Across the United States, the healthcare system is based on a model of sickness, not wellness. Providers and hospitals are paid when they see us or touch us; there’s little incentive to keep us well. Additionally, medicine has become so complex that people with multiple conditions and medications need a lot more than a doctor can provide during the standard four 15-minute visits they get throughout the year.

Here in Hawaii, despite the enduring benefits of Hawaii’s Prepaid Healthcare Act, our healthcare system is troubled by fragmentation, uneven quality, and unsustainable costs.

Our island geography results in inequity in the distribution of physicians, mental health services, dentists, and other healthcare resources. The Abercrombie administration recognizes that healthcare needs an overhaul and the good news is, with a modest initial investment, improving our health system will also save money.

Let’s take a look at the state’s healthcare delivery system: We call it a system but it hardly merits that term if by system we mean coordinated activities working together toward a single end. Ideally, we consumers visit one practitioner for all our health concerns but, depending on our condition, we may be referred to labs, radiologists, specialists, or hospitals. The recipients of these referrals may have gotten little information from our referring doctor and as a result could order the same tests. They may even send us to additional specialists. Each provider along the way may prescribe medications and may not know what, if any, other health conditions we’re being treated for and what drugs we’re taking for them.

This fragmentation and inadequate information sharing leads to duplication of services and errors, which lead to higher costs and poor quality throughout our system. This system breakdown is of most concern for the people with the greatest (and most expensive) healthcare needs – the elderly, who are more likely to have a variety of medical problems. It is also a big problem for people with chronic diseases and people who need follow-up care after being discharged from the hospital. We consumers are left to our own devices to coordinate our care and report to all our doctors about lab work, x-rays, treatments, and prescriptions we got from other providers. Few of us can do this effectively and we shouldn’t have to.

Our system wouldn’t be so fragmented if all parts of the healthcare system used health information technology effectively. Electronic health records are the foundation for sharing critical records among all the providers a patient is seeing. Exchange of these records provides the whole picture for each, including prescriptions, labs, and treatment. EHRs also help doctors flag patients with on-going health needs who haven’t been in for a while or who may be struggling to improve their health with the prescribed regimen. Health IT is an important tool for increasing the quality of care and reducing duplication and waste.

Our current method for paying for health care also contributes to the problem. In a simpler day just paying for visits and procedures made sense but now that model may support services and treatments that are unnecessary and even harmful to patients. Today we need to get the system off the fee-for-service “treadmill” and have insurers help us coordinate care, link payment to the effectiveness of care, and encourage patient to embrace healthier behaviors.

A recent visit from Dr. Craig Jones of the Vermont Blueprint for Health provided useful insights to where one state is heading for coordinated care, effective use of information, and rethinking payment strategies. Vermont promotes cost-effective patient-centered primary medical homes supported by community care teams available to any patient who needs help to coordinate their care. They use health information to measure their successes and identify areas that still need more attention. And they ensure that all public and private insurers pay to support these services.

It is true that most parts of our health care system will have to change to make things better.

Physicians? Yes, many will have to get used to using electronic health records, change the way they think about patient access, and work with care coordinators. The upside for them is that it will be easier to ensure that their patients are getting the best care, including services that they themselves don’t provide such as mental health care.

Hospitals? Yes, among the changes needed for healthcare is a reduction in emergency department use for non-emergencies and prevention of avoidable hospitalizations and readmissions. Hospital services will, of course, continue to be critically important but the size and roles of hospitals are changing.

Ancillary services? Yes, success means fewer duplicated diagnostic tests and wasted prescriptions. These service providers will be looking to new ways to be part of the integrated care system we need.

Consumers? We all need to be part of transforming the system so that it empowers us to be active agents for our own health.
Change is already taking place and Hawaii is up for the challenge. There is widespread enthusiasm for the effort just now getting underway to bring together stakeholders in our healthcare system – consumers, insurers, providers – to develop a coordinated plan for transformation. Over the next two years I will be working with the Hawaii Institute for Public Affairs to support this effort. Collectively, we stakeholders recognize a need to develop a real system. In our island state, solutions need to include better services everywhere and a thoughtful response to our physician shortage.

The specific strategies and priorities we arrive at over the months ahead remain to be seen but will surely address how we deliver and pay for care. One goal is clear: Our destination is better health, higher quality, and lower costs.

About the author: Beth Giesting was appointed the first Healthcare Transformation Coordinator by Gov. Neil Abercrombie, effective September 1, 2011. In that role, she also serves as the state’s Health Information Technology Coordinator, assists in the development of Hawaiʻi’s Insurance Connector, and supports and coordinates public and private sector initiatives related to improving our health and healthcare system, including those opportunities and mandates that are part of the Affordable Care Act.