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EW NEWS & OPINION 24 January 2016 Insights by J.C. Noreika, MD, MBA when he helped found the Commu- nist Party of China; Hugh Hefner first published Playboy at age 27; 21-year-old Steve Jobs founded Ap- ple with gray-beard Steve Wozniak who was 26; and Charley Kelman was in his 30s when he transformed ophthalmology a couple of times. Japan has done something interesting. "In June 2015, an advisory panel of young experts, appointed by Health Minister Yasuhisa Shiozaki, presented its vision of health care for Japan in 2035." This paper, "Japan Vision: Health Care 2035," combines concepts new and old, formatting a future delivery system by engaging those who will live with and pay for it. Lennon and McCartney were in their 20s when they sang, "Well, we all want to change the world." Maybe this is the way. EW References 1. Ginsburg PB, et al. Challenges for Medicare at 50. N Engl J Med. 2015 Nov 19;373(21):1993–5. 2. Reich MR, et al. The Future of Japan's Health System – Sustaining Good Health with Equity at Low Cost. N Engl J Med. 2015 Nov 5;373(19):1793–7. Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for 35 years. Contact information Noreika: JCNMD@aol.com "further payment reform is clearly in order." Ginsburg and Rivlin go on to reprise potential models: accountable care organizations (ACOs), bundled payments, pa- tient-centered primary care medical homes. If it is to achieve cost contain- ment and deliver high-quality care, America's health system needs new blood and innovative ideas. Con- sider some of our thought leaders. Harvard-trained economist Paul Ginsburg is approaching 70. He was the founding executive director of the Physician Payment Review Com- mission. Thirty years ago, he over- saw William Hsiao's RBRVS reform. He has been writing on healthcare policy since the 1970s. Alice Rivlin is 84, graduated from Bryn Mawr College while Truman was president, worked under Lyndon Johnson, served at the Brookings Institution, was the first director of the CBO starting in 1975, and under Bill Clinton was the first woman to hold a cabinet-level position. An alterna- tive to the Ginsburg/Rivlin model is "Managed Competition" cham- pioned by Stanford emeritus Alain Enthoven. He is 84. He finds little in ACOs to recommend them. These are brilliant academics. Once novel, their ideas are now sclerotic. It is time to move on. You want a revolution? Consid- er this. Napoleon was 34 when he became Emperor of France; Lenin was 23 when first exiled to Shushenskoye; Mao Zedong, 33 Thomas Carlyle may have been misquoted, but economics is a dismal science. Japan has harsh demographic issues. More than 25% of its population is 65 years or older. In 2014, 14.5% of America's popula- tion was over 65. Only 5% of India's 1.25 billion people is over 65. The capacity to care for any population meets at the intersection of demo- graphics and economics. Anywhere cost and benefit vary based on age and employment, politicians must grapple with issues of fairness. With 3,500 different insurers, Japan's health system will consume 11% of their gross domestic product. This compares favorably to the United States' 17%, although I remain skep- tical of international comparisons. Prime Minister Shinzo Abe mandated the elimination of Japan's fiscal deficits by 2020. There has been slippage; Japan is in recession for the fifth time in 7 years, its economy deflationary. Its national debt hit 250% of GDP at the end of 2015. Increasing taxes, stimulus and subsidies abet other fiscal miscre- ants. Japan's value-added tax was increased to 8% in 2014 while Abe spearheaded "politically popular but economically ineffectual spending measures on child care and help for the elderly." Governments might remember the advice of Nobel Prize economist James M. Buchanan: "The amount of any public good that (a person) will prefer will depend on the share in its cost that he individ- ually must bear. Most persons would prefer a larger quantity the lower their own share in the payment." That is known as the "free-rider" dilemma. Ginsburg and Rivlin's Medicare article disappointed me. "Medicare will be under huge pressure in the next few years from the demograph- ic bulge and rising per-enrollee spending." Tell us something we don't know. "We see this challenge as an opportunity for the program to take more aggressive action to improve care delivery." The next several hundred words are devoted to rehashing the same old, same old of provider consolidation, quality of care through big data, risk adjust- ment, and competitive bidding for patient populations. Of course, An old competitor on hard times considers fresh ideas for the thorny problem of healthcare reform A n aging population, low birth rate, slowing eco- nomic growth, shrinking middle class, promoting health insurance on a lev- el playing field, ever-changing goals of primary care medicine, insatiable demand for medical technology against mortality's inevitability, and the pull of social good against the push of political expedience, and "value" for ever-scarce treasure spent. The United States? No, Japan. In November, the New England Journal of Medicine published 2 articles weeks apart. One, by Paul Ginsburg and Alice Rivlin, addressed America's Medicare program on its 50th anniversary. The other spoke to the challenges facing Japan's univer- sal healthcare system. In 1988, my MBA classmates ended every week by sharing wine and cheese with one of the indus- try's captains. I can't remember who waxed philosophical about the oxymoron of business ethics, but I remember a friend, a Vietnam vet who knew a snafu when he saw one, asking one luminary's guidance once we matriculated beyond financial algorithms and game theory. His answer? Learn Japanese. Those were boom days for Japan Inc. Its just-in-time, disci- plined economy was transmuting the world. In 1986, Kaizen: The Key to Japan's Competitive Success was published. As late as 1995, Eammon Fingleton, editor of the Financial Times in London and Forbes Maga- zine, wrote Blindside: Why Japan is Still on Track to Overtake the U.S. by the Year 2000. Since then, America has survived terror, wars, too-big- to-fail companies, government dysfunction, and the Kardashians to endure as the world's dynamo. You can buy Fingleton's hardcover book on Amazon for a penny. You say you want a revolution J.C. Noreika, MD, MBA