New Health Dialogue

IN THE STATES: San Francisco's Ride on the Health Reform Trolley

Paul Testa — Thu, 03 Jul 2008 16:54:00 -0400

Rice-A-Roni may be the San Francisco treat, but health reform has been the topic du jour of late for the Bay City. As the San Francisco Chronicle noted, yesterday marked the one-year anniversary of Healthy San Francisco—the city’s ambitious plan to make health care accessible and affordable to its uninsured residents.

Like a cable car descending Nob Hill, there have been a few bumps along the way—the growing pains health reform—as well as uncertaintity because of a pending decision from the Ninth Circuit regarding the legality of the city’s efforts. Still, the plan is an innovative effort from one of the cities described in a recent Families USA report as being on the front lines of America’s health care crisis.

The key elements of San Francisco’s plan are laid out nicely here, but we’d like to highlight two points from the initiative:

An emphasis on medical homes in which a participant chooses one of 27 participating clinics to coordinate their care.
Shared and individual responsibility represented by income-based cost-sharing on the part of individuals and an employer contribution for firms with more than 20 employees.

New America health policy program director Len Nichols provided a positive and realistic assessment of the plan for the Chronicle article:

For a city to try to do it at all is pretty amazing. Ultimately, we're going to need federal help to make health care access a reality in this nation, and it's impressive San Francisco is trying to do it in whatever patchwork way they can.

REFORM: Watch Out Harry and Louise, Here Comes Elizabeth

Joanne Kenen — Thu, 03 Jul 2008 16:38:00 -0400

Harry and Louise, watch out for Elizabeth Edwards.

The New York Times politics blog reports that Health Care for America Now, a coalition of labor, health care and liberal organizations pushing for comprehensive health reform, will roll out a new television commercial next Tuesday, part of what the group says is a $40 million planned campaign to promote affordable health care under the next administration. The idea is to have a pro-reform media message as powerful as the insurance industry's Harry and Louise ads were in fighting health reform when Bill Clinton was president.

Elizabeth Edwards, breast cancer patient, wife of former Democratic Sen. John Edwards, health policy blogger and visible proponent of health reform, will speak at the group's inaugural event in Washington next week.

The Times reported that after the initial buy of $1.5 million for national television, print and online advertisements, the coalition plans to pour $25 million into additional advertising. The first commercial will run in national newspapers, on CNN and MSNBC and online.

We expect to see lots of ads battling back and forth as the issue heats up. It's an election year, so we realize that things will get rather heated. Here at New America, we're still hoping that both sides don't get so caught up in the politics that, whoever is in the White House next January, they can't sit down and start working together for sustainable solutions that will help all Americans get the health care they need in a way our country can afford.

COVERAGE: Living on a Prayer

Len Nichols — Thu, 03 Jul 2008 14:35:00 -0400

If a pastor gets sick, given a choice between "a wing and a prayer" or "a wing and a prayer and health insurance," he or she would probably choose the second option—if it's available.

A recent survey by the National Association of Evangelicals found that the churches and related evangelical organizations are having the same challenges as other Americans, and jerry-rigging some of the same partial solutions. But significant numbers of pastors—the format of the NAE's survey wasn't designed to produce a precise estimate—go uninsured. Others get their coverage through their spouse's job, or by holding down a second job outside their church that gives them access to coverage. Those over 65 can get Medicare. Some are poor enough to qualify for Medicaid. Young pastors who are relatively healthy sometimes opt to get a private policy instead of buying into a church or denomination-sponsored plan, meaning the bills go up for the older and sicker.

"Only a few of our churches are adequately addressing this problem," one denominational leader was quoted as saying in an NAE report. "We tried two or three items to provide health insurance, but we have not been able to make it work," lamented another.

"This is a large and growing problem for American pastors and churches,' said Leith Anderson, NAE president, "So many churches are small and too many pastors are uninsured. There is no room in limited budgets for premiums or no way to get adequate insurance at any price. As clergy age with the rest of America's population, we may see a growing list of pastors entering retirement with bankrupting medical bills."

The NAE has been instrumental in cultivating support within the Christian community for addressing global warming and issues of environmental sustainability more generally. We have hope they might someday come to play a similar role in broadening support for a more sustainable health care system that works for all. I was in West Virginia last week for a series of meetings coordinated by the West Virginia Council of Churches. Evangelical churches are not part of the Council there, but representatives from their community did come and participate in two of the meetings in Charleston. Let's just say we all learned a lot, and hope and expect to continue dialogue about what Scripture has taught us ought to be and what health policy analysis has taught us can be.

COST: Weighing in on the Value of CT Scans

Guy Clifton M.D. — Wed, 02 Jul 2008 20:39:00 -0400

Sunday's New York Times's article, the first in a series on evidence-based medicine, got me thinking about how we set standards for the practice of medicine, and what it will take to get doctors to follow voluntary ones.

The extensive front-page article examed the prevalence and value of computed tomography (CT) angiography. In brief, CT scanners can generate a complete image of the heart (see NBC's Matt Lauer's here and Oprah Winfrey’s here).The technology is impressive. So is the price. A CT scanner costs about $1 million. Doctors and hospitals that make the investment have a large incentive to recoup their costs by ordering CT scans, ($500-$1,500 a test). In some specific circumstances, CT angiography provides more information than other heart studies. The Times noted certain situations in an emergency room where it could be highly useful. But in most circumstances it is more like a screening tool to search for hardening of the arteries. But the CT scan doesn't say whether someone needs the blockages opened. That has to be determined by coronary angiography, placing a catheter through a vessel in the groin and then threading it up to the heart. That's an invasive procedure that provides necessary details on the exact location and extent of blockages.

The question raised in this article is, "What is the value of CT angiography of the heart as screening tool for heart disease?" How many people have no symptoms of heart disease but have some risk of developing it? Almost any adult. With the possibilities for using the imaging technology virtually unlimited, how do we set limits? Don't assume Medicare will. As the Times noted, Medicare did say last year that it wanted more evidence before paying for these scans, but backed off after extensive lobbying of the agency and Congress by cardiology groups.

Some of the cardiologists in the Times article describe detecting lesions that they otherwise might not have discovered; others, more critical of the spreading technology, countered that they hae other tools to monitor and diagnose their patients. The American College of Cardiology has established some general guidelines for the use of CT angiography of the heart based upon the limited information that is available. The use of CT angiography to detect heart disease in patients with low risk for heart disease is considered "inappropriate". Its use to detect heart disease in patients without symptoms who are at high risk (such as those with high cholesterol and a family history) is of "uncertain" value.

One risk of this procedure is that the level of radiation delivered has a cumulative effect on a patient's risk of cancer. Another is that it can give either false positive or false negative results leading to either unnecessary additional procedures or a potentially dangerous sense of false security. Therefore, the American College of Cardiology considers its use "appropriate" under only very specific circumstances.

These and other guidelines like them are issued by organizations, but an individual doctor's adherence to them is neither measured nor reported. Such guidelines, therefore, have almost no impact on medical practice and pretty clearly have not influenced the debate over the use of this technology.

Not surprisingly, the article generated a rash of responses almost all of them decidedly critical of the current environment in which CT scans are used. The Health Care Blog picked up on an especially interesting section of the article, in which a Dr. Harvey Hetch responded to criticism of his decision to order a CT angiography saying: "it's incumbent on the community to dispense with the need for evidence-based medicine. Thousands of people are dying unnecessarily."

The irony of Dr. Hecht's words is that the opposite is more likely true. I would say that the lack of measured and reported standards of medical practice kills people. The adherence to evidence-based standards of practice could saves lives and a lot of money.

As it is now, a patient that goes to a doctor has only about a 55 percent chance of receiving treatments that are the standard of care.

We in medicine must know what care our patients need -- and then we must provide it. We shuld not provide unneeded care. Thinking about coronary CT scans, and medical innovation in general, raises the following issues:

What is the relative weight of risk to benefit of new technology in specific patient groups?
Since no agency or company is required to determine the value of new technology, only its safety, who should do it?
Doctors can use new technology as they wish, even if they profit from ownership of the equipment. Should use of new technology be restricted to circumstances in which its benefit is proven?
If there were reliable standards for the use of technology such as CT angiography, who will measure the pattern of a doctor's practice to determine if he or she is practicing mostly within standards or far outside of them?

As a neurosurgeon, I do not want to impede the development of new technology. I have seen what technological breakthroughs have done for patients. But appropriate assessment and use are not impediments. They serve to protect the public.

REFORM: Fixing Medicare Could Help Us All

Joanne Kenen — Wed, 02 Jul 2008 20:32:00 -0400

We all know Medicare has problems. What you may not know is that we really do know a fair amount about how to fix it—and part of the solution has to do with changing the kind of medicine we use to take care of our over-65 population. Inside E Street, an AARP television production, (click here to watch—and you don't have to be 50 to learn something from it) invited several experts including New America's health policy program director Len Nichols to brainstorm.

Among the suggestions: use technology not only to keep better medical records that help doctors coordinate care across several specialists, but also to take better care of people at home. We have the means—and we'll develop more in coming years—to monitor people at home, and know when and how to intervene before a crisis develops in a patient with conditions like diabetes or congestive heart failure.

Len reminds us that Medicare can be a catalyst because the program has so much influence over the whole health sector. So fixing Medicare is good for all of us—not just because of the economic implications but because by getting care right for the elderly we can probably improve health for us all.

REFORM: Kennedy Spurs Bipartisan Conversations about Health Legislation

Joanne Kenen — Wed, 02 Jul 2008 17:10:00 -0400

We perk up when we hear phrases like "bipartisan support for a major healthcare initiative," especially when the bipartisan push is coming from Senator Edward Kennedy. Today's Boston Globe reports that while Kennedy recuperates from his brain tumor surgery, his office has begun a series of bipartisan meetings with an array of health care specialists to prepare for a major push to cover all Americans when the new president takes office next year. The paper reported:

Those involved in the discussions said Kennedy believes it is extremely important to move as quickly as possible on overhauling the healthcare system after the next president takes office in January in order to capitalize on the momentum behind a new administration.

Kennedy is chairman of the Senate Health, Education, Labor and Pensions Committee; Obama is a member, and his Senate staff has attended the roundtable discussions, the Globe reported. But Republican staff is also involved, as Kennedy tries to identify areas of agreement, possible starting points. Kennedy has made health care a signature issue in his 45 years in the Senate, and even before his aggressive brain cancer was diagnosed he made no secret that he wants to seize the moment and act next year.

"You have got to think this will be the Ted Kennedy Health Reform Act, because he's a beloved figure and he's championed the issue for so long," said John Rother, policy director for the AARP, which has been involved in the discussions. "There are a lot of unknowns right now, but what we do know obviously is he is very close to Obama, and he also has quite a network of health policy experts that he can draw from."

The newspaper reported that Kennedy's aides have also been working with a network of Massachusetts advisers, talking about ways the state's health program could possibly be adapted to a national model.

The many lessons of the 1993–94 health care reform debacle include that it was too partisan, and that the Clinton White House did not involve Congress enough in developing its plan. Kennedy is not alone in trying to do things differently this time. The Senate Finance Committee, chaired by Montana Democrat Max Baucus, in June held a day-long bipartisan summit on health reform. Oregon Democrat Ron Wyden and Utah Republican Bob Bennett have a health reform proposal that has attracted bipartisan interest. Various nonprofit groups are running bipartisan programs to help congressional staff better understand the challenges of health care reform. We know from our conversations with people around Washington that there really is a desire to do things differently this time, so we're thrilled to see Kennedy make this a priority for his country, even as he confronts his own health ordeal.

QUALITY: Pharmacy Bar Codes Aren't As Smart As They Look

Joanne Kenen — Tue, 01 Jul 2008 17:31:00 -0400

Bar codes on medication have been hailed as a remedy for drug errors in hospitals. Medication errors are not a small problem; the Institute of Medicine in 2006 estimated that at least 400,000 preventable medication mistakes occurred annually in U.S. hospitals, leading to about 9,000 deaths and $3.5 billion in extra cost. About one-third of U.S. hospitals now use bar codes to track medications and match up patients and their medicine. Most other hospitals are expected to introduce bar coding in the next few years.

But an interesting story by Josh Goldstein in today's Philadelphia Inquirer, however, reports that what works for your local grocery store doesn't always work so well on the hospital floor. A system that seems great on paper can be flawed in practice if, say, the computer can't be taken into an isolation room (meaning it's down the hall where the nurse can't hear the beep-beep alert of an error) or nurses who find ways of working around the bar code system, for instance, when they have to retrieve insulin for four different patients from a refrigerator on a different floor, scan in the code, and then carry all the medicine on one single tray back to four patients all awaiting different doses.

The piece summarizing findings by researchers at the Universities of Pennsylvania and Wisconsin is quite interesting. It hadn't ever occurred to us, for instance, that the simple technology could be so mismatched with nurses' actual workload and habits that they'd find ways of basically outsmarting it. But we wish Goldstein didn't bury the good news. If you read to the end of his story, you find out that most of the problems are fixable. Not just in theory but in practice. By following eight key recommendations, he wrote, four of the five hospitals studied were able to greatly improve the system and reduce the errors.

The most important thing that hospital executives can do to make the bar code systems work as intended, the article continues, is to "spend time actually watching how the systems are used and to demand that the vendors design systems for the real world of care."

Simple fixes. Solved problems. Reduced costs. Saved lives. Sounds good to us. Wouldn't it be nice if all the rest of the health care cost-coverage-quality challenges in our system were so simple?

CULTURE BEAT: It's Not Funny, Honey -- Health Reform Meets the Comedy Club

Julie Barnes — Tue, 01 Jul 2008 13:14:00 -0400

If you're a politician, you know you've hit the big time if a late night talk show host makes fun of you. Ditto for an issue -- it's big time if it makes the leap from think tank "Issue Brief" to a riff in a stand-up comedy routine. At the D.C. Improv the other night, it was pretty clear that the state of the American health care system has hit the big time. Jake Johannsen had the packed house doubled-over or nodding vigorously to a series of truisms about our broken system. It was only after I left that I remembered that it's not really funny.

Jake, who has been on Letterman and the other major late night shows, is Seinfeld-esque in that he manages to talk about all the mundane realities of life in a way that makes your sides hurt from laughing. When we saw him, he was on a "How The Man Sticks It To The Little Guy" run when he used health insurance as an example. First, he mentioned how lucky most of us feel if we can buy insurance through our employers (unspoken subtext: because if we get health insurance at work, we don't have to worry about being denied coverage because of preexisting conditions). But then we don't feel so lucky if we get sick and, even with coverage, get a pretty big bill. At least then, Jake joked, we could complain about how our boss was "sticking it to us." But some of us have to purchase our own insurance directly, so, he deadpanned: "I end up sticking it to myself! That doesn't seem right." (If he were a wonk instead of a comedian, he'd explain that many of us are underinsured, or facing a bigger share of costs even with insurance.)

Then, in surprisingly fluent health insurance-speak, Jake went off about how he could barely keep up when his insurance broker was trying to explain his policy choices:

an HMO
an HMO with a POS
a PPO
variances between the deductible, premiums, co-pays, co-insurance and out-of-pocket maximums

Jake asked "but which one is best" and the broker replied "it depends on the individual." And Jake, being a comedian, said: "Let's say, hypothetically, that the individual is me." The broker responded: "You have to make your own decision about what's best for you." At which point, Jake made a funny face that meant "You've got to be kidding" and the audience responded with gales of laughter. (Tragicomedy gets them every time.)

Unfortunately, we are not living a comedy routine. As things currently stand, no one (not even those of us who work on health policy for a living!) can make truly informed decisions about which health care policy is best for us. It is difficult to determine whether paying more up-front or taking the risk of paying more later or having more or less provider choice is the way to go. This kind of confusion is not funny, which is why transparency and consumer-friendly decision support tools (real ones, that real people can understand) must be part of any health reform.

I woke up the next morning with my sides still hurting, but very glad that I could come to work and try to offer solutions to the problems Jake joked about. We have to offer more Americans coverage, make sure that millions aren't still uninsured, and reduce health care costs so that we can afford the coverage. If we don't get well down this path in 2009, you can bet I won't be laughing. Not sure if Jake will be either.

COST: Jumping on the Wellness Bandwagon

Elena Harman — Mon, 30 Jun 2008 20:55:00 -0400

The Cleveland Clinic is using wellness programs to practice what it preaches. The clinic, well known for its quality cardiac care, stopped hiring smokers in September 2007, banned trans-fats from its menus and vending machines earlier in 2007, and has now announced its plans to offer Weight Watchers programs to employees for free, according to an AP report. But it’s not just large companies with mammoth health care costs and doctors who constantly see the effects of unhealthy lifestyles that are investing in wellness efforts. Small companies and insurance providers are starting to jump on the bandwagon too.

Small Businesses. Many small businesses already have trouble meeting rising health care costs,so how can they afford to add wellness and prevention programs? Last week, the Wall Street Journal examined programs that even employers on a tight budget could consider workable. Suggestions included discounts for healthy living (using screening tests provided by some insurance companies), online wellness programs, care advocates (to help employees with claims questions, treatment options, or locating a doctor), disease management, nurse hotlines, and purchasing cooperatives (banding together to gain the bargaining power of a large company).
Insurance Providers. WellPoint has recently adopted a wellness and prevention program—but not one aimed at improving the wellness of its own employees. Instead, the insurance company gives financial incentives to its employees for improvement in the quality of preventive care received by plan members or beneficiaries. WellPoint’s 42,000 employees received bonuses linked to improvements in the quality of prevention, screening, and care management of their 35 million members in 2007, according to a recent article in the Chicago Tribune. It’s a different approach to be sure, but an interesting one.

Data to support cost savings of wellness programs is scattered. There is some debate over whether the wellness programs will prove to be a good investment for businesses in the long-term, as workers change jobs so frequently. It's possible that having health plans invest in a healthier population might turn out to be a better economic model. We're just beginning to think about how to shift our health care system from one oriented to chronic disease, not just acute episodes. The more that providers, employers, insurers—and individuals who can avail themselves of things like Weight Watchers or smoking cessation—think about how to achieve this transformation, the better.

QUALITY: California Medical Error Reports Raise New Payment Questions

Joanne Kenen — Mon, 30 Jun 2008 17:53:00 -0400

California now requires that hospitals inform state officials of substantial injuries to patients. The first batch of reports are in: 1,002 cases of "serious medical harm" in the 10 months starting last July, according to the LA Times. By "serious" the state means things like taking out the wrong person's appendix, patients dying after being given the wrong drug, a nine-day-old baby not getting enough oxygen when a ventilator hose is hooked up according to a diagram that was drawn backwards.

The point of error reporting isn't hand wringing or finger pointing. It's coming up with solutions to improve patient safety. The California Department of Public Health can now fine hospitals over safety errors. And increasingly, Medicare, some big health insurers and now a few states are deciding that they want to make patient safety good business—or at least they want to make safety errors bad business. They won't pay for the care needed to fix the mistakes. You break it, you pay.

The newspaper reported that California Assemblyman Mike Feuer has introduced legislation to ban the state MediCal program from paying for the same preventable errors that Medicare has announced it will no longer pay for. It's not clear from the newspaper report or this related Wall Street Journal blog post how much support Feuer has, or how likely his bill is to become law. But it is clear that more policymakers at the state and federal level, instead of the usual bromides about how we've got the best medical care in the world, are thinking about where we aren't doing so well, and how to improve it.

One last point—Judging from some comments we've seen on other blogs, some people mistakenly think the patient who is the victim of the error somehow doesn't get treated or has to foot the bill. No, the hospital just doesn't' get extra from Medicare, the insurer, or perhaps eventually MediCal, for treating the patient for an avoidable medical error. The idea is to give the hospital financial incentives for getting rid of those problems that can be gotten rid of.