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Tag: Policy

Voices from the deserving mob

From the (UK) Independent. Real quotes from real people attending the free care in LA this week:

“I had a gastric bypass in 2002, but it went wrong, and stomach acid began rotting my teeth. I’ve had several jobs since, but none with medical insurance, so I’ve not been able to see a dentist to get it fixed,” she told The Independent. “I’ve not been able to chew food for as long as I can remember. I’ve been living on soup, and noodles, and blending meals in a food mixer. I’m in constant pain. Normally, it would cost $5,000 to fix it. So if I have to wait a week to get treated for free, I’ll do it. This will change my life.”

***

She works for a major supermarket chain but can’t afford the $200 a month that would be deducted from her salary for insurance. “It’s a simple choice: pay my rent, or pay my healthcare. What am I supposed to do?” she asked. “I’m one of the working poor: people who do work but can’t afford healthcare and are ineligible for any free healthcare or assistance. I can’t remember the last time I saw a doctor.”

***

“You’d think, with the money in this country, that we’d be able to look after people’s health properly,” she said. “But the truth is that the rich, and the insurance firms, just don’t realise what we are going through, or simply don’t care. Look around this room and tell me that America’s healthcare don’t need fixing.”

And that last one is the money quote.

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Shaking my fist at Jon Cohn

Today Stephen Hawking gets the Presidential Medal of Freedom. Not bad for a guy the British NHS had its “death panel” kill off in the 1960s.  Meanwhile the real star of the day is not the guy who was on Canadian TV yesterday, but instead it’s The New Republic health care guru (and blogger at The Treatment) Jon Cohn who was just great on the Colbert —even revealing to Colbert that his insurance policy included death panels too. Colbert of course thought that this meant he could have his staff put to death.

The Colbert Report Mon – Thurs 11:30pm / 10:30c
Jonathan Cohn
www.colbertnation.com

Fame! (In Canada only)

TV is fascinated by my views on American health reform. Well not American TV (you have to be called Michael Cannon to get on American TV).

Following my record-setting appearance on France 24 TV (record was fewest every viewers for a news show), today I’m going to be on CBC News. That’s CBC as in Canada. I think you can find it here and I should be on at 11.15 PST or 2.15 EST

Kids Can’t Vote but Health Reformers Should Still Listen

Alan_L._Goldbloom

Depending on who you listen to, health care reform in Washington is either closer to reality than it has ever been, or it’s on life support.   Competing ideas are all over the map in terms of how health care should be delivered in America, and how we should pay the tab.  About the only thing everyone seems to agree on is that the current system doesn’t work, and that we need to get something – anything – done.

But with all the energy and effort going into reform, getting “anything done” isn’t good enough.  This is a chance to change the core values of our health care system to deliver access to high quality, low cost care.  It’s time to “invest” in the health of our nation.  We can’t settle for anything less.

As president and CEO of Children’s Hospitals and Clinics of Minnesota, my number one concern is the health of children, and I feel a responsibility to be a voice for children in this debate.  The simple fact is, children don’t vote.  They don’t have political action committees and they don’t make campaign contributions.  But the decisions that elected officials will make about health care will have a huge impact on the health and well being of our children.

If we want to provide the best quality care for children, a few key principals must guide any and all health care reform decisions.

First, we need to address issues around Medicaid reimbursement.  Medicaid is the single largest insurer of children in the country. In Minnesota Medicaid reimburses only around 80 percent of the cost of care, and in many other states, it’s less.  In fact, for all the talk about poor Medicare reimbursement levels, Medicaid pays providers at rates 20 to 30 percent lower than Medicare.  That’s why more and more doctors and clinics are declining to treat Medicaid patients, leaving families without access to proper care.

The current House bill recognizes this inequity and proposes to increase primary care physician payments under Medicaid to 100 percent of Medicare by 2012.  However, it does not address inequities for other key providers such as pediatric hospitals and specialists.

At Children’s of Minnesota, we served more than 42 thousand children on Medicaid in 2008.  We treat all children regardless of insurance status, but Medicaid reimbursement rates do threaten our ability to provide the kind of high quality, specialized services we believe children in our community deserve.

The second key element to reform involves a simple philosophy: we need to reward quality rather than quantity.   My state, Minnesota, has a well-deserved reputation for delivering high quality, low cost health care. Because of this, our reimbursement rates are among the lowest in the country.

We are very concerned about any reform proposals that would apply across-the-board cuts to existing reimbursement rates, without taking into account the value of care already being delivered.

We need reform that provides incentives to caregivers to be innovative around efficiency.  We should be rewarding providers who develop unique care models that eliminate waste while delivering excellent results.  Only then will we see the cost savings that health care reform advocates are promoting.

Finally, we need to change the way we think about health care for children.  Providing health coverage for all children should not be a luxury in this country.  We have already acknowledged that every child has a right to an education, and as a society, we pay for it.  Children’s health care deserves the same support.  After all, the money we spend on children’s health is an investment that pays off for 70 or 80 years, not only in productive lives, but in avoidance of long term health costs. No other health care expenditure has that kind of return on investment.  The needs of children must be front and center in this debate.

There are no easy answers for health care reform.  Honest and thoughtful people can disagree on how we should go about changing the system.  But by sticking to these core principals around Medicaid reimbursement, encouraging efficiency, and investing in children, we will have a good foundation to build on.

Alan L. Goldbloom, MD, is president and CEO of Children’s Hospitals and Clinics of Minnesota, the 7th largest pediatric health system in the United States.  Previously, Dr. Goldbloom was executive vice president and chief operating officer at The Hospital for Sick Children in Toronto, Canada’s largest children’s hospital.  After graduating in medicine at McMaster University in Hamilton, Canada, and training in pediatrics at Boston Children’s Hospital, Dr. Goldbloom practiced General Pediatrics and served as Director of Residency Training at both Dalhousie University in Halifax and at the University of Toronto, before becoming involved in hospital management.

And the real reason health reform matters

And in case you’d forgotten what the health care reform battle is really about, here’s video from Reuters about an open air clinic for the uninsured in Virginia… 

The Master and I agree on the goals

Writing in his blog in the NY Times, Uwe Reinhardt sets out three overarching goals of health reform

1. Financial barriers should not stand between Americans and preventive or acute health care that they sincerely believe will address concerns over a troubling medical condition, in a timely manner, before that condition grows into a critically serious illness.

2. Having received needed health care, no American family should be so financially devastated by medical bills that it cannot meet routine daily living expenses — for example, make utility or mortgage payments on time or finance the education of the family’s children.

3. The future growth in national health spending should be constrained to fall significantly below currently projected spending growth, which has the United States devoting about 40 percent of its G.D.P. to health care by mid-century.

All other goals are subordinate to these three overarching goals, as are the means to reach them.

Last week I posted a very similar Two rules by which to judge a health reform bill.

Rule 1 A health care reform bill needs to guarantee that no one should find themselves unable to get care simply because they cannot afford it. Neither should anyone find themselves financially compromised (or worse) because they have received care.

Rule 2 A health care reform bill needs to limit the amount of GDP that is going to health care to its current level, with an overall aim of reducing the share of health care going to GDP.

Uwe is a touch more eloquent in his goals 1 and 2 which split apart my Rule 1, and he’s a touch less aggressive in his goal 3, which is my Rule 2. But other than that these are the same.

Unfortunately in his column of the previous week Uwe created a list of 8 (but it could have been 20) completely contradictory statements about the completely “confused state” of what Americans seem to demand from health reform.

And right now the confusion seems to be winning.

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Dumb and Dumber

I can’t say that I’ve been fantastically impressed by the Democrats’ choice of this year to go after health reform, or their explanation of what it is. And I understand that the only interest of the Republicans is to destroy any political win in the hope that they get a repeat of 1994…although it is just possible that despite their confidence the voters also remember the 2000–2008 period which will also precede the 2010 election.

However, the amount of crap emanating from the right about what’s in the health bills and the evidence of that by what’s showing up in the “tea parties” now invading Democrat congressional members’ town halls is quite extraordinary and does require at least some notice.

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Finally, A Reasonable Plan for Certification of EHR Technologies

A caution to readers: This post is about methods for certifying Electronic Health Record (EHR) technologies used by physicians, medical practices, and hospitals who hope to qualify for federal incentive payments under the so-called HITECH portion of the American Recovery and Reinvestment Act (ARRA). It may not be as critical as the larger health care reform effort or as entertaining as Sarah Palin, but it WILL matter to hundreds of thousands of physicians, influencing how difficult or easily those in small and medium size practices acquire health IT. And indirectly for the foreseeable future, it could affect millions of American patients, their ability to securely access their medical records, and the safety, quality, and the cost of  medical care.

Three weeks ago, on July 14-15, 2009, the ONC’s Health IT Policy Committee held hearings in DC to review and consider changes to CCHIT’s current certification process. The Policy Committee is one of two panels formed to advise the new National Coordinator for Health IT, David Blumenthal. In a session that was a model of open-mindedness and balance, the Committee heard from all perspectives: vendors, standards organizations, physician groups, and many others.

And then, on July 16, they released their final recommendations on what is now referred to as “HHS Certification.” The effects of their recommendations – these are available online and should be read in their entirety to grasp their extent – are potentially monumental, and could very positively change health IT for the foreseeable future.

At the heart of these hearings was the issue of who will define the certification criteria and who will evaluate vendors’ products. Among many others, we have voiced concerns that the Certification Commission for Health Information Technology (CCHIT), the body currently contracted by HHS to perform EHR certification, has been partial to traditional health IT vendors in defining the certification criteria, and in the ways certification is carried out, and thereby able to inhibit innovation in this industry sector. Despite its leaders’ claims that the certification process has been developed using an open framework, CCHT’s obvious ties to the old guard IT vendors have created an overwhelming appearance of conflict of interest. That appearance has not been refuted by CCHIT’s resistance to and delays in implementing interoperability standards, or by its focus on features and functions over safety, security, and standards compliance.

In the hearings that led to the recommendations, longtime IT watchers were treated to some extraordinary commentary, much of which dramatically undermined CCHIT’s position.

“HHS Certification means that a system is able to achieve government requirements for security, privacy, and interoperability, and that the system would enable the Meaningful Use results that the government expects…HHS Certification is not intended to be viewed as a ‘seal of approval’ or an indication of the benefits of one system over another.”

In other words, as the definition of Meaningful Use is now tied to specific quality and safety improvements and cost savings that result from health IT — among them e-Prescribing, quality and cost reporting, data exchange for care coordination, and patient access to summary health data — HHS Certification will closely follow. Rather than pertain to an EHR’s long list of features and functions, some of which have nothing to do with Meaningful Use, certification will be focused on each IT system’s ability to enable practices and hospitals to collect, store, and exchange health data securely.

Who Determines the Certification Criteria

The Office of the National Coordinator – not CCHIT – would determine certification criteria, which “should be limited to the minimum set of criteria that are necessary to: (a) meet the functional requirements of the statute, and (b) achieve the Meaningful Use Objectives.” As regulator, funder for this project, and a major purchaser of health services, the government, not users or vendors, will now determine HHS’ Certification criteria.

A New Emphasis on Interoperability

“Criteria on functions/features should be high level; however, criteria on interoperability should be more explicit.” That is, functions/features criteria will be broadly defined, but there will be a greater focus in the future on the specifics associated with bringing about straightforward data exchange.

Multiple Certifying Organizations

ONC would develop an accreditation process and select an organization to accredit certifying organizations, then allow multiple organizations to perform certification testing. In other words, the Committee recommended that CCHIT’s monopoly end.

Third Party Validation

The “Validation” process would be redefined to prove that an EHR technology properly implemented and used by physician or hospital can perform the requirements of Meaningful Use. Self-attestation, along with reporting and audits performed by a Third Party, could be used to monitor the validation program.

Broader Interpretation of HHS Certification

HHS Certification would be broadly interpreted to include open source, modular, and non-vendor EHR and PHR technologies and their components.

These bold, forward-thinking proposals from the HIT Policy Committee have not been accepted yet. But in our opinion they should be. These measures would encourage new technologies to enter the market for physician medical practices seeking EHR technology, and wrest control away from the legacy health IT vendors that have maintained barriers and delayed adoption, so you can be sure that the old guard players are doing everything possible to have them rejected.

But these are hugely progressive steps in the right direction, toward allowing HIT to enable improvements in care and cost efficiencies that would be in the best interests of users and the public at large. If implemented, the changes recommended by the HIT Policy Committee would create greater choice, more standardization, lower price, less interruption of the practices — as well as a check from CMS or Medicaid each year to help smooth the implementation, starting in 2011.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies. Brian Klepper PhD is a health care market analyst. Their collected collaborative columns may be found here.

The Case for Taxing “Cadillac” Healthcare Coverage

With President Obama’s plan for healthcare reform recently being dealt a tough blow by the Congressional Budget Office over soaring federal deficit projections, I am beginning to wonder if it is time for the President to modify his stance against taxing “Cadillac” healthcare coverage offered by employers.  It’s no secret what Senator Max Baucus, the Democratic Chairman of the Senate Finance Committee and one of the most powerful people in the healthcare reform debate, thinks President Obama should do.  Senator Baucus has been a vocal advocate of taxing healthcare benefits.  He recently told reporters that taxing employer-sponsored benefits is “the best way to raise money for an overhaul of the healthcare system.”  He has also been somewhat critical of President Obama’s decision to not tax healthcare benefits by saying, “Basically, the president is not helping us.”

In recent days, the Congressional Budget Office (CBO) estimated that the House Democratic legislation would add more than $230 billion to the federal budget deficit.  On the Senate side, Senator Baucus, who has been working with Senate leaders to formulate another plan, has pointed out the difficulties his committee has had with funding reform without some other type of significant revenue.

One way that raises enough revenue to cover well over the $230 billion figure projected by the CBO is through taxing employer-sponsored health benefits.  The nonpartisan Joint Committee on Taxation estimates that taxing employer-sponsored benefits above the value of the Federal Employees Health Benefits Plan (FEHBP), adjusted for inflation, would generate nearly $420 billion over the next 10 years, which would easily fund the difference in the budget gap.  Many other estimates place this number considerably higher.  Furthermore, many experts believe that this policy is a key way to reduce costs, because tax-free benefits encourage more spending on health care.

About 18 months ago, as I worked with a committee that I chaired in Tennessee called the Rolling Hills Group to create a structural model for national healthcare reform, I ran into the same problem that President Obama is facing today.  How do you pay for reform?  After considering several options on how to finance universal insurance, our group kept coming back to the same, single solution – the same one that Senator Baucus is a proponent of, taxing “Cadillac” healthcare benefits.

Under our proposal, we created a basic level of coverage similar to what members of Congress are offered today, known as the FEHBP standard option plan.  This plan is very generous and has been successful in holding down costs compared to other plans.  In order to make sure our plan was budget neutral, we decided we would no longer allow what we consider “Cadillac” coverage benefits to be tax free.  For example, in 2009, under our proposal, any individual policy worth more than $5,871.84 or any family policy worth more than $13,445.64 would be subject to a tax.  Anything less than this amount would be tax free.  For individuals, any amount above the base value of the plan would be considered income.  While for companies, any amount above the base value of the plan would no longer be deductible as a business expense.

We had this idea vetted by the Moran Company, who said that our plan is actuarially sound and budget neutral for the federal government once fully phased in.  Just as a note, in our plan we also derive revenue from Disproportionate Share Payments (DSH) and hold down up front costs by phasing in the reform over a 10 year period.  Disproportionate Share Payments is funding that hospitals receive for treating indigent populations.  Thus, it is reasonable to decrease DSH payments as the uninsured population decreases.

If taxing “Cadillac” coverage raises enough revenue to make healthcare reform budget neutral and encourages less spending on healthcare, why has such an attractive option for reform been pulled off the table amidst the President’s insistence on urgency?  As is usually the case with healthcare reform, the answer may be in the politics.

In recent weeks, several articles have outlined strong opposition by labor unions to the taxation of their healthcare benefits. In the Washington Post, the AFL-CIO stated its opposition to taxing “Cadillac” coverage.  Michael Sullivan, the President of the Sheet Metal Workers Union, has also adamantly stated his opposition to taxing healthcare benefits by saying, “Any bill that taxes health care benefits is dead on arrival.” Understanding these political difficulties, but still seeing the taxing of benefits as a viable way forward, lawmakers have demonstrated that there may be room for compromise.  Senator Baucus himself has hinted that he might consider grandfathering in the taxation of health benefits that are part of a collective-bargaining agreement, which would allow union plans to remain tax-free until new contracts can be negotiated.

Labor unions are not the only ones who have come out against the taxation of “Cadillac” plans, as many large corporations have exhibited significant opposition as well.  However, if healthcare reform is going to happen this year, Congress and President Obama may want to take a harder look at taxing “Cadillac” healthcare benefits as a means of raising revenue and achieving their other healthcare priorities.  I think it is fair to say that if Obama explains to the American people that the Government is only going tax the most lavish of benefits, he might find greater support from the American public for the change in health care that he promised to bring and that this nation so desperately needs.

Clayton McWhorter is a former President and chairman of HCA and current chairman of Clayton Associates and the Rolling Hills Group.  He is the founder of the group SHOUTAmerica, a Nashville based organization that uses social networking and other internet-based technologies to push for change in the healthcare system.

Say we get some sausage–then what?

sausage (sô´sǐj)
n. A highly seasoned minced meat usually stuffed in casings of prepared
animal intestine.

MPainter

Congress is obviously in the thick of the sausage making. The August recess is pending. Bills may or may not be moving. The legislative process, especially at this point, is not particularly pretty or, to be honest, as thoughtful as we all might hope. It is the process, though, right? There was essentially no way around something like this intestine stuffing, especially in an effort to fix health care–such a large sector of the American economy. And in spite of the messy work and depending on the day, the observer and the poll, it nevertheless seems likely that something will come out of the kitchen, right? It is also probably safe to say, though, that any reform law is not going to be the panacea–the ultimate health and health care fix. Instead, if a law indeed passes, it's clear that we're going to spend the next five, 10, 15 years adjusting, backtracking, redesigning and working toward better care. In other words, the implementation is going to matter, and it's going to matter a lot. On July 30 in Washington, D.C. at the Hart Senate Office Building, the RWJF-funded High-Value Health Care Project led by Mark McClellan of the Engelberg Center at Brookings hosted a panel discussion focused on just that–the implementation. Specifically, Mark, Carolyn Clancy of AHRQ, John Tooker of the American College of Physicians, Steve Findlay of the Consumers Union and Jim Chase of Minnesota Community Measurement talked to a large Capitol Hill audience about what it will take to make health care deliver sustainable high value. 

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