultural mistake by thinking that health care is an industry.”

Rather than see patients as “statistics and lab results,” we have to notice each patient and treat them as individuals. “We have to care for you, not just patients like you,” said Montori.

We do have the capacity to create a health system with love in the center,” said Saini, in response. “And that’s why we have to be on this journey together.”

That’s all for now, but stay tuned for much more from the conference!