June 18th, 2009 by John Briley in Health Policy
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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.
June 15th, 2009 by KevinMD in Better Health Network
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A 90-year old man with a pancreatic mass, almost definitely pancreatic cancer, was admitted to a hospital.
Surgeon Jeffrey Parks does the initial surgery consult on this terminal case, and recommends hospice care.
The next evening, he’s shocked by the “astounding amount of medicine [that] had been practiced” during the day:
Consults had gone out to GI, oncology, and nephrology. The GI guy had ordered an MRCP and, based on some mild distal narrowing of the common bile duct, had scheduled the patient for a possible ERCP in the morning. A stat CT guided biopsy of the liver lesions had also been done. The oncologist had written a long note about palliative chemotherapy options and indicated he would contact the son about starting as soon as possible. The nephrologist had sent off a barrage of blood and urinary tests.
It’s often said that we spend the most money in the world on futile care, often with little benefit to the patient. The preceding account was that phenomenon in action, replicated thousands of times on a daily basis.
A microcosm of what’s wrong with American medicine indeed.
*This blog post was originally published at KevinMD.com*
June 15th, 2009 by DrRob in Better Health Network
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I am a flaming moderate. Yes, I know that is an oxymoron but the fact remains that I am both passionate and moderate in my political opinions.
And I am in the mood to rant, so beware.
Living in the deep south, I often seem like a radical communist to those I see. I frequently get patients asking questions like “So what do you think about Obama’s plans to socialize medicine?”, or “I wanted to get in here before Obama-care comes and messes things up.” I usually smile and nod, but find myself getting increasingly frustrated by this.
The house is burning down, folks. Healthcare is a mess and desperately needs fixing. How in the world can someone cling to old political yada-yaya-yada when people are dying? I am not just talking about the conservatives here because to actually fix this problem we all have to somehow come together. A solution that comes from a single political ideology will polarize the country and guarantee the “fix” to healthcare will be one constructed based on politics rather than common sense.
No, this doesn’t frustrate me; it infuriates me. The healthcare system is going to be handed over to the political ideologues so they can use it as a canvas for their particular slant. In the mean-time, people are going to be denied care, go bankrupt, and die. Yes, my own livelihood is at stake, but I sit in the exam room with people all day and care for them. I don’t want to be part of a system that puts ideology above their survival.
So here is what this radical moderate sees in our system:
- The payment system we have favors no one. Every single patient I see is unhappy with their health insurance to varying degrees.
- Stupid and wasteful procedures shouldn’t be reimbursed. This is business 101; if you don’t control spending, you will not be able to sustain your system. This means that we have to stop paying for procedures that don’t do any good. Some will scream “rationing” at this, but why should someone have the right to have a coronary stent placed when this has never been shown to help? Why should we allow people to gouge the system for personal gain in the name of “free market”? I got a CT angiogram report on patient today who has fairly advanced Alzheimer’s disease. I twittered it and the Twitter mob was not at all surprised. These things happen all the time. The procedures do no good and cost a bundle. The procedure done today probably cost more than all of the care I have given this patient over the past 5 years combined!
- The government has to stop being stupid. Why can’t I give discount cards to Medicare patients? Why can’t I post my charges, accept what Medicare pays me, and then bill the difference? The absurdity within the system is probably the best argument against increased government involvement. Who invented the “welcome to Medicare physical??” I never do it because the rules are utterly complex and convoluted. If the rules can be this crazy now, how much worse will it be when the government takes over? If my medicare patients are confused now, how much more will we all be if the government grabs all of the strings?
- The money is going somewhere. In the past 10 years, my reimbursement has dropped while insurance premiums have skyrocketed. There are more generic drugs than ever and I am no longer able to prescribe a bunch of things that didn’t get a second-thought 10 years ago. Hospitals stays were longer and procedures were easier to get authorize. So where is the money going?? We do know the answer to this question – there is no single culprit. Drug companies were to blame for a while, but now they are going to the dogs; and yet the rates aren’t dropping. The real problem is that there are far too many people trying to capitalize on the busload of money in healthcare. Shareholders, CEO’s, and simple corporate greed has bled money out of the system like a cut to the jugular.
- Docs have to stop being idiots. We like our soap boxes to rant against EMR, malpractice lawyers, drug companies, and insurance companies. We stand on different sides yelling our opinions but don’t come up with solutions. Instead of doing what is right for our patients, we join the punching match of politics. Is EMR implementation important? Duh! There is no way to fix healthcare without it. But the systems out there are designed by engineers and administrators and don’t work in the real life. So why can’t we computerize ourselves? Every other industry did. Why must we cling to the archaic paper chart because we don’t like the EMR’s out there? Aren’t we smart people? Aren’t we paid to solve problems? Stop throwing darts and start finding solutions. Med bloggers are terrible in this – they rant constantly against EMR, but don’t ever say what would work. It’s fun to criticize, but nobody wants to propose an alternative.
- We need to get our priorities right. Healthcare is about the health of the patient. Yes, it is a job for a lot of people. Yes, it is an investment opportunity. Yes, it is a good thing to argue about – whether it is a “right” or not. Yes, it is a major political battleground. But in the end, these things need to be put behind what is most important. As it stands, we are more passionate about these other things than we are about the people who get the care. In the end it is about making people well or keeping them that way. It is about saving lives and letting people die when it is time. If we were all half as passionate about what is good for patients (and we are all patients) as we are about these other issues, we wouldn’t have half of the problems we have.
As a flaming moderate I get to offend people on all sides. We need to fix our system. It is broken. It is not a playground for those who like to argue. It is not a place to be liberal or conservative. This is our care we are talking about, not someone else’s. The solution will only come when we all come to the table as potential patients and fix the system for ourselves.
Is it easy? Heck no. This rant is not meant to show I am smarter than the rest of you; it is meant to get all of us away from the other issues that make any hope of actually fixing our problem remote. Given the fact that we all are eventually patients, our political posturing and plain stupidity may come back to haunt us. No, it may come back to kill us.
*This blog post was originally published at Musings of a Distractible Mind*
June 14th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
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Everyone is reading Atul Gawande’s article in the New Yorker about health care costs. But I think most people misunderstand Gawande’s major point.
Everyone’s At It
The conventional wisdom on Gawande’s piece is this: our problems are caused by bad incentives in our health care system. They encourage doctors to overprescribe care. McAllen, Texas is the poster child of this problem. If we can change the economic incentives, doctors will behave better. They will follow medical evidence, not their bottom lines, and from this will emerge a rational, affordable system.
This isn’t what Gawande is saying.
Gawande went to McAllen expecting to see a microcosm of the American health care system. As expected, he found excessive, even abusive spending, and a culture that encouraged both. But he also found that in nearby El Paso, Texas, medicine wasn’t practiced this way, nor in most other places in the country. And so he came up with a surprising insight. Yes, McAllen is a reflection of what can happen based on the incentives in the system. But if every incentive works this way, why is McAllen such an outlier?
Gawande concluded it had to do with the “culture” of medicine in each community. Most doctors go into medicine to help patients. In Gawande’s visit to McAllen, he heard stories that money had become more important than quality care. What Gawande realized was how important this question of “culture” was to how McAllen became McAllen. It made him think of places that had a completely different culture, like the Mayo Clinic.
The doctors of the Mayo Clinic decided, some decades ago, to put medicine first:
The core tenet of the Mayo Clinic is “The needs of the patient come first” — not the convenience of the doctors, not their revenues. The doctors and the nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. . . . Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially feasible.
Gawande couldn’t believe how much time doctors at the Mayo clinic spent with each patient, and how readily they could interact with colleagues on difficult problems. While it is true, the Mayo Clinic has financial arrangements that make this easier, it is the culture of patient care that dominates, not questions of pay:
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But almost by happenstance, the result has been lower costs.
“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” [Denis] Cortes [CEO of the Mayo Clinic] told me
And this is where Gawande is being misunderstood.
The “cost conundrum” that Gawande talks about is not about how to cut costs, or how to change who pays for health care and how much. It’s deeper than that. Gawande’s point is that we have been fixated for so long on the question of money in health care that we are starting to forget about medicine. By focusing on ever more clever ways to pay doctors, we have systematically undervalued everything that makes for high quality medicine. Things like time with your patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.
We discount what he calls the “astonishing” accomplishments of the Mayo Clinic on this score. And instead of designing health care reform around ways to help more hospitals become like the Mayo Clinic, we choose instead to think about money, to focus our attention on how to cut costs in places like McAllen.
Politically, it makes sense – it’s convenient to have a poster child like McAllen to explain why one reform plan or another should become law. But the pity is that in this important time of reform we’re not talking about trying to put the needs of the patients first – to put medicine back in the center of health care. The pity is that in spite of the fact that everyone’s reading Gawande’s article, his most important insight is being misunderstood.
If we continue to be focused on money over medicine, we will lose the “war over the culture of medicine – the war over whether our country’s anchor model with be Mayo or McAllen.”
*This blog post was originally published at See First Blog*
June 13th, 2009 by Shadowfax in Better Health Network, Health Policy
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Ezra opines a bit on the role of doctors in health care with the strangely misleading headline:
Listen to Atul Gawande: Insurers Aren’t the Problem in Health Care
This wasn’t Gawande’s point at all, and is something quite tangential to Klein’s point:
The reason most Americans hate insurers is because they say “no” to things. “No” to insurance coverage, “no” to a test, “no” to a treatment. But whatever the problems with saying “no,” what makes our health-care system costly is all the times when we say “yes.” And insurers are virtually never the ones behind a “yes.” They don’t prescribe you treatments. They don’t push you towards MRIs or angioplasties. Doctors are behind those questions, and if you want a cheaper health-care system, you’re going to have to focus on their behavior.
Yes, doctors are a driver — one of many — in the exponentially increasing cost of health care. Utilization is uneven, not linked to quality or outcomes in many cases, and may often be driven by physicians’ personal economic interests. All of this is not news, though certainly Atul Gawande wove it together masterfully in his recent New Yorker article. (I’m assuming you’ve all read it — If not, then stop reading this drivel and go read it immediately.) Nobody disputes that doctors’ behavior (and ideally their reimbursement formula) need to change if effective cost control will be brought to bear on the system.
But it’s completely off-base to claim that insurers aren’t one of the problems in the current system. There are two crises unfolding in American health care — a fiscal crisis and an access crisis. I would argue that insurers are less significant as a driver of cost than they are as a barrier to access. Overall, insurers have, I think, only a marginal effect on cost growth, largely due to the friction they introduce to the system — paperwork, hassles & redundancy and internal costs such as executive compensation, advertising and profits. It would be great if this could be reduced, but it wouldn’t fix the escalation in costs, only defer the crisis for a few years until cost growth caught up to today’s level. In the wonk parlance, it wouldn’t “bend the cost curve,” just step it down a bit.
But as for access to care, insurers are the biggest problem. It’s not their “fault” per se in that they are simply rational actors in the system as it’s currently designed. Denying care, rescinding policies, aggressive underwriting and cost-shifting are the logical responses of profit-making organizations to the market and its regulatory structure. Fixing this broken insurance system will not contain costs, but it will begin to address the human cost of the 47 million people whose only access to health care is to come to see me in the ER.
*This blog post was originally published at Movin' Meat*
