Tag: Policy

Health Reform Prospects Fade as Presidential Campaign Enters Homestretch

Jeff Goldsmith is President of Health Futures, Inc, and a professor of public  health sciences at the University of Virginia.

As presidential aspirants geared up their issue analyses last fall, health reform ranked as the number one domestic policy item the next President should address in many national public opinion polls. As the campaign season draws to a close, however, health reform has virtually disappeared from the headlines, supplanted by concern about gas prices, home mortgage foreclosures, soaring food costs and, most recently, the "Soviet" invasion of Georgia. Though you will hear campaign rhetoric  from both parties at their upcoming conventions, health reform has been demoted to the second tier of campaign issues. Their platforms and campaign pledges on health reform seem increasingly unlikely to decide who is the next president of the United States.

As previously argued in this space, "health reform" really meant doing something about "health costs for my family" to most voters, not reducing inequity in access to coverage. Ninety-three percent of the voting public has health insurance of some kind. It is clear now that  voter concern last fall about health reform was really a leading indicator of anxiety about the deteriorating economy and their own household economic insecurity. As Brian Klepper pointed out a few months ago in THCB, the purchasing power in real dollars of the American paycheck moved into negative territory last September, thanks to the rising price of energy, food and the resetting of home mortgages to higher rates. All these problems have worsened materially in the ensuing year

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A few socialist musings for Monday

I just watched the closing ceremony of the Olympics, and the word is that state sponsorship of little known or cared about sports like swimming, gymnastics and cycling gets more medals and so should be encouraged. Bob Costas told me that China spent $40 billion on the games, even if London is going to spend less than half that. So it got me thinking about socialism.

Kevin Pho, blogger of KevinMD fame, and usually reliably anti-government in his views, asks for more socialism, at least directed in the direction of him and his fellow MDs. In this USA Today op-ed he suggests rightly that cutting doctors fees in itself saves little in health costs..

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Merck’s Marketing for HPV Vaccine Trumps Science

I first wrote about Gardasil on The American Prospect online in the summer of 2006, just weeks before the Merck vaccine designed to protect against cervical cancer went to market.

There, I noted that “the hullabaloo began in June when the FDA approved Gardasil, a vaccine widely described as ‘100 percent effective’ in preventing cervical cancer, a disease that kills some 233,000 women worldwide each year. The drumbeat grew louder last month when a federal panel recommended that all American girls and women ages 11 to 26 should be inoculated. And now there is talk that states may mandate the vaccine for all school-age children.

“But before prescribing for the entire population,” I suggested, “it’s worth asking a few questions: Why does the vaccine cost $360 for a three-shot regimen? How much do we know about the new product? And is this a cost-effective use of health-care dollars?”

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Health IT policy: the fur is flying

Some fur is flying in the rarefied world of health IT policy geeks this morning. Health Affairs has three articles. The first from Markle’s Carol Diamond, writing with Here Comes Everybody author and Internet guru Clay Shirky, more or less says that obsessive attention to rigid standards is not helping and actually may be hindering the IT adoption process. And yes, in case you were wondering they do mean CCHIT and ONCHIT’s current policies and agenda which has been going for four years and which they’re accusing of “magical thinking.” Instead, we need new policies which target desired outcomes measured in improved patient care, instead of assuming that creating new technology standards will get us there. And by policies I think they mean money, and its redirection by current payers. After all, if putting in a RHIO costs hospitals operating revenue in reducing admissions and tests, why would they do it?

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Pay Doctors For the Value They Offer Patients

When Medicare first created a fee schedule, critics suggested that it was a Marxist invention. Nevertheless, the schedule, which lists what Medicare is willing to pay for some 7,000 procedures, has become the master list for physician reimbursement in our health care system: Most private insurers peg their payments to the Medicare schedule.

The notion of deciding the precise worth of some 7,000 diagnostic and therapeutic procedures is mind-boggling. How exactly does Medicare do it?

The process began in the late 1980s when officials at the Department of Health and Human Services decided that the way Medicare paid doctors should be overhauled. At the time, Medicare was reimbursing physicians  based on what was considered “customary, prevailing and reasonable” in a particular market — in other words the “market value” of the service in that region.

Instead, reformers urged Congress to begin paying doctors in a way that reflected the real cost, to the doctor, of providing the service. (This is where Marx comes in: rather than letting the local market decide what a service is worth “the system appears to be based on the Marxist ‘labor theory of value,’” sputtered Susan Mandel in a 1990 piece in the National Review.)

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A Primary Care Paradigm Shift

Dick Reece is a retired pathologist and a prolific health care commentator with an active following, particularly among physicians. An astute, incisive observer, he is the author of 10 books; the latest is Innovation-Driven Health Care: 34 Key Concepts for Transformation. He is regular columnist on HealthLeaders, and writes his daily posts at MedInnovation Blog. THCB welcomes him. — Brian Klepper

RreeceSomething profound is happening in buyers’ and the public’s attitudes towards primary care and the health system. With inexorable rises in costs and corresponding decreases in access to primary care doctors, buyers and the public are mad as hell, and they’re deciding they’re not going to take it anymore. Something is badly and sadly wrong, and corrective measures are being put in place.

Signs of Paradigm Shift

Signs of a paradigm shift – a change in assumptions about the system’s basic structure – are everywhere. No longer do we accept the notion every patient should have a specialist for every disease, every life-improvement procedure, every orifice, and every organ. Care, it’s now assumed, must be coordinated to prevent people from falling through the cracks. We must stop wasting time and resources for patients and the system as a whole.

The U.S. system lacks timely access to primary doctors who oversee care. And specialty services are overused. Yet the U.S. has fewer primary care physicians per capita than any other country in the developed world. On the other hand, we have more specialists per square mile than other countries.

What’s Driving the Paradigm Shift?

•    Major corporate buyers, led by IBM, which spends $1.7 billion on health care, have created an activist organization, The Patient-Centered Primary Care Collaborative. Paul Grundy, MD, MPH, IBM’s Director of Health Transformation, chairs the Collaborative. It is based partly on IBM’s experience in Denmark, where it owns a company, and where patient satisfaction with care is 97% versus 50% in the U.S. Grundy believes every citizen should have a personal physician, and every physician should be rewarded for offering same day access, managing a patient panel, and be compensated for telephone and email consultations.

•    A vibrant movement is underway to “disintermediate” health plans. “Disintermediation” occurs when access to information or services is given directly to consumers. In the process, “middlemen” in the form of health plans may be ended, or their services transformed. That’s what consumer-driven health care is about, that’s why their existence in their present form is threatened, and that’s why health plans are moving rapidly to high deductible plans linked to health savings accounts.

•    The “medical home” concept is gaining traction. This concept hinges on two ideas: 1) placing the primary care physician at the center of care by having him/her coordinate overall care; 2) giving primary care doctors “ownership” control of specialty care referrals. America wants a health system in which the primary physician uses a secure computer platform to coordinate efforts of specialists, pharmacists, therapists, and others. Increasingly patients don’t appreciate why they must fill out a new form at each doctor’s office, why doctors don’t communicate with each other, and why doctors duplicate tests and don’t know what other doctors do. A number of medical home pilot studies are now being conducted. To make medical homes happen, doctors will need financial incentives and support to introduce technology, and coordinate care. Payers will need to step up the payment plate to help medical homes become real.

•    New business models to reduce cost and offer convenience are fast evolving. These include retail clinics, medical offices at the worksite, specialty clinics, urgent care clinics, elective surgical centers, and ambulatory facilities offering imaging, multiple specialty services, and one-stop care. Most of these are outside expensive hospital settings. Some are currently beyond the control of primary care physicians. At last count, there were over 1000 retail clinics, 500 worksite clinics, and roughly 3,000 urgent care facilities.

•    The physician empowerment movement is growing. The Physicians’ Foundation for Health System Excellence, which represents state and local medical societies, has completed a survey of 300,000 primary care physicians to highlight their problems, to educate the public, and to persuade policy makers to take steps to enhance the supply of primary care doctors, to pay them better, and to give them tools to offer comprehensive coordinated care. Sermo, a physician social networking site, has 75,000 members and will soon issue an “Open Letter to the American Public,” signed by 10,000 doctors to reflect physician grievances and to indicate how the system can be improved. These efforts, coupled with the Patient-Centered Primary Care Collaborative, are designed to improve the lot of primary care physicians.

Conclusion: A new primary care paradigm is upon us and will fundamentally change how the U.S. delivers care.

Flacks peddle false “reality”

Such a pity that the NY Times has been so beaten up by the commies amongst us that it actually now feels that it has to point out where Peter Pitts and Janet Trautwein get their money. Although, as per the last time it let Pitts write an op-ed, it didn’t mention his day job as a PR man for pharmaceutical companies. After all, who could be opposed to “Medicine in the Public Interest” — after all it is in the interest of the public to pay for all and any medicine at any price that PhRMA chooses, right?

And let’s not get started on underwriters (for whom Trautwein is the main flack). After all Grace-Marie Turner thinks that they’re the health care heroes! Perhaps they’re heroes because they drive sick people into the uninsured population so that the under-paid clinical staff working in America’s public and community health system get to show their worth by caring for them —even if they’re less heroic than underwriters.

But that’s OK, Pitts & Trautwein can be printed in the NY Times cherry-picking problems with other countries health care systems. Because as we all know there’s absolutely nothing wrong with ours, eh?

And why should Pitts quote the peer-reviewed 2007 Commonwealth Fund study that showed that waiting times for surgery were longer in the US than in the communist hell-hole of Germany, when instead he was able to cite an 11 year old study about longer waiting lists for one specific type of surgery in the Netherlands, which has completely revamped its health care system since then. Something he and Trautwein have helped stop us doing — preserving a dismal status quo they obviously want to maintain.

Those two wouldn’t last 92 seconds in a debate with Uwe Reinhardt or Hillary Clinton.

On the other hand, there’s no letter from Karen Ignagni to make up the trifecta. Did she negotiate some summer vacation time along with her $1.3m salary?

The call for government EHR unification

While on my VistA kick (here and here), I need to respond to several important errors of understanding in the recent press release hailed with a “Bravo!” from Fred Trotter. I also wanted to take the opportunity to mention a significantly broader and more meaningful opportunity that the open source community should be rallying around.

First, so people are clear – the Department of Defense does NOT currently use VistA. They haven’t since their 1988 decision to have SAIC fork the code. The only reason that VistA is mentioned as part of the DoD’s selection process is that their own physicians are clamoring to throw away the current system in favor of VistA. While the DoD is correct in identifying some of the weakness of VistA, they also appear to recognize many of its outstanding clinical attributes.

Comments from a July 21 letter from Principal Deputy Assistant Secretary of Defense for Health Affairs Stephen Jones seem to indicate a ray of hope for a VistA compromise: “There is a strong feeling here and at the VA that the best approach is a convergent evolution of the two systems. This approach optimizes the strengths of both systems while creating interoperability that will drive more universal information exchange.“

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Voters shielded from high health costs don’t see the residual impact

The health care issue has a history of being named by voters as one of the biggest problems we face — until the problem de jour comes along and pushes it off the list. In 2008, that seems to be happening again with the economic downturn, the mortgage mess, and $4 gas surpassing health care as the big issues.

When asked to name the most important financial problem facing families today by the Gallup organization:

    * 29% said energy and gas prices    * 18% said the high cost of living and inflation    * 14% said a lack of money and low wages    * 9% said health care costs

Policy experts can point to the high cost of health care but Joe and Mary Middle- America are still clearly sheltered from the real impact of these costs largely by the employers who still provide so many of us with affordable health care.

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Healthy Howard coverage expansion could inform future reforms

Howard County, Maryland is set to launch an ambitious universal health coverage, and the county’s top health officials says the effort will provide valuable lessons for future reformers.Fastfacts

Starting next month, 2,200 of Howard County’s 20,000
uninsured residents can enroll in the Healthy Howard Plan,
which will provide them access to primary, specialty and hospital care, and
prescriptions drugs for $85 or less a month.

Dr. Peter Beilenson, Howard County health commissioner and former Baltimore City health commissioner who ran for Congress in 2006, said this is the most ambitious local effort at universal coverage since San Francisco launched a universal coverage plan in April 2007.

Like Healthy San Francisco, Healthy Howard is not portable health insurance but rather health coverage for local treatment. Instead of levying a "pay or play" tax on businesses like San Francisco, however, Healthy Howard’s funding comes from individual premiums, county general fund dollars and substantial amounts of charity. (The Golden gate Restaurant Association is battling San Francisco in court over its tax.)

Beyond the grand ambition to provide universal health coverage, what Beilenson says  distinguishes Healthy Howard is its emphasis on personal responsibility, mandatory health coaching and a forthcoming rigorous evaluation.

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