Throughout his career, Paul M. Ellwood Jr., M.D., has exemplified the spirit of the cowboy who gets right back on his horse after a tumble. He has done it as a practicing doctor and as a sculptor of national healthcare policy.
And he has done it, quite literally, on his horse.
Ellwood's friend and colleague Harry Cain, retired executive vice president of the Blue Cross and Blue Shield Association, recalls the last time he saw Ellwood in late 1998 at Ellwood's ranch in tiny Bondurant, Wyo. Ellwood had been thrown from a horse and broken his neck, and the halo protecting his skull and neck had just been removed. But he was saddling up to ride another horse.
"That was typical," Cain says. "He had a very serious accident, but that didn't change his mind about what he wanted to do with his future. He is uninhibited by problems that arise."
This perseverance, Ellwood's ability to go forward after setbacks and challenges, is one of the many qualities that set him apart as a maverick healthcare reformer. Others include his creativity and his focus on quality and value.
And then there's his talent for bringing together great minds, often of vastly differing opinions, to navigate possibilities for the future of delivering quality medical care.
HMO revolutionary. Ellwood, 72, is perhaps best known as the person who brought the concept of health maintenance organizations, indeed the term itself, into health policy discourse. In 1968 Ellwood delivered an address to health insurance industry leaders in which he proposed that their companies take more responsibility for the cost and quality of the healthcare they were paying for. The seeds of the HMO revolution were sown.
"I felt the HMOs would be better than the fee-for-service system in terms of more prevention," Ellwood says. "And HMOs would better provide continuity of care than the old system."
Instead of waiting for the insurers to act, he convened a coalition of health, consumer and political leaders known as the American Rehabilitation Foundation, which later would evolve into the think tank InterStudy, based in Minneapolis.
The group concentrated primarily on Ellwood's ideas on prepaid group medical practices, or PPGs as they were known then. Looking to the market and the private sector to help contain the rising costs of healthcare, Ellwood advocated preventive and prepaid medicine delivered by organized groups of caregivers.
In the early 1970s Ellwood met with leaders of Congress and members of the Nixon administration to pitch his idea.
"His educational efforts led to the HMO Act of 1973," notes Alain Enthoven, professor of public and private management at the Graduate School of Business at Stanford University in Palo Alto, Calif. That law provided for start-up grants and loans for not-for-profit HMOs and required large employers to offer HMOs as a choice for employees.
While this public policy was evolving, Ellwood continued his crusade for tracking and improving quality in healthcare. His 1973 book, Assuring Quality in Health Care, was "prophetic," Enthoven says, and became the foundation for outcomes-based quality measurement, management and regulation in the industry.
It took 15 years, however, for Ellwood's ideas about quality to catch on. In 1988 he delivered the lecture "Outcomes Management-A Technology of Patient Experience" to the Massachusetts Medical Society. It inspired a wave of research on measuring medical outcomes and the demand from employer coalitions for more outcomes reporting.
Filling a think tank. The late 1980s also witnessed the emergence of the Jackson Hole Group, an organization founded and led by Ellwood, in collaboration with Enthoven and Lynn Etheredge, an independent consultant who works with the Health Insurance Reform Project at George Washington University in Washington. These annual meetings-convened in Ellwood's home in Teton Village, Wyo., part of the region known as Jackson Hole-brought together a remarkable collection of healthcare industry leaders, researchers, and legislators and other public officials.
"We started with a discussion about how to come up with a blueprint for the 21st century health system," Etheredge says. "Paul spends a lot of time thinking about who will be there and what the agenda will be. He creates a chemistry that allows great things to happen."
The Jackson Hole Group served as the key development forum for managed competition, a strategy for purchasing healthcare in a way that obtains maximum value for purchasers and recipients. In 1992 and 1993, this work was reflected in the Managed Competition Acts, introduced to Congress with bipartisan support. But without solid backing from the Clinton administration, the legislation was never enacted.
Fostering change. Ellwood says that was a bitter pill to swallow and that he will be more hesitant about getting involved in "grandiose political schemes" again. However, he has found other fronts on which to fight.
"Paul has really made a career, a life, around trying to foster social change," Etheredge says. "His impact is not an accident."
Ellwood attributes what he calls a "weakness for trying to change things" to his parents, nurse Mary Rebecca Ellwood and doctor Paul Ellwood Sr., who raised their family in Oakland, Calif. Ellwood's father worked into his 80s at a community health center in a poor urban neighborhood.
Ellwood spent the first 17 years of his own career treating patients he thought were underserved, especially those with chronic illnesses such as polio.
From 1954 until 1959 he led the acute-care Poliomyelitis Treatment Program at the Sister Kenny Institute in Minneapolis while training in pediatrics and neurology at the University of Minnesota. Ellwood became a rehabilitation medicine leader in the 1960s, serving as president of the Association of Rehabilitation Centers and receiving the Gold Key award from the American Academy of Physical Medicine and Rehabilitation.
But Ellwood says he thought he could be more effective working at the organizational level on a national scale than with individual patients. And he believed that through comprehensive health planning, he could fulfill his career-long objective of measuring and improving the quality of healthcare based on outcomes.
All three of his children have carried on in the Ellwood tradition of social service through reform.
David Ellwood is a professor of political economy at Harvard University's John F. Kennedy School of Government in Cambridge, Mass. He was instrumental in crafting welfare reform, serving two and a half years in the Clinton administration as an assistant HHS secretary.
Deborah Ellwood analyzes policy issues affecting children. She worked recently at the Nelson A. Rockefeller Institute of Government in Albany, N.Y., and will soon become vice president for community programs at the Rochester (N.Y.) Area Community Foundation.
And Cynthia Ellwood has been deeply involved in school reform in Milwaukee, where she is a school principal.
Among his own contributions, Ellwood says, managed care has successfully contained costs, but his larger dream of comprehensive care hasn't been met. Since 1992 healthcare spending has fallen below the rate foreseen in federal Office of Management and Budget projections, saving the U.S. economy almost $1 trillion. But Ellwood says for most HMOs, the balance between their fiscal responsibility and healthcare responsibilities has shifted too far toward insurance and away from quality.
Quality crusader. Recognizing the limits of HMOs and understanding the vulnerability of patients, Ellwood has come full circle and is refocusing on empowering the individual consumer. In 1994 he helped create the not-for-profit Foundation for Accountability, or FAcct, to help consumers exert more influence on the health system through information.
Based on evidence that shows consumers believe that doctors, not organizations, are the key to whether medical care is good or bad, FAcct is using the Internet to take the idea of HMO quality report cards to a new level.
By coaching consumers on how to manage illness and what to ask of the healthcare system, FAcct will provide feedback to help patients compare the quality of care they are receiving with what other patients might be experiencing. Ultimately, all this information should help consumers choose the health plan, doctor or system that best meets their needs.
"I've learned just how vulnerable patients are, even if they are presumably powerful and knowledgeable," Ellwood says. "Once I went through the business of being a really sick patient, it changed my whole outlook."
Two near-fatal encounters in recent years, his broken neck and a prostate cancer diagnosis (he was successfully treated), exposed Ellwood to both sides of the quality coin, he says. With his spinal injury, Ellwood says he felt he had no influence with and therefore no trust in his doctor. But during his cancer treatment at Mayo Clinic in Minnesota, he actively participated in his care, and that helped in his recovery.
"My regained optimism comes not from surviving the broken neck, but because we've identified the means to make a midcourse correction and shift the power to patients and their relationships with doctors," Ellwood says.