Jim Tallon: Crisis, Opportunity, A Bit of Both

Release Date: 12.08.2009
Contact: rdeluna@uhfnyc.org
Contact Phone: 212 494 0733

The “crisis-opportunity continuum” has received so much attention that it has become cliché, so much so that we may fail to recognize both situations staring us in the face.

But confirmed reports by New York State officials of a $3-billion-plus revenue shortfall have the ring—and gloom—of genuine crisis. Now, more than sixteen months after the Governor’s initial television address, and despite approved spending reductions and freezes, new tax brackets and fees, and a healthy dose of federal stimulus money, the bottom continues to fall out. New York faces more cycles of budget distress, as fiscal improvement awaits a still-tentative national economic recovery. We’re poised on the lip of a vortex whose exit could be located in downtown Sacramento. “Crisis” is often spoken, rarely seen, but this is the real thing, measured both by severity and by likely duration.

SYMBOLISM AND POTENTIAL
It’s hard to find a focus on opportunity amid the daily negative media chatter. But barring fundamental political collapse it still seems likely that the President will sign legislation, late this year or early next, exceeding a “glass half full” response to the challenge that has eluded generations of American leaders. In the end, the political symbols—some version or not of a public insurance plan—will matter less than the creation of new mechanisms and subsidies to increase coverage, and a radical simplification and expansion of Medicaid for lower-income people.

Even the service delivery improvements that dominated the early “bending the curve” portion of the debate, while overtaken by insurance issues, may gain renewed emphasis through payment reform and care coordination policies. Having rejected ideologies of the left and right, and adding new investment over ten years, we will have set the stage for substantial improvement in our uniquely American system. Viewed especially from where policy stood five years ago, the potential result measures up to a real opportunity.

SHORT TERM, LONGER TERM
Genuine financial crisis presents no good choices, especially in the short term. Experience demonstrates, however, that it often sets the stage for broader policy change. New York’s financial crisis of the 1970s led directly to more than a decade of comprehensive hospital rate regulation. The sharp downturn of 1990-91 directed New York toward Medicaid managed care. Other examples exist as well. How will crisis and opportunity intersect in New York’s health care world in the years ahead?

Remarkable consensus exists in the health policy community on the keys to balancing the conflicting forces of access, cost control, and quality. Increased investment in primary care, better coordination of the myriad interventions for acute and chronic illness, revamped payment systems, more comprehensive and ongoing quality assessment, and improved information technology are all elements of a better-performing system, with the potential for generating future savings. How, though, do we take these steps in a real world of fiscal crisis?

To start, we need combined public-private leadership capable of assessing the impact of federal reform and identifying transition milestones, community by community. While state government will continue to play an important role, genuine leadership must include service delivery and financing entities throughout our regional health care markets—an all-payer discussion with more grassroots provider participation than in the past.

Next, given the extraordinary distortions of public perception molded in this national debate, credible engagement of broadly based consumer constituencies is essential, to ensure their understanding of not only the forces that affect health and wellness but also how insurance works, how tradeoffs exist in quality and convenience—indeed, how beneficial change could occur.

BUILDING SUCCESS
We also need to identify and build on examples of success. Debate often focuses on shortfalls. But across the state we have numerous examples of emerging medical homes, of potential accountable care organizations, of health information networks, and of broadly based community collaborative arrangements. A catalogue of New York initiatives could serve as a catalyst for more rapid adoption of innovative change.

Finally, we simply have to keep score. We have myriad data streams but their very complexity and conflicting origins and purposes obscure a meaningful understanding of reform’s big picture. Budget crises will be measured in short-term cycles. But quantifying the translation of federal reforms into next-generation performance is essential.

This agenda requires further detail. And it requires a will to look beyond the turmoil of immediate budget crisis to define longer-term opportunity. The former is a given. The latter is a choice.