June 7th, 2010 by Stanley Feld, M.D. in Better Health Network, Health Policy, Opinion, Research
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Last week I heard a lecture about Accountable Care Organizations by a physician leader working for one of the major hospital systems. His discussion made me realize that large physician organizations and hospitals are spending lots of time solving problems of quality medical care. In my opinion quality medical care has not been adequately defined.
A working definition right now is to decrease hospital stays, efficient medical care for a disease at lower cost, avoidance of medical errors in the hospital, and avoidance of hospital acquired infections. These are important goals. They must be attached to monetary incentives. Many of these problems can be solved now.
The solution demands the development of processes of care. An important question is how much money will process improvement save? I estimate that this process improvement could save an estimated 7 to 10% of the healthcare dollar.
The real question should be focused on how to repair the healthcare system by decreasing costs while improving the health of Americans. Read more »
*This blog post was originally published at Repairing the Healthcare System*
May 26th, 2010 by BobDoherty in Better Health Network, Health Policy, Humor, Opinion, Research, Uncategorized
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Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it.
— From A.A. Milne’s “Winnie the Pooh and the House at Pooh Corner.”
Internists, I expect, will identify with Edward Bear.
Richard Baron’s study in the NEJM on the amount of work he and his colleagues do outside of an office visit — the “bump, bump, bump” of a busy internal medicine (IM) practice — has resonated with many of his colleagues.
Jay Larson, who often posts comments on this blog, did a similar analysis for his general IM practice in Montana, and found that for every one patient seen in the office, tasks are done for 6 other unscheduled patients. Jay writes: “So really there [are] internists [who] are managing about 130 patients per day. Not much consolation when they only get paid for 18 per day.” Read more »
*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*
January 11th, 2010 by RyanDuBosar in Better Health Network, News
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ACP Internist’s wrap-up of current events continues with ping-pong for health care reform, how the recession curbed health care spending and how legislation preventing patient-dumping can hurt the physicians required to provide treatment.
Health care reform
Negotiations for health care reform will avoid the formal conference procedure and instead negotiate directly. The “ping-pong” talks, which don’t have to be public, will send the bill back-and-forth between the House and Senate until both chambers agree. C-SPAN wants to televise the negotiations. The goal is to pass the legislation by a State of the Union speech scheduled for February. (Los Angeles Times, C-SPAN, Baltimore Sun)
The recession did what Congress has struggled to do–slow spending for health care. Spending on physicians and services rose by 4.4% in 2008 over the previous year, the slowest increase in 50 years of tracking by the Centers for Medicare and Medicaid Services. Still, spending totaled $2.3 trillion, or more than 16% of the entire economy. The credit freeze in the most recent recession may have dissuaded people from paying large deductibles. (AP, USA Today) Read more »
*This blog post was originally published at ACP Internist*
June 15th, 2009 by Gwen Mayes, J.D. in Health Policy, News
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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” (www.healthreform.kff.org) 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
