Medicare

In his 2012 nomination acceptance speech in Charlotte, President Obama argued that this election represented “a choice between two fundamentally different visions for the future.” It is also true to say that we faced a choice between two fundamentally different visions of the past. And despite Obama’s reelection, the debate rages on in a closely-divided electorate and in Washington. Underneath disagreements over Obamacare, Medicare advantage cuts and Medicare vouchers, and individual retirement accounts, there is an argument about which model of social policy is best for the country.

Last night, CBS's 60 Minutes aired a segment reporting on the allegations that for-profit hospital chain Health Management Associates (HMA) has committed widespread Medicare fraud, including by pressuring ER docs to admit at least 20% of their patients (and at least 50% of patients over 65!), and by using a computer system that automatically ordered tests before patients even saw a doctor. The company has denied the accusations, but they are under investigation by the Justice Department.

Obviously, if HMA was breaking the law, it should be investigated and punished. But it's important to note that similar questionable admissions happen all the time, at hospitals across the country, without any deliberate Medicare fraud. Supply-sensitive admissions are a huge and expensive problem that the 60 Minutes story didn't address. It doesn't matter to a patient who ends up getting an infection if they were admitted explicitly to make more money, or "just in case" and because there was a bed available. Preventing fraud is yet another reason we need much better evidence on when being admitted to the hospital is helpful, and when it just puts patients in harm's way.

CBS based the report on conversation with a large number of former HMA employees, as well as on some documents that apparently show the pressure from inside the organization. We've asked to see the documents, and will update this post to reflect anything we hear about that request from CBS.

Watch the full segment here!

For much of the last three decades, policy debates in the United States have been dominated by a quixotic concern about deficits, debt, and demographics. This concern has distracted policy from fundamental economic issues that have much more direct bearing on economic well-being, most notably the growth (and bursting) of the housing bubble in the last decade. While large deficits can have a negative impact on economic growth, this impact has been hugely misrepresented in public debates.

Tara Parker-Pope, Well columnist for the New York Times website, highlighted overtreatment as a serious problem in a blog post yesterday. The post describes several people's direct experiences with unnecessary testing and treatment, and does a good job conveying the physical, emotional, and financial harm that comes from a disorganized system prone to overtreatment.

Overtreatment is a human issue, and reducing the personal harm it causes is at least as important as controlling healthcare spending growth. But healthcare spending is a crucial political issue, so it was smart to put the post on the Times's current campaign issues channel, The Agenda. Tackling overtreatment will be a defining issue of the next few years--either because we make crucial progress toward eliminating overse and reducing total medical spending, or because the next President ignores the problem while we continue on the ruinous path of letting healthcare strangle the rest of our economy.

Given the importance of the issue, though, I wish the post had looked a little bit closer at the policy issues involved. Most importantly, the post doesn't address the causes of overtreatment, including the financial incentives faced by clinicians and hospitals, lack of research on what treatments are effective, and physicians' failure to communicate to patients about their treatment options. The thing is, there are huge differences in policy between the two tickets on those issues. Since the post appeared on The Agenda, it could have done a lot more to point out those differences--like the fact that the ACA moves Medicare away from paying for the volume of services and toward rewarding higher-quality, more cost-effective care, or that it funds patient-centered outcomes research to determine which treatments actually work. On the other hand, Romney's running mate, Paul Ryan, recently parroted the absurd idea that IPAB is a "death panel," even though it is specifically prohibited from rationing care. That kind of rhetoric is hard to square with the notion that a Romney/Ryan administration would be willing to take any political risk to push back against unnecessary care.

Finally, on a related note, Dr. Aaron Carroll of The Incidental Economist has pulled together an incredibly useful set of politically difficult truths about reducing healthcare spending, in a set of posts titled "Why is this so hard to understand?" All of them are important and worth reading:

Part 1: When Medicare spending goes up, seniors’ premium costs go up.

Part 2: You can be for reducing Medicare spending, or you can be for increasing Medicare spending, but you can’t be for both.

Part 3: If you spend more on Medicare, someone has to pay for it.

Part 4: Don’t argue that reducing government involvement is the way to reduce spending.

We don't often weigh in on electoral politcs here on New Health Dialogue, but the introduction of Paul Ryan into the race as Mitt Romney's running mate has distinctly shifted the focus of the debate onto Medicare, at least for the moment, and the editor of Delve Into '12, the New America campaign blog, asked for our thoughts.

You should definitely check out the full post (here) and the rest of their campaign commentary, but if you're short on time, here's an excerpt from the end of our post:

[...T]he Ryan budget slashes government healthcare spending, but it does relatively little to reduce total health spending. (In fact, if Ryan’s plan was implemented, it could reduce Medicare’s bargaining power and actually increase total spending.) While the ACA includes specific programs aimed at reducing waste (for instance by giving doctors incentives to reduce spending on ineffective treatments, funding research on which treatments actually benefit patients, and making it easier for cheaper generic drugs to get approved), the Ryan plan’s main savings mechanism is competition among private insurers. In theory, giving people a choice of insurer should reduce healthcare spending –people will choose plans that offer  better value, forcing inefficient plans out of the market. But competition among private insurers has failed to control spending in the private insurance market for decades, so some skepticism of its ability to rein in spending on the elderly is warranted. If that doesn’t actually work and total medical spending doesn’t go down, the Ryan budget saves money by shifting spending from the federal government to individuals.

Ultimately, the Ryan budget's laser-like focus on reducing the federal deficit has led to a glaring oversight in the proposal’s healthcare component. Policy should be focused on reducing total healthcare spending, including private insurance premiums and out-of-pocket payments, not just on reducing what the federal government spends. Healthcare spending has become a drag on the economy, accounting for up to two percentage points of unemployment—and that drag isn’t dependent on whether it’s funded by the government or the private sector. That’s the much more important challenge, and the Ryan budget ignores it completely.

Enjoy the weekend!

Hosted this week by Dr. Jaan Sidorov at the Disease Management Care Blog, it's "A Brainy Health Wonk Review on Health Reform, the Affordable Care Act and Lots More!" Go check it out.

Health Wonk Review will be back on September 13th, hosted by Louise Norris of the Colorado Health Insurance Insider Blog.

The health wonks have responded en masse to the Supreme Court's decision on the ACA.  Here are the links to this special edition of Health Wonk Review.

Part 1

Part 2

On Wednesday, June 27th my roommate convinced me that we should give up the comfort of our intern-housing beds for the cold hard concrete of justice and the company of other "Supreme nerds," waiting in line to witness the historic ruling on the ACA.  I'm usually not that compulsive, and I resisted at first. After some powerful persuasion, I eventually consented to go.  Interning here in DC this summer has presented me with many invaluable opportunities, but none has been as amazing as what awaited me next morning.  I owe my roommate a big "Thank you" for not succumbing to my stubbornness.

You could feel the excitement in the air.  Most of us were students or recent graduates, interns or nearby residents. Many didn't sleep that night, choosing instead to stay up night sharing opinions and speculations. Some finally succumbed to exhaustion.

We woke up in a sea of cameras. At 5:00 AM there were more camera crews set up than at 10:00am on Monday, when the Arizona case was released.  

As the morning wore on, I found myself constantly mulling over what might happen inside that beautiful building later that day. This would be among the most important, far-reaching cases of my lifetime.  

Politically I have always found a bit of both sides in myself.  With conservatives, I share concerns about the growing powers of government.  I was wary of the expansion of power that upholding the mandate would grant to Congress's interpretation of the Commerce Clause. (Yes--I was concerned about the broccoli argument.)

On the other hand, as I have learned more about the Affordable Care Act, it has become more and more appealing.  As a future physician I love the patient protections and expanded access that the health care law provides.  I also believe that sometimes the spirit of the law is more important than the letter of the law.

I hoped for a ruling that satisfied my views on both ends of the spectrum.  

While we waited inside I talked with a political science major from Johns Hopkins University.  When I asked her how she would respond to someone who believes that the ACA violates the Constitution she told me about her "Comparating Constitutions" class.  

"Under the United States Constitution, the government would not be violating its duty if it just sat back and did nothing," she said.  "Other countries' constitutions  have specific provisions written in them that forbid the government from doing nothing.  They have to provide certain services. Because of this, they are much more welcoming of big social changes like health care reform." When I asked if she advocates amending the constitution to have such duties she said, "Well, that's so long and difficult."

Her attitude surprised me.  In effect, she was saying, "Yeah, I realize there are limits in our Constitution, but they shouldn't get in the way of doing what society believes is right." 

Eventually we were shown upstairs to a room with small lockers where we were told to leave all electronic devices and other personal items.  From there we were directed to the courtroom where we waited and whispered for half an hour. Despite my profound lack of sleep, as soon as the Justices walked in a surge of adrenaline flooded my body.  No one but this relatively small group of people I was sitting with would ever witness these words uttered out of Justice Roberts's, Ginsburg's and Kennedy's mouths.  It was amazing to think that I was watching history before anyone else.  

The mandate was found unconstitutional under the Commerce Clause, but constitutional under the taxing power, and the rest of the law stood with it. (The Court did overturn the expansion of Medicaid as coercive, but the only part that was actually removed was the threat of removing all Medicaid funding for states that choose to opt out of the expansion.) I don't think there was a soul there who saw what was coming. As for me, I was elated! Upholding most of the ACA meant that meaningful health care reform would continue, and the check on the Commerce Clause abated my fears of growing Congressional power. Both of my concerns had been addressed.

I was surprised, however, by the "strike-the-whole-thing-down" position taken by the four justices who wrote the dissent.  As I see it, there are many parts of the ACA that are completely constitutional. The opinion of the dissenters seemed to be the mirror opposite of the opinion I had heard from the political science student just an hour earlier. According to the dissent's view of Congress's taxing and spending power, "the Court has long since expanded that beyond ... taxing and spending for those aspects of the general welfare that were within the Federal Government's enumerated powers." They cited "the Department of Education, the Department of Health and Human Services, [and] the Department of Housing and Urban Development" as "sizeable federal Departments devoted to subjects not mentioned among Congress' enumerated powers, and only marginally related to commerce."

In other words, they were saying, "Yeah, these agencies are solving pressing problems, but they extend beyond Congress's constitutional powers." Under similar logic, they argued that the whole Affordable Care Act should be struck down.

Picture:  Associated Press

After the Court finished the rulings, and the term, we were quickly ushered outside.  

Michelle Bachman was on a loudspeaker in the middle of the Tea Party crowd, insisting that since the justices had failed it now falls to the voters to repeal Obamacare.  She was drowned out, at times, by boos and chants of "Four more years" by people holding "we love Obamacare" and "stand up for women's health" signs.

 I stopped to ask a woman holding a "Protecting Our Care" sign what she thought about the ruling.  She was happy, of course, that the law had been upheld.  I followed up by asking her what she thought about Justice Roberts' ruling that the mandate doesn't stand under the Commerce Clause yet does stand under the taxing power.  She gave me a confused look and said, "I don't know what you're talking about."  Caught off guard, I awkwardly ended the conversation as I came to a profound realization:  most of these people here don't care about the specifics.  They're not here to find out how all the details play out.  

I would venture a guess that nearly everyone there that day would very comfortably identify themselves with one of two groups: those for limited government or for social justice.  In each group, as long as their ends are met, the details aren't important.  The limited government crowd wanted the law overturned--despite the fact that our health care system is on life support and millions don't have access to care.  The social justice crowd was elated by the ruling--regardless of its implications for the federal government's power.

In contrast to these groups, Court's job is only to determine whether the law in question is Constitutional--nothing more, nothing less.  As Justice Roberts put it, "we possess neither the expertise nor the prerogative to make policy judgments. Those decisions are entrusted to our Nation’s elected leaders, who can be thrown out of office if the people disagree with them." 

In that sense, it seems like this discussion--between two parties who care more about the ends than the means--is sort of out of place in front of the institution that is primarily concerned with the means. It was precisely the means, the details, that allowed me to feel like the day had been a win-win. By knowing the specifics of the law and the case against it, I felt like I was the only one reveling in a two-sided victory!

If the limited government crowd would have paid a little more attention to the details they may have found a silver lining in their defeat--the ruling on the Medicaid provision could end up being a major limit on federal power over the states, and some liberal bloggers have been complaining that the Court's ruling has "gutted the commerce clause."

Instead of examining the ruling, the groups were too busy volleying taglines. When this type of one way discussion takes place and people disregard the details, they tend to talk past each other.  The result is conflicting, often embarrasing, messages...

...like this:    

...or polls like this (CBS News/NY Times):  

And yet, while it might not always make sense, we have a long tradition of protesting in front of the Supreme Court.  I'm not suggesting that should end. Nor am I suggesting that we need to avoid the use of hyperbole to get one's point across.  Sometimes it can be entertaining.

But, are the two positions really irreconcilable? Can we fix the health care system and still keep limits on governmental power?  I believe we can, and I believe that is what we saw last Thursday.

Politics will continue to play on, speculations about Justice Roberts's reasoning will continue, but if we want to get things done we need to stop talking past each other, care enough to see what the other side has to offer, and build off our common ground.  

In the coming months and years, health care reform must continue. The ACA, though a good step forward, is far from a complete solution to the health care crisis. We have some tough questions ahead of us involving the quality and cost of care. Solving these problems will require our meaningful dialogue and thoughtful consideration of the details.

And by considering the details we may just discover, like I did, that solving problems doesn't have to be one-sided. We can find a middle-of-the-road solution that covers everyone's needs. That way, no one has to feel like they are "left out in the open."

I have an early-onset type of cataract, and my vision has gotten so bad I’m ready for surgery. As a patient, I’m not too happy about being in this situation, but as a health-care-policy wonk, this seems like the perfect opportunity to test one of the central tenets of conservative health-care-reform plans: comparison shopping. Conservatives think one of the reasons health care costs so much is that patients are for the most part completely unaware of the price of medical services. Their solution? Give patients more “skin in the game.”

If you ran a summer camp that never reported the vast majority of times that you hurt one of your campers, you'd probably be shut down, arrested, or worse. The situation would be similar if a restaurant repeatedly made customers sick, or if a skydiving business habitually gave people the wrong parachutes.

Why, then, do hospitals only report about one in seven of the hundreds of thousands of medical errors, infections, and other adverse events that harm patients every year? And why can they get away with it?

That's a crucial question posed by Shannon Brownlee's most recent piece on TIME Ideas: An American Hospital: The Most Dangerous Place? Brownlee addresses the recent report from the US Department of Health and Human Services, which catalogued problems with the reporting system for medical errors and other patient harm. She argues that the reporting problems are only a piece of a larger quality and safety problem, and that hospitals need to move quickly to adopt checklists and other types of safety mechanisms:

"Some hospitals have made great strides in reducing errors and infections using — you guessed it — checklists. About 10 years ago, Dr. Peter Pronovost, an intensive-care specialist at Johns Hopkins Hospital in Baltimore, and a team of colleagues put together a series of checklists for some of the most common procedures performed in the intensive-care unit. For example, they created a list of steps for how to put in a central line — a tube for delivering medication directly into a vein in the patient’s chest — in a way that reduced the risk of infection. They made a checklist to prevent patients on a ventilator, or breathing machine, from contracting pneumonia. When Pronovost was given a grant to get every ICU in the state of Michigan to use just three of his checklists, the result was 1,500 lives saved and the state of Michigan saved $100 million."

You can read the full story here: http://ideas.time.com/2012/01/09/american-hospitals-the-most-dangerous-place/