CONSUMER CENTRAL? CANBERRA, THE CAPITAL

(Originally published at EisenhowersLastSmoke.com on 8/7/2013)

My last stop in Melbourne before I had gone to the airport for Canberra had been at Cabrini Hospital, where Dr. Simon Woods shared a quote from a British actor whose name I didn’t capture. The quote went roughly like this: “Australia is the most civilized place in the world. In all other nations, they allow politicians to roam amidst the population. In Australia, they quarantine them all in one place. It’s like a free range zoo for politicians.” (I learned here that disdain for elected officials, even in a place that generally accepts government intervention, is universal.)

At the airport, which I spent about 6 hours in just to travel 1 (faulty radio, waiting for part, etc), I met a resident of Canberra who called it "the most boring city in the world" which I think is a common saying, not just his opinion. He also  told me that Canberra itself represents Australian pragmatism. When Sydney and Melbourne squabbled about which would be the capital city, they decided instead to split the difference and create a capital roughly in between.

I had travelled to the capital because there's no way around that some of the people you want to meet need to be in the capital. For example, I met with the people who oversee operations of Medicare, the government insurance program. The division I met is responsible for the service centers (remember all Australian health care is retail), billing, data analysis, utilization management, and ultimately, the results of the program. They do not set policy, but they have to make the policy work.

They outlined the history of Medicare as more than just a safety net, as many people see it today, but an actual universal coverage system. Though Medicare began with no real sense of limitations on services, there had always been small gaps between what many general practitioners charged and the portion that Medicare picked up. Those gaps are growing – in some cases dramatically – causing some to wonder, “What has happened to our universal system.” Like virtually every other nation, Australia is recognizing they can’t, or won’t be able to continue to afford their health care system at current growth rates. And people are feeling it.

The upside of the increasing consumer cost sharing is some amount of market power for consumers. Consumers can choose not to go to a GP who charges above and beyond what Medicare covers. They can also negotiate are protected by their ability to vote with their feet (sounds like a market to me). My host here described consumer empowerment in terms her father, who, upon hearing of what he felt to be an outrageous price of a procedure, argued, “Fred down the road charged my golf buddy less, so maybe I’ll go see Fred instead.” And wouldn’t you know, he got a reduced fee.

Australia’s Medicare is also meeting consumers naturally evolving behaviors. For example, patients have had the option to submit claims right in the doctors’ office for almost a decade, and as of last year, the government eliminated cash payments and now offers direct deposit and electronic funds transfers. They’re even working on a system where people can snap a photo of their bills or other documents about which they have questions, upload them, and get help over the phone.

The Medicare retail centers are also evolving with the times. The government has realized it’s inefficient to have different retail arms side by side, run independently from one another all with taxpayer money. Moreover, fewer people are visiting Medicare branches in person since they can do more transactions online. So the new Centerlink sites combine a range of government services. However, Centrelink has a primary focus on lower-income residents who qualify for assistance programs, whereas Medicare had been a broadly middle class program; there is some concern that middle class people won’t seek services in a Centrelink branch. It’ll be interesting to see how Australian stated values of egalitarianism play out in this arena.

After Medicare, I met the CEO of Consumers Health Forum (CHF), Carol Bennett. Consumers Health Forum is known as a “peak body” for Australian health care consumer advocacy. I knew about CHF from my research and it was the reason I had booked time in Canberra. I couldn’t think of a more fitting person to meet given my focus area.

I found Carol to be more than up for the task of representing consumers in the Australian health care policy world. She is clearly media savvy and strategic about how to get issues on the public policy radar screen. Among CHF’s top issues is the rising out-of-pocket costs hitting consumers, particularly vulnerable ones, and on the huge variability in doctors’ fees (sounds familiar). Of course consumers have no idea why prices vary, and Carol argues that for price signals to work, there should be some rationale for the differences. Thus, you could argue that Australia in fact has a market failure in this regard. “We should have access to comparison data to make informed decisions.” (If I knew Carol better I’d say, ‘Amen Sister!’). CHF is also about to start a body of work on informed financial consent, wrapping financial disclosures and consent into the existing clinical informed consent framework. Pretty genius. Hopefully it’ll work.

Carol had really interesting views on the need for more pay-for-performance and less fee-for-service in the Australian system. While this is the conventional wisdom in the U.S., I found it rather a rare view. One reason for less blind faith in incentive-based payments is that it would require a broader adoption of a medical home model, which would in turn require residents to sign up with a single provider and apparently, Australians don’t like to be locked in. Perhaps it’s a residual effect of arriving in Australia as convicts.

One of my favorite parts of my meeting with Carol was her explanation of how Australia fits sort of in between the U.S. and the U.K. (I had heard shades of this before and being in the country, it feels intuitive though I wouldn’t have been able to articulate it on my own). Australians are worried about turning into America, paying way too much for lower-quality outcomes with a sense that government should have no role. On the other extreme, the U.K. is seen as way over-regulated and providing insufficient choice to suit the Aussie independent streak.

Australians see a role for government in public health, in preventing market failures, and in protecting the public good. On the other hand, their acceptance of government programs is by no means “socialist” or particularly based on a “rights” framework. Rather, there’s a sense that “we’re taxpayers, so we’re paying for this system, and we use it when we need to.” In this way, Australians are every bit consumers in the way I have been arguing Americans need to be. They understand that they pay for their health care one way or another. They expect good information, good results, and to be part of the process. Australians expect government to operate responsibly and transparently, and to fix it if the system fails.  They hold the government accountable because, after all, they are paying the bill.  “We are active participants not passive recipients.” And thus, I had gotten what I came for and the capital seemed worth the long journey.

On my flight from Auckland to Brisbane later the following week, I caught the first half of “Canberra Confidential,” a show done by my fellow Eisenhower Fellow Annabel Crabb (@annabelcrabb) who I’d gotten to meet in Sydney. Her show was a sort of satirical expose looking for clues into the scandalous history of this very boring capital city. Though I didn’t catch the conclusion, and though I am every bit the Annabel Crabb fan (as was everyone I met), I am not sure I’m convinced that the place itself is at all interesting. But for me, Medicare, Consumers Health Forum, and several others that I met sure were.

"ALL (AUSTRALIAN) HEALTH CARE IS RETAIL”

(Originally published at EisenhowersLastSmoke.com on 7/24/2013)

(This image shows that this government Medicare office is within a mall, alongside stores and cafes.)

(This image shows that this government Medicare office is within a mall, alongside stores and cafes.)

I left my first meeting with the Director General of NSW Health and started walking as if I knew where I was going (which I definitely did not). It had turned into a warm and sunny day, and I strolled with purpose (which I absolutely did not have). Within minutes I came upon a Medicare office. This did not look anything like a government agency service center might in the U.S. Rather, it was akin to a retail bank branch, complete with color-coordinated signs and fixtures. It was bright and orderly. There were no lines (sorry, queues), but rather an electronic system to assign numbers to people (do bakeries still have those ‘take-a-number’ dispensers?) and thoughtfully arranged banks of comfortable seats. The seats were also color coordinated.

 

And once you get in there, here’s what you can do at a Medicare office:

And the signs...color coordinated

 

 

 

 

 

 

Health insurance in Australia isn’t just literally retail, but it’s also “retail” in the sense that it is overwhelmingly a direct-to-consumer business here. On my walk through The Rocks area of Sydney near my hotel that evening, I noticed all the major private insurers also had retail locations.

(And one was even selling products -- see yoga mats for sale below)

One of the large private health insurance funds told me that of the very small number of employers they serve, only 10% of those were subsidizing coverage. Most employers who subsidize health insurance for employees are those with U.S. origins or start-ups seeking to attract talent.

Retail operations are part of health insurers competitive differentiation. They provide service to help people navigate a complex product, and provide an opportunity to connect and build loyalty with consumers.

I think they're on to something. Complex product - check. Competitive market - check. Need to get closer to the consumer - check.

THE BUS TO OZ

(Originally published at EisenhowersLastSmoke.org on 7/15/2013)

The summer after I turned 12, I went to camp somewhere in upstate New York. My mom took me to stay with my grandparents in Brooklyn , and then my grandfather (remember Ike) drove us to the city to meet up with the bus to camp. I had spent a lot of holidays and long weekends in Brooklyn, and had hardly been to any other part of New York, city or otherwise.

I remember the car ride to that bus clearly. I remember literally wishing it would go on forever. Not that riding around with my mom and grandparents was my tween ideal of a good time, but I was terrified of getting out of the car, and starting the new adventure I was about to have. Sleep away camp. For eight weeks. On my own – no sister with me, no school friends, no friends of friends. I wanted to go to camp, but I dreaded getting on that bus.

That 7th-grade feeling returned this past weekend, as I packed and repacked for my Eisenhower Fellowship to Australia, New Zealand, and Singapore. I’ll hit about 10 different places in at least three climates over about five weeks. I’ll meet dozens of new people, and I’ll probably spend a lot of time alone.

Don’t get me wrong, I want to go on the fellowship. In fact, I cannot believe how lucky I am that I was chosen to have this experience or that I have such a supportive family and employer to enable me to do it.  But traveling across the world, to a place I’ve never been, on my own, is frankly, as terrifying as it is exhilarating.  Actually, more terrifying.

The plane ride to L.A. is like the car ride to the bus. I’m packed. I’m going. It’s really here and this is really happening. And now, all I can do is put one foot in front of the other. Follow my itinerary. Get to my hotel. And start exploring Australia and its health care system in search of ideas and insights to bring back home.

One of the best things my mother taught me was that I could always come home. Whenever I left on any trip or adventure, of which there have been many, my mom has always assured me that I could come home if it was terrible. And I’ve always believed her, that if I needed to bail, there’d be no judgment, and maybe even plane fare or a ride. But of course, I’ve never taken her up on it.

So Oz, here I come. One foot in front of the other. A laptop, a camera, a notebook, (yes, like with paper inside), and way too many outfits.  But did I bring enough shoes?

AUSTRALIA: BUILDING CONSUMER CAPACITY FOR HEALTH CARE DECISION-MAKING

(Originally published at EisenhowersLastSmoke.com on 7/7/2013)

Credit: Jennifer Hill, creator of the series, Places I've Never Been.  http://www.jhilldesign.com/products/a-toast-to-australia

Credit: Jennifer Hill, creator of the series, Places I've Never Been. http://www.jhilldesign.com/products/a-toast-to-australia

My first question to Australian Eisenhower Fellow David Flanagan (@DavidFlanagan_) when we met on a chilly April morning in Philadelphia at the Eisenhower Fellowships opening session was uninspiring. “How cold does it get in the winter really?” Not that I was regretting my timing to visit Australia in its winter season or anything…”Let’s just say that this morning I went for a walk,” replied David, “and it was the coldest I’ve ever been in my life.” I was delighted to hear that a cool Philadelphia spring was worse than all the Australian winters of David’s life!

A few hours later, he stood up to introduce himself and explained that he believed the success of the iron-ore mining company which he had founded was based in part on the way in which they had engaged their community in the business. Not in a superficial public relations sort of way, but rather in an authentic and comprehensive manner that demonstrated a genuine respect and concern for the company’s neighbors. I leaned over to my husband who was sitting in on the introductions and said, “And that’s why I’m going to Australia!”

It seems that Australians have a culture and collective philosophy of civic engagement that transcends industry or issue. At least a subset of consumers in Australia actually believe they have a voice in issues that affect them, and that corporations and government agencies facilitate that voice. The Australian government is focused on “capacity building to enable individuals to exercise control in their environment and make appropriate health choices.”  Australian health policy focuses on social determinants of well-being as well as physical and mental health, placing individual decision-making in the broadest possible context of health. The International Association for Public Participation (IAP2) is active in Australia, with certificate programs and public participation practitioner training to support government and corporate public engagement initiatives. Less obvious and more day-to-day, I’m told that when you ride in Australian taxi, you sit in the front seat, signaling equality between driver and passenger. Does that hold in the doctor-patient relationship as well?

Structurally, Australia’s health system combines a national health insurance plan, Medicare, with a private market for individual insurance, which gives subscribers more choices and more services. The government uses a mix of carrots and sticks to make sure people who can afford private “cover”, as it’s called, buy it. For example, if you buy private health insurance by age 30 you pay a lower premium for the rest of your life; each year after 31 that you sign on adds 2% more to the price of your health insurance. Moreover, high-income individuals who do not purchase private cover pay a Medicare surcharge.

And the Australians get impressive results. They spend approximately 9% of their GDP on health care, and they think it’s high. Of course, everything’s relative. Australia spends HALF what the U.S. spends on health care as a percent of GDP. Imagine what America could do with 9 points of GDP to invest in say, education, infrastructure, or technology?

Australians’ life expectancy is higher than Americans’ by about 3 years. At first blush that doesn’t sound like a lot, until you think about in terms of your own life or the lives of your loved ones. And their infant mortality is lower, at just over 4 deaths per 1000 live births compared to our 6[1]. Again, not a huge number until you think of two American babies who don’t survive their first year despite the good fortune to be born in one of the wealthiest nations in the world.

Though the Australian system should generally be a point of pride, there is an asterisk next to the national health care record. Australia’s indigenous people, who comprise about 2% of the population, have a life expectancy approximately 15 to 20 years shorter than the national average, and disease burdens estimated at three times greater.  But Australians are facing the issue. There is a campaign, for example, called Close the Gap, devoted to closing the health and life expectancy gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians within a generation.  The Australian Department of Human Services has developed a dedicated help line and outreach strategies for Aboriginal and Torres Strait Islander people.

It should also be noted that Australians are not universally happy with their system. A doctor I contacted when I was planning my trip reported “disgust” with the way her father-in-law had been treated during a recent hospitalization. And a public involvement expert I plan to meet, Max Hardy of Twyfords ( http://www.twyfords.com.au/about-us/our-people/max-hardy) has suggested that Australia may be behind in consumer engagement. And he understands how vital it is. “Think of any challenge in our health system.  Including consumers in a meaningful way is all about addressing those challenges more effectively.”[2]

However imperfect the system may be, there should be much to learn from the Australians. As we approach 2014, approximately 12 million Americans are about to encounter the American individual market via health insurance exchanges. It’s a good time to understand what makes their individual market work, with approximately 50% of Australians buying in. Additionally, Australia manages to provide a universal safety net to provide for all citizens at a significantly lower cost. Even with that, they have marked disparities between their Aboriginal population and others, and they seem committed to doing something about the inequality. Here too, there should be much to learn about how to be sure the benefits of a high-functioning health care system accrue to low-income and minority populations, too.  And with 48 meetings scheduled and counting in four cities over 15 days, I should have a lot to report. Stay tuned!

[1] https://www.cia.gov/library/publications/the-world-factbook/fields/2091.html

[2] “Busting some myths about consumer and community engagement in health decision-making,” Melissa Sweet, Croakey, Nov. 16, 2012

BANISHING INSULARITY, PATRIOTICALLY

(Originally published at EisenhowersLastSmoke.com on 7/4/2013)

On this Fourth of July holiday, while Americans celebrate our nation’s independence and an excuse to eat juicy hamburgers with minimal guilt, I am packing for a trip that will take me pretty much as far from the U.S. as possible.  In just a week, I’ll be setting off on my five-week journey to Australia, New Zealand, and Singapore to study their health care systems and what role consumer empowerment has in the effectiveness of these systems.

Image 7-28-17 at 2.25 PM.jpg

Why go anywhere else? Don’t we have the “best health care in the world?” While I hear this notion quite a bit, most often from elected officials in political debates, data abounds to the contrary. The U.S. ranks #37 on the World Health Organization’s World Health Report, two slots above Cuba and 32 slots below Malta, a set of islands south of Sicily, and a member of the European Union.

Need more to go on? Well, the U.S. spends 18% of our GDP on health care , which is almost double the average spent in Organisation for Economic Co-operation and Development (OECD) countries and a third more than the next most spendy country, the Netherlands. Yet, in the U.S. we have 45 million people without health insurance. We rank 33rd in the world for life expectancy. And we rank 34th in the world in infant mortality: we have almost 7 deaths per 1000 live births per year[1] . (We’re just behind Cuba on this one.)  If you’re not a data wonk, then I invite you to think about your own experiences at the doctor’s office, hospital, or on the phone with an insurance company. Tell me your experience feels “best in class”. (Seriously, tell me: I’d love to know where that is). According to Gallup, 67% of Americans rate their health care coverage as excellent or very good[2]. That's not too bad, but we could do better. If that were a test score, it'd be a C- at best.

The chest-thumping patriotism espoused by politicians – “We’re the best in the world” – strikes me as a funny expression of love for country. If we’re truly invested in our country and our kids, a more nuanced approached might involve recognizing our weaknesses and taking examples anywhere we can. So,  I am going to see what’s happening in a few of these countries that are beating us on these lists. And patriotism aside, I’m wicked competitive. I take our wholly mediocre health performance personally.

Image 7-28-17 at 2.23 PM.jpg

I’m certainly not the first one to get this idea. In search of a health care system that works better than ours in the U.S., author T.R. Reid set out on a similar journey, which he chronicled in The Healing of America.  He quickly realizes “better than ours” does not sufficiently narrow down his choice of destinations! Reid actually dedicates his book to President Dwight D. Eisenhower, citing Eisenhower's willingness to use the best ideas, wherever they may have come from, as his own inspiration. Eisenhower reportedly demanded bigger thinking and better ideas for the U.S. interstate highway system based on what he had seen of the German autobahn. No matter that Germany had been an American enemy or that he observed the superior German highway system while at war. Their way worked better, and we ought not settle for less.

Many of us curse the number of cars that fit on these superhighways as we travel to our July 4th destinations. But the fact is, we have a better highway system because someone had the vision and pragmatism to look abroad for ideas and then to do the most patriotic thing possible: insist on the best for America.

To that end, I’ll go back to packing for a trip looking for ways to engage Americans in their health care. Over the next week I’ll post more about where I’m going and why, and in the meantime, you can get a preview here.

I’m also looking forward to grabbing a burger. Happy 4th, everyone!

[1] "CIA – The World Factbook: Infant Mortality Rate"Archived from the original on December 18, 2012 (Older data). Retrieved May 15, 2013.

[2] http://www.gallup.com/poll/159455/americans-satisfaction-health-coverage-slips-slightly.aspx