Cost

Representing the economically troubled state of Michigan, home to the auto industry, Democratic Sen. Debbie Stabenow just has to look around her to see how sky-high health care costs have eroded the global competitiveness of U.S. industry. Still, she told a New America-sponsored forum on Capitol Hill the other day, it's "nice to be joined by the data in something that I have been talking about for a long time."

Stabenow, the opening speaker at our forum about employer health costs in a global economy, described how the "most expensive and crazy structure in the world"—aka the U.S. health care system—was damaging the economy, hurting industry, threatening the middle class. "We are literally losing jobs," she said, spending more than our competitors on health but having less to show for it. (Click here for the webcast, here for the study, here for our earlier post.)

A lucky 13 top-notch health policy wonks outlined concrete and achievable stops to improve quality, reduce cost, and repair our health care system in the May/June issue of Health Affairs. For instance, beyond the common refrain for increased use of "evidence-based" medicine, the "Quality Crossroads Group" called on Congress to immediately create a national center to support effectiveness research so we can at least get started on examining what treatments work best and when to administer them.

We also liked the call by the authors, including New America's Len Nichols, to replace the fee-for-service payment model with systems that reward clinically effective and efficient population health management--like bundled chronic care episode payments and paying for population health performance.

As we continually say in this space and elsewhere, successful reform must address coverage, costs and quality at the same time. This Quality Crossroads Group outlines better and more succinctly than most how quality improvement, cost containment, and coverage expansion are inextricably linked. Ultimately, the group offered five ways to achieve a high-performance health system:

We've all done a lot of looking back to the lessons of 1993-94, and the long list of reasons the highly complex, ill-timed and politically-polarizing Clinton health care plan failed. But today the journal Health Affairs published an essay looking back not just at the failures of the Clinton plan but at the successful passage of two major health reform initiatives--the truly bipartisan State Children's Health Insurance Program (SCHIP) and the Medicare Modernization Act, which added prescription drug coverage for seniors.

Maggie Maher, a health blogger we read regularly, has a poignant post today about untreated pain, inappropriately aggressive high-tech care, and the lessons that young medical students (not to mention some older doctors) still must learn about why "good care" and "cure" are not synonymous.

Maher spent some time with Dr. Diane Meier, a geriatrician and national leader in palliative medicine at Mt. Sinai Hospital in New York, and she watched Meier share with medical students some of what she has learned about how to help seriously ill or dying patients. I learned a lot from Meier and her colleagues at the Center to Advance Palliative Care last year when I was doing an extensive reporting project on palliative care and hospice. (Click here, here, and here).

You may have heard about Rep. Steve Kagen, a Wisconsin allergist turned Democratic lawmaker who has spurned Congress's generous health coverage until all his constitutents can get health insurance too. Ivan Oransky, a writer who gets both science and health policy, has a good profile of Kagen at the Scientific American website:

Kagen, 58, is now one of millions of Americans, including at least nine million children, without health insurance. "I have absolutely no health coverage at all," he told ScientificAmerican.com during a recent interview. "I have no health conditions and am pretty darn healthy." And if he gets sick? "I'd be just like the 47 [million] to 50 million American citizens who don't have coverage," he says, "and I'd have to negotiate with hospitals and doctors for the best-priced coverage."

Yesterday we posted the first part of our conversation with Carol Diamond, M.D., M.P.H., the Managing Director of the Health Program at the Markle Foundation in New York. She spoke about the potential of health information technology to improve the quality and restrain the costs of our care, as well as the research benefits. Today, in the second and final installment, she discusses some of the barriers to bringing 21st century tools to a paper-based health system, and the path to overcome them.

Q: What are the challenges to a national health information technology system?

A: There can't be one information technology "system." We start with a vast, highly fragmented and very diverse health care delivery model that is not centrally controlled or run. The only practical way forward is to acknowledge existing networks, and let them grow incrementally under a basic, common sense set of policies and standards. That's how the Internet grew.

The health care sector has a set of unique challenges that need to be overcome—and some have nothing to do with technology.

The first critical challenge is trust. Without it, patients and physicians will not be willing to use new technologies due to fear of privacy breach or the misuse of personal health information.

We're suckers for medical mysteries like the one in today's Washington Post health section headlined "Five Doctors, Stumped." Today's medical whodunit (or more accurately who-didn't-do-it) was about the misdiagnosis of a woman named Bettie Munro, thought to have Parkinson's disease. Munro did not have Parkinson's. Instead, an upset stomach among other things had changed how her aging body was absorbing lithium, creating a toxic condition. One sentence near the end of the story particularly struck us, "One physician said he thought another had checked her (lithium) level, so he didn't bother." It made us think about the interview we just posted with Dr. Carol Diamond, an expert on health information technology at the Markle Foundation. We don't believe (and Diamond doesn't assert) that health IT will stop every medical mistake, avoid every misdiagnosis, create a perfect world of health and harmony.

Just about everybody who writes about health care has weighed in on the relative scarcity of primary care docs (including geriatricians) and the relative abundance of extremely well-paid specialists. Now the Wall Street Journal reports that we are even running low on certain specialists—the ones that don't make as much money.

The Journal story focuses (no pun intended) on neuro-ophthalmologists who treat complex, baffling visual disorders connected to the brain. They spend a lot of time testing, examining and talking to each patient. But our payment system doesn't reward time-consuming low-tech procedures. High-volume and high-tech is the way to go to maximize income. A neuro-opthalmologist has more training than a general ophthalmologist, but he makes about a third less money.

"Many in health-policy circles have focused on how the current health-care payment system is helping create shortages among primary-care doctors, internists and others on the front lines of medicine. But often lost is how the system is endangering some of the country's most highly trained specialties as well," the article continues, citing endocrinologists, rheumatologists, and pulmonologists.

First Focus, a children's advocacy group, this week in its Children's Budget 2008 reported that only one cent of each "new" dollar of federal spending (excluding defense) goes to kids. A lot of the report focused on education, so we asked them how does health spending add up. The answer: not so hot.

The overall share of federal, non-defense spending going to children's programs has dropped by 10 percent over the past five years. Real discretionary spending on children has declined by more than 6 percent since 2004, while at the same time all other non-defense discretionary spending has increased by more than 8 percent, the group reported.

Because so much of spending on children' health is through Medicaid, SCHIP, and other entitlements, not out of the discretionary budget, spending on health programs did grow from 2004–08. However, total spending on children's health amounts to less than 2 percent of the total federal budget, and less than 0.4 percent of the Gross Domestic Product.

Outside the mandatory programs, discretionary spending on children's health has declined in real terms. Discretionary spending is down 6.3 percent. As a share of total federal spending, children's health spending has lost ground. Children's health spending currently makes up 1.9 percent of all federal spending, while in 2004 its share was 1.97 percent, a 3.5 percent drop.

No, your eyes aren't deceiving you. We CAN guarantee all Americans quality health coverage and improve our delivery system without breaking the bank, according a report released today by the Congressional Budget Office (CBO).

Today's letter signed by CBO Director, Peter Orszag, and Joint Committee on Taxation Chief of Staff, Edward Kleinbard, says the bipartisan Healthy Americans Act would be budget-neutral in its first year and would get better after that. CBO analysts also predict that the HAA, sponsored by Senators Ron Wyden (D-OR), Bob Bennett (R-UT), and 12 others, would actually, "become more than self-financing and thereby would reduce future budget deficits or increase future surpluses," over time.

Stay tuned for more information from the press conference...