As a medic and former White House adviser, Dr Mark McClellan is a natural opinion leader on health policy. He explains his vision

As a medic and former White House adviser, Dr Mark McClellan is a natural opinion leader on health policy. He explains his vision

As the former head of the US Medicare and Medicaid Services and senior policy director for healthcare at the White House, Dr Mark McClellan is something of an expert on the future direction of healthcare.

Former roles include associate professor of medicine at Stanford Medical School, associate professor of economics at Stanford University and director of a programme on health outcomes research. He was also a research associate of the National Bureau of Economic Research and a visiting scholar at the American Enterprise Institute, to name just some posts he has held.

Now out of government, he is exploring international healthcare issues and taking the opportunity to share information on improving health systems.

On healthcare reform, he says there is no single magic bullet solution, but many steps that can be taken to improve the way health systems function. Despite a number of reasons to be pleased about the direction healthcare is heading - not least increased life expectancy and health benefits outweighing expenditure - innovation and improvement is not necessarily well received.

Public dissatisfaction

'Around the world the reaction the public have is not one of pleasure or happiness that we are doing so much better, it's one of worry and concern and, in the US, almost outright anger. We are seeing new technologies and people are really worried they may not be able to afford them. The problem of healthcare financing in supporting the increasing capabilities in medical systems are universal,' he says.

In the US discussions over major healthcare reform become debates over financing mechanisms or, as Dr McClellan says, 'moving the dollars around'. He does not feel this addresses the fundamental issue that healthcare systems can and should be delivering better value in the services they provide.

'We have a tremendous amount of work to do and while it may be controversial and make some people mad, there is so much potential to deliver a better system for people in the US and the UK,' he says.

'We need to look beyond normal financial reforms and go right to the key issue of how we get better healthcare, how we give better support to professionals and consumers in maintaining their health at the lowest cost. With a high quality, prevention-oriented, personalised healthcare system, we can do it.'

For the big picture trends in healthcare, Dr McClellan sets down three main building blocks for reform: measuring what we want to achieve, paying for results, and providing support for health professionals and patients so they are properly incentivised to participate.

'In the US we have seen care that has not been very well co-ordinated,' he says. 'Treatments that are often underused, overused or misused, so despite all the progress there is a long way to go. It's not surprising that people feel frustrated - they feel a big disconnect in what they pay in their insurance and taxes and what they are getting. But we are getting better at measuring what we want.'

Quality measurements can fall into a number of different categories but developing quality measures relating to results and the outcomes of care is increasing and later this year all hospitals in the US will be reporting on a consistent set of measures for patient satisfaction and some common care outcomes.

In paying for what we want, Dr McClellan points to the fundamental similarities in the UK and US with the move towards providing better financial support to providers that deliver care more efficiently and with better results.

Something which is far more prevalent in the US than the UK is taking those same principles to the consumer side of healthcare by helping patients take more control over their health and opportunities to meet their medical needs at a lower overall cost.

Shifting priorities

'I have a longer-term vision for healthcare where we really do succeed on focusing on what we want - better outcomes, lower costs,' he says. 'The way healthcare is delivered 10 or 20 years from now may be fundamentally different, it may involve a much stronger emphasis on preventive or. pre-emptive care, outside the realm of traditional medicine.

'There will be much more effective ways of helping people understand risk and the things they can do that influence their health. Medical care is important, but much more important is lifestyle choice, behavioural activities and nutrition over an entire lifetime.'

Dr McClellan envisages a truly integrated approach to getting people the best health for the longest time, where people put their trust not just in doctors but in the organisations that are helping them achieve this goal for better health at a lower cost - a much broader way of delivering care.

The final building block for reform is providing better-quality support for clinicians and patients in achieving better results.

With activities in the US and UK focused on helping individuals and providers make better decisions about care, Dr McClellan believes we are heading towards an era of more personalised medicine. 'The more support that can be delivered at a personal level the more we can achieve this goal of high-value healthcare.'

During the major reforms in Medicare over the past few years, Dr McClellan says they tried to take on all of these major themes. A significant part of that reform was changes to prescription drug coverage as people were given a choice of different healthcare providers.

Once the cynicism towards this system subsided it was, says Dr McClellan, replaced with confusion and frustration that people had to choose coverage and not just take what the government handed them.

Web savvy

To cope with this a lot of money and effort has been spent on developing a set of website tools that give people very personalised information about drugs, pharmacies and particular healthcare needs, and how they can meet them at a lower cost. This has been backed up with a large phone support for people who do not want to go online and a grass-roots approach by working with tens of thousands of community organisations.

'This may be a distinctive feature of US culture,' he says, 'while it is not known for being a big single payer or for big government solutions, it is known for neighbour helping neighbour and community groups taking an active role in helping people improve their lives.

'I got to spend a very large amount of time at church socials, at synagogues and at senior centres all over the US where, on a person-by-person basis, local volunteers would help people find out about this new programme and help people enrol.'

The result was 90 per cent participation in the voluntary scheme, costs 40 per cent below the projected figures and high levels of satisfaction.

'What turned out to be important was our staff working with a large number of non-government as well as government organisations that touched people, as we like to say, where they lived, worked, prayed and played. We were talking about some major reforms that people needed to know about to make individual decisions. We concluded that we were not going to reach many of them if we put out the traditional government communications.'

Patient focus

While the US Medicare and Medicaid systems are the largest insurance payers in the world, Dr McClellan still stresses the need for a patient-focused system.

'In the US we have an expression for some of the reforms we have implemented in Medicaid - it's called money follows the person. So when a person is making choices that help them get better health at a lower cost, that's where we want the money to go.

'We don't want money tied to a particular institution or provider, we want it to go with what gives patients the best results. It's a different way of organising care but many of the reforms being implemented today are steps in that direction.'

Dr Mark McClellan spoke earlier this year at a Public Policy Projects event,