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Health Care Reform: More Than The Money

Much of the debate this week over health care reform centers on the money: Will reform place undue burden on some silos of the health care sector? Will we need new taxes on the middle class to fund this thing? Will providers choose to pass on added costs (to consumers and others) rather than change habits to become more efficient?

Fair questions, all. This is America and money is king. But far more important right now is enacting measures that require wholesale changes in health care training, delivery, tracking and accountability.

A Bipartisan Model

At a press conference in Washington, D.C., a bipartisan triad of former Senate majority leaders yesterday unveiled a model of what those changes could look like. Former Sens. Howard Baker, Tom Daschle and Bob Dole, all of whom are among the founders of a think tank called the Bipartisan Policy Center, released a broad spectrum of policy suggestions that includes mandatory health insurance for all Americans, zero premiums for people in poverty and a revised payment system that rewards providers who heal the sick and prevent illness in the well.

Baker, Daschle and Dole insist their plan is “budget neutral” – i.e. will break even over 10 years. And, like seasoned parents trying to teach their kids to play nice, they highlighted compromises made in drafting the plan.

Daschle, for example, wanted a public plan (government-run health care) but said he “compromised significantly” on that issue (the proposal as released includes a moderate public plan run by states with federal seed money). Dole opposed mandatory health insurance for every American but he backed away from that.

As Dole said at the briefing, “If we can’t compromise…how can we expect to get a bill passed?”

Nice gestures and sound bites but, as Baker, Daschle and Dole readily acknowledge, they have no legislative power – or riled up constituents lighting up their phones – so it remains to be seen if their goodwill will inspire similar flexibility in current members of congress.

The fairly detailed plan consists of four pillars.

1. Promote high-quality, high-value care by:

  • Investing in information technology that will greatly raise efficiency in the system – and reduce medication and hospital errors;
  • Developing reliable measurements on how to define “quality care” and how to ensure patients are receiving it;
  • Reforming provider payments in Federal programs to reward high-value care;
  • Focusing on prevention of chronic diseases – like diabetes and heart disease – by rewarding providers for early recognition of risk factors and effective intervention.
  • Investing in the healthcare workforce (for example, through enhanced training and continuing education).

2. Make health insurance available, meaningful and affordable by:

  • Guaranteeing coverage, even to the very poor – for example, no premiums for those at or below the poverty line and tax credits for those living at up to 400 percent of the poverty line.
  • Guaranteeing access regardless of health status – i.e., no more denial of coverage for pre-existing conditions!
  • Creating state or regional insurance exchanges so consumers and businesses could easily comparison shop for plans.

3. Emphasize and support personal responsibility and healthy choices by:

  • Mandating purchase of insurance.
  • Offering premium reductions for healthy behaviors.
  • Creating a public health and wellness fund – $50 billion over 10 years – to invest in evidence-based prevention and wellness programs (through schools, community organizations, state agencies and even employers).

4. Develop a workable and sustainable approach to health care (this is the money part) by:

  • Charging companies – 1 to 3 percent of payroll – that do not offer insurance to employees.
  • Modernizing delivery and payment systems.
  • Reducing payments to home health and skilled nursing facilities “to address overpayment and inappropriate utilization concerns.” This is in line with recommendations from Med PAC.
  • Creating an approval pathway for generic versions of biologics.

Looking Beyond the Money

The total plan would cost $1.2 trillion over 10 years. Again, the former senators insist that their plan would pay for itself, through savings from increased efficiencies and fees for certain players.

I will not delve into the money debate because, honestly, it is over my head and best left to experts. But I do know human behavior, and I know that good habits are very hard to establish and bad ones even tougher to break.

And, to me, that means that whatever legislation emerges from congress better include strict and crystal clear requirements to prod insurance companies, hospitals, doctors, nurses et al to act in the best interest of patients, at all times and without loopholes to do otherwise.

Sharing the stage yesterday with the former senators was Mark McClellan, director of Engelberg Center for Health Care Reform and Leonard D. Schaeffer Chair in Health Policy Studies at the Brookings Institution.

McClellan, who has a deep health policy resume, including a stint as Food and Drug Administration commissioner and administrator of the Centers for Medicare & Medicaid Services, said this about Medicare: “We don’t get there by cutting provider payment rates and assuming they can do the rest. Payments are tied to measureable improvements in value [and] in care.” If your patients get better results and you slow down costs, he added, you get paid more. “Not the opposite like we have today.”

New Standards for Hospitals?

This is soothing to hear, and I’d like to add one brief rant on a related topic: Health care reform legislation must include strong mandates for reforming how we run our hospitals.

In 2008 two patients – one in Brooklyn, N.Y., and another in Goldsboro, N.C. – died in waiting rooms after being neglected for hours by hospital staff. In the Goldsboro case, a security camera records workers sitting in the waiting room playing cards while the patient, who had not been fed or attended to in 22 hours in the hospital, slumps in a nearby chair. In the Brooklyn case, a camera captures a woman collapsing and convulsing on the floor – after 24 hours in the waiting room; two guards and a member of the hospitals medical staff stop to observe her briefly before walking away.

While those tragic cases may be extreme, tales abound nationwide of substandard hospital operations – including medication and procedural errors, physical and sexual abuse of patients, rodent and roach infestation and general filth. Some hospitals in this country have infection rates that top 20 percent, meaning more than one-in-five patients leave the hospital with an infection they acquired during their stay.

Yes, this is only one part of the big picture, and yes, many other silos of the health care system are equally ripe for attention. But I would hope that whatever legislation emerges from congress includes elevated standards for training all hospital staff, not just doctors and nurses, along with strict accountability measures and some way of penalizing hospitals that are not clean, orderly and welcoming to patients.

I caught Sen. Daschle after the briefing and asked him about this issue. He repeated much of what had been said on improving health care in general – tying payment to value, ensuring transparency, and relying on evidenced-based research to set policy – but he also told me this: “We need to encourage hospitals and doctors to use a more episodic [approach] to health care rather than a procedural [approach]. That will help.”

Translation: The system must reward providers who treat the whole patient and improve overall health/outcomes over time. Doctors should be paid to keep people well, not to keep people sick and in treatment, as is often the case under the current system.

Former HHS Secretary Tommy Thompson On Tom Daschle’s Withdrawal

Many Americans have been surprised and disappointed by Senator Tom Daschle’s withdrawal as HSS Secretary nominee. I asked Tommy Thompson, former Governor of Wisconsin and the 7th U.S. Secretary of Health and Human Services, what he made of this. You may listen to our full conversation by clicking on the podcast arrow, or read a shortened summary below. Enjoy.

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Dr. Val: Tom Daschle’s withdrawal as HHS Secretary nominee has been a real shock for most people. Some are saying that without Daschle’s influence, healthcare reform will take a back seat to other economic priorities this year. What do you think?

Thompson: I don’t think that will happen because we’re in such dire need of reform that even without Tom Daschle there’s going to be a tremendous transformation of the healthcare system this year. Two healthcare bills are already undergoing the legislative process, and one is ready to be signed into law – the expansion of SCHIP, the insurance plan to cover poor children. The second bill involves the expansion of COBRA, which allows unemployed individuals to buy in to their previous employer’s health insurance plan.

But beyond this, the new stimulus package has 20 billion dollars set aside for health IT infrastructure – to create an electronic medical record for all Americans and beef up broadband access. There will also be a lot of money set aside for preventive health initiatives – to help Americans become healthier so they won’t need as many medical services.

Of course, Senator Kennedy is pushing for a “play or pay” plan modeled after Massachusetts’ law. There will be a lot of pressure to get this done quickly due to his ailing health. So you can bet your bottom dollar that the healthcare system that we know today is going to be changed so considerably that I doubt if you’ll recognize it a year from now.

Dr. Val: Do you have any idea who might replace Tom Daschle as HHS Secretary nominee?

Thompson:  I’ve been hearing a lot of names. Governor Kathleen Sebelius from Kansas is very much in the running. Howard Dean’s name has also come up. Overall I do think it will be a governor or former governor who gets the position.

Dr. Val: What sort of person would have the skills for the job?

Thompson:  I think a governor is the ideal person for the job because they already have experience running both state and federal programs – both initiating and managing them.

Dr. Val: Do you think that being a physician could be an advantage as well?

:  There are so many physicians in the department that I don’t believe that being a physician adds or detracts from the position. Being the Secretary of HHS is an administrative position and although doctors have many skills, I’m not sure that running a large agency of over 67,000 employees with a budget of over 600 billion dollars is something that most doctors have the experience to do well.

Dr. Val: Do you think Daschle made the right choice to withdraw?

: Tom Daschle is a friend of mine. I think he’s an honorable person and I think he would have made an outstanding Secretary of HHS. I’m sorry he’s withdrawn, but the debate about his taxes was splashy enough to be affecting the stimulus bill and diverting attention from it. So I think overall it was probably the right thing to do.

Dr. Val: What’s the most important thing for the American people to know about the Daschle case?

Thompson: They should know that there is no double standard between people in power and those not in power. All of us are equal in the eyes of the law, and we’re a country of laws, not of men. We’re all responsible for our own personal decisions, and that includes paying our taxes.


See KevinMD’s excellent round up of further thoughts about Tom Daschle.

Grand Rounds Edition 5:18, January 20th – Call For Submissions

Dr. Val is hosting the historic inauguration day Grand Rounds at MedPageToday. Please send your submissions to this email address: valjonesmd AT gmail dot com. Put “Grand Rounds Submission” in your email title and please use this format for the body of your email:

  1. Post title
  2. Post url
  3. Short description of the post
  4. Blog title
  5. Blog url

Although I have never done a themed Grand Rounds before, it would be terribly remiss of me not to acknowledge healthcare reform on the very inauguration day of our new President, Barack Obama. So please send me your best posts about the change you’d like to see in healthcare. If we do a really great job of this, maybe Tom Daschle will take a looksie? Don’t laugh, but DC is a small world – I share a hair stylist with Tom’s wife, Linda!

Please send me your submissions by midnight, ET, Sunday January 18th. I will include all submissions, but will give more weight to those that are about healthcare reform.

For those of you who are reading this and wondering what on earth I’m talking about – please read about Grand Rounds here. It’s the weekly summary of the best blog posts from the medical blogosphere.

My inaugural Grand Rounds will be published at MedPageToday at 8am, Tuesday, January 20th. (This link will work from that time on). I hope that we’ll reach an unprecedented number of readers on this platform.

I look forward to receiving your submissions!

Warmest Regards,


P.S. Please enjoy Barbara Kivowitz’s Grand Rounds this week – it has a Sci Fi theme! The January 27th edition of Grand Rounds will be hosted by: Chronic Babe.

Ten Good Things About The U.S. Healthcare System

President-elect Obama and Secretary of HHS designate, Tom Daschle, invited concerned Americans to discuss healthcare reform in community groups across the country. My husband and I hosted one such group at our home in DC yesterday. Although we had been instructed to compile a list of compelling stories about system failures – instead we decided to be rebellious and discuss “what’s right with the healthcare system” and compile a list of best practices to submit to the website.

The event was attended by a wide range of healthcare stakeholders, including a government relations expert, FDA manager, US Marine, patient advocate, health IT specialist, transportation lobbyist, real estate lobbyist, health technology innovator, Kaiser-trained family physician, medical blogger, and EMR consultant. Here is what they thought was “right” with the healthcare system:

1.    Customer Service. Market forces drive competition for business, resulting in increased convenience and customized service. Healthcare consumerism has driven patient-centered innovations that improve quality of life. Examples include convenient walk-in clinics, online scheduling, services available in a one-stop location, and seamless transfer of health information (such as within the Kaiser Health system).

Memorable Quote: “We have a tremendous amount of choice in our system. That’s very good for patients and I hope we never lose it.”

2.    Accommodations For People With Disabilities. Kaiser Permanente was cited as an organization that takes special interest in facilitating good patient experiences for vulnerable populations and people with disabilities. For example, extra time is allotted for travel to and from the clinic, and schedules are built with flexibility to accommodate mobility impairments.

Memorable Quote: “Kaiser trains all its staff to be sensitive to people with ethnic, racial, and sexual preference differences. They learn to listen to the patient, and never assume they know what they think or feel.”

3.    Specialty Care. So long as a person has health insurance, access to the very best specialists in the world is available in a very democratic fashion to all patients. Several success stories included surgery and follow up for major multiple trauma, and congenital anomaly repair.

Memorable Quotes: “I’m only here today because of the technical skills of a U.S. surgeon who saved my life…” “I’ve traveled all over the world, and I wouldn’t want to get my medical care in any other country.”

4.    Social Media. Internet-based tools and social media platforms are leveling the communication “playing field” between providers and patients. People are discussing their care and treatment options with others like them online, as well as socializing with physicians and receiving real-time input on health questions.

Memorable Quote: “On Twitter I have I.V. access to physicians. I asked a health question and within 10 minutes I had 6 physicians answer me.”

5.    Access To Allied Health Professionals. Scheduling time with mid-level providers is easy, convenient, and effective. Patients enjoy the ability to access generalist care with nurse practitioners (for example) who provide quality care at a more relaxed pace.

Memorable Quote: “I love my nurse practitioner. She really listens to me and her schedule is much more flexible than physicians I’ve known.”

6.    Drug Development For Rare Diseases. The U.S. government offers grants, extended patents, and exclusivity to drug companies willing to develop drugs for rare diseases. This dramatically improves the quality of life for patients who would otherwise have no treatment options.

Memorable Quote: “The FDA recently approved the first drug for Pompe’s disease. Only a few hundred patients in the U.S. have the disease, and yet this life-saving medication was developed for them thanks to government incentives.”

7.    Patient Autonomy. The healthcare consumerism movement has replaced medical “paternalism” with care partnership. Patients are seen as consumers with choices and options who must take an active role in their health.

Memorable Quote: “Patient accountability is key to better health outcomes. But they need guidance and decision support… General health literacy is at a sixth grade level.”

8.    Health Education. Technology has improved health education dramatically. Patient education about their disease or condition is often facilitated by demonstration of computer-based anatomic models.

Memorable Quote: “I think that doctors are getting much better at communicating with patients in ways they can understand.”

9.    Coordination of Care. Some hospitals like the Mayo Clinic do an excellent job of coordinating care. For example, they provide each patient with photos and names of all the physicians, nurses, and specialists who are on their care team. Nurses update the patient’s schedule daily to reflect the tests and procedures anticipated and provide dignity and sense of orientation to the hospital experience.

Memorable Quote: “The Mayo Clinic has gone Facebook.”

10.    Democratization of Information & Transparency. Patients have the right to view and maintain all their medical records. They have many PHR options, and may be provided with CDs or thumb drives of their personal radiologic information to take with them to their next provider. Many doctors write their notes with the understanding that the patient will be reading them.

Memorable Quote: “One day soon, hospital stays will no longer occur in a black box. Family members and friends will be invited by the patient to view their daily schedule online, while nurses update planned procedures, events, and meetings. Family members won’t miss the opportunity to meet with the patient’s care team, because it will be on the schedule. MyChart (from EPIC) is working on making this hospital experience a reality at the Mayo Clinic soon.”


Thanks so much to all of you who attended. My husband will be preparing a report for the transition team shortly.

Did You Or Someone You Know Break the Health Care System?

Tom Daschle and Barack Obama’s transition team have asked that Americans – interested in the subject of healthcare reform – lead community meetings to create a list of ideas for the new administration. So my husband took the invitation to heart and has decided to lead a group in our home right here in DC. Please respond if you’d like to join us. Here’s a copy of the email he’s been sending to friends:


Did You Or Someone You Know Break the Health Care System?

Has our health care system failed you personally?  Is it broken?  I don’t want to hear about it….

….come join me for a Health Care Community Discussion ( about what’s right with the U.S. Health Care System.

Be prepared to discuss one experience in which your interaction with the health care system was positive.

The goal will be to gather those observations and submit them to the Obama-Biden Transition Health Policy Team to be applied as best practices across the entire industry.  Why do we always have to approach reform by looking at what’s wrong?  Let’s discuss what’s right.

If you would like to attend this event, please RSVP to szlotkus at

Date: December 30th
Time: 7-9pm
Location: Dupont Circle, Washington DC (I will provide the exact address to attendee’s via e-mail)
Total attendance will be limited to 15 people.

Bring a friend, or pass on this web page to someone you think might be interested in coming.

Steve Z

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