Health Reform

HEALTH REFORM: A Reporter's Guide to Covering Health Issues

Paul Testa — Tue, 17 Feb 2009 20:43:00 -0500

The Alliance for Health Reform has released the first chapter in the new edition of Covering Health Issues—an online guide to the major topics in health policy. From national health reform to local health disparities, each chapter provides readers with the basic facts, background on the issue, and overview of the likely policy debates.

The first chapter, written by our colleague Joanne Kenen, tackles the issue of health reform in its entirety. Kenen lays out likely policy debates, noting that "this time around, politicians and policymakers are talking about the intertwined issues of coverage, cost and quality." She provides an overview of the ongoing debates in each, while also addressing related reform issues such as public health and health information technology.

Designed with reporters specifically in mind (although it's useful for other people working in health policy or just wanting to learn more), each chapter also features helpful tips and story ideas for covering health issues. Kenen, formerly an award-winning reporter for Reuters, offers up her own thoughts on some of the common mistakes in health reporting, such as equating more health care with better health care.

The Alliance for Health Reform will post new chapters shortly, and will also add an updated list of sources and resources —-some familiar voices, and some new ones.

IN THE NEWS: Follow us on Twitter!!!1!111

Paul Testa — Tue, 17 Feb 2009 17:26:00 -0500

It's the latest fad. All the cool kids do it. Shaq does it. Politicians do it. Journalists really do it. Now we do it too.

That's right, you can follow us on Twitter at:

http://twitter.com/NewHealthDialog

We'll use twitter to keep you informed of what we're up to. In just 140 characters you'll be able to find out what we're writing, thinking, hearing, and seeing. We'll spare you what we're eating. Catch up on our lastest posts and hear updates from events we attend.

Why twitter? This blog was started as way to promote a new dialogue on health reform and we're always looking for new ways to continue that discussion. So submit questions, give us feedback, and help us bring that conversation to a new audience.

You can sign up for Twitter here, and have all your questions answered here. And if you're still unsure exactly what all this is about, don't stress. We'd suggest David Pogue's recent piece in the New York Times. As he says Twitter is what you make it.

HEALTH REFORM: Stimulus Eases Short-Term Crisis, But No Substitute for Comprehensive Reform

Kyle Noonan — Tue, 17 Feb 2009 17:23:00 -0500

The stimulus package, signed into law on Tuesday, provided a "down payment" on comprehensive health reform by funding two initiatives, health information technology and comparative effectiveness research, that stand to create jobs and lay the foundation for a high-quality, efficient delivery system.

To prevent states deep in the red from shedding hundreds of thousands from their Medicaid rolls, the stimulus allocated billions to the program. For workers who've lost their jobs—and hence their insurance—since September 2008, the stimulus provides a 65 percent subsidy for COBRA premiums. Those provisions will help many people. But it won't fill in the health coverage gaps for everyone. Noam Levey in the LA Times takes a look at who the stimulus helps and who it doesn't.

Several provisions once included in earlier versions of the legislation were not included in the final package. COBRA subsidies were limited to workers who lost their jobs after September 2008, a controversial move given that the recession was already underway for months by then. The final bill did not open Medicaid coverage to additional unemployed workers (previous versions of the bill would have allowed unemployed workers who were not eligible for or who could not afford COBRA to enroll in Medicaid). And it struck a provision that would have allowed workers over age 55 to remain on COBRA until they became eligible for Medicare.

Though the COBRA premium subsidies and additional funds for Medicaid will blunt the immediate crisis by preventing many from losing insurance, the comprehensive reforms needed to extend coverage to all Americans and address our system's cost and quality issues are still as necessary as ever.

The National Journal's health experts blog has a variety of views on how effective the health provisions in the stimulus will be in spurring economic recovery and getting the newly jobless/uninsured through hard times.

QUALITY: Comparing Perspectives in Comparative Effectiveness Debate

Paul Testa — Mon, 16 Feb 2009 16:13:00 -0500

The New York Times' Robert Pear examines the content and contentiousness of the comparative effectiveness provisions of the $787 billion stimulus package.

HR 1 provides $1.1 billion (pdf starting on page 156) to AHRQ, NIH and the HHS to evaluate the relative effectiveness of different health care services and treatment options. The goal is to create a process of funding and disseminating comparative effectiveness research that is transparent, professional and free from conflicts of interests. As the Dartmouth Atlas' Elliott S. Fisher, MD, tells Pear, the funding would be used to try to answer questions such as:

Is it better to treat severe neck pain with surgery or a combination of physical therapy, exercise and medications? What is the best combination of "talk therapy" and prescription drugs to treat mild depression?

How do drugs and "watchful waiting" compare with surgery as a treatment for leg pain that results from blockage of the arteries in the lower legs? Is it better to treat chronic heart failure by medications alone or by drugs and home monitoring of a patient's blood pressure and weight?

In health care, though, simple questions rarely have simple answers. Nor will answers be static; biomedical science changes at a pretty astonishing clip. We wrote about this topic twice last week, and we expect to hear more about it as the health reform debate intensifies. Last week Kyle Noonan wrote about some of the alarmist rhetoric surrounding the issue, and Joanne Kenen wrote a longer piece about how comparative effectiveness fits into "health" as well as health care reform. We also want to point out Bob Laszewski's posts at the Health Care Policy and Market Place Review, which has provided interesting coverage on this topic. In his most recent post he worries that the final bill's focus on clinical effectiveness will not translate into cost effectiveness. Commenters on the post have suggested that getting the clinical data right is the hard part and that once that information is available it will be easier to work out the questions of cost and value.

Beginning to measure what works best for what patients or populations under what circumstances can provide a baseline. Providers and patients will have access to information that will help them better understand their choices and the likely consequences. Providing that information in a manner that is transparent, credible, and easily understood will go a long way to ensuring that all Americans receive the most effective care whether they live in Florida or Nebraska or California.

HEALTH REFORM: Relax, Folks

Kyle Noonan — Fri, 13 Feb 2009 18:55:00 -0500

It's not just the blogosphere that's agog about some of the pretty astonishing things being said about comparative effectiveness. Steven Pearlstein's Washington Post column debunks some of the wild arguments being made against the comparative effectiveness and health IT provisions in the stimulus bill. Pearlstein provides an insightful look at how the controversy got started and addresses the alarmist rhetoric. He rightly points out:

There's nothing particularly new about comparative effectiveness research—the National Institutes of Health, along with the Agency for Healthcare Research and Quality, have been doing it for years, with a budget last year of about $335 million....nearly all experts agree (comparative effectiveness research) is a necessary first step to reforming a broken health-care system.

Pearlstein punches holes in the argument that the research would lead to denial of appropriate care and makes the case that our health system would be, well, healthier if we had better information on what works and what doesn't:

And there is no reason we cannot set up reasonable procedures, overseen by independent health professionals, to protect patients who can demonstrate a special need for a treatment that is not normally cost-effective.

...(O)urs is an economy that is sinking under the weight of a health-care system that costs twice as much as any in the world while delivering poorer health outcomes. The cost of health care has crippled entire industries, disadvantaged our companies in international competition and brought millions of families into bankruptcy. Worst of all, in denying vital medical services to the 40 million Americans without health insurance, we engage in the most immoral kind of medical rationing imaginable—rationing by the ability to pay.

By the way, in this blog's Thursday post about comparative effectiveness and partisanship, we asked, "Where is Judd Gregg?" An hour or two later, we found out...

HEALTH POLITICS: Skip the Flowers and Chocolate, Show Economy You Care With Health Reform

Paul Testa — Fri, 13 Feb 2009 18:35:00 -0500

Congress is set to pass a $787 billion economic stimulus package—with more than a $130 billion in health-related funding. The House is expected to vote this afternoon, with the Senate scheduled to follow suit this evening.

Congressional leaders worked late into the night Thursday, to reconcile he House and Senate versions of HR 1. The conference report detailing the compromises in the final legislation is available from the House Committee on Rules. Just how late were lawmakers up hammering out the details? The 496-page pdf is filled with handwritten notes and last-minute edits.

Here are the press releases from Appropriations, Energy and Commerce, Ways and Means and Senate Finance detailing their committee provisions in the final bill.

Below is a brief highlight of legislation's health related spending:

$87 billion in additional federal Medicaid funds for states, including an across the board increase in FMAP of 6.2 percent, with further reductions in state share based on unemployment rates.
$24.7 billion for federal subsidies to COBRA covering 65 percent of the cost of health insurance premiums for a maximum of nine months
$19 billion for health IT, with $17 billion for investments and incentives through Medicare and Medicaid
$10 billion in funding for NIH,
$1.1 billion for comparative effectiveness research
$1 billion for prevention and wellness programs

For Congressional leaders looking to tell the economy they care this Valentine's Day, nothing says I love you like health reform. While no bill's perfect, the health spending provided in this legislation will not only help stimulate the economy but also lay the foundation for broader comprehensive health reform. Considering the price of roses these days, we'd say it's a bargain. But health reform isn't just for special occasions. So we hope Congress and the administration will continue to show the economy and the American people, just how much they care, by addressing broader health reform efforts early and often in the coming weeks and months.

Health Reform: Wal-Mart Tackles Health Costs and Coverage

Kyle Noonan — Fri, 13 Feb 2009 16:50:00 -0500

The Washington Post's Ceci Connolly reports that Wal-Mart, once widely critiqued for having many uninsured workers, is now seen as an innovator. She writes about how the huge retailer is expanding coverage, trying to control costs, and experimenting with care management programs to improve outcomes and quality. The company still has its critics, naturally, but its efforts also say a lot about what businesses can (or can't) do in the current health care climate:

...Wal-Mart itself warns that in a global market with a weakened economy, it cannot—or will not be able to—accept annual health-care increases of about 8 percent indefinitely.

"It starts to impact us competitively," said Linda Dillman, the company vice president tapped to oversee the health plan.

To Andrew Stern, president of the Service Employees International Union and a frequent Wal-Mart critic, the company's health contributions are not commensurate with its financial success. The moral, he said, is that "volunteerism has its limits."

But to Mark Smith, head of the California HealthCare Foundation, an independent nonprofit focused on health-care quality and efficiency, Wal-Mart's experience provides a different lesson.

"Even a company as big and successful as Wal-Mart cannot possibly solve this problem on its own," he said. "There are limits to what one company can do."

Additional take-home points from Connolly:

Wal-Mart shopped around for value, contracting with the Mayo Clinic for all transplant services, for example, based on its excellent record.

Wal-Mart is utilizing the model of a patient-centered medical home. For its pregnant workers, the company provides a nurse to provide counseling on lifestyle changes and infant care.

Wal-Mart's low-wage workers are still paying a lot of their income for plans, and many have high deductibles.

As Smith noted, comprehensive health reform is too big even for even the nation's largest private employer to tackle alone.

(Disclosure: New America is partially funded by the Wal-Mart Foundation, along with other foundations with a variety of perspectives on health system reform. All support our general approach to creating policy and political space for a bipartisan agreement that will work for all Americans. A complete list of our funders can be seen here).

HEALTH REFORM: Mixed Results from Medicare Experiments

Kyle Noonan — Thu, 12 Feb 2009 16:22:00 -0500

In a promising sign for health care delivery system reform, a Pennsylvania nonprofit substantially reduced costs and improved outcomes for Medicare patients with chronic illness in a care management study. The success of this trial—and the limited accomplishments of others in this experiment—provides more evidence of the need to involve physicians in any disease management reform.

The February edition of JAMA describes 15 care coordination trials started in 2002 by CMS. The pilots tested the ability of care coordination programs to keep elderly, chronically ill patients out of the hospital, on diet and exercise regimens, and otherwise improve health and lower spending.

The results demonstrate three major points. First, the concept of a patient-centered medical home may not be easy to put into practice, but it can work. The Pennsylvania pilot gave high-utilization patients monthly visits and coordinated care from a nurse. The nurse encouraged lifestyle changes and developed a relationship with the patient. The pilot restructured care around the patient, and the nurse served as a sort of medical home for the patient.

Second, as Robert Berenson of the Urban Institute has posted on this blog before , successful disease management must involve the provider. Both of the successful pilots, in Pennsylvania and Iowa, included regular personal contact between a provider (in these cases, a nurse) and the patient. Since patients look to their providers, generally physicians, for responsibility for their health care, any disease management reform must include provider involvement. Past Medicare pilots that failed to save money because they attempted to involve outside entities in a patient's health rather than the provider.

Third, as the study author pointed out, it is challenging to get either providers or patients to change their behaviors. Most of the pilots struggled to get patients to exercise, improve their diet, stop smoking, and make other lifestyle changes necessary to improve health and reduce cost. Similarly, physicians who are used to operating as "lone rangers" without oversight of their work have a difficult time changing to a new model. The lesson here is that patients and providers need incentives to change their behavior. (See the USA Today story on financial incentives to quit smoking.) Any comprehensive reform has to provide appropriate incentives to improve health and cut costs.

So it is possible to save money and improve outcomes with a new care management model, but to work, it must be structured for success. (See our post on a previous Medicare pilot .) It needs to provide appropriate incentives, involve providers, and focus care on the patient. Hopefully the results of this experiment will inform future attempts at delivery system reform.

QUALITY: A State of the Health Care Union

Paul Testa — Thu, 12 Feb 2009 16:21:00 -0500

In less than two weeks, on February 24, President Obama will address the Congress in what amounts to his first State of the Union. Health care, The Atlantic decided, couldn't wait that long.

Hosting a State of the Union for Health Care on Wednesday, the magazine brought together experts from across the health care spectrum to lay out where we are and where we need to go in the coming year.

In terms of where we are, much should sound familiar to our readers. Health care costs too much. It covers too few, and the care it does provide is too often mediocre.

As David Walker, President & CEO, Peterson Foundation, told the audience, health care is our nation's single largest fiscal challenge, with the potential to bankrupt our government and cripple our competitiveness. The fact that some 46 million are left without health insurance, Walker said, was shinola.

In terms of quality, Mark Chassin, M.D., President, The Joint Commission, noted that each day there are about six wrong-site surgeries in the U.S. "Twenty five years ago, health care was cheap, safe and totally ineffective," Chassin said. "Today, health care is effective, expensive and totally unsafe." It's not surprising then, as Mary Woolley of Research! America told the audience, that more than 70 percent of Americans no longer believe we have the best health care system in the world.

As for fixing that system, Senator Bob Bennettt (R-UT)—in a welcome reminder that there are some who still want to solve the health care crisis on a bipartisan basis—laid things out clearly describing what he called the "big Aha moment" in health reform. "If you have health reform that focuses on quality health care for everyone you save bundles of money," he said. "The secret to cost control in health care is quality. The best health care is the cheapest."

So how do we get to a high-quality, high-value health care system? The event's discussion focused around the concepts: transparency, public reporting, and realigning incentives to drive better outcomes.

As we've said before, you can't manage what you don't measure. Much has been made about the need for more public reporting in health care. The real consumers of this information about outcomes and quality are not patients but providers, argued University of Virginia's Elizabeth Teisberg, Ph.D. As Toby Cosgrove, CEO of the Cleveland Clinic said, "There's no group that's more competitive than doctors. These are people used to being at the head of their class... You put the numbers up, the quality will improve."

In constructing these measures, Teisberg asserted that it was important to distinguish between process measures (did a patient receive this recommended treatment or test) and outcome measures (not just mortality, but readmission rates, length of stay, etc.).

Furthermore, Chassin argued that more attention and effort had to be paid to getting what we know works adopted as a standard of practice. It takes close to 17 years for the introduction of medical innovations to achieve general acceptance in our health care system. Publicly reporting process and outcome measurements can help speed up that process. It can serve as the foundation for the kind of comparative effectiveness research our colleague Joanne Kenen talks about in a post early today. It can help realign incentives so that we're paying for better outcomes and higher value care. And it can happen soon.

Representative Frank Pallone, Jr. (D-NJ) spoke at lunch about trying to move comprehensive health reform legislation this year. Congress, Pallone said, had already laid a strong foundation with SCHIP and the Stimulus bill. He said that leaders in Congress and the administration were committed to moving forward as quickly as possible, and that his committee planned to begin holding health reform hearings after the President's Day break. We hope we here a similar message two weeks from now in the president's address to Congress.

QUALITY: Comparative Effectiveness Is About Caring Effectiveness

Joanne Kenen — Thu, 12 Feb 2009 15:19:00 -0500

Imagine plunking down more than $2 trillion a year and not knowing what you are getting for it. Imagine that what you are purchasing gets more complicated and convoluted every year. Imagine that lives, literally, hang in the balance.

Then imagine that someone comes up with a sensible approach to solving or at least shrinking the problem. And they get hit on the head for their efforts.

Welcome to the world of comparative effectiveness.

The partisan warfare over the stimulus bill (which frankly has surprised some of us with its intensity—Judd Gregg where are you?) gives us glimpses of some ugly battles ahead in health care. Comparative effectiveness research is an early battleground. Advocates range from the Institute of Medicine to the AARP; both Sen. John McCain (R-AZ) and President Barack Obama advocated some form of the research during the presidential campaign. The Medicare prescription drug law, which was largely written and backed by the Republicans, explicitly authorized comparative effectiveness research. But critics, who as the Wall Street Journal reported this week include powerful drug companies and medical device makers, say it is a first step toward government rationing or penny-pinching-driven medicine. Conservative commentators have launched a full-scale assault on the concept using some pretty shrill and scary imagery.

But comparative effectiveness is just what it says. Comparing two or more treatments, therapies, drugs and devices, and figuring out which one works better for patients. There is room for legitimate debate—indeed, the debate has already begun and has been part of the stimulus fight—about whether costs should be an intrinsic part of that equation, or whether cost-benefit analysis should be a separate, second step. But the primary goal of comparative effectiveness is just what it sounds like. Compare two or more drugs, devices, or other interventions, and figure out which works best in which circumstances. If a really cheap old medication works way better than a really expensive new one, it should be pretty darn clear which should be the first line of treatment for most individuals. If a really expensive new drug prolongs lives or controls symptoms or eases pain, then we'll have reason to spend the money (why some of these drugs cost so much is a whole different issue, as Gooznews often reminds us). In many many cases, the answers won't be so clear-cut, or they will change over time as we learn more. But we'll have data and science—not well intentioned guesswork or pervasive marketing—on which to base clinical decisions. Yes, the goal is to spend smarter. But it's also to make people healthier. Health is, after all, the point of health care.

The AARP's CEO Bill Novelli put it aptly:

They're at it again. Opponents of health reform are now using scare tactics in a misguided attempt to stop progress in its tracks, blocking attempts to fix the broken health care system that is hurting American families and our economy.

The latest attacks revolve around a smart policy in the economic recovery package that would fund ‘comparative effectiveness research'—a wonky term that just means giving doctors and patients the ability to compare different kinds of treatments to find out which one works best for which patient.

Opponents—like some drug companies and medical device makers—don't want this research. They fear it will cut the profits they make on ineffective drugs and equipment.

But they won't tell you that this research could save your life by giving your doctors better information so they can prescribe the best treatments available to you.

Really, it's not like the AARP is going to be out there agitating for something that will prevent older Americans from getting good health care!

But if you don't like what the AARP and Consumers Union discovered in their recent research and forum on the subject, see what the Institute of Medicine has to say. IoM had a conference with top policy experts on evidence-based medicine in 2007 and outlined the main issues in comparative effectiveness in a 32-page report last summer. The IoM wrote:

Medical care decision-making is now strained, at both the level of the individual patient and the level of the population as a whole, by the growing number of diagnostic and therapeutic options for which evidence is insufficient to make a clear choice. Biomedical insights and medical innovation continue to advance opportunities to increase the health and life-span of the American public, yet to capitalize fully on this potential requires enhanced capacity to ensure that decisions, in the face of increasing complexity, can be supported and guided by the best available scientific information.

The information gap is growing daily:

As the boom in pharmaceuticals, devices and biologics has left us with a need for information on clinical utility and as innovations in the pipeline come to fruition, the information gap will widen. The rate with which new interventions are introduced into the medical marketplace is currently outpacing the rate at which information is generated on their effectiveness and the circumstances of best use. If trends continue, the ability to deliver appropriate care will be strained and may be overwhelmed.

So when a doctor prescribes something for us or our families, we want to know that the doctor has a scientific reason for doing so. When an insurer says we can or cannot have something, we want to know the insurer has a scientific, not monetary, reason for doing so. When a drug or device comes on the market, we want to know it has a scientific reason for being there. As the Institute of Medicine and others have pointed out, there are lots of unresolved questions about who should do the research, how it should be funded, and precisely how to use the data in our payment policies. But there are answers to those questions about the framework. And once we answer them, we can get on to the questions that really matter: What works?