Month: November 2010

The War Between the States

Nov 10, 2010• 3

By MICHAEL TURPIN

Christmas is the time when kids tell Santa what they want and adults pay for it. Deficits are when adults tell government what they want and their kids pay for it. ~Richard Lamm

The day after a mid-term tidal wave of anti-incumbency sentiment swept through Congress resulting in the GOP reclaiming a controlling majority in the House and closer parity in the Senate, a seemingly contrite President Obama took personal responsibility for his party’s dismal showing at the polls. In a carefully worded conciliatory message, the President shared that, “the American people have made it very clear that they want Congress to work together and focus their entire energies on fixing the economy.”

Newly minted House Majority leader, John Boehner, subsequently reconfirmed that the GOP would not rest until Congress had reined in government spending. This would be partly achieved by deconstructing the highly unpopular and “flawed” Patient Protection and Affordable Care Act – a “misguided” piece of legislation that would actually increase costs for employers thereby reducing the nation’s ability to jump-start an economy that relies on job creation and consumer spending. In Boehner’s mind, government is not unlike the average American, overweight – it’s budget deficits bloated by the cost of financial bailouts, Keynesian stimulus spending and failure to discuss the growing burden of fee for service Medicare.

The President’s failure to acknowledge healthcare reform in his speech was interpreted by many as deliberate and only served to cement the perception that in Washington, it will impossible to have constructive dialogue around the imperfections and potential unintended consequences of PPACA. The White House’s resolve to defend its hard-fought healthcare legislation is likely to extend the polarizing partisanship that has come to characterize Congress. The impasse may very well spark a two-year period of bruising, bellicose finger-pointing over how to fix rising healthcare costs.

Dartmouth Launches New Degree Program in Health Care Delivery Science

Nov 10, 2010• 1

In the wake of health care reform, leaders in the industry need a new set of tools to navigate through a health care landscape that has changed forever. In response, the Tuck School of Business at Dartmouth and The Dartmouth Institute for Health Policy and Clinical Practice (TDI) have joined together to create a new and timely Master of Health Care Delivery Science (MHCDS) degree program. Applications are currently being accepted.

Aimed at working managers and professionals in health care organizations with high potential to become change agents in their field, the 18-month MHCDS program will combine a strategic mindset and a scientific approach to current and future health care delivery challenges.

“Reform of the existing health care system has been desperately needed,” said Dr. James N. Weinstein, Director of TDI and recently-named President of the Dartmouth-Hitchcock Clinic. “The challenge for those of us running systems today is to transform our institutions to succeed in this new world by focusing on how to provide high-value, high quality care, while lowering the costs of delivering that care.”

Launched by Dartmouth College President Dr. Jim Yong Kim, the interdisciplinary program will blend TDI’s pioneering research in health care pattern and practice, delivery innovation, and payment models, with the Tuck School’s expertise in strategy and how to effectively create and execute change.

The Race is On for the Next Generation of Healthcare

Nov 9, 2010• 1

By CAROLE HODSDON

I continue to be amazed at the speed at which the mobility and portability of healthcare is developing. It is readily apparent that the technologies, devices and other innovations that we always knew would transform the delivery, consumption and administration of healthcare—but that always seemed years away—are in fact now here.

It’s kind of like that car commercial from a few years ago that asked why we’ve never actually seen the cool and futuristic concept cars that auto manufacturers have teased us with over the years; except in this case, all of the neat and futuristic stuff is right there just waiting for us to put it to good use. It’s called telemedicine, at the risk of oversimplifying, and combined with the change that has actually been legislated for healthcare over the past year, it’s putting the system on the threshold of an entirely new era.

For example: Remember the dark ages of, say, 1998 or 2000 when patients were given heart monitors to wear and then had to phone their doctor to report the various data? Well, it’s pretty safe to say that we can relegate those to the same time capsule as the VCR and the rotary telephone. Fast forward to today and you’ll find wireless, Bluetooth-enabled devices that can deliver the same information—and a lot more, in fact—in real time, 24/7. How about unlimited geographic boundaries for the delivery of medicine? Think of a lung specialist in Philadelphia rendering his expertise to a patient in rural Australia without leaving the comfort of his desk chair. Tired of being handed a clipboard and then interrogated about your medical history every time you see a new doctor? What if that information—in more breadth and detail than you can remember or are probably even aware of—was delivered to your doctor long before you even showed up for your appointment? And how about if, afterward, it was updated automatically and then followed you to your next specialist appointment?

THCB Healthcare Marketplace

Nov 9, 2010

The OptumHealth Culture of Health Institute is hosting a webinar that explores how employers can boost employee participation in wellness programs by adopting marketing strategies used by top consumer retail companies. This event will feature Rohit Kichlu Senior Director Wellness Marketing, OptumHealth and John Waters Director Wellness Consulting, OptumHealth. November 9, 2010, 1 – 2 pm EST. You can register here —

http://innovate.optumhealth.com/ImprovingWellnessEngagement1110_18/

Health Care and the 2010 Midterms

Nov 8, 2010• 15

By ROBERT LASZEWSKI

The election has given us a Republican House and a still Democratic controlled Senate. But, instead of Democrats having the 60 Senators they had when health care was passed in December, they will have a slim majority in the new Congress of 53 seats when the two Independents who caucus with them are counted.

Exit polls clearly show an anti-health care law sentiment. Exit polls done for the AP found 48% of Tuesday’s voters want the new health care law repealed, 31% want it expanded, and 16% want it left as is.

Remember those swing Democratic House votes that were on the fence over the health care bill last March? Most who voted for it are out of work this morning—and all but 11 of the 34 of them who voted against it also went down to defeat. Why did even those who voted against the new health care law lose their jobs? Because of one vote they all had in common–they voted for Pelosi as Speaker.

An issue, guaranteed

Nov 8, 2010• 16

By PAUL LEVY

I don’t mean this in a partisan way, but it is really distressing to read this New York Times article about Republican plans to dismantle parts of the recent health care bill by using the appropriation powers of the House of Representatives. I say this because of the unintended consequences that will result if they are successful in this approach. Let me give an example.

I think one of the most important aspects of the law is “guaranteed issue” of health insurance: Insurance companies will no longer be permitted to use pre-existing medical conditions as a bar to coverage. A concomitant of guaranteed issue is the individual mandate, the requirement that all people purchase health insurance. Why?

Left to their own, insurers will impose pre-exisiting conditions types of restrictions because they understand the moral hazard aspect of insurance. Healthy people provide an actuarial balance to sick people. If people only buy insurance when they need care, the risk profile of the insured population rapidly swings, upsetting the actuarial calculations used to establish premiums. So, if these restrictions are outlawed, everybody needs to be in the risk pool. Accordingly, you have to ban optional insurance.

But look at this quote from the article cited above:

Republican lawmakers said, for example, that they would propose limiting the money and personnel available to the Internal Revenue Service, so the agency could not aggressively enforce provisions that require people to obtain health insurance and employers to help pay for it.

I think the Republicans know that guaranteed issue is popular with Americans, and so they do not directly want to repeal that provision of the new law. But what will happen if healthy people start to opt out of getting insurance, only to return when they get sick? The system will quickly get out of balance. Ironically, this will only cause premiums to rise. I don’t understand why the Republicans would want that to happen, and I fail to see a strategic political advantage arising from that result.

This makes me wonder if they have thought this through completely and whether they understand the unintended consequences of their proposed actions.

Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

The $6-an-Hour Health Minimum Wage

Nov 8, 2010• 7

By JOHN GOODMAN, PhD

The stunning election results will put even more pressure on Congress to deal with the economy and jobs when it reconvenes in mid-November. But as it turns out, one way to boost the economy is to reconsider the health reform bill.

Most people intuitively know that the worst thing government can do in the middle of the deepest recession in 70 years is enact policies that increase the expected cost of labor. Yet that is exactly what happened last spring, with the passage of the Affordable Care Act (ACA).

How bad is it? As I explained at my own blog the other day, right now we’re estimating the cost of the minimum benefit package that everyone will be required to have at $4,750 for individuals and $12,250 for families. That translates into a minimum health benefit of $2.28 an hour for full time workers (individual coverage) and $5.89 an hour (family coverage) for fulltime employees.

Granted, the law does not specify how much of the premium must be paid by the employer versus the employee — other than a government requirement that the employee’s share cannot exceed 9.5% of family income for low- and moderate-income workers and an industry rule of thumb that employers must pick up at least 50% of the tab. But the economic effects are the same, regardless of who writes the checks.

In four years’ time, the minimum cost of labor will be a $7.25 cash minimum wage and a $5.89 health minimum wage (family), for a total of $13.14 an hour or about $27,331 a year. (I think you can see already that no one is going to want to hire low-wage workers with families.)Continue reading…

Wachter: Three Stories

Nov 8, 2010• 5

By ROBERT WACHTER, MD

In my travels, I frequently hear short stories that help illuminate my work and world. Here are three recent examples; think of them as little health policy tapas.

I recently spoke in a session with Peter Pronovost, the Johns Hopkins intensivist who is the world’s top researcher in safety and quality. We were talking about why engaging physicians in this work – so called “adaptive change” – is sometimes so difficult. Peter recalled a story about his son, who at age 6 came home and told his parents that he was terrified to enter the school bathroom. “There are monsters in there,” he said. His parents reassured him that there weren’t, but the next day he returned, wide-eyed and still panicked. Peter called the school to see if they had any explanation for his son’s sudden bathroom phobia. “Oh, we put in automatic flush toilets last week, and I guess we didn’t explain it to the kids,” said the teacher.

Peter’s point was that we often ask physicians (and others in healthcare) to absorb a tremendous amount of change without giving them the background and tools they need to understand these “monsters.” It’s a lesson worth remembering.

At the same conference, I went to a terrific session given by one of my UCSF colleagues, Adams Dudley, another critical care physician and one of the nation’s experts on the impact of transparency and pay-for-performance strategies on quality. Adams was discussing his observation that physicians often feel that they – unlike every other soul on the planet – are not influenced by monetary incentives. He told this story:

Sharing the Burden

Nov 8, 2010

By RICHARD SLOAN, PhD

Jessie has written about her perspective as the patient in an extremely stressful situation. I can add a different one: that of the husband of my seriously ill wife.

As a public person, Jessie not only has a great many friends and loved ones but also many colleagues and professional acquaintances around the country and the world. She had time to tell only a handful of people about her new diagnosis and that surgery was imminent. We discussed at length about how open she wanted to be about her condition and she decided that being completely open was “walking the walk” of a patient advocate. So I gathered a list of e-mail addresses to alert a wide network of friends and with the assistance of another friend, set up a website where I would periodically post updates on Jessie’s condition, and got a Google Voice phone number for people to leave messages for her.

Because the website was publicly accessible, I was concerned about just how much to share. Since Jessie’s major interest is in the role that people play in their health care, she has been exceptionally open about her own medical history and it is no secret that she has had multiple cancer diagnoses and a serious heart condition. Accordingly, disclosure of the nature of her stomach cancer and the surgical realities seemed in order. So I provided some details in the blog, most especially the significant surgical result: that the tumor was successfully removed and that Jessie retained about one-fourth of her stomach. The rest of the blog consisted of “color commentary,” like how many laps she had walked around the floor and whether she was bored.

A Prevention Revolution

Nov 8, 2010• 9

By SUSAN BLUMENTHAL, MD

“I will prevent disease whenever I can, for prevention is preferable to cure.” These are the words of the Hippocratic Oath, an ancient vow that has been recited by physicians for centuries. However, with seven out of 10 deaths in America attributable to largely preventable chronic illnesses, including heart disease, stroke, chronic lung disease, diabetes and some types of cancer, we have yet to see these words put into practice. Such is the history of our nation’s health care — or, perhaps more appropriately, “sick care” — system, where 75 percent of today’s U.S. health care dollars are spent on chronic illness and only three to five percent to prevent these diseases. Until now. As implementation of the recent health-reform legislation begins, our nation is finally putting prevention into practice. By providing significant financial support for preventive services and programs, the Patient Protection and Affordable Care Act (ACA) builds the foundation for a prevention revolution and moves our country closer to making Hippocrates’ vision a reality today.

Thanks to the new law, patients now will receive free preventive services at the doctor’s office. The ACA mandates that private health insurance plans established since March 23, 2010, must cover, without cost sharing, the services recommended by the U.S. Preventive Services Task Force. Additionally, as of September 23, 2010, all insurance plans must include these preventive services with their annual enrollment cycle except for those plans that have been grandfathered. This requirement will also apply to Medicare by the year 2011 and to Medicaid on a state-by-state basis. Recent research has shown that providing just five of these services — colorectal and breast-cancer screenings, flu vaccines, counseling on smoking cessation and regular aspirin use — could avert as many as 100,000 deaths every year. As a result of these new provisions, millions of Americans will now have free access to these preventive services and others, including additional cancer screenings, routine check-ups, vaccinations, prenatal care, and counseling regarding smoking, alcohol use, nutrition and obesity. This expansion of coverage represents a leap forward in our nation’s shift towards a prevention-oriented health-care system, to the benefit of millions of people. However, what happens in the clinic is only one element of a comprehensive public health approach that is needed to make this transformation a reality.