Tag: Policy

Open Wide: Here comes the change you thought would never happen

The morning after the election, I posted a speculative blog in Health Affairs on three possible scenarios for President-elect Obama’s implementing health reform: folding it into a bold, ambitious emergency legislative package (Complete the New Deal), carving funding out of the current $2.5 trillion national health spend (Braveheart), and postponing implementation until the economy recovers but taking steps now to prepare for it (Wait/Lay the Groundwork).

At the time, the Wait/Lay the Groundwork option seemed 70 percent likely. But with economic conditions worsening, I’m now convinced Obama will probably opt instead for the Complete the New Deal option, and try to implement health reform in the first 120 days of his Presidency, before the health care industry “dragon” can even stir from its cave.

Let’s call Obama’s program The Real Deal. We can already see its contours: an economic stimulus program including highway construction and other state-directed public works, a green energy spending initiative, emergency housing assistance including a foreclosure prevention measure, an auto industry bailout, labor law reform and income supports through tax credits for low income people.

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Is much more than we think really possible?

On THCB today Maggie Mahar basically tells the health reform crowd to be patient. But two members of the unreconstructed left in other venues don’t agree. In the NY Times Paul Krugman says that deficit spending is OK, and correctly points out that Obama has a real mandate to fix the underlying problems of middle America (and yes that would include health care). And yes polling data shows that on balance America is as liberal now as it was in the 1960s. 35 years of blind-ish belief in conservatism is more or less over.

And if you want to see the optimist’s view on what Obama might do, Jonathan Cohn has a long article in The New Republic called Surgical Prep explaining why now is the time for health care reform and how the brass knuckles approach is being put together to get it done.

I’m not sure I’m there but let’s not underestimate how big a political win this was.

Now, a real bipartisan opportunity in health care exists

President-Elect Obama, and about every candidate for Congress, has said he wants to change the partisan tone in Washington. Obama, the Democratic Congressional leadership, and the Republicans have a terrific opportunity to do just that on health care when they all come to Washington early next year.

As I posted earlier, I do not believe there is any chance we can see the enactment of the comprehensive Obama health plan in the near term.

But there are a number of important steps that can be taken next year and each of them have enjoyed strong bipartisan support during the past year:

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If You Have a Right to Health Care, How Much Care?

Hat tip to Kevin M.D. for calling my attention to “The  Covert Rationing Blog,” where Dr. Rich offers a concise summary of the dilemma we  face as we move toward a consensus that health care is not a privilege, but something that every human being should have. (One can call that a “right” or a “moral obligation that a civilized society has to provide health care to everyone.”)

The point Dr. Rich is making is that once you decide everyone deserves health care, the question is “how much care.” As he puts it:

“Exactly how much health care are you entitled to  if you have a right to health care?  Do you have a right to certain  specified health care services, to a certain dollar amount of health care per  year or per lifetime, to  whatever health care it takes to achieve perfect health, or to some other limit or non-limit?

“The question of limits (whether we should have  them or not, and what should  they be) has been a central theme of this blog and of DrRich’s book. To reiterate the fundamental problem: 1) In America we believe that it is wrong to limit health care in any way, that  everyone is entitled to the very best health care, that any bit of health care that offers even a small potential of benefit should be provided, and that death itself is merely a manifestation of insufficient research (or actionable incompetence, or systematic discrimination against the  unwealthy, or corporate greed).  2) But against that closely held belief, we must balance the unremitting law of  economics which tells us that there is simply not enough money in the known  universe to buy all the health care that might potentially offer some small  amount of benefit to every person. Health care spending has to be limited,  or it will become a fiscal black hole.”

Dr. Rich is correct on all counts. Our American love affair with medicine — and in particular, medical technology — is all  tied up with our fear of death, and a feeling  in some quarters, that “American optimism” demands that to strive for immortality. We put such emphasis on the individual, and the individual ego; how can we accept that, someday, it will be extinguished? (I’ll always remember the doctor who told me, in an interview, “Of course, one day, most people will die.” I wonder who he was  excluding from “most people”? )Continue reading…

Confessions of a Physician EMR Champion

Starting this month and continuing for the next year or so, I’ll be presenting a standard talk to physician audiences entitled “Confessions of a Physician EMR Champion,” subtitled “A Conversation with American Physicians About How to Save Medicine in the Age of Information.”

The broad message is that, to be successful, the adoption of health IT by physicians, nurses, and staff must extend communication and health data exchange beyond the narrow confines inside the four walls of their practice. Health IT needs to empower all providers to act as effective members of a team which includes the patient, medical home, specialists, and ancillary service providers such as pharmacists and lab technicians.

My “confession” is that for several years I led a team effort by the American Academy of Family Physicians, its state chapters, and its members, to promote adoption of electronic medical records, or EMR software systems. Between 2003 and 2007, the percentage of the AAFP’s active membership of 60,000 doctors who utilize an EMR from a commercial vendor in their practices jumped from about 10 percent to almost 50 percent. The overwhelming majority of the doctors in these practices consider this a good thing, and would never go back to paper systems. The accumulated knowledge and experience about EMRs among the AAFP’s membership is unparalleled.Continue reading…

Perhaps Obama will have to do rather more than he says he will

I feel like Mrs Miggins in my favorite comedy show, Blackadder. It’s the scene when Blackadder says “The hustings are down, the candidates have spoken and after the madness of a general election, we can return to normal” and Mrs Wiggins says “Has there been an election? I’ve never heard about it?” (Yes that is a much younger version of Dr House playing the Prince Regent).

Anyway I’ve had my head so far up the Health 2.0 rear that until this week I haven’t really paid too much attention to the election. In all honesty (speaking as a Democrat who could never conceive of a Republican win in the current circumstances) I’ve been trundling along expecting an Obama win with the same set of Democrats running Congress but not with the vicious efficacy that Tom Delay & friends showed in getting their bills passed in 2001–2004. So I haven’t been expecting that much change in the healthcare system.

But if you do believe something is going to happen, over at the HuffPo Susan Blumenthal, whom I saw earlier this week, nudges me towards her side by side comparison of the  U.S. Presidential Candidates’ Health Care Plans.

On the other hand, and I’ll be writing more about this before the election, if the recession is bad enough—and this morning’s numbers suggest that it could be—what Obama is proposing may be torn up and we might do something much more radical. It sounds crazy, but then again a year ago you wouldn’t have thought that the US taxpayer was going to own the biggest insurance company and most of the banks. After that actually IS socialism according to Lenin’s “owning the commanding heights of the economy” definition, no matter how much Sarah Palin rails against it. And socialism in health care makes rather more sense than socialism in banking, or autos.

So if there are 90 million uninsured and 15% unemployed, perhaps a Federal rescue package for health care is on its way—we just haven’t seen it poke its head out of the water yet. And if it does, it will likely be much more radical than the gentle proposal Obama is starting with, which the conventional wisdom says is a non-starter anyway.

Safeway uses incentives and transparency to improve employee health

In this interview on “The Business Case for Health 2.0,” Ken Shachmut,
Senior VP Strategic Initiatives, Health Initiatives, and Health
Re-engineering at Safeway, shares is thoughts on some of the highly
impressive results that the company has obtained by introducing market-based
health plans.

SS: Ken, thanks for making time today. Tell me a little about your background?

KS: I have been active as an executive and
management consultant for over 30 years. I graduated from Princeton in
Engineering and later obtained my MBA from Stanford. In consulting, I
worked first with McKinsey & Company,
later at Booz Allen Hamilton, and for awhile independently.  I had done
some consulting for Safeway. I later joined Safeway and have been there
the last 15 years in various capacities.

Due to my consulting background and analytical focus, I am
frequently asked to look at new challenges and opportunities for the
organization. As health care costs continued to rise, we started
looking at ways that we could engage our employees or work with the
unions to control costs. The process has been highly successful, and we
now have broad participation in “market-based health care” (MBHC) plans
– starting with our non-union population and evolving into our union
plans currently. In consequence, our employees are now much more
actively involved in their health care and are making better choices
that improve their health. As a result of our learning and success, we
have helped to create the Coalition to Advance Health Care Reform
(CAHR) which is led by our CEO Steve Burd. CAHR now has over 60
companies as members.

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The inconvenient truth

The Los Angeles Times ran a great series last week called "Shedding Risk" in which it detailed through compelling human stories the erosion of the health insurance market. It’s definitely worth finding the time to read.

Matthew has talked about this eroding model for a while, including in a speech about three inconvenient truths that he gave to health plan executives in March.

Here are four key paragraphs from the first article in The Times‘ series to give you a sense of the articles:

At the heart of the problem is the clash between the cost of medical care and insurers’ need to turn a profit.Today, four publicly traded corporations — WellPoint Inc., UnitedHealth Group, Aetna Inc. and Cigna Corp. — dominate the market, covering more than 85 million people, or almost half of all Americans with private insurance.On Wall Street, they showcase their efforts to hold down expenses and maximize shareholder returns by excluding customers likely to need expensive care, including those with chronic diseases such as asthma and diabetes. The companies lobby governments to take over responsibility for their sickest customers so they can reserve the healthiest (and most profitable) for themselves.Meanwhile, insurance premiums are becoming a heavier burden on employers, many of which say that rising healthcare costs cut into their ability to compete and, in some cases, to survive.

Here are Matthew’s three inconvenient truths to the insurance execs:

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Be careful what you wish for

Charlie Baker is the president and CEO of Harvard Pilgrim Health
. This post first appeared on his blog, Lets Talk Health Care.

The show is
pretty much the same – every time. Public sector entity gets in budget
trouble, cuts have to be made, and providers who do business with the
public sector get hammered – hard. It’s happened with Medicare at
the federal level for years, and it happens with Medicaid at the state
level with some frequency as well.

Well, the show is back in town, as state governments face declining
revenues. In Massachusetts, the state is not only cutting Medicaid
payments prospectively – it’s cutting Medicaid payments for some
providers retrospectively – simply choosing not to make payments to
them they had planned on and expected.

I must say, each time this happens, I can’t help but wonder if the
hospital operators and physician leaders who think a single-payer like
Medicare For All is a good idea ever stop to think about how these
agencies deal with their financial problems.  When they have a problem,
they unilaterally whack their provider community hard – in ways private
sector payers would never consider.

And then those same providers who think Medicare For All is a great
idea turn to the private health plans they do business with and say,
“Hey – you need to help solve my Medicare/Medicaid deficit – which just
got worse.”

Sheesh. All I can say is, “be careful what you wish for.”

A Fantasy Brought to You by the New York Times: Medicine Without Risk

Sometimes I agree with New York Times’ editorials. Sometimes I don’t. But I rarely learn much from them. To my mind, the problem with the form is that it encourages opining without evidence. So, I admit, I rarely turn to the editorials.

But Buckeye Surgeon pricked my curiosity by referring to a recent New York Times editorial as a “masterpiece of naiveté and contempt.”

Such strong language suggested that the editorial might be entertaining. Thus, I went back and read what turned out to be a piece congratulating Medicare for having decided it “will no longer pay hospitals for the added cost of treating patients who acquire any of 10 ‘reasonably preventable’ conditions while hospitalized. Those include incompatible blood transfusions, severe bedsores, injuries from falls, poor blood sugar control, and infections after certain surgeries.”

This is what I mean about editorials: typically they are monologues that cry out for a good copy editor who asks sensible, logical questions.  The first query that springs to mind is this:  exactly what does “preventable” mean?  How is a “fall” preventable?Continue reading…


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