Translator: Silvana Loli Reviewer: Helena Bowen
One of my most deeply imprinted childhood memories
came on a day when my mom picked me up from middle school.
We rolled to a stop at a red light,
and I asked her a question from the passenger seat.
When she didn't respond, I looked to see why.
She was trembling and tears were starting to come down her cheeks.
She reached her arm over to mine and she said, "You're going to be OK."
I said, "What do you mean?"
She said, "You're going to be OK. You don't have cancer."
In my innocence, I just realized that the intense health care tour
I had been through all lead to that moment.
Months prior, they found a lump underneath my chin.
The lab tests were run.
I toured the country and visited specialty hospitals,
and surgeons removed a mass underneath my right arm
the size of a softball.
Until finally my mom got the call.
She heard her new favorite word: benign.
But in reality, my health care tour started much earlier.
I had an aggressive skull surgery as a baby to correct the shape of my skull
because doctors said I would be socially unacceptable without it.
I was hospitalized as a teen
because I had a pneumonia that was non-responsive to antibiotics.
Doctors had to physically insert a chest tube between my ribs
to drain the fluid from my lungs.
It extends to today, where I stand here, quite literally,
because I take a weekly injection to treat arthritis that would otherwise cripple me.
And as painful as it is, I compare my mom's experience
to the experience of a mother I spoke with in Nepal seven years ago.
It was a mother of a malnourished girl,
and we were talking because
there'd just been a new treatment introduced in her community:
a simple paste that allowed her to treat her daughter at home.
So I asked, "What did you do before this existed?"
After a long pause,
the translator responded hesitantly and said,
"The mother said the only available prescription before this
was to wait to let her child die."
I was stunned.
Never before had I felt such indignation, not at the mother of course.
Her statement was not a reflection of apathy.
It was a reflection of desperation.
I'm deeply troubled by this, because I believe
they way we design our healthcare systems speaks about our identities as a society.
The choices we've made to date put the values we all share at risk.
No one would ever willingly place a mother in the position
where she didn't have a treatment for her child
and no one would ever wish for a hardworking family
to go bankrupt due to the cost of their medical bills
in the world's wealthiest country.
Yet, these are the two health care worlds I move between.
Here, a system of excess.
There, a system of access.
And confronting that reality
created the driving question of my career:
can we design health care systems that meet our moral aspirations?
I'm here because we can,
and it's very easy to say that this is all just about money, to dismiss it that way.
That if people in Nepal and places like Nepal were just wealthier
their health care problems would go away.
But you don't need to look beyond
the failures of the U.S. health care system to see that that's not true.
It's undeniable that we get low value for tremendously high cost.
Why?
It's a design issue.
We have a more-is-better mindset,
and it's exaggerated by a fee-for-service payment structure
that creates the wrong incentives.
This more-is-better mindset rewards clinicians
for giving excess care that satisfies patients' desires,
instead of solving for patients' needs,
even if it demands fewer medical interventions.
This is extremely costly.
In 2011, we spent 226 billion dollars
on unneeded prescriptions and procedures.
Even worse, is that the way we pay for health care in this country
has become a form of trauma itself.
The leading source of personal bankruptcy is paying for medical bills,
and it's responsible for an astonishing 57% of personal bankruptcies.
So you can't really argue that this is just about money.
Yet, what I find strange is that people believe
that exporting this system of excess
to places that are struggling with access provides an answer.
We see countries all over the world combining a more-is-better mindset
with the irresistible incentives of a fee-for-service model,
and all they're getting is a pretty poor nickel-and-dime approach to health care
that leads their most disenfranchised in a terrible place.
Every year we have 100 million people that are driven into extreme poverty
by paying for health care out-of-pocket.
That's worth saying again:
health care is the driving force
pushing 100 million people into extreme poverty every year.
So if this system of excess that we have here
isn't going to provide the answer to places that are struggling with access,
where do we look?
Well I've had the great privilege, working over the last few years
with an incredible team,
trying to build health care systems in the world's most impossible places.
Places like this in rural Nepal,
located 36 hours by bus one way from the capital city of Kathmandu,
where people make an average of under $200 per year,
and are offered very little in terms of basic services,
like roads, electricity, and water.
What I've found during this pursuit
is that an unlikely idea is holding us back.
That idea is the idea of sustainability.
Now I know there is risk in trying to take down sustainability,
especially in Colorado, but let me explain.
Very few people know that we have gone through two great eras
where we attempted to define sustainable health care,
yet all it lead to was widespread misuse of the idea.
In 1978, world leaders convened upon Kazakhstan to sign a declaration
that said we would have health care for all by the year 2000.
But what happened as a result was that we didn't commit
to building health care systems that worked fully for the poor;
we chose a path of selective health care.
Essentially a basic minimum package
that made it pretty easy to go after the low-hanging fruit.
Because this in theory was cheaper and easier to execute,
it became our definition of sustainability.
So we lowered the bar.
Then in the early 90s, when we saw that we were very much off the mark
to hit health care for all by 2000, we made another attempt.
We pursued an aggressive fee-for-service approach,
saying that this would only happen if the poor were put in a position
where they would have to pay for each of their services.
So what you get when you put together both of these attempts
is a definition of sustainability
that equates to a minimum package of health care,
and special rules for the poor
that we would never allow to be applied to those we love.
So where does this leave us?
I would argue that sustainability is not a benign term
as it relates to healthcare for the poor.
That it's actually lead to vast failures of imagination,
and it's prevented us from building health care systems
from the way they need to be built.
But now we're in a different era.
I'm actually gonna just go and say I think we should just do away with
the word sustainability as it relates to health care all together.
I think it's too flimsy,
it has a scarred history of being used against the poor, and we can do better.
We need to move away from the errors of sustainable health care
and pursue a new approach: something I call durable health care.
Durability demands more than sustainability.
Sustainability is based on satisfying patients who can pay.
Durability is based on solving for patients
regardless of their position in society.
Sustainable health care means something different for different people,
but durable health care is one clear promise:
it says we'll build health care systems the poor can rely on to escape poverty,
rather than be one that drives them further into it.
Durable health care is also a system design
that helps us avoid the failures of traditional approaches.
After years of working in Nepal,
we realized that these traditional models have their failings,
that none of them alone fully solve for the poor.
The private sector isn't accessed due to cost,
the public sector often fails to deliver in quality,
and the philanthropic sector,
though it can create great pockets of excellence,
never achieves the scale needed.
Yet each of these sectors also has strengths.
The private sector can execute effectively with great management.
The public sector provides access to its country's poorest citizens.
The philanthropic sector allows us to take risks and to innovate.
So what durable health care does
is that it combines the strengths of these three traditional approaches.
The way it does that is it puts a non-profit health care company
inside the government's existing health care infrastructure
and asks that company to deliver health care,
and it says that that company can only get rewarded with financing
if it gets the results that really matter.
Now this brings together the strengths of the sectors.
It allows the government to provide the infrastructure and financing.
It allows the company to provide the management acumen
and it gives them the financial engine to get the results we all want to see.
But because that company is a non-profit,
it means that the financial engine can be driven by cost recovery,
and not profitability, and that changes everything.
It means a non-profit health care company can dare to go to markets
where the private sector didn't previously see any opportunity.
They can go there and they can combine government funding and philanthropy
to build those systems we want to see,
the ones that work fully for the poor.
Because the incentives are very different than our system of excess,
we remove ourselves from the trap of more-is-better and fee-for-service.
So delivering durable health care is more than just a dream.
Governments around the world are looking for better opportunities
to serve the poorest in their countries.
We've come to terms a bit with our history with sustainability and realized
that it's been a bit misguided.
What we need now is to put aside our ideological boxes
to put the poorest patients at the center of our health care design,
and to get clinicians in front of those patients
with the incentives to do the right thing.
What will emerge is a durable health care that does meet our moral aspirations,
that honors the dignity of the poor
and allows us to say to more patients what my mom said to me:
"You're going to be OK."
Thank you.
(Applause)