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Health Care Reform: More Than The Money

June 18th, 2009 by John Briley in Health Policy

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.

Tags: Bipartisan Model, Bipartisan Policy Center, Bob Dole, Costs, Finance, healthcare, Healthcare reform, Howard Baker, Plan, Tom Daschle