Recent articles highlight challenges with holding providers accountable for the care they deliver. One of the major thrusts of efforts to transform the American healthcare delivery system has been to become more patient-centered and to allow patients to provide feedback that matters.
Emblematic of this is the emphasis on patient involvement in the final rules for the Shared Savings Program accountable care organizations (ACO).
Echoing former Centers for Medicare & Medicaid Services Director Don Berwick’s plea on the behalf of patients (“Nothing about us without us”), the ACO final rules emphasize patient engagement in governance, quality improvement and the individual doctor/patient interaction.
Michael Millenson’s white paper provides a summary of the patient empowerment movement.
The development of the patient activation measure (PAM) and the Center for Advancing Health’s 43 engagement behaviors has allowed us to study patient-centeredness with more specificity. Studies have shown that activated patients are less likely to choose surgical interventions, have better functional status and satisfaction, are more likely to perform self-management behaviors, and report higher medication adherence rates.
Healthcare policy experts and payers have embraced the argument outlined above, and patients’ reports of their satisfaction with both physicians and hospitals have increasingly been used to calculate financial rewards.
The new Patient-Centered Outcomes Research Institute (PCORI) has been asking different stakeholders about the most important issues to address with the hundreds of millions of dollars the quasi-governmental group will shortly be doling out in grants. Not surprisingly, the stakeholders have been more than happy to respond.
PCORI’s most recent day of dialogue, which I attended as a representative of the Society for Participatory Medicine (SPM), was characterized by genteel civility and a big question mark: “Is PCORI serious about transforming health care?” When I asked directly, I didn’t get much of an answer. The reason, I suspect, goes to PCORI’s origins. It is the offspring of a shotgun marriage between goo-goos and pinky-ringers, and no one is quite sure yet what this child will be once it grows up.
Let me pause here a moment to parse the political shorthand. “Goo-goos” are “good government” types, the kind of folks who trumpet the need for transparency in government or better public transit. Goo-goos, seeing the half trillion dollars or so of waste in U.S. health care system, called for a new national organization to carry out comparative effectiveness research in order to help Americans get the most value for our money.
The goo-goos pointed out that our current regulatory structure is designed to ensure that treatments are safe and effective, not compare them. Nor does the private sector have much incentive to pay for comparative studies that may undermine products currently selling quite nicely, thank you.
With some pundits predicting that President Obama’s re-election could be sabotaged by a slim level of white voter support, I decided to dig through the small print on Obamacare to see how this right-wing lightning rod actually affects my fellow Caucasians.
It turns out that the high-profile legislative highlight of Obama’s first term is very good for white people. When the Affordable Care Act is fully implemented, 12.3 million more white people will have health insurance than have it today, according to an analysis in Health Affairs.
Obamacare looks even more positive for the pale skinned when put next to the Romney-Ryancare alternative. If Obamacare is repealed and replaced by the health reform plan Presidential-candidate Romney now proposes – not to be confused with the plan Massachusetts then-Gov. Romney enacted into law — an extra 24.8 million white people will not have health insurance. (That’s if you apply current demographics to a recent Commonwealth Fund analysis.)
By way of perspective, that’s nearly equivalent to the entire population of Texas (but all white people) having to cope with serious problems accessing medical care and paying for it. Or to use a more politically compelling comparison, 24.8 million white people would be more than twice the size of the whole population of Ohio.
The flap greeting Mitt Romney’s cheerful admission that as president he’d defund Big Bird’s nesting place on public television could turn out to be good news for a federal agency promoting safe medical care that faces a similar extinction threat. But we won’t know till after the election whether the little-known agency benefited from Big Bird’s protective presence.
The stage was set for Romney’s Big Bird boast by a bill Republicans pushed through a House Appropriations subcommittee in July that slashed or eliminated budgets for a host of programs, including public television’s parent, the Corporation for Public Broadcasting. A committee statement at the time said the move was meant “to encourage CPB to operate exclusively on private funds.” That same bill completely abolished the Agency for Health Care Research and Quality (AHRQ).
The end of AHRQ didn’t even rate a separate mention in the committee’s lengthy press release. And while Politico reported that a Democratic subcommittee member called it “the only federal agency whose sole mission is to improve the quality, safety and cost efficiency of health care,” the subcommittee’s GOP chairman said, in effect, the death sentence was nothing personal. It was just a budget-balancing action and “not a reflection on anything.”
There is a corner of the health care industry where rancor is rare, the chance to banish illness beckons just a few mouse clicks away and talk revolves around venture deals, not voluminous budget deficits.
Welcome to the realm of Internet-enabled health apps. Politicians and profit-seeking entrepreneurs alike enthuse about the benefits of “liberating data” – the catch-phrase of U.S. Chief Technology Officer Todd Park – to enable it to move from government databases to consumer-friendly uses. The potential for better information to promote better care is clear. The question that remains unanswered, however, is what role these consumer applications can play in prompting fundamental health system change.
Michael W. Painter, a physician, attorney and senior program officer at the Robert Wood Johnson Foundation, is optimistic. “We think that by harnessing this data and getting it into the hands of developers, entrepreneurs, established businesses, consumers and academia, we will unleash tremendous creativity,” Painter said. “The result will be improved and more cost efficient care, more engaged patients and discoveries that can help drive the next generation of care.”
The foundation is backing up that belief with an open checkbook. RWJF recently awarded $100,000 to Symcat, a multi-functional symptom checker for web and mobile platforms. Developed by two Johns Hopkins University medical students, the app determines a possible diagnosis far more precisely than is possible by just typing in symptoms as a list of words to be searched by “Dr. Google.” Symcat also links to quality information on different providers and can even direct users to nearby emergency care and provide an estimate of the cost.
The empowered patient, skeptical of professional authority, is not a new phenomenon: he was actually created by the American Revolution.
Reading through historian Gordon Wood’s Pulitzer Prize-winning book, The Radicalism of the American Revolution, I came across a passage describing how national independence from the British led to an independent turn of mind in other spheres. Wood writes that Charles Nisbet, president of Pennsylvania’s Dickinson College, complained as early as 1789 that Americans were carrying their reliance on individual judgment to ridiculous extremes. He fully expected, he said, to see soon such books as “Every Man his own Lawyer,” “Every Man his own Physician,” and “Every Man his own Clergyman and Confessor.”
In fact, New York’s Medical Repository wrote in 1817 of a shortage of “professional pharmacists” at a time when they did drug-mixing and diagnostic duties. But while the Repository acknowledged the lack of professionalism might lead to some mistakes, it continued that “these mistakes would be no more than occurred in Paris, London or Edinburgh, ‘where pharmacy, as a profession, is scientific, exclusive and privileged,’” writes Wood. (Emphasis in original) What a remarkable attitude!
Around this same time, the word “statisticks” appeared for the first time in American dictionaries. However, in America, there was a growing opinion that facts could speak for themselves without expert interpretation. As one popular journal put it in 1811, “The reflections arising out of [the facts] should be left to the reader.”
Like the hero in an old-time movie, Chief Justice John Roberts metaphorically untied Obamacare from the railroad tracks and, with four of his colleagues, pulled it away from the onrushing destructive force of his right-wing colleagues in the nick of time. In doing so he also saved President Obama from political disaster.
Alas, just like in the movies, the villains will soon be back.
While the next five months will determine whether the Court ruling upholding health reform was a victory or just a reprieve, the president has been plucked from the perils of a politically ruinous headline: “Signature achievement of constitutional lawyer president declared unconstitutional.”
In doing so, the Court showed why Americans hate the other guy’s lawyer and love theirs. Roberts embraced his inner reactionary by ruling that the individual mandate did not meet the requirements of the Commerce Clause — even though virtually all respected conservative jurists believe it does, and the conservative Heritage Foundation clearly believed it did when proposing the idea under a Republican president.
However, the Court avoided what would look like a political decision overturning the entire law by ruling that the penalty for not buying health insurance was a constitutionally permitted tax. Which made the law constitutional. Game. Set. Match. (Well, unless you were a poor person counting on an expansion of Medicaid. But if you’re poor, you should be used to losing.)
Don’t you love clever lawyers? At least when they’re on your side?
While it’s comforting to just blame the GOP for the unhappiness with health reform threatening the president’s re-election, the truth is that Barack Obama repeatedly botched, bungled and bobbled the health reform message. There were three big mistakes:
The Passionless Play
While Candidate Obama proclaimed a passionate moral commitment to fix American health care, President Obama delved into legislative details.
When a Baptist minister at a nationally televised town hall asked in mid-2009 whether reform would cause his benefits to be taxed due to “government taking over health care,” Candidate Obama might have replied that 22,000 of the minister’s neighbors die each year because they lack any benefits at all. Instead, President Obama’s three-part reply recapped his plans for tax code fairness.
While Republicans railed about mythical “death panels,” and angry Tea Party demonstrators held signs showing Obama with a Hitler moustache, the president opted to leave emotion to his opponents. The former grassroots organizer who inspired a million people of all ages and ethnicities to flock to Washington for his inauguration never once tried to mobilize ordinary Americans to demand a basic right available in all other industrialized nations. In fact, he hasn’t even mobilized the nearly 50 million uninsured, who have no more favorable opinion about the new law than those with health insurance!
“We are now contemplating, Heaven save the mark, a bill that would tax the well for the benefit of the ill.”
That’s not a quote from oral arguments at the Supreme Court over the constitutionality of the Affordable Care Act or from one of the earnest conservatives demonstrating against it outside. It’s actually the beginning of an editorial in the Aug. 15, 1949 issue of The New York State Journal of Medicine denouncing the pernicious effects of health insurance. To be clear: not government-mandated health insurance, but all third-party health insurance.
I wrote about that editorial in a July 16, 2009 blog entitled, “GOP to Uninsured: Drop Dead.” My blog was prompted by a Wall Street Journal op-ed the previous day from Dr. Thomas Szasz, an emeritus professor of psychiatry, who counseled readers not to confuse ethics and economics:
The idea that every life is infinitely precious and therefore everyone deserves the same kind of optimal medical care is a fine religious sentiment and moral ideal. As political and economic policy, it is vainglorious delusion….We must stop talking about “health care” as if it were some kind of collective public service, like fire protection, provided equally to everyone who needs it….If we persevere in our quixotic quest for a fetishized medical equality we will sacrifice personal freedom as its price.
This was a month before Oklahoma GOP Sen. Tom Coburn, a physician, told a sobbing, middle-aged woman that “government is not the answer” after she confessed she couldn’t afford care for her brain-injured husband. The crowd of Coburn constituents gathered to discuss health care reform applauded. And it was before Texas Rep. Ron Paul, also a physician, responded evasively when asked by moderator Wolf Blitzer at a September, 2011 GOP presidential debate what should be done about an uninsured 30-year-old working man in a coma.
The Medicare program is betting on a new course of action to curb what one medical journal has dubbed an “epidemic” of uncontrolled patient harm.
The effort is pegged to the success of a little-known entity called a “hospital engagement network” (HEN). In December, the government selected 26 HENs and charged them with preventing more than 60,000 deaths and 1.8 million injuries from so-called “hospital-acquired conditions” over the next three years. That would be the equivalent of eliminating all deaths from HIV/AIDS or homicide over the same period.
Despite those big numbers, and an initial price tag of $218 million, it’s unclear whether the HENs are adequately ambitious or still only pecking away at the patient safety problem. While this is by far the most comprehensive public or private patient safety effort ever attempted in this country, it still aims to eliminate less than half the documented, preventable patient harm.
The inspiration for these networks comes from similar collaborative projects run by the Institute for Healthcare Improvement and other groups. Dr. Donald Berwick, IHI’s founder and president, headed up the Centers for Medicare & Medicaid Services for two years and launched a larger Partnership for Patients that includes the HENs.
In December, the government chose a mix of national and local groups — primarily health systems and hospital organizations — to run individual HENs. Each HEN is charged with spreading safety-improvement innovations that have been proven to work in leading hospitals to others through intensive training programs and technical assistance. Although the program lasts three years, initial HEN contracts are for two years, with an “option year” dependent upon performance.