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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.

Healthcare Reform Views From A Flaming Moderate

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:

  1. The payment system we have favors no one. Every single patient I see is unhappy with their health insurance to varying degrees.
  2. 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!
  3. 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?
  4. 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.
  5. 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.
  6. 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*

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

Ezra Klein: Missing The Point

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*

The Five Cornerstones Of 21st Century Medical Care

Eight years ago, the Institutes of Medicine published a paper entitled Crossing the Quality Chasm: A New Health System for the 21st Century, which envisioned the future medical practices. Many of the concepts discussed were adopted and endorsed in years to come by the American Academy of Family Practice, The American College of Physicians,  the American Medical Association, among others.

The five major innovations of care outlined by this study include:
1.    A communication-centered practice model,
2.    Information management,
3.    Technology replacing office staff,
4.    Reduced pricing and transparency in billing, and
5.    Removing external conflicts of interest between doctors/providers and patients.

Complete adoption of these innovative concepts can cut at least 30% of primary care costs while significantly improving patients’ quality of care, and further reduce overall health care costs by offering immediate and highly accessible care that avoids emergency room visits, enhances wellness, manages chronic illness and diagnoses disease early. These cost savings and quality improvements are enabled by utilization of advanced communications and information technology that replace much of office overhead and staff, and encourage patients to seek the most cost-effective and convenient care possible.  Many medical practices have adopted some of the recommendations, yet less than 1% have transitioned to complete and consistent adoption because they frankly have few financial incentives to do so.

These innovations are the cornerstones of retooling our broken healthcare system, and in turn can pave the way to “fixing” many of the issues plaguing this system. The five cornerstones provide for what so many Americans are clamoring for yet are unable to find: continuous access to a medical provider team thus enhancing patient access, control, and convenience of care; increasing the quality and speed of treatment; reducing the cost of care; creating transparency in pricing; and removing external parties that create conflicts of interest between doctor and patient and often interfere with providing quality and speed of care to patients.

I’ve built my own primary care practice on these five concepts, and while all can significantly lower costs while vastly improving the patient experience,  I’d like to take a look at the concept I find to play a pivotal role: a communication-centered practice model.

A Communication-Centered Practice Model
Twenty-first century, day-to-day-primary care starts with the primary care provider being the first in line to answer a patient’s phone call or email. During this call or email, the provider reviews a patient’s history, and bearing in mind that the provider already knows has a professional relationship with the patient, then can make appropriate decisions.  At least 55% of the time, the patient’s situation does not require an office visit, however instead involves going straight to the pharmacy for medications, going to labs for tests, getting an x-ray, or recommending a referral.   In this model of practice, the doctor spends at least half the time of the time answering phones and emails, thereby providing immediate access and convenience to the patient.

If either the clinician or the patient believes there is a need for an office visit, the visit is arranged immediately.  Patients can talk to their medical expert or an on-call member of the medical team 24/7. This instantaneous access can result in patients having most of their day-to-day  issues addressed within 10 minutes of reaching the practitioner, and can expect care from their personal provider from home, work or anywhere in the U.S.

As mentioned above, over 50% of medical issues can be addressed by telemedicine, specifically by phone or email, as long as a patient-doctor relationship exists. This results in people being healthier and on the road to recovery much faster, thus not taking time off from work.   Office hours are flexible and can be arranged day or night and any day of the week including weekends.

The importance, barriers to adoption, and the unexamined assumptions as to why 97% of all  medical care currently occurs in a medical office and nowhere else has been reviewed in several of our prior postings:

Are Face-to-Face Office Visits Really Required to Provide the Highest Quality Care?
In Defense of Remote Access Medical Visits
The Commonplace Tool That Can Revolutionize Health Care
Telemedicine Care: A Malpractice Risk? Au Contraire …
Telemedicine Checks In On Chronic Health Care Problems

In the future, I plan on taking a look at the additional four cornerstones that need to have traction if the Obama administration hopes to restore vitality to the primary care system.

Until next time, I remain yours in primary care,

Alan Dappen, MD

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