Health Reform

HEALTH CARE: In Case You Get Tired Of Football Over Thanksgiving....

Joanne Kenen — Tue, 24 Nov 2009 21:17:00 -0500

We finally had a chance to see the documentary Money-Driven Medicine the other day, and you can download it here, or check out screenings (some sponsored by Consumers Union). It's based on a book of the same name by Maggie Mahar, who blogs over at the Century Foundation's Healthbeat.

For us, the most moving part of the film was probably the story of Brianna Weinstein, who was diagnosed with leukemia as a toddler and died at age 12. Her father is Dr. Jim Weinstein, who now heads the Dartmouth Institute for Health Policy and Clinical Practice. He wasn't focused so much on the "money-driven" aspect of her care as the imbalance in decision-making. It was bad enough to watch her endure so much painful treatment during her too-short life, but he also felt many of the choices were out of the family's hands. Even though he is a doctor and understood what was at stake. At one point, her oncology team threatened to sue the Weinsteins if they didn't do exactly what the doctors ordered. She died in the late 1990s. There's been some discussion since then about patient autonomy and patient-doctor relationships, and there's also been some effort to improve oncologist-patient communication. But certainly we have not yet learned how to best help patients through decision-making, particularly when the decisions are not so clear, the science not so certain. It's easy to know that an appendix has to come out. It's not so easy to know which of several complex (and possibly experimental) cancer protocols are best. Much of Weinstein's own work now focuses on how to create better ways of having doctors and patients (and families) share in informed decision-making. We've written about it before, and expect to write more in the foreseeable future.

More about Weinstein in an interesting article Mahar wrote for a Dartmouth publication.

HEALTH REFORM: Four Goals for "Dysfunctional, Disorganized and Wasteful" System

Joanne Kenen — Tue, 24 Nov 2009 18:20:00 -0500

Dr. Jack Wennberg, the father of the Dartmouth Atlas, and Shannon Brownlee, the author of Overtreated and a New America colleague, recently posted on the Health Affairs blog, recapping four major goals for repairing the "dysfunctional, disorganized, and wasteful delivery system."

1. Improve the science of health care delivery.

The stimulus package boosted comparative effectiveness research, and the health reform bills in Congress would build on that. But studying effectiveness of treatments, in isolation, isn't enough, they argue. We also need to develop a "science of health care delivery" which they call a "black box." Patients with similar conditions are treated in very different ways and we aren't doing the necessary research into how to best to allocate resources and deliver the most effective care.

2. Foster the expansion of organized systems of care.

These new systems, often described as Accountable Care Organizations, would reward providers that show they can be efficient and use resources judiciously -- while delivering high quality care. Shared savings (giving providers a portion of the savings during a transition period) gives the providers an incentive to bring down costs.

3. Informed patient choice (rather than informed consent) should become the standard of care.

Patients facing elective surgeries, tests, and procedures often don't understand exactly what they are consenting to -- or what options they may have.This can lead to higher costs when they get treatment that they may not have chosen (ie surgery instead of giving physical therapy a chance), and it may encourage malpractice suits. Shared decisionmaking could reduce unwanted care, they write, but to make this the norm providers need to be paid for the time and tools they employ. (Medical homes, the authors write, are a good payment fit for informed choice.)

4. Constraining the undisciplined growth in health care capacity and spending.

The health reform bills get most of their CBO-scored savings from cutting provider payments. But Wennberg and Brownlee content that these equal-opportunity cuts (no distinction between high quality efficient hospitals and the most wasteful ones) is a lost opportunity. They would like to see Medicare's payment clout employed to "encourage slower spending growth and greater accountability." Those who demonstrate high quality and cost accountability should be eligible for bonuses, and those that fail to restrain excess spending should face penalties (nick the payment "updates"). That would save some money in the near term but "but more importantly, it would serve as a signal that Medicare is serious about reducing future spending growth." Alternatively, payment updates could be reduced in a high-cost growth region, discouraging the "local medical arms races" that add to excess utilization and skyrocketing costs.They write:

Either way, reducing updates to high-growth regions or specific providers should discourage the easy flow of money from bond and equity markets for hospital expansion, and could spur the most inefficient providers to participate in ACOs and other shared savings programs. The key here is encouraging local providers to consider how to slow -- or even reduce -- local spending on unnecessary care. Some communities that have successfully held down costs did so by merging hospitals and eliminating unneeded capacity.

Wennberg et al also weighed in on the controversy (some emanating from University of Pennsylvania's Richard Cooper) over whether the vast Dartmouth Atlas research into geographic variation in Medicare spending adequately took health status into account, ie did the "high spending" hospitals spend more because their patients were poorer and sicker, or because they were less efficient. Wennberg and Brownlee post data showing that even in apples-to-apples comparisons (ie looking at academic medical centers in poor, urban, black communities, or even at two academic medical centers in the same community) the variations persist. Kaiser Health News recently wrote about Cooper, the controversy he engenders, and other health policy experts' assessment.

HEALTH REFORM: Polls Holding Steady Into Thanksgiving Break

Meredith Hughes — Tue, 24 Nov 2009 18:10:00 -0500

The latest Kaiser Health Tracking Poll is in, and the health care reform approval numbers are holding pretty steady. Slightly more people than last month, 54 percent, believe the country will be better off if health reform passes. And 42 percent -- an improvement from earlier this year -- believe that health reform will personally benefit them or their families.

The number who believe health reform will hurt them (24 percent) or the country (27 percent) is down slightly from last month. Roughly the same one-in-four don't think health reform will affect them. Democrats and Independents are more likely than Republicans to view health reform as positive. However, when asked about specific provisions in the health care bills, a majority ranked as "extremely" or "very" important these components of reform: affordable, available health insurance, coverage for people with pre-existing conditions, providing subsidies to help the uninsured purchase coverage, requiring all Americans to have health insurance, filling the Medicare donut hole, and not adding to the U.S. budget deficit.

The Robert Wood Johnson Foundation Health Care Consumer Confidence Index (RWJF Index) found that Americans' confidence in their health insurance coverage and access to care increased in October, from 96.6 in September to 104.4 points.

The Kaiser tracking poll also asked Americans about health reform financing options, including a tax on high income earners, or a "Cadillac tax" on high value health plans. A near majority of Americans, 47 percent, strongly favor the tax increase for high income individuals and families (like the one found in the House bill), while 29 percent strongly support the Cadillac tax.

The poll also revealed the ongoing problems Americans face in accessing affordable care during economic hard times. In the past year, a majority of Americans (53 percent) reported putting off care because of cost. According to the RWJF index, 20.6 percent of Americans reported difficulty in paying their health care bills.

For more detailed analysis of what polling data means for health reform, check out our earlier posts.

HEALTH REFORM: Dialysis Done Right

Allison Levy — Mon, 23 Nov 2009 21:30:00 -0500

Medicare hasn't put the finishing touches on its new dialysis reimbursement policy quite yet (you have until December 16 to get your comments in) -- but has decided to invest in educating the public on various dialysis treatment options. It's part of a longer term effort to give patients more of a say in managing their chronic diseases, and in changing some of the inefficient ways Medicare pays for kidney care.

More than 350,000 Medicare patients with end stage renal disease undergo dialysis. Most patients undergo out-patient treatment three times per week at either an independent or hospital based facility -- in the United States, fewer than a tenth are treated at home. (Rita Rubin of USA Today notes that three treatments per week is the standard not necessarily because it is "optimal but because that's the way it has been done for nearly four decades.")

But Medicare's education campaign will help patients make more informed decisions about where and how often they are treated.

"These education sessions will provide patients with chronic kidney disease information they need to understand their treatment options and participate in better management of their own care," Dr. James Sloand, senior medical direct of Baxter's North American renal business, told the Chicago Tribune recently. "This program empowers individuals to take measures to slow the progression of their kidney failure."

One option, as Bruce Japsen explained in that Tribune story, is for more patients to get dialysis at home. It's less expensive -- and research suggests that it is more effective as patients can "dialyze" more frequently, for longer periods of time and on their own schedule.

As Japsen explains, reimbursement for dialysis is complicated by Medicare's current payment structure, a "prospective payment system known as the basic case-mix adjusted composite payment system." In case you need a translation -- dialysis outpatient facilities bill Medicare for the routine dialysis service separately from some injectable medications and non-routine laboratory tests. These separately billable items account for 40 percent of total Medicare payment per dialysis treatment -- and are billed on a fee-for-service basis.

But, in September, the Centers for Medicare and Medicaid Services released a proposed rule to change that. Beginning January 1 of 2011, Medicare will "bundle" all the routine dialysis outpatient care -- the dialysis itself, the drugs and those lab tests -- into a single base payment (around $200 but adjusted for location and patient characteristics). (Look at this presentation for more specific details.)

Since 1972, the government has financed dialysis treatment regardless of the ESRD patient's age -- it cost an annual $10,000 per dialysis patient then, and more than $73,000 now. But Medicare believes that by bundling the payment, unnecessary medications will be eliminated and patients will receive efficient, quality and patient-centered care.

"Combining a fully bundled prospective payment system with required performance standards would encourage facilities to operate more efficiently and ensure that beneficiaries receive high quality care, while saving dollars for both beneficiaries and the Medicare program," said Jonathan Blum, director of the agency's Center for Medicare Management. (Here is another recent post about another form of bundled payment.) Not only will patients receive efficient and high quality care -- but they will be able to make an informed choice concerning the treatment option that works best for them.

HEALTH POLITICS: Senate Dems Not Giving Up On A Bipartisan Bill

Meredith Hughes — Mon, 23 Nov 2009 20:33:00 -0500

Maine's Republican Senators Susan Collins and Olympia Snowe both voted with fellow Republicans Saturday against the Democratic bid to bring health reform legislation to the Senate floor. Yet both are moderates who have broken with their party in the past, and both have signaled they would consider voting for the health bill -- if Democrats change it enough, reports The New York Times. Collins told the Times,

I have ruled out voting for this bill, but I still very much want to vote for a bill and that is why I am continuing to have discussions. I still cling to the belief that it is possible for a group of us to come together and rewrite the bill in a way that would cause it to have greater support.

Everyone was pretty excited when Senator Snowe decided to vote for Senate Finance chairman Max Baucus's version of a health care reform bill. Yet at the time, Senator Snowe warned her colleagues loudly and clearly that her vote to get that bill out of committee didn't assure her vote on final passage.

Since then, several moderate Senators expressed similar sentiments -- Ben Nelson (D-NE), Mary Landrieu (D-LA), Blanche Lincoln (D-AR), and Joe Lieberman (I-CT) voted to move ahead with debate but have made it quite clear they aren't entirely happy with the bill. Like Lieberman, Snowe is concerned about including the much debated public option. Collins worries the Senate bill does not go far enough in lowering health care costs and providing coverage.

In their remarks on the Senate floor this past weekend, neither Snowe nor Collins endorsed the bill, but they did not engage in the same line of anti-health reform attacks as other Republicans. According to the Times,

Both senators have talked privately with Democrats and independents about devising joint amendments on areas like cost control, and both said they would keep seeking compromises. Ms. Snowe said that would "be a true test of whether there is a will to improve this legislation in a non-ideological, bipartisan manner.

In the race to get to 60 votes on the Senate floor, every vote counts. With just a few moderate Democrats (and Independents) on the fence about health reform legislation, Senate Majority Leader Harry Reid might really need the support of moderate Republicans like Snowe and Collins to get final bill passed. Reid told the Times he isn't giving up on a bipartisan bill,

We reach out to our Republican colleagues, and we would like to work with them. But everyone should understand we're going to do a bill. We hope that we don't have to do it with Democrats, but if we have to, we will.

HEALTH POLITICS: Money, Money, Money, Money

Joanne Kenen — Mon, 23 Nov 2009 18:31:00 -0500

The Washington Post ran an interesting chart about how senators voted on Saturday. It included the uninsurance rate back home, and the health industry contributions they have received (although it wasn't clear either there, or on OpenSecrets.org exactly how this particular chart defines the health industry -- and of course some sectors of the health industry favor reform). But no matter how you look at the relationships between the votes and those numbers, it did come down -- no surprise, unfortunately -- to a party line vote.

USA Today also has a piece on the massive amount of lobbying money being spent on the health care battle. It seems that just about everybody has hired a lobbyist, and the total cost exceeded $422 million during the first nine months of 2009. The paper also has a useful run down of what four provider groups (doctors, hospitals, drug companies and insurers) and four health insurance purchasers or consumers (employers, the insured, seniors, and the uninsured) stand to win and lose under current versions of the legislation.

HEALTH REFORM: One Hurdle Down, Many More To Go

Joanne Kenen — Mon, 23 Nov 2009 13:48:00 -0500

"A Motion to Invoke Cloture on the Motion to Proceed" seems like a pretty obscure way to start the Thanksgiving holiday festivities, but we'll take our victories where we can get them.

We all know the obstacles remaining -- from a (abortion) to z ( we couldn't think of a really great Z on Monday morning -- Xanax only sounds like a Z. For now we'll settle for Zocor as a placeholder for more fights on pharmaceutical pricing). But a supermajority of the United States Senate has agreed to begin the historic debate on health care reform after the holidays. And that's an achievement which gets us closer to another achievement.

We're not going to rehash everything in the weekend papers, because we expect that a ridiculous proportion of our readers were either watching the vote on C-Span or at least tracking it on their Blackberries. But a few good links to point you to:

At the Treatment, Harold Pollack writes on the absurdity of listening to Republicans complain that the Democratic health care bill is too skimpy in its help for the poor.

One says that the program is too stingy. He recounts a heartrending tale of seriously-ill Texas children going without needed care because pediatric specialists would not take low Medicaid reimbursement rates. Another notes disparities in neonatal mortality between Medicaid and private insurance patients. "Care delayed is care denied," he intoned to great effect. A third laments that poor people will be consigned to the "medical Gulag" of Medicaid. A fourth suggests that the only reason poor people are made eligible for Medicaid rather than for private coverage is to make the CBO numbers look better.

Maybe not quite Dada-esque, and unfortunately the bottom line is too serious for Monty Python.

At the Boston Globe, Lisa Wangsness has a reasonably upbeat assessment of the changes of compromise on the public option. It's obviously still a big hurdle, but as Ohio Democrat Sherrod Brown noted, there is a lot of support in the Democratic party -- and in the country as a whole -- for inclusion of some form of a public option.

At the Health Affairs blog, law professor Tim Jost has several posts giving a good strong summary of what the Senate bill does and doesn't do.

A lot of ink over the weekend on Blanche Lincoln. This piece from the LA Times offers a good look at what Lincoln is facing back home a year before she faces the voters for re-election. The Washington Post's Dana Milbank also weighed in, noting that the Senate debate had a bit of Southern Gothic/Tennessee Williams flavor to it... down to a leading role played by a Southern woman named Blanche...

HEALTH REFORM: The Cost of Doing Nothing... Part 984,039,825

Allison Levy — Fri, 20 Nov 2009 21:49:00 -0500

As we have discussed several times, doing nothing is simply not an option. We need to reform our health care system -- not despite our economic crisis, but because of the significant impact health care has on U.S. workers and businesses.

In an article for the Washington Post this morning, Peter Orszag, Director of the Office of Management and Budget, stresses that "as we enter the homestretch, the greatest risk we run is not completing health reform and letting this chance to lay a new foundation for our economy and our country pass us by."

He states that if we do not do anything to slow the rising cost of health care, the federal government will end up spending more on Medicare and Medicaid than all other government programs combined. And our country could not afford to let that happen.

We have established that the cost of doing nothing is high, yet, as Orszag notes, some still have their reserves. These are the people wondering whether it is truly possible to achieve comprehensive health reform in a fiscally responsible and sustainable manner.

But just in time for the Senate vote, Orszag takes the time to explain why in fact we do not need to fear the fiscal impact of health reform.

First, he emphasizes that the nonpartisan Congressional Budget Office has concluded that both the House and Senate bill would reduce the nation's deficit over the next ten years (and by more in the following decade). And the CBO's analyses, he stresses, are "based on hard, tangible savings -- not on the harder-to-quantify, yet very real steps that hold the most promise of transforming health care." This is good news.

What should also come as good news is this letter to President Obama. And the fact that the four elements that this group of 23 economists (consisting of Republicans, Democrats, former Bush administration officials and Nobel laureates) believe are absolutely critical to keeping the cost of health care under control -- can all be found within the pages of the legislation currently being reviewed.

The economists argue that responsible health reform legislation must include deficit neutrality, an excise tax on high-cost insurance plans, an independent Medicare commission and delivery system reforms:

Including these four elements ... will reduce long-term deficits, improve the quality of care, and put the nation on a firm fiscal footing. It will help transform the health care system from delivering too much care, to a system that consistently delivers higher-quality, high-value care. The projected increases in federal budget deficits, along with concerns about the value of the health care that Americans receive, make it particularly important to enact fiscally responsible and quality improving health reform now.

To all of you losing sleep over the impact of health reform on our budget -- rest easy tonight.

HEALTH POLITICS: Everybody's Working For The Weekend

Meredith Hughes — Fri, 20 Nov 2009 18:28:00 -0500

Or, at least, the Senate will be working this weekend. The Senate plans a rare Saturday night vote on a motion to proceed with Senate Majority Leader Harry Reid's $848 billion health care reform bill, released earlier this week. The pressure is on for Senate Democrats, who need 60 votes to ensure the bill makes it to the floor to begin debate.

Reid melded the Senate Finance and HELP committee's reform bills, but his "deep personal involvement in assembling the overhaul of the health care system," makes it "Reid's bill," writes Carl Hulse in The New York Times. If Reid successfully guides the health care reform bill through the Senate, it could be the biggest victory his career, and a huge boon for Obama and the Democratic Party, writes Hulse, but if he fails, it could mean disaster for the Democrats and an even tougher re-election battle for Reid in his home state of Nevada. Many Democrats expressed faith in Reid's skills as a legislator and a tactician, according to the Times,

Colleagues say Mr. Reid's extensive knowledge of Senate tactics and well-honed understanding of what drives and divides his Democratic colleagues leave him well positioned to pull off a legislative coup that has eluded seasoned and determined lawmakers for decades.

"I don't think there are many people in the whole world other than Harry Reid who could do this," said Senator Mary L. Landrieu, Democrat of Louisiana.

Landrieu however is one of three Democratic centrists who Reid is still wooing, along with Ben Nelson (D-NE) and Blanche Lincoln (D-AR). Moderates cite concerns about the cost to states and the abortion language. Nelson has now said he will vote with Reid on the first procedural motion. Lincoln told Reid her plans, but hasn't made them public. But as CongressDaily noted,

...the fact that Democrats aren't backing away from the weekend vote suggests that Lincoln has accepted the argument from leaders that Democrats should vote to move the bill, even if they oppose it and might vote against it in the end.

As we've mentioned before, Senator Joe Lieberman (I-CT) has threatened to block the final bill if it contains a public health insurance option. But for now he's agreed to vote with Democrats to get the debate started.

Reid even struck up a compromise of sorts with Republican opponents. According to Politico, Republicans agreed not to read the 2,074 page health reform bill out loud in its entirety. Instead, Reid offered them a full day of debate on Saturday before the evening vote. That means that everyone (even us!) gets a chance to head home for Thanksgiving.

Earlier this week, top Democratic strategists, such as pollsters Mark Mellman and Geoff Garin, White House communications director Dan Pfeiffer and White House deputy chief of staff Jim Messina, met with Senate Democrats to discuss the importance of health reform, reports TIME. Mellman urged senators to remember they are all in this together. A victory on health reform is important to the American people who are struggling with health care cost and coverage. But it's also important to the president's agenda and the Democratic Party's success in the upcoming midterm elections, said Mellman. Health reform wasn't the only element in the deep and wide Democratic losses following President Clinton's failure to pass health reform in 1994, but it was a big factor.

The battle could get uglier as the health reform bill moves through the Senate, but for now it looks like the Democrats are ready to get started on this debate. Time to make history. Time to make progress.

HEALTH POLITICS: A Fresh Look at Malpractice

Joanne Kenen — Fri, 20 Nov 2009 16:46:00 -0500

Over the past year or so, we began detecting some subtle changes in how Democrats were talking about malpractice. They weren't embracing the Republican tort reform agenda, weren't about to start limiting damages and saying "Sorry Charlie" to people who had suffered heartbreaking harm. But they weren't just changing the subject either. They were recognizing a problem, and considering solutions. Liability problems as well as larger obstacles to addressing serious patient safety problems.

We posted about it a few times (here and here). I started reading more about it, and I started talking (and listening) to what doctors had to say. Not just lobbyists for doctors, but doctors. Including some progressive docs in primary care who favor health reform or a single payer system. I have a piece online in American Prospect today, outlining some alternatives to traditional malpractice lawsuits that are worth trying. (Not to replace the current court system, but to test alternatives. And while we test alternative dispute resolution or other approaches, it should be voluntary.) One of my conclusions was that malpractice is getting in the way of all sorts of other things we need to do to fix our system. Getting in the way politically and economically. And getting in the way of some of the changes we need to make to create a system that is safer, evidence-based, and less wasteful. Some doctors will resist changes to the system -- because change is hard, or change is something that they don't think applies to them, or, for some doctors in some settings, change can sock them in the wallet. Getting the malpractice piece out of the way, or at least minimizing it a bit, may remove the legal smokescreens and let us get to the heart of the change resistance.

The CBO recently did its first estimate on the price of defensive medicine. I left out that figure from this article because it was based quite specifically on potential savings from Republican legislation ($11 billion a year). I don't think there is an agreed upon overall estimate that defensive medicine in the current system costs -- to federal health programs, the privately-insured, the doctors. But for readers who want a summary of some of the recent literature on this, Factcheck.org has a good wrap.

The approaches I mentioned -- health courts, "disclose and apologize" and certificates of merit -- aren't the only ideas floating around. As we do more comparative effectiveness research, and learn more about what doctors should be doing and why or why not, we may be able to weave more "safe harbors" into the legal system. Right now, as all the current confusion about prostate screenings and mammograms illustrates, we still have a lot of trouble agreeing on and comprehending best practices.

In the near future, we're going to post a bit more on patient safety (which we wrote about the other day) and have a bit more to say on the AMA's evolving views on malpractice and health reform. For now, we're going back to watching the Senate....