New Health Dialogue

Ordinary Americans may not realize how closely linked their health care is to the U.S. tax code, but a bevy of analysts and economists could give them an earful. The major health reform plans on the table involve changes—in some cases pretty significant changes to tax treatment of health insurance, particularly the tax breaks for insurance we get through our jobs. Over at the Taxvox blog, sponsored by a joint program of the Urban Institute and the Brookings Institution, Howard Gleckman explains some of the options in a post nicely titled, "Forget Death and Taxes, How About Health and Taxes?"

Gleckman focuses on proposals for a Value Added Tax or VAT, a model seen in several European countries. VAT scenarios are circulating more in the academic/think tank world right now than in the political discourse about health care, but as Gleckman points out:

"The expiration of the Bush tax cuts and the ongoing Alternative Minimum Tax mess will surely drive big tax changes in 2009 or 2010. Health reform is also on the table, although short-term odds for reform may be longer. The question is: How will these two mega-issues fit together?"

There's a big story (subscription required) in this week's Modern Healthcare magazine describing the great care being delivered by the Baylor Health Care System in Dallas. The article is inspired by the National Quality Healthcare Award that Baylor will receive tonight from the National Quality Forum, Modern Healthcare, and the Studer Group.

The article states that through devotion to data transparency and analysis, Baylor is able to identify preventable adverse events including falls, medication errors, and surgical site infections, and analyze not only the degree to which they can be prevented, but also specific actions (such as a malfunctioning safety device or poor communication) as well as inactions. They also provide quality and performance data on their intranet so that physicians and staff can track their performance.

But my favorite anecdote is this:

Inpatients at Baylor Health Care System in Dallas don't have to wait until they're in crisis to get a visit from a rapid response team.

Premier Hospitals are best known in health policy circles for their innovative and successful Pay-for-Performance initiative, as well as winning a Baldrige Award in 2006. This week they unveiled a new program aimed at eliminating preventable birth injuries at 16 participating hospitals.

According to their presentation, three birth-related injuries occur per 1,000 deliveries, and most of the time the specific causes can be identified. Participating hospitals will implement a 21-month collaborative using care bundles (more on that below), identify best practices and measure the cost and quality associated with those practices, and share outcomes to help other hospitals improve. It runs from April 2008 to December 2009.

Approximately 115,000 babies will be delivered at these six hospitals during the nearly two-year program; that means as many as 345 injuries could be prevented, including birth asphyxia (little or no breathing by the infant), cerebral palsy, permanent disability, and death.

Minnesota Gov. Tim Pawlenty has vetoed a health care bill, saying it would expand coverage without doing anything to restrain costs or improve quality, the Star-Tribune reports.The bill had passed the state Senate with a veto-proof margin, but the vote was closer in the House.

The bill would have made more people eligible for MinnesotaCare, the state's subsidized health insurance program for the working poor. It would have covered an estimated 40,000 people.

"The state cannot afford to further expand subsidized health programs without certainty of reform that will control costs," Pawlenty wrote.

Pawlenty noted that the bill would subsidize households with incomes of up to 400 percent of federal poverty guidelines, making eligible a family of four with an income of $84,800. "This is simply too high," he wrote.

The governor said there were parts of the bill that he liked, including promotion of electronic health records, development of medical homes and payment reform for doctors.

Health Affairs, as you know if you've read us or any other health policy blog this week, devoted its May/June issue to health reform, and held a forum on health politics in DC this week. (Merrill Goozner did a nice summary including an update of what the Congressional Budget Office is doing to gear up for health reform.) They also did a conference call recently summing up the political landscape with Bob Blendon of Harvard's Kennedy School and School of Public Health, Julie Rovner of NPR and Robert Laszewski, of Health Policy and Strategy Associates Inc. and the Health Care Policy and Marketplace Review blog. Here's a recap from the Health Affairs blog, and here's the transcript.

This week we attended a Health Affairs event on Health Reform and the 2008 Election at the Willard (excellent coffee), where Celinda Lake (Lake Research Partners) and Bill McInturff (Public Opinion Strategies) entertained the crowd with the good, the bad, and the ugly stories of polling Americans' great thoughts on health care reform. The pollsters represent different sides of the aisle but agreed that: 1) Americans believe that health care costs are linked to the well-being of our overall economy; and 2) The next American president has a "unique window" to change the health care system early in the first term.

Lake, the Democrat, offered many interesting tidbits about what Americans want in their health care reform:

1. Prevention (not wellness)
2. Provider choice (they definitely don't want to lose access to their doctors)
3. Peace of mind about plan choice (they want to keep their policy and benefits if they like them)
4. Control (this is related to the previous two elements)
5. An American Solution (not Canadian-style reform—they want something uniquely American).

Lake also discovered what Americans do not want to hear:

Since 2006 more than 340,00 previously uninsured residents of Massachusetts have gained health insurance. As The New York Times recently noted, the expansion in coverage stretched the state's health care resources, especially in primary care. That's why we were particularly encouraged to read Elizabeth Cooney's Boston Globe piece on how community health clinics in Massachusetts have successfully recruited much-needed primary care physicians through a loan repayment program.

Funded by a $5 million grant from the Bank of America and administered by the Massachusetts League of Community Health Centers, the program provides up $25,000 a year for three years to repay loans. In its first year the program recruited 47 clinicians—more than double what they expected. Before the incentives, these centers last year had been unable to fill about 10 percent of their primary care positions.

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.