By MAGGIE MAHAR

When President Obama named Dr. Donald Berwick to head the Centers for Medicare and Medicaid (CMS) last March, I wrote this:

“Most who know Berwick describe him a ‘visionary’ and a ‘healer,’ a man able to survey the fragments of a broken health care system and imagine how they could be made whole.  He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. health care.”

To understand what I meant, view these clips from the film, Money-Driven Medicine, where Berwick speaks about the need for healthcare reform. Soft-spoken and charismatic, Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it could be.

And now, it appears that we are going to lose him. Thursday, 42 Senators delivered a letter to President Obama demanding that he withdraw his support for Berwick to head CMS. The Boston pediatrician and co-founder of the Institute for Health Care Improvement (IHI) had received a temporary appointment in July while Congress was on vacation. President Obama re-nominated him in January. But Berwick still needs to be confirmed by the Senate, or he will have to leave his post at the end of this year.

With 42 out of 100 Senators firmly opposed to him, it appears that Berwick’s supporters won’t be able to muster the 60 votes needed to clear the Senate floor. Reportedly, Senate liberals already have given up. According to Politico.com’s Brett Coughlin: “At a meeting with Senate staffers Friday, health care lobbyists and advocates were told that there will be no confirmation hearing and that they’ll soon be discussing ‘next steps’ for CMS.”    If this is true, Berwick is now a lame-duck CMS director without power—as of today. Continue reading “The Fall of Berwick?”

By MAGGIE MAHAR

When I was in my twenties, I was diagnosed with glaucoma. At the time, I didn’t worry about it. I was twenty-something, busy teaching, having babies, writing a book—and, with glasses, my eyesight was 20/20.

It was only when I moved to Manhattan twenty-five years ago that I began to take the disease seriously. A friend recommended an ophthalmologist who, I was told, was one of the best in the city. He regularly turned up on lists of New York’s star specialists, had an office on Park Avenue, and didn’t take insurance of any kind. Twenty-five years ago, this was unusual. But, my employer’s insurance was generous and paid most of his very high fee.

At my first appointment, I mentioned the early diagnosis of glaucoma. After examining my eyes, Dr. X told me that that I must begin using eye drops immediately. I also should begin making appointments to see him every four months so that he could check the “pressure” on my optic nerve. Glaucoma is the second leading cause of blindness in the U.S. There is no cure, but usually it can be controlled with eye drops. “It must be watched carefully,” said Dr. X.

Over a period of years, I saw Dr. X regularly, and continued to use the eye drops, morning and night. At least once a year he prescribed a “field vision test” to check whether my peripheral vision was degenerating. Meanwhile, an appointment with Dr. X killed an afternoon. He kept his waiting room full. And while he had many minions (young assistants who seemed afraid of him), he was a solo practitioner, so the line moved slowly. He once explained to me that he preferred solo practice because, “I don’t want anyone looking over my shoulder.” Continue reading “Guess Who Has Been Over-Treated For More Than Twenty Five Years?”

By MAGGIE MAHAR

The Mainstream Media Rarely Tries to Explain the Congressional Budget Office’s nearly unbelievable claims that the Patient Protect and Affordable Care Act can:

1)  Pay for itself

2)  Provide coverage for 32 million uninsured Americans

3) Trim this nation’s deficit by some $143 billion over the next ten years

And, that’s not all. Medicare’s Trustees say that the reform legislation puts Medicare on the road to financial solvency–while limiting co-pays and beefing up benefits.

You might well ask: How can this be? How can we provide insurance for an additional 32 million people, improve Medicare, and simultaneously save money?

The media has not been a great help in answering these questions. This is, in large part, because the good news lies in the details—dozens and dozens of details. Fleshing out the myriad ways that the ACA generates new revenues while reining in health care spending would take up far too much time on a cable television show—and way too much space in most newspapers.

Continue reading “How Reform Law Funds Itself, Strengthens Medicare, and Cuts the Deficit: Part 1″

By MAGGIE MAHAR

The emphasis on primary care as the “key” to lifting the quality of U.S. healthcare may be exaggerated according to a report, released today, by Dartmouth’s Institute for Health Policy & Clinical Practice.

“Primary care forms the bedrock of a well-functioning, effective health care system,” the researchers observe. But– and this is an important caveat- “simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage, may not be enough to improve the quality of care or lead to better outcomes.”

Wait a minute. In past reports, didn’t Dartmouth’s researchers tell us that patients fare better if they see fewer specialists and more internists?

No. Dartmouth’s earlier studies have shown that when patients see more specialists, care is more aggressive and more expensive, but, on average, outcomes are no better—and sometimes they are worse. This, however, doesn’t mean that primary care, by itself, ensures better care, even if a patient sees her PCP on a regular basis.

As the report points out: “Primary care is most effective when it is embedded in a high-functioning system, where care is coordinated, where physicians communicate with one another about their patients, and where feedback is available about performance that allows physicians and local hospitals to continually improve.”

Policy should “focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals,” says Dr. David C. Goodman, lead author and co-principal investigator for the Dartmouth Atlas Project.

Continue reading “Primary Care is Not a Panacea: It Takes a Team”

By MAGGIE MAHAR

If conservatives manage to kill health care reform legislation, what will happen next?

I really don’t want to go there.

First, I’m convinced that conservatives won’t be able to repeal the Affordable Care Act (ACA). Democrats will hold onto the Senate, and President Obama still has a veto. If necessary, he will use it to protect the bill. Meanwhile, the majority of the public either favors the legislation or want to “wait and see” how well it works. Most voters would be utterly disgusted if Congress returns to the health care debate this fall. It was ugly the first time around; virtually no one wants to watch re-runs on C-Span. In the months ahead, Americans hope that their elected representatives will do just three things: create jobs, create jobs, and create jobs.

Secondly, if conservatives somehow succeed in crippling the reform bill, we will find ourselves back in a world of laissez-faire health care where medical spending continues to spiral by 4.5% to 9% a year (just as it has for the past ten years), thanks to a combination of climbing prices and rising utilization.

Here, I’m not talking about how much insurance premiums rose: reimbursements that private insurers, Medicare and Medicaid paid out to hospitals, doctors and patients over the past ten years have been climbing by 4.5% to over 9% annually.

In some years, Medicare reimbursements were growing faster; in other years, payouts by private insurers levitated. Over the same span, Kaiser reports that premiums for a family plan rose by an average of 13.1% a year.

Continue reading “If Reform Fails”

By MAGGIE MAHAR

This week, the Cato Institute released a 52-page report on health care reform titled: Bad Medicine: A Guide to the Real Costs and Consequences of the New Health Care Law.

The tract was written by Michael Tanner, a senior fellow at the Institute, and it rests on the thesis that the Patient Protection and Affordable Care Act (ACA) is both Unaffordable and Unfair. Inevitably, Tanner’s claims about affordability are shaky; in truth no one can project how much reform will cost over ten years—and how much it will save. There are too many variables involved. Nevertheless, Tanner seems sure: the legislation will add to the deficit, he asserts, and force insurance premiums higher. Moreover, he stamps the legislation “unjust”: it would turn private insurance companies into regulated “public utilities,” forcing them to insure sick people, while “redistributing income” from families earning “over $348,000” to families earning “$18,000 to $55,000.”  Ultimately, he argues, reform represents yet another step toward turning the U.S. into a “Nanny State.”

Why a 52-page report on health care reform now? Tanner makes his purpose clear in the Introduction where he suggests that conservatives will make the new health care legislation the “centerpiece of Republican campaigns this fall,” as they lobby for repealing the Affordable Care Act, or at the very least, replacing it. Bad Medicine is meant to serve as a playbook for those who hope to kill reform.

With that in mind, The Century Foundation decided that the document deserves scrutiny. In the weeks ahead, I will be analyzing and rebutting the report’s many arguments against individual and employer mandates, insurance regulation, subsidies, reductions in Medicare spending, and the CLASS Act, a much-needed national long-term care program. Continue reading “A Reply to the Cato Institute”

By MAGGIE MAHAR

Tuesday night the White House Blog explained: “In April, President Obama nominated Dr. Donald Berwick to serve as Administrator of the Centers for Medicare and Medicaid Services (CMS). Many Republicans in Congress have made it clear in recent weeks that they were going to stall the nomination as long as they could, solely to score political points.

“But with the agency facing new responsibilities to protect seniors’ care under the Affordable Care Act, there’s no time to waste with Washington game-playing. That’s why tomorrow the President will use a recess appointment to put Dr. Berwick at the agency’s helm and provide strong leadership for the Medicare program without delay.”

A “recess appointment” means that the president is putting Berwick in place while Congress is on recess (i.e. is taking a vacation). As a result, Berwick won’t have to go through a Senate confirmation hearing. Senate conservatives had made it clear that they hoped to defer this hearing for as long as possible.

The White House Blog notes that “CMS has been without a permanent administrator since 2006, and even many Republicans have called on the Administration to move to quickly to name a permanent head.”

Continue reading “In a Surprise Move, Administration Appoints Berwick to Head CMS”

By MAGGIE MAHAR

Kaiser Health News (KHN) reports that “the nomination of Dr. Donald Berwick to run the agency overseeing Medicare appears to be languishing.”   Friday, KHN’s “Health Policy Week in Review” quoted a story that appeared in the New York Times a few days earlier:

“Hospital executives who have worked with Dr. Berwick describe him as a visionary, inspiring leader. But a battle has erupted over his nomination, suggesting that Dr. Berwick faces a long uphill struggle to win Senate confirmation. Republicans are using the nomination to revive their arguments against the new health care law, which they see as a potent issue in this fall’s elections, and Dr. Berwick has given them plenty of ammunition. In two decades as a professor of health policy and as a prolific writer, he has spoken of the need to ration health care and cap spending and has confessed to a love affair with the British health care system.”

KHN also points out that according to The Hill, although Senate leaders are nearing an agreement to allow more than 60 Obama nominees to be approved to begin work, Berwick is not on the list  . “‘He will not get unanimous consent,’ a spokesman for Senate Minority Leader Mitch McConnell (R-Ky.) told The Hill.

I am not at all persuaded that Berwick’s confirmation is in trouble. As the highly-respected president and CEO of the Institute for Health Care Improvement, Dr. Berwick enjoys support that ranges from the AARP to three former directors of the Centers for Medicare and Medicaid (CMS) who served under Republican presidents. “This is not really about Don Berwick,” John Rother, executive vice president for policy and strategy at the AARP told McClatchy Newspapers. “In ordinary times, the nomination of somebody with Don’s record and standing in the field would not be controversial.” Thomas Scully, who led the CMS under President George W. Bush agrees: “He’s universally regarded and a thoughtful guy who is not partisan. I think it’s more about … the health care bill. You could nominate Gandhi to be head of CMS and that would be controversial right now.” Continue reading “Dr. Berwick’s Last Stand?”

By MAGGIE MAHAR

Friday, June 18, the Senate aproved a plan that blocks a 21 percent cut in Medicare payments to physicians; the axe was scheduled to fall that day. Leadership on both sides of the aisle pushed for the reprieve; it will remain in place for six months. The measure will now need to be considered by the House, which in May approved a fix that would last longer. If the House agrees–and it is all but certain that it will–the 21 percent cut wil be replaced with a 2.2 percent pay hike. The bill will not add to the deficit. The proposal is fully offset by changes in Medicare billing regulations, antifraud provisions and the tightening of some pension rules, eliminating Republican objections that it would push the federal government deeper into debt.

In six months, Congress will have to consider the matter once again, just as it has ever year since 2003. This is the third time this year that Congress has averted Draconian cuts to physician’s payments. What, you might wonder, is going on? Here is the backstory: in 1997, Congress enacted a so-called “sustainable growth rate” (SGR) mechanism to keep Medicare physician reimbursement rates in check. Congress has never allowed the full cuts called for under the SGR formula to take effect and it never will.

Why don’t legislators simply repeal the cuts to doctors’ fees that they have been postponing for years? Why just put off the measure for another six months?

Because too few of our elected representative possess the chutzpah to stand up and say that blind across-the-board cuts were an extraordinarily dumb idea in the first place.

Continue reading “Nope. Won’t Happen.”

By MAGGIE MAHAR

Last week, I commented on a New York Times story that appeared Wednesday, June 2, attacking the Dartmouth Research.  The work that Dartmouth has done over the past two decades suggests that hospitals in some parts of the country are over-treating patients. Over-treatment means that patients who didn’t need to be in the hospital in the first place are exposed to the side effects of treatment as well as gruesome hospital- acquired infections, medication mix-ups and a host of other medical errors. Thus unnecessary care puts patients at risk while helping to drive health care bills heavenward— and suggests that we could rein in Medicare spending by squeezing some of that hazardous waste out of the system.  But according to the Times: “Data [from Dartmouth] Used to Justify Health Savings Effort is Sometimes Shaky.”

In Part 1 of this post I discussed what two of the Times’ sources told me about how the Times’ reporters misrepresented what they said. Both Harvard economist David Cutler and Yale’s Dr. Harlan M. Krumholz complained that the story made it seem that they are critics of the research, when in fact they agree with Dartmouth on the basic message of the data, and see the work as, in Krumholz’ words “pivotal to moving us forward  . . . we all agree that there is lots of waste and it is unevenly distributed across the country.” A third source in Washington D.C. who talked to the Times reporters confided that they seemed to have a clear agenda: “to take down Dartmouth.”

Today, I received evidence from yet another unhappy source—the Wisconsin Collaborative for HealthCare Quality, a voluntary consortium of organizations working to improve the quality and cost-effectiveness of healthcare in Wisconsin. Chris Queram, the Collaborative’s president, and Jack Bowhan, who guides the development of value metrics for the group, report that they tried to caution New York Times reporter Gardiner Harris that he was misusing their data,   “comparing apples to grapefruits,” and “jumping to a conclusions that  you just can’t make.”  Harris ignored their warnings.

As proof, they produced a series of e-mails that they sent to Harris, and with their permission, I’m quoting from those messages. But first, an excerpt from the Times’ story talking about the Collaborative’s data.

Continue reading “Apples to Grapefruits”