The New Health Dialogue

HEALTH CARE: In Malpractice Debate, Perception Counts

Joanne Kenen — Thu, 02 Jul 2009 17:59:00 -0400

Put President Obama and a U.S. physician in a room (or in a virtual room as the case may be) and chances are, the talk will turn to malpractice costs.

You can make—and many have—the argument that rhetoric and perception aside, malpractice costs don't add much to the overall health bill, a percent or two. (Although at a time when we're looking for all the savings we can get in the health system, one or two percent can add up in a $2.2 trillion system).

But rhetoric and perception do matter. Politically, addressing malpractice could get an obstacle to reform out of the way—-both from doctors who are truly convinced malpractice is really The Big Problem With the System, as well as from anti-reform forces who would rather inflate the malpractice issue than look at all the things wrong with the status quo.

In terms of perception—if we address doctors' concerns (and some well-intentioned, even progressive pro-reform, doctors sincerely believe that the threat of malpractice lawsuits is distorting the practice and cost of medicine no matter what the CBO says)—maybe it will be easier, both in raw politics and in changing attitudes, to get doctors on board for all the changes we need to make in health care in this country. That includes rethinking the delivery and payment system, which will require adjustments from doctors, and a frank look at the rate of medical errors, how to reduce them, and finding a fair way of helping the victims. Right now, we aren't systematically addressing the root causes of errors, nor are we necessarily compensating those that have been worst hurt. According to Brandeis research on malpractice, less than one in seven patients who are actually injured by negligence file a claim; and only one in six claims that are filed actually involve negligence. It can take five or 10 years to settle a case, and then more than half the payouts go to administrative and legal costs, not the injured patient. It is not a model system.

Obama isn't about to embrace caps on damages. Challenged at the Virginia health care town hall about caps by Texas Republican Rep. Michael Burgess, a physician, and in his recent AMA speech, Obama explained that he opposes them. They are arbitrary, they aren't a good answer for people who suffer egregious harm. On their own, they also don't solve the problem, which is more complex than flaws in the tort system. When Burgess talked about the success of caps in Texas, Obama swiftly parried: Tell that to McAllen, Texas. On top of all that, caps aren't going to happen; Congress, even when controlled by Republicans, has rejected them time and again.

But what Obama signaled to the AMA was an acknowledgment that this matters to them, and that he was willing to reach out and consider new solutions, not just recycle old partisan stalemates. Some were surprised. We weren't. When Tom Daschle spoke about health policy here at New America last year, we noted his openness to some kind of malpractice solution, possibly health courts. Presidential adviser Zeke Emanuel, a physician, addressed the AMA a few months ago in D.C. and told them he understood their concerns and that malpractice was part of the policy mix. Researching this post, we came across a New England Journal of Medicine essay dating back to 2006 jointly authored by no other than Obama and Hillary Clinton. They were working together in the Senate at the time on legislation that would use disclosure, apology, and settlement as an alternative to bitter litigation.

Health CEOs for Health Reform, a group we've been working with, wants a federal task force to move us toward a "safe harbor" for clinicians following best practices. (See page 12 of their white paper) A recent New England Journal of Medicine Perspective essay lists all of these options—safe harbors, health courts, disclosure programs—as worthy of consideration.

Obama said he wants to help doctors reduce liability and fear of lawsuits when "they haven't done anything wrong, where they perform effectively." He also wants someone who gets a surgical sponge left in their belly to have redress.

Overall, he told his town meeting, he believes that reforming our health care system "is the best way for you to keep the care you've got." Reforming the malpractice system may also be the best way for doctors to give us the care we need.

COST: Fixing the "Invisible Wiring"

Alex Mazerov — Thu, 02 Jul 2009 16:14:00 -0400

The nation’s largest health insurer says we can save well over $300 billion in the health care system over the next decade by streamlining administrative procedures and making better use of technology.

In a report released yesterday, UnitedHealth Group proposed twelve broad reforms to the administrative and transactional aspects of the U.S. health care system that it estimates can save $332 billion over 10 years.

Through twelve building blocks we identify administrative savings opportunities of $332 billion in national health expenditure over the next decade. These savings would be likely to benefit families and employers through lower health care costs. As importantly, they would simplify the lives of patients, and eliminate much frustration on the part of doctors and hospitals.

The proposed changes include more widespread use of automated swipe cards to validate patient benefits, elimination of paper checks and remittance advice (to be replaced with electronic systems), and creation of a national payment accuracy clearinghouse. The report, “Health Care Cost Containment—How Technology Can Cut Red Tape and Simplify Health Care Administration” also recommends using predictive modeling to pre-score insurance claims.

Simon Stevens, UnitedHealth’s executive vice president, said that these changes must be applied across the entire health care sector for maximum effect. From BNA:

Stevens said the administration of health represents the “invisible wiring” of the system and must be addressed as part of comprehensive reform. “Getting it right offers huge opportunities to simplify the experience that patients have every day when they interact with the system and to reduce a lot of the frustration that doctors, hospitals, and health plans all experience,” he said.

"Other sectors of the economy have mastered it long ago, and it's time for healthcare to catch up," Stevens told Reuters.

COST: Douglas Elmendorf and the Chamber of Secrets

Paul Testa — Thu, 02 Jul 2009 16:11:00 -0400

CBO scores are like Harry Potter books for policy wonks. Everyone makes a big fuss and works themselves up into a frenzy, only to do it all over again when the next one comes out.

The latest estimate from CBO puts the cost of the Senate HELP bill at $611.4 billion over ten years—a far cry from the preliminary estimates a few weeks ago that put the costs of reform over $1 trillion. (We told you they were preliminary.)

The biggest changes? The current estimate includes provisions for a public health insurance option and details on an employer mandate that were left out of the previous score. Politico has the letter from Senators Edward Kennedy and Chris Dodd to the rest of the HELP Committee members detailing the changes.

On the public plan, Kennedy and Dodd remain somewhat vague, describing it as a "national plan" available through Health Insurance Gateways with rates negotiated by HHS—all of which is keeping with the contours of the HELP public option leaked earlier this week.

On the employer mandate, the proposal would impose an annual fee on employers of $750 for each full-time worker not offered coverage and $375 for each part-time worker. Firms with fewer than 25 employees would be exempt. The CBO estimates the fees would generate about $52 billion over 10 years—which would help pay for subsidies for low-income individuals to purchase insurance. The fees would also prevent many employers from dropping coverage—a major issue from the preliminary estimate. In total, the CBO predicts the bill (in conjunction with measures under the Finance Committee's jurisdiction) would expand coverage to 97 percent of Americans.

With Senate Finance also making progress on its portion of legislation, the latest CBO score, at the very least, provides good optics and reassuring data (after that spell of mid-June sticker shock) as Congress returns to session after the July 4th break. It shows progress from a committee dedicated to expanding coverage while controlling costs. But provisions will change, and estimates will go up and down. A CBO score is not a magic wand, but a guiding light for reform. And right now, it seems Congress is pointed in the right direction.

QUALITY: IOM Panel Lists 100 Priorities for Comparative Effectiveness Research

Meredith Hughes — Wed, 01 Jul 2009 20:50:00 -0400

Earlier this week, we discussed the Federal Coordinating Council for Comparative Effectiveness Research's recommendations for comparative effectiveness research. Recently, an Institute of Medicine panel released a similar report, which offers a comprehensive list of 100 health issues ranked according to priority.

Comparative effectiveness research gives doctors and patients access to verified, scientific information on best treatments that they otherwise could only get through their best guesswork.

"Health care decisions too often are a matter of guesswork, because we lack good evidence to inform them," Dr. Harold C. Sox, a co-chairman on the panel and the editor of The Annals of Internal Medicine, told the New York Times. "For example, we spend a great deal on diagnostic tests for coronary heart disease in this country, but we lack sufficient evidence to determine which test is best," he added in a press release.

Here is a rundown of the some health issues that were flagged as top priorities for the Administration, specifically, the HHS:

Compare the effectiveness of treatment strategies for atrial fibrillation (the most common kind of abnormal heart rhythm) including surgery, catheter ablation, and pharmacologic treatment (aka drug therapy).
Compare the effectiveness of the different treatments (hearing aids, cochlear implants, or rehabilitation methods such as sign language) for hearing loss in children and adults, especially individuals with diverse cultural, language, medical, and developmental backgrounds.
Compare the effectiveness of various screening, prophylaxis, and treatment interventions in eradicating methicillin resistant Staphylococcus aureus (MRSA—a dangerous, common hospital acquired infection) in communities, institutions, and hospitals.
Compare the effectiveness of management strategies for localized prostate cancer (e.g., active surveillance, radical prostatectomy [conventional, robotic, and laparoscopic], and radiotherapy [conformal, brachytherapy, proton-beam, and intensity-modulated radiotherapy]) on survival, recurrence, side effects, quality of life, and costs.
Compare the effectiveness of various strategies (e.g., clinical interventions, selected social interventions [such as improving the built environment in communities and making healthy foods more available], combined clinical and social interventions) to prevent obesity, hypertension, diabetes, and heart disease in at-risk populations such as the urban poor and American Indians.
Compare the effectiveness of imaging technologies in diagnosing, staging, and monitoring patients with cancer including positron emission tomography (PET), magnetic resonance imaging (MRI), and computed tomography (CT).

Over at Gooznews.com, Merril Goozner pointed out a "sleeper" towards the top of the list, (number five to be precise)...

"Compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others."

Given that Congress will probably insert language in health care reform legislation stipulating no one should ever be bound to actually use the findings of comparative effectiveness research (why that's like EVIL BIG GOVERNMENT coming between YOU and YOUR DOCTOR), it's probably a good idea for someone to study how to "disseminate and translate" this information so that parts of the health care system might actually put it to use.

A summary of all 100 items is attached below.

HEALTH REFORM: Faith Based Groups: "America Can Do Better"

Paul Testa — Wed, 01 Jul 2009 20:34:00 -0400

Industry groups may be holding their ad fireworks until after the Fourth of July, but a coalition of a faith-based groups will take to the airwaves this Independence Day weekend with ads presenting health care reform as a moral and ethical imperative.

The spots will run in Arkansas, Colorado, Louisiana, Nebraska, and North Carolina (states which just happen to be home to potential swing senators like Ben Nelson and Mary Landrieu...). Sponsored by a coalition of religious groups, including PICO National Network, Faith in Public Life, Faithful America, Sojourners, Gamaliel, and Catholics in Alliance for the Common Good, the ads feature local preachers from each state. Using passages from Scripture, they argue that the status quo on health care is "not who we are as a nation" and that "America can do better." You can listen to ads here. Dan Gilgof, writing on U.S. News and World Report's God & Country, has the text of an ad to be run in North Carolina:

It's a vision first proclaimed by Isaiah: No more shall there be an infant that lives but a few days, or an old person who does not live out a lifetime.

This is Rev. Joe Harvard from Durham, and we've got work to do.

In North Carolina, people are being denied the care they need because of their age or an illness they had years ago. Or getting sick because they can't afford preventive care.

This is not who we are as a nation. America can do better.

The challenge is great, but God has not given us a spirit of fear, but of power and love. And our love must be a thing of action.

This Independence Day, join thousands of people of faith in asking Senators Hagan and Burr to rise to the challenge by supporting reform that makes quality health care choices affordable for all families.

Please add your voice, and learn more at www.coverallfamilies.org. Paid for by Faithful America.

In addition to the ads the groups are also calling on local pastors to hold health care Sabbaths and encourage measures of their congregations to call their congresspersons to urge them to support reform.

New America's Len Nichols has been one of the leading voices arguing that health care reform is a not just an economic necessity but also a moral imperative. In a recent essay, Len addresses the issues of stewardship and health care as they relate to the kind of society do we want to live. Showing the core definitions of society remain the same from Thomas Jefferson to Leviticus, Len asks:

What does the right to life mean if one does not also have access to known and widely available life-preserving and life-enhancing diagnoses and treatments? How can one meaningfully pursue any individual definition of happiness if one cannot afford essential care for a sick child, a breadwinner, or a disabled spouse or parent? In short, what is life and happiness without health?

To hear more on the moral case for reform check out this video below:

IN THE NEWS: Follow the White House's National Discussion on Health Reform

Paul Testa — Wed, 01 Jul 2009 16:43:00 -0400

We'll be tweeting President Obama's national discussion on on health care reform this afternoon at 1:15 pm EDT. Hosted at Northern Virginia Community College in Annandale, VA, the event will feature questions from an audience of about 200, as well as those submitted online via YouTube and Twitter. The White House is streaming the event live here, and you can follow our coverage on Twitter (tags: #WHHCQ #HCR), and read our wrap up of the discussion later today.

HEALTH REFORM: Wal-mart Supports Employer Mandates and Cost Control

Len Nichols — Wed, 01 Jul 2009 14:25:00 -0400

I applaud Wal-Mart's embrace of shared responsibility for health care financing and its support for an "employer mandate." Their recent letter (also signed by SEIU and CAP) to President Obama represents the kind of leadership we will need to finally achieve quality, affordable health care for every American.

As critical (if not more so) is their emphasis on cost control. Time and time again we reiterate that rising health care costs threaten not just households, but also employers and governments. To shore up our nation's fiscal future and sustainably finance reform, we must guarantee that health care reform will slow the rate of health care cost growth.

In their letter, Wal-Mart, SEIU, and CAP identify one possible solution outlined by former majority leaders Howard Baker, Tom Daschle, and Bob Dole. In addition, I would point you to the ideas put forth by Health CEOs for Health Reform at our recent event. Their paper, Aligning U.S. Health Care Incentives to Better Serve Patients and Taxpayers, not only calls for providers to be held to cost and quality standards by a specified date to achieve cost control goals, but also outlines a pathway toward high-value, coordinated care that will make patients healthier and save money.

Wal-Mart's support of the employer mandate proves rising health care costs are a serious threat to even the most efficient business models. Health CEOs for Health Reform's willingness to embrace provider accountability and move away from volume-driven, fee-for-service medicine proves it is possible to improve quality, while controlling the costs that hamper households, employers, and governments.

A successful health reform effort will demand extraordinary leadership from lawmakers, but it will also require forward-thinking support from key stakeholder constituencies. Wal-Mart should be congratulated and other business leaders should echo their call.

(PS. If you want to know more about Wal-Mart's path in terms of covering its own workers and looking for value in health care, read this February piece from the Washington Post.)

HEALTH REFORM: Wal-Mart Joins SEIU, CAP to Support Employer Mandate, Serious Cost Control

Health Policy — Tue, 30 Jun 2009 19:04:00 -0400

In the spirit of shared responsibility, Wal-Mart, the nation's largest employer, joined SEIU and the Center for American Progress to support an employer mandate to provide coverage if it is coupled with steps guaranteed to slow the rate of health care cost growth.

The letter to President Obama states clearly, "We are for shared responsibility...We are for an employer mandate which is fair and broad in its coverage." It also recognizes the varying ability of employers to contribute by saying, "Not every business can make the same contribution, but everyone must make some contribution."

Wal-Mart, SEIU, and CAP emphasize that "guaranteeing cost containment is essential," and express their support for one proposal to ensure savings put forth by the Bipartisan Policy Center to "implement pre-specified targets for spending growth and enact a ‘trigger' mechanism that automatically enforces reductions." A similar idea to "hold providers accountable to cost and quality standards at a specified date" was proposed by Health CEOs for Health Reform.

More on this announcement later. But for now it is encouraging to see Wal-Mart not only talking the talk, but walking the walk on shared responsibility for our health care goals.

HEALTH CARE: Stopping the Revolving Hospital Door

Joanne Kenen — Tue, 30 Jun 2009 18:45:00 -0400

Not a lot of aspects of U.S. health care still have the power to stun me, but when I first heard the statistics on U.S. hospital readmissions I was, well, stunned. I wrote about readmissions in today's Washington Post (in a collaboration with the new Kaiser Health News.) Readmissions is a pretty sprawling topic, but I think the reason it interested me so much is because it's a nexus of so much of what's wrong with our health care system. Errors of omission and commission. A system so complex and fragmented that we lose track of what the patient needs. Financial penalties (in some although not all cases) for hospitals that try to make things better.

For a Medicare patient who has been hospitalized, about one in five are rehospitalized in 30 days, one in three within 90 days. Within a year, two-thirds are either rehospitalized, or dead. For younger patients, the figures are better but not great. After all, don't we all have friends and family who have gotten out of the hospital and headed right back in again a week, two weeks, a month later?

Not every rehospitalization is unnecessary; people who have excellent care can still have setbacks. Diseases can and do progress. But a lot of these hospitalizations (some experts argue a majority of them) result from patients falling into one crack after another in our chronic care system.

Dozens if not hundreds of projects and initiatives are underway to reduce high readmissions rates. A few lessons have already emerged. For instance, Stephen Jencks, one of the experts I interviewed (he worked for Medicare for a long time and now consults for IHI) told me that one of the biggest factors is whether a patient sees his or her own physician outside the hospital quickly. (Finding out how many don't or can't get an appointment is another stunner). The quality of personal communication is also crucial. The Iowa "Teach Back" program I wrote about sounds so simple, but it actually takes careful effort over several days. The nurses make sure the patient understands what medicine he needs to take when he goes home from the hospital. Easier said than done. Patients who are groggy from their drugs, anxious because they are sick and in the hospital, in too much pain to concentrate or suffering from dementia or short-term memory deficits aren't going to understand complex directions. (Take the little orange pill four times a day on an empty stomach, take the big blue pill three times a day on a full stomach, take the pink pill as needed for pain, take the red pill before the pain starts, avoid grapefruit with the square white pill but have some yogurt to coat your stomach before the oblong white pill, take the little green one to help you sleep but don't take the big green one at night because it will keep you up...Add about a dozen more instructions for an elderly person with several chronic diseases, and call me in the morning). Teach Back is more complex than it sounds at first blush (and it can sound plenty daunting to nurses who are already overburdened by staffing shortages).

Relationships and self-care both seem to matter. The patients at Inova's Heartlink call in their health status, and they have to pay attention to their own bodies—their weight, their breathing, swelling in their limbs. (A relative can take this on if the patient is not well enough or not cognitively able to handle it). But the HeartLink nurse is keeping track. If someone doesn't call in, she notices and she'll check in. Some telephone-based disease management programs have not worked well. The Virginia program I wrote about is new, so their data is still quite preliminary and anecdotal. But it's also very encouraging. It's phone monitoring, but it's phone monitoring with a heart. The HeartLink nurse knows most of the patients in person, or she develops ongoing relationships over the phone. She isn't just a detached voice from out of town. Most of the HeartLink patients are treated by a small cardiology group that works closely with the high quality community hospital. Technically it isn't an "integrated" system, but the relationships—between doctor, nurse, patient and hospital—appear to work.

One last thought. As regular readers of this blog know, I've done a lot of writing on end of life and palliative care. Sometimes we send patients back to the hospital even though they might not really want to be there if their doctor had an honest conversation with them about the severity and likely course of their condition. At some point, even well-managed chronic diseases can become terminal diseases. Instead of going through the revolving door, back into ERs and ICUs, sometimes it is time, as nurse Honora Fowler noted, to have a conversation about palliative care or hospice. It can be hard. But the alternative can be harder.

QUALITY: Report Details Recommendations for CER Money in Stimulus

Meredith Hughes — Tue, 30 Jun 2009 18:31:00 -0400

Remember that $1.1 billion in the economic stimulus package (aka the American Recovery and Reinvestment Act) dedicated to comparative effectiveness research? Though many of us have had a lot on our minds lately with health care on the Hill, others have stayed focused on how to best use those stimulus funds. This week, the Federal Coordinating Council for Comparative Effectiveness Research, an independent advisory committee, released recommendations.

Comparative effectiveness research provides insight into the best treatments based on real world data. The Council's goal is to create a solid foundation of research that both patients and clinicians could use to inform their treatment decisions.

Health care is a large, diverse field, so the Council also had to come up with a framework for prioritizing research areas. To be considered, a research topic has to meet certain criteria:

Does it fit with the definition of CER?
Is it going to provide useful information to patients, clinicians, and stakeholders?
Does it respond to the needs expressed by patients, clinicians, and stakeholders?
Is it feasible to research? (Can we actually produce something valuable in a reasonable amount of time?)

High priority CER research topics had:

a large potential impact (looking into health conditions that are particularly widespread, burdensome, or costly)
high variability or uncertainty in clinical practice
the potential to positively effect diverse and/or large populations (priority populations include racial and ethnic minorities, persons with disabilities, persons with multiple chronic conditions (including co-existing mental illness), the elderly, and children)
the potential to lay a strong foundation and get the ball rolling on future research
the potential to affect areas that other organizations are unlikely to address

According to the report, "the primary investment for this funding should be data infrastructure. Data infrastructure could include linking current data sources to enable answering CER questions, development of distributed electronic data networks and patient registries, and partnerships with the private sector."

The Council's recommendations are directed specifically at the Office of the Secretary of HHS. The Council expects the Agency for Healthcare Research and Quality (AHRQ), which received $300 million of the $1.1 billion, and the National Institutes of Health (NIH), which received $400 million, to fill in the gaps in translating and distributing the findings of CER to the right places. Thus "dissemination and translation of CER findings, priority populations, and priority types of interventions" are a secondary priority for CER investment.

The Council prioritized transparency and public input in their recommendations; they held numerous public listening sessions, collected feedback through their website, and heard testimony from doctors, patients, and stakeholders.

The full report is available here.