Friday, October 16, 2009

California Healthcare Policy Forum Spotlight: Dr. Mark Smith

Dr. Mark Smith is president and chief executive officer of the California HealthCare Foundation and will be a part of CHI’s upcoming California Healthcare Policy Forum, to be held in San Francisco at the Mark Hopkins InterContinental, from 11:30 a.m. to 6 p.m. The Foundation is an independent philanthropy with assets of more than $700 million, headquartered in Oakland, Calif., and dedicated to improving the health of the people of California through its three program areas: Better Chronic Disease Care, Innovations for the Underserved, and Market and Policy Monitor.

A board-certified internist, Smith is a member of the clinical faculty at the University of California, San Francisco, and an attending physician at the Positive Health Program for AIDS care at San Francisco General Hospital. He is a member of the Institute of Medicine and serves on the board of the National Business Group on Health.

Prior to joining the California HealthCare Foundation, Smith was executive vice president at the Henry J. Kaiser Family Foundation. He previously served as associate director of the AIDS Services and assistant professor of medicine and of health policy and management at Johns Hopkins University. He has served on the Performance Measurement Committee of the National Committee for Quality Assurance and the editorial board of the Annals of Internal Medicine.

Smith received a bachelor's degree in Afro-American studies from Harvard College, a medical doctorate from the University of North Carolina at Chapel Hill, and an MBA, with a concentration in health care administration, from the Wharton School at the University of Pennsylvania.

Q: What have you witnessed in your interactions in DC with congressional aides, administration officials, policy analysts, and others as the healthcare reform debate continues?
A: The first thing that’s notable is that the terms of the debate have changed subtly from health care reform to health insurance reform. The good news is that realistically, it’s probably all that one can expect to happen at this point in the debate. The bad news is that the fundamental condition of American healthcare, which is that it costs too much, is unlikely to be dramatically changed by any of the things that are on the agenda right now. It remains to be seen how much will survive in the proposed legislation.

Q: Your organization, the California HealthCare Foundation, is dedicated to improving the health of the people of California through three program areas: Better Chronic Disease Care, Innovations for the Underserved, and Market and Policy Monitor. Tell me how these programs play in to healthcare reform.
A: Our sense is that in the long run, healthcare as it is currently configured is unsustainable. All three programs are designed to attack what we see as the basic elements of our cost problem. The system right now is dramatically tilted toward acute disease management and high cost, inpatient hospitalization. We think the real benefits in terms of reducing costs lie in attacking the chronic disease problem. We don’t focus on the development of guidelines on how diabetes, asthma and hypertension should be treated, but rather on narrowing the gap between what experts say should happen with these patients and what actually happens.

Q: How does that work with the current incentive structure in healthcare? Right now physicians get paid and get paid more if patients are in an acute condition and get paid relatively little for preventive care. Are you working on restructuring incentives?
A: To be honest, I think that’s probably not work we can do on our own. The primary physician doesn’t get paid if her patient is in the ICU, but she is at least beginning to be paid for the adequacy of the control of her patients’ blood sugar or blood pressure. So part of why we were active in helping to catalyze the pay for performance model was to start changing the incentives for the physicians who are treating chronic disease. One problem we’ve noticed is that many physicians don’t have good “population management” tools, such as registries, to be able to capture these data, so that’s something we work on.

Q: As the head of a foundation that engages deeply with providers, hospitals, government, insurers, payers, and patients in California, and with particular concern for underserved communities, how do you see California positioned in this debate?
A: It’s interesting. A lot of the leading actors in Congress are from California. We’re certainly ahead of the rest of the country with regard to the existence of large groups who provide care in an organized and systematic way. We’ve always had Kaiser and large, sophisticated medical groups. However, some of our in-state regulatory decisions are lagging in terms of the types of developments that will allow cooperation among small practices that will be necessary to deliver care in a rational, organized way.

Q: You have said in recent statements that measures passed as part of the stimulus package, including health IT financing, comparative effectiveness research, and support for electronic medical records implementation will create much greater reform to healthcare delivery than what is being proposed as part of healthcare reform packages being considered now in Congress. Can you explain some of the implications for this technology?
A: Comparative effectiveness and support for IT adoption by physicians are an essential part of the infrastructure necessary to reform healthcare. Are you familiar with OpenTable? It brings to mom and pop restaurants information technology sophistication, visibility to customers, other benefits of being in a big chain without having to shut down and become a chain restaurant. So modern technology can bring to small physician practices that same kind of sophistication. The promise is that some modern technology and service solutions can help drive the same outcomes as the large practices.

OpenTable has taken away the need for restaurants to have their own server and IT staff. Think about the analogy for a small physician’s office. Most small practices don’t have an IT staff and would never be able to sustain a huge system for tracking patient information. I think this model provides some hint about how we might be able to achieve the group-wide outcomes and sophistication of a huge practice.

CHI represents very technologically advanced companies. Yet the healthcare industry is probably 15 years behind other industries on IT. If the industry is to be focused on increasing both efficiency and quality and being able to measure them, let alone improve them , we can’t rely on one-off, ad hoc, retrospective research projects, which is basically how we know what little we do know about the quality of care.

Every other industry has a data and analysis stream that allows them to analyze quality and efficiency in real-time. Take the example of Walmart. Walmart knows more about its customers than most doctors know about their patients. They know what the customer has bought, what they bought last week, what they’re likely to buy next week, and exactly how long it will take the store to restock the shelves with those items. They don’t hire someone to do all that days later. If we’re ever going to have a shot at being able to afford knowing what we’re doing, let alone improving what we’re doing, we have got to have a robust digital data stream that is a part of how the industry is run.

Q: As a physician who specializes in AIDS, do you see advances being made in the diagnosis, treatment and prevention of AIDS in the next 25 years?
I used to run the AIDS clinic at Johns Hopkins and I still see patients at the AIDS clinic at San Francisco General, arguably the two best clinical centers for AIDS in the world. I am living proof of how far we’ve come. Ten years ago, if I had a patient with AIDS and a mildly increased blood pressure, I really wasn’t going to sweat the blood pressure. Now I have to be up on PSA tests, colonoscopies, lipids, because I expect my patients to be alive 20, 30, 40 years from now. In recent weeks there has been some really promising news on the first AIDS vaccine. I continue to believe that we have got to work on behavioral changes to halt the spread of HIV, but in the long run, what we need is an AIDS vaccine.

Dr. Smith will be participating in CHI’s California Healthcare Policy Forum on Nov. 5 from 11:30 a.m. to 6 p.m. Click here to register for the event.
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