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Hot Topics In Healthcare Reform: A Primer

For those of who believe there is a pill for every ill, the recent flurry of legislation and ensuing debates on health care reform may be just too big a pill to swallow.

You’ll need a very large glass of water for sure.

“There’s a lot to consider and not everyone is going to like everything about this legislation,” Rep. Lois Capps (D-CA) told participants at Avalere Health’s conference on Raising the Bar:  Payment Reform and CV Disease on Friday, June 12 in Washington.  Capps, a 20 year veteran school nurse, co-chair of the Democratic Heart and Stroke Caucus and member of the House Energy & Commerce Health Subcommittee describes the pending legislation in terms of “choice” and “a balance” but readily admits that finding a way to pay for it will be difficult.

For those who might not feel up to speed on the latest buzz on health care reform, here’s a quick primer:

Public Option. To cover the 47 million uninsured or underinsured Americans, the President is asking for a public plan that would compete within the insurance market place either directly on cost, or indirectly with clout.  Supposedly, this plan (yet to be included in the Senate HELP health reform legislation introduced last week but rumored to be coming in the markup) will be subject to the same rules and regulations of the private health insurance market.  It could be an extension of Medicare, Medicaid or a hybrid of approaches involving capitation and integrated systems for physicians and hospitals.

The debate about whether or not to introduce a new public option to the current health insurance system involves more than a sense of fairness or simply closing the gap.  The private insurance business is strongly tied to state regulations and competitive forces that will remain as long as 15% of Americans purchase their insurance out of pocket and another 40% have insurance through employment .  Designing the right form of public assistance that can compete with private insurance but not control the market place is surely to reflect the strong differences between political parties.

Centralists in Congress, namely Sen. Kent Conrad (D-ND), have proposed co-ops as a third approach between a public option and the status quo.  Co-ops are membership-owned and operated non-profit organizations that adhere to state laws for health care coverage and provide health insurance for individuals and small businesses.  Reaction has been mixed but some believe co-ops will hit the right balance of competition and public assistance needed for passage in the Senate.

Comparative Effectiveness. Comparative effectiveness research seeks to compare the clinical effectiveness of two alternative therapies for the same condition.  It’s rooted in the idea that our system of paying for the volume (e.g., “fee-for-service”) should be replaced with payment for effectiveness and value that is based on the best science possible.  Recent examples of comparative effectiveness research include trials comparing bare metal coronary stents to drug-eluting stents and comparing older versus newer drugs for treatment of schizophrenia.   All this can be extremely valuable to clinicians and patients trying to decide between alternative courses of treatment.  And to the extent that comparative effectiveness research improves the quality of care, it can also reduce costs.

But clinical data alone cannot reflect patient preferences or whether a treatment course for the overall population is the best one for an individual.   The hot button here is how to encourage clinical research that can help physicians and patients make the best treatment choices yet safeguard it from being used by insurance companies and the government to deny coverage or set payment.  What, exactly, will be compared needs close scrutiny.

Accountable Care Organizations (ACOs). An ACO is a combination of one or more hospitals, primary care physicians and possibly specialists, who are accountable for the total Medicare spending and quality of care for a group of Medicare patients.   Various carrots and sticks are being discussed, but the idea is to control Medicare spending and improved quality of care.  While most physicians recognize the need to move away from Medicare’s fee-for-service approach, the incentives and infrastructure needed to coordinate among providers isn’t apparent.  What about rural areas where coordination of care is a misnomer?  This may be a hot topic for systems change, but practitioners are skeptical.

Patient-Centered Care. It’s hard to imagine that the American College of Cardiology felt the need to launch a new initiative, the “Year of the Patient” or the British Medical Journal depicted tango dancers on its cover story, “Partnering with the Patient” but re-infusing the health care debate from the patient’s perspective is long overdue.   Look for it in every piece of legislation, new commission and advisory group.  Raising the voice of a few on a plum commission or panel discussion  is a laudable start, but we’re all, at one time or another, patients.  We’re all consumers of health care and drawing upon our own experiences to improve our professional stance will be necessary.

Gateways. The Senate HELP Committee’s legislation introduces the concept of “gateways” or “exchanges”, a clearinghouse of sorts on a state level to help consumers parse through insurance plans and public services.  The program would be optional for states for the first six years then federal compliance would prevail.  Organizations such as Kaiser Family Foundation have already established online “gateways” ( to inform consumers wanting to know more.

Health reform is coming fast and furious.  On Monday, June, 15, the Congressional Budget Office is expected to release their projections on what it will take to pay for such massive reforms.  Hospitals and physician groups are deeply concerned about cuts in Medicare payments – estimated by the President on his weekend radio chat as an additional $313M on top of the $309M included in the Administration’s FY2010 budget.

Further legislation will be released this week; keep an eye on the Senate HELP Committee, Senate Finance Committee, House Energy & Commerce, House Ways & Means, and House Education and Labor.

There’s much more to health reform than covered here.  I encourage you to find a passion point of entry and share your insights.

And get ready to swallow a very big pill.

Here’s a quick list of what’s hot in health care reform:

  • Public Option
  • Electronic Medical Records
  • Elimination of pre-existing exclusion
  • Patient-Centered Care
  • Accountable Care Organizations
  • Payment based on value not volume
  • Integrated health delivery systems
  • Federal Health Board
  • Transparency in data, costs and outcomes
  • Personalized health care/personalized information
  • Chronic care models/Transitional Care Models
  • Prevention and wellness programs
  • Comparative Effectiveness
  • Payment reform/Medicare cuts
  • Shared decision making

Health Care Policy Summit Brings Together Unlikely Allies

Better Health’s policy writer, Gwen Mayes, caught wind of an interesting new conference being held tomorrow in Miami. She interviewed Ken Thorpe, Ph.D., one of the conference organizers, to get the scoop. You may listen to a podcast of their discussion or read the highlights below. I may get the chance to interview Billy Tauzin and Donna Shalala later on this week to get their take on healthcare reform initiatives likely to advance in 2009. Stay tuned…

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Mayes:  Tell us about the upcoming conference in Miami on January 28th called “America’s Agenda: Health Care Policy Summit Conversation.”

Thorpe:  The conference will start a conversation on the different elements of health care reform such as making health care more affordable and less expensive, finding ways to improve the quality of care and ways to expand coverage to the uninsured.  The conference is unique in that we’ve brought together a wide range of participants including government, labor, and industry for the discussion, many of whom have been combatants over this issue in the past.

Mayes:  Will there be other meetings?

Thorpe:  This is the first of several.  There will others in other parts of country over next several months.  President Obama and HHS Secretary Designee Tom Daschle have talked about engaging the public in the discussion this time around.  So part of this is an educational mission and part of it is to reach consensus among different groups that have not always agreed in the past.

Mayes:  What encourages you that these groups will be more likely to reach consensus now when they haven’t in the past?

Thorpe:  The main difference is that the cost of health care has gotten to the point that many businesses and most workers are finding it unaffordable.  In the past, most businesses felt that, left to their own devices, they could do a better job of controlling health costs by focusing on innovated approaches internally.  What we’ve found, despite our best efforts, working individually we haven’t done anything to control the growth of health care spending.    The problems go beyond the reach of any individual business or payer and we need to work collectively.

Mayes: How will health care reform remain a priority in this economy?

Thorpe:  The two go hand in hand.  As part of our ability to improve the economy we’re going we have to find a way to get health care costs down.  Spiraling costs are a major impediment to doing business and hiring workers.  To the extent we can find new ways to afford health care it will be good for business and workers.

Mayes:  Health information technology is also an important aspect.  What are the common stumbling blocks to moving forward?

Thorpe:  There are three issues we have to deal with.  First, we have to have a common set of standards for how the information flows between physicians and physicians, and with payers and hospitals.  What we call interoperability standards.   Second, we have to safeguard the information.  Finally, cost is the biggest challenge because most small physician practices of 3 or 4 physicians don’t have electronic record systems in place.  To put in a state-of-the-art system can cost $40,000 per physician and most cannot afford this expense.  I think the stimulus bill will provide funds to help with these costs.

Mayes:  There’s always growing interest in the patient’s role.  How will this be addressed?

Thorpe:  We have to find a better way to engage patients in doing better job of reducing weight, improving diet and those with chronic disease to follow their care plan they worked out with their physician.  We also want to make it more cost effective for patients to comply with the plan.  Patients who comply with health plans will have better outcomes at lower costs. 

Mayes:  Who’s on the agenda in Miami?

Thorpe:  It’s at the University of Miami so it will be hosted by President Donna Shalala who was Secretary of HHS under the Clinton administration so she is well versed on health policy.  Also attending is the head of PhRMA, Billy Tauzin, a former Congressman and former majority leader of the House, Dick Gephart.  There will be some lay people as well for a nice cross section of consumers, labor, providers, business and others.

Mayes:  How can people learn more about American’s Agenda and the conference?

Thorpe:  The executive director of American’s Agenda is Mark Blum.  He can be reached at 202-262-0700 or at America’s

Having A Ball: Kentucky Style

I’m writing this post mostly to embarrass my girlfriend Gwen Mayes, but also because I’m mentally exhausted from preparing Grand Rounds for publication tomorrow, and thought I’d engage in some frivolity.

Gwen and her friend Scott are pictured here en route to the Kentucky Inaugural Ball in Washington, DC. Most states are hosting their own celebratory ball tonight – and Kentucky’s Bluegrass Ball won an “Editor’s Pick” from the Washington Post. It’s one of the largest and best balls, and I suppose that makes sense if one assumes that southerners do this kind of thing well (I lived in Texas for four years, so I’m allowed to joke about that).

The Bluegrass Ball has some predictable highlights, including the “Kentucky Bourbon Trail” sponsored by the Kentucky Distillers Association, and a guest list that includes everyone from Governor Steven Beshear and Senate Republican Leader Mitch McConnell to the band “Joey and the Cruisers.” What I did not expect, however, was that the caterer for the event would import “720 heads of Bibb lettuce” as part of a “Kentucky-friendly menu.” I soon learned that Bibb lettuce was first cultivated in Kentucky by Jack Bibb in the late 19th Century. Am I the only person who didn’t know this?

I’ll be attending a few events on Pennsylvania Avenue tomorrow during the inauguration day parade. Gwen and Scott will be spending the night at my place – and I can only hope that they bring me back a goodie bag filled with Kentucky goodness – especially the Bibb lettuce.

Addendum: My friends make a b-line for the Maker’s Mark booth…

And here they are horsing around:

And no, they didn’t bring me any Bibb lettuce back from the ball (dang it)… just a floral arrangement they picked up from some guy in the subway who was returning home from the Indiana Ball. Oh… and some Maker’s Mark.

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