Tag: Health Care Reform

Johns Hopkins Medicine and the Health Care Debate

Mar 1, 2010• 8

Photo courtesy of the Johns Hopkins Gazette

While concepts for health care reform volley back and forth in Washington, D.C., and around the nation, Johns Hopkins has quietly but meaningfully injected itself into the debate.

Johns Hopkins Medicine has been working with a group of 12 academic medical centers to explain the key role of these institutions in the delivery of health care to millions of Americans.

The group —which includes Emory University, Mount Sinai Medical Center, UCSF Medical Center, the University of Pennsylvania and others—is focusing on a number of issues, including a proposal to create “Health Care Innovation Zones” that would offer support for providers working with stakeholders in their regions to redesign a more patient-centered delivery of health care.

Pioneer Speaks about MA Health Reform

Mar 1, 2010• 2

By PAUL LEVY

The Pioneer Institute is a public policy research center in Massachusetts. On the political spectrum, most people would call it conservative, or a least free-market oriented. In my opinion, regardless of your particular position along that spectrum, the institute’s work is worth reading.

Last month, it issued a paper about the Massachusetts health care reform experiment that serves as a report card on a number of factors, with particular focus on the question of the equity and sustainability of the financing of the health care insurance access system put in place by Chapter 58 of the Acts of 2006.

For those interested in the possible applicability of the Massachusetts model to the national scene, authors Amy M. Lischko and Kristin Manzolillo say:

It is undeniably premature to enact a reasoned national-level solution based on Massachusetts’ or other state experiments. . . .Continue reading…

It’s Up To Us …

Feb 27, 2010• 4

By PAUL LEVY

A conversation with a reporter yesterday helped me clarify my thoughts about federal health care legislation. In my view, the most effective role of the federal government would be to provide national standards by which the health insurance companies operate (e.g., with regard to pre-existing conditions, rescission, and lifetime limits), require the existence of insurance exchanges, and establish the conditions under which universal access to insurance is made possible. Other items I would suggest for federal legislation are summarized below.

I am hoping the US government will not attempt to control the costs of health care by making legislative decisions with regard to clinical matters. Not because we should abandon cost control; but because federal efforts in this sphere are likely to be crude and not clinically appropriate. You just have to look at the process by which the USDA food pyramid is influenced by food product lobbyists to imagine how the government would attempt to regulate the design and provision of care among medical specialties, equipment and supply manufacturers, and pharmaceutical companies.

As should be evident to readers, I think it is possible for the participants in the health care system to accomplish major changes in the rate of medical cost inflation. Two articles have this theme. One is by Business Week’s Catherine Arnst. The other is by Lucien Leape, Don Berwick, and others in Quality and Safety in Health Care. Both are worth reading, and they overlap in recommending several areas — reducing infections and other preventable harm; empowering patients and families to participate in their care; and disclosing and apologizing for mistakes.

Beyond these articles, there is a remarkable consensus on these items, and yet hospitals and doctors often fail to implement them. Even hospitals that house some of the most accomplished authors in these fields often do not follow the advice of those colleagues when it comes to making improvements in the delivery of patient care.

It is not unusual for industries facing structural change to be slow to move. Why? Because the leaders of those industries were promoted based on their success in the past financial, political, and social environment. They were hired for their ability to maintain the status quo, rather than for their ability to make change. Eventually, though, societal forces make themselves felt. If an industry does not adapt, the government will step in. The medical profession has to decide whether it wants to take charge of this process or abdicate to Congress the right to act in its stead.

Pay (Only) for Health Care that Works

Feb 26, 2010• 30

By DAVID HYMAN

Health care is expensive partly because governmental payers and insurers foot the bill for large quantities of medical services that are ineffective, unnecessary, or unproven. According to a RAND report, studies of clinical efficiency “indicate that one-third or more of all procedures performed in the United States are of questionable benefit.”

When state and federal governments set the minimum terms for insurance coverage, this problem is likely to worsen. Governmental decisions reflect the political power of providers (who want to sell more services), the sympathy felt for patients (who want to consume more services and have other people pay for them), and the desires of bureaucrats (who generally want to maximize their budgets and their importance). These interests coalesce, causing governments to aggressively mandate coverage of services that may or may not be necessary.Continue reading…

The Messy Business of Transparency

Feb 25, 2010• 4

By NAOMI FREUNDLICH

President Obama’s latest plan for health reform brought a flurry of commentary in the last two days; including divergent views on whether his commitment to “transparency” is helping or hurting the process. Yesterday, the Los Angeles Times blamed the current “healthcare backlash” on Obama’s insistence that the messy business of hashing out health reform be done in Congress, not behind closed doors in the Oval Office. In the L.A. Times’ view, there’s been too much transparency:

“By leaving the overhaul in the hands of Congress, [Obama] has given the public a full view of how lawmakers do business. The result is an anti-Washington mood that Republicans have tapped into.”

Meanwhile, the House GOP leader John Boehner, calls the Obama plan—introduced yesterday on the eve of the “bipartisan” health summit—a “Democrats-only backroom deal” that “doubles down on the same failed approach that will drive up premiums, destroy jobs, raise taxes, and slash Medicare benefits.” In the Republican’s view of things, there’s been too little transparency in the health reform process.

So which is it: Back-room dealing or a too-public view of the dirty business of lawmaking?

At the very beginning of the health reform process, the Obama administration made a conscious decision not to repeat the mistakes that doomed Bill and Hillary Clinton’s plan for universal coverage in 1993. The consensus was that the Clinton plan ultimately failed because the bulk of the planning went on behind closed doors—Congress and the American people felt locked out and were blindsided by the cost of the proposal. “With a task force that operated largely in secret, the first lady drew up a detailed and complicated plan that met with fierce opposition by the health care industry and Republicans before it ultimately sank of its own weight in a Democratic Congress,” writes Peter Baker in the New York Times.

The President’s Proposal

Feb 25, 2010• 60

By MAGGIE MAHAR

You might be wondering why I haven’t written about the President’s Health care bill. The reason is that I have very little to say.

This, I realize, is unusual. But the truth is that the president’s proposal is very similar to the Senate bill—which is not a surprise.

Nevertheless, I am very glad to see the proposal. I was worried that the White House had put reform on the back burner.

Will it pass? As always, I’m trying to be optimistic. But I think that everything depends on whether the White House decides to twist arms. The president will have to persuade House liberals that this is a good first step—and that we can worry about improving the plan over the next three years.

I would still like to see a public option, and I hope that, in the end, the federal government will wind up overseeing the state-based exchanges. But the legislation doesn’t goes into effect until 2014; that gives us more than enough time to improve on it.

The President also will need to keep an eye on Senate moderates. I would favor sending Joe Lieberman on a special mission to South Korea. A relative who is stationed there tells me that the demilitarized zone is particularly bleak this time of year.

There is no need to worry about the Republicans. They can be counted on to vote against any reform bill that even attempts substantive reform. Universal coverage is not their top priority, and they definitely don’t want to pay for it.

How Maryland “Broke the Curve”: A Solution For Massachusetts?

Feb 14, 2010• 41

by MAGGIE MAHAR

Massachusetts has succeeded in providing health care insurance for all but 2.6% of its citizens.

Yet the Commonwealth still struggles to make that coverage affordable. Health care inflation is driving Massachusetts’ system toward a cliff. Total outlays for medical services and products are climbing 8 percent faster than the state’s economy. Unless something is done to rein in the cost of care, health care spending in Massachusetts is projected to nearly double over the next 10 years, hitting $123 billion in 2020. State officials know they must find a way to put a lid on spending so that it grows no faster than the state’s gross domestic product.

But how?

With that question in mind, The Massachusetts Division of Health Care and Policy (DHCFP) contracted with the RAND Corporation to develop a menu of cost containment strategies and options. In September RAND came back with a report that recommended 12 strategies for reducing health care bills.Continue reading…

We Need a Doctor In the House — And the Senate

Feb 13, 2010• 39

By C.L. GRAY, MD

Historically, practicing physicians have shunned politics. If our democracy is to survive, these times demand thoughtful solutions and difficult decisions. Few individuals are better suited to the task than the Hippocratic physician.

Behind the scenes, a quiet and unassuming movement is afoot destined to reshape the future of American health care—and possibly the entire landscape of American politics.

The House currently has fourteen physicians. The Senate has two. This means less than 3% of our elected officials in Washington come from one of the most trusted professions in America—medicine. But that is about to change.Continue reading…

Massachusetts’ Problem and Maryland’s Solution

Feb 9, 2010• 43

By MAGGIE MAHAR

While health care reformers argue about what it would take to “break the curve” of health care inflation, the state of Maryland has done it, at least when it comes to hospital spending.

In 1977, Maryland decided that, rather than leaving prices to the vagaries of a marketplace where insurers and hospitals negotiate behind closed doors, it would delegate the task of setting reimbursement rates for acute-care hospitals to an independent agency, the Maryland Health Services Cost Review Commission.

When setting rates, the Commission takes into account differences in labor markets and how much a hospital pays in wages; the amount of charity care the hospital does; and whether it treats a large number of severely ill patients. For example, the Commission sets the price of an overnight stay at St. Joseph Medical Center in suburban Towson at $984, while letting Johns Hopkins, in Baltimore Maryland, charge $1,555. For a basic chest X-ray, St. Joseph’s asks $81 and Hopkins’ is allowd to charge $155. The differences reflect Hopkins’s higher costs as a teaching hospital and the fact that it cares for generally sicker patients.Continue reading…

How to Get Enough Votes in the Senate

Feb 7, 2010• 33

By PAUL LEVY

When Hillary Clinton was running for President, she set forth a more modest agenda for health care reform than her competitor, Barack Obama. Maybe she understood better, based on her experience, how difficult it is to get a comprehensive bill through Congress in this field.

What is possible now that the President has lost the 60-vote majority in the Senate? I think the thing to remember is that he was having trouble even holding together the 60 votes he used to have. He had to agree to an assortment of give-aways — to Nebraska, to Louisiana, to the labor unions — to get the votes he needed. In part, that proved to be the undoing, as Massachusetts voters watched this sausage being made and sent a message through the election of Scott Brown that they didn’t like what they had been seeing.

Now, it may be that the Republicans will act to kill anything that might come along. I don’t think so. I think they are willing to be part of a bill, but it has to be a bill for which they can claim credit among their constituencies. What might it be?

Insurance reform: People, irrespective of party and political leanings, despise the practices of insurance companies that limit or take away coverage. The use of pre-existing conditions to deny coverage, lifetime limits of coverage, and rescission of policies are nasty and unfair. These practices remain as sources of insecurity among Americans, even those with insurance. There should be near-universal support to change them.

Tort reform: I think that most people feel that, while people should have a right to sue for medical malpractice, the process that exists today is inefficient and arbitrary for both plaintiffs and defendants. Any doctor will tell you that fear of such suits also leads to the practice of defensive medicine, driving up costs for all of society. Tort reform does not require limitations on payments. It could be accomplished with the establishment of specialized courts and procedures that would add greater certainty to outcomes and reduce the tensions and abuses associated with the system. This should not be a partisan issue.

Payment reform: Nobody likes the results of a system that systematically underpays primary care doctors and leads them to a life of 18-minute appointments and a role as triage doctors, a way station to referrals to higher paid specialists. If Congress were to order Medicare and state Medicaid plans to take the lead in establishing reimbursement rates for PCPs that reflected their value to families and patients, we would be on the way to a more rational system of care. Likewise, if physicians were paid for care delivered by telephone and electronically, millions of unnecessary and time-consuming office visits could be eliminated. If these steps were taken for Medicare and Medicaid, private insurers would follow.

Transparency: A national mandate for public disclosure of the rates paid by insurers to providers would help drive greater rationality in payment methodologies in the states. Disclosure of clinical outcomes in clinically important arenas would provide impetus to improvement in patient safety and quality. How can this be a partisan issue?

Now what about access? I fear that expansion of insurance coverage is the third rail in this debate. Why? Because it requires revenue to support the subsidies that would be required, and tax increases are really hard to achieve. The President made this issue more radioactive than necessary by proclaiming at the start that you could get access, choice, and lower costs all in one neatly wrapped package. Everybody in the field knew that you could not. This then resulted in sleight-of-hand revenue measures that became the undoing of the bill as Christmas tree ornaments were added to undo the effect on particular states or interest groups.

As I have stated here, a fair approach to generate the revenues for expanded access is to eliminate or reduce the pre-tax treatment of insurance premiums. Doing so would use the progressive income tax system in a way that would apply a larger percentage of these costs to more wealthy people. Could this approach gain a bi-partisan consensus? It could not gain support even among the Democratic majority, so I am guessing not. And the Republicans seem to express no interest at all in mandates for greater access. Maybe we have to accept as a reality the idea that expanded access is a casualty in this debate. I hope not, but I don’t yet see an answer to this that can get 50 votes, much less 60.