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All the Care that Money Will Buy

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By JOHN GOODMAN

I believe we could spend our entire national income on health care. Not by frittering money away, but by spending it on goods and services that even in small ways could improve the odds of better health. (Examples below.)

I find that most people in health policy agree with that assessment, but rarely do they see its logical (and I would say obvious) implication. If we spent all our income on health, we would have nothing to eat, nothing to wear, no place to sleep. There would be only health care. Since that’s clearly an undesirable state of affairs, it must be good for people to refrain from obtaining all the useful care that money will buy. Further, such restraint needs to be exercised quite often.

What brings this to mind is a new RAND study finding that people with Health Savings Account plans consume less care than people with conventional insurance and have lower health care costs. The people who were studied cut back on such “useful care” as mammograms, screenings for cervical and colorectal cancer and even childhood vaccinations.

Some critics pounced on this result and claimed that consumer-directed care is bad for patients. The critics are, of course, very wrong.Continue reading…

Making Hard Decisions Easier

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By AMY BERMAN

Shortly after I was diagnosed with inflammatory breast cancer a scan showed a hot spot on my lower spine.  Was it the spread of cancer?  My oncologist scheduled a bone biopsy at my hospital, Maimonides Medical Center, in order for us to find out.

A few days before the procedure, I went in for preadmissions testing.  As part of my formal intake, in addition to collecting my insurance information and poking and prodding me a few times, the nurse asked me if I would like to fill out an advance directive. This was not because she was a miraculous oracle who knew the outcome of my biopsy, which would leave me with a Stage IV  diagnosis. No, her question was merely standard procedure.  I said yes, and shortly, a specially trained social worker arrived to walk me through the process.

A cheerful young woman reminiscent of camp counselor sat down next to me with papers neatly attached to her clipboard.  The first step, she explained, is appointing a health care proxy, someone you trust to make health decisions for you should you become incapacitated.  Being a nurse, I knew this, but it was comforting having someone there with me while I filled out the form. I chose my mother.  Since my diagnosis, she and I had had numerous conversations about what I wanted should my disease progress and take away my quality of life. I trusted that she would respect my wishes, even if that meant making painful decisions as my disease progresses.

There is another form of advance directive that I haven’t completed yet—but will—with the assistance of that same social worker.  It is nationally known as the POLST or Physician Orders for Life Sustaining Treatment.  Developed in Oregon and disseminated by the California Healthcare Foundation, POLST turns the treatment wishes of seriously ill individuals into physician-signed medical orders that the health care team must follow.

Continue reading…

Inconvenient Facts (For Both Republicans and Democrats)

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By ROBERT LASZEWSKI

I call your attention to Ezra Klein’s column in the Washington Post this morning.

In it he cites data that has been out there for a long time but Ezra puts some perspective on it that never occurred to me before.

Examining the Kaiser Family Foundation brief, “Health Care Spending in the United States and Selected OECD Countries” he points out, “Our government spends more [as a percentage of GDP] on health care than the governments of Japan, Australia, Norway, the United Kingdom, Spain, Italy, Canada, or Switzerland.”

The data would seem to indicate that even our single payer government-run American health care programs, Medicare and Medicaid, cost way more than similar health plans in these nations.

The argument is often made that we should adopt a single payer—or perhaps a “public option”—health plan in the United States in order to control costs and cover everyone. But it would appear that even those programs in America are way too expensive when compared to similar programs in other industrialized nations.

As for the Republican market-based approach, Klein also points out that those programs have been ineffective at cost control. House Republican Paul Ryan often cites the Medicare Part D drug benefit as proof his proposals to privatize Medicare would work better than what we have. But as Klein points out, Part D premiums have risen 57% since 2006 and the program is on track to see nearly 10% growth in annual costs over the next decade.Continue reading…

Vouchercare for Cancer

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By MERRILL GOOZNER

The health care cost debate takes place on two stages using two languages, one scientific, the other economic. The net result is a failure to communicate.

The scientific texts emanated over the weekend from the American Society of Clinical Oncology meeting in Chicago. Ongoing clinical trials showed that science has come up with new drugs that can reduce the incidence of breast cancer and prolong life for people with skin cancer. The former is an estrogen inhibitor that would have to be taken by tens of millions of older women to have a major impact on reducing the rate of breast cancer. The latter would only be given to a subset of the 68,000 new cases of melanoma each year, and would extend life from a few months to a few years for some of the 7,700 who die from the disease each year. Again, most of those people are older, although there are a number of younger people, especially young women, who disproportionately get advanced skin cancer.

For both groups, the cost to the health care system when these drugs are approved, as they inevitably will be, will be calculated in the billions. Medicare will pick up the lion’s share of the tab, since most of the patients in both groups will be over 65.

Now let’s step around the corner to stage two, where the debate in this morning’s papers (if you read the Washington Post and New York Times every day, as I do) is over Rep. Paul Ryan’s plan to turn Medicare into a voucher program. Paul Samuelson, the top economics columnist in the Post, essentially endorses the plan saying “under Ryan’s plan, incentive would shift. Medicare would no longer be an open ATM; the vouchers would limit total spending.” What he doesn’t say is that it would only limit total spending by government. It would require seniors to pick up a growing share of the bill, and limit their own purchasing of health care, either by purchasing plans that didn’t cover expensive end-of-life care, or simply denying themselves routine treatments to avoid co-pays and deductibles.Continue reading…

Coordinating Care Coordination

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By MARGALIT GUR-ARIE

Care coordination is one of the four pillars of Meaningful Use, one of the six NCQA Patient Centered Medical Home (PCMH) standards and one of the main goals of Accountable Care Organizations (ACO). Care coordination, particularly for patients with multiple chronic conditions, is expected to reduce unnecessary repetition of laboratory testing or imaging and the number of avoidable admissions. Other than reducing overall costs, care coordination is also supposed to improve quality of care. According to experts like Joe Flower, “Lack of care coordination is at the core of the mess healthcare is in”, and nobody in their right mind would argue that it is best that medical care remains disorganized and uncoordinated, if it is indeed so. It seems that our fee-for-service, fragmented and fractured (lots of f-words here) health care system is not conducive to care coordination. When patients float around in a sea of hospitals, physicians, nursing homes and other facilities, each care provider gets paid, and is responsible for the piecework performed at their independent entity and nobody is minding the handoff of patients to the next provider of care, and nobody is assembling a comprehensive picture of the entire care process, let alone orchestrating, or coordinating, the progression of patients between stages of care and the overall needs of patients in transit. What would it take then, to see that the bits and pieces of health care we now have, become a safe and affordable continuum of care?

CMS is taking the lead, as it should, in an all-out effort to encourage health care coordination through various carrot-stick initiatives, aligned to ultimately base payment for medical care on value to the patient, as measured on a population level, instead of fee-for-service and no accountability for outcomes. These initiatives fall into three general categories:

  1. Health Information Technology to assist with documentation, information exchange and measurements as required in any coordination effort.
  2. Incentives and penalties for providers based on measures thought to be influenced by care coordination (e.g. preventable hospitalizations, readmission rates, etc.)
  3. Financial and structural encouragement for vertical integration of the delivery system (e.g. ACOs, consolidation, employed physicians, etc.)Continue reading…

Calling All Health Innovators: Health Data Palooza

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By Todd Park

This week the Health 2.0 team will be at Health Innovation Week DC, and the biggest event there will be the Health Data Initiative Forum. One day, 50 demos, mixing more government and private data than you can imagine. We’ve been helping at the periphery of the Health data Initiative and we’ll be be having a special session talking more about the Health 2.0 Challenge, including our upcoming work running Challenges for ONC. We’re incredibly excited and enthusiastic, but no one is as enthusiastic as Todd Park! Here’s the CTO of HHS telling you about his brainchild, Health Data Palooza–Matthew Holt

Almost exactly one year ago, we launched a vital new HHS Open Government effort: The Health Data Initiative (HDI). The Initiative was publicly launched by HHS Secretary Kathleen Sebelius, Deputy Secretary Bill Corr, Institute of Medicine (IoM) President Harvey Fineberg, and White House CTO Aneesh Chopra at a forum held at the National Academy of Sciences.

The Health Data Initiative is an incredibly exciting public-private collaboration that is encouraging innovators to utilize data made publicly available by HHS and others to help fuel applications and services that can help improve health and health care. Over the past year HHS has been working very hard to make our data ever more accessible to the public – both publishing brand new data and making more of our existing data machine-readable, downloadable, accessible via application programming interfaces (APIs), free, and vastly easier to find. We’ve launched major new data and information websites (the HealthData.gov community, the Health Indicators Warehouse; and HealthCare.gov).

Equally importantly, we’ve been energetically publicizing our data, through challenges, code-a-thons, and many sessions with innovators of all kinds – educating folks around the country about what data we’ve made available and its potential to help power health  improvement. Innovators from across America are taking our data and are using it to build and power an amazing and rapidly growing array of applications in creative and powerful ways to help advance health. This movement has included entrepreneurs and change makers from all sectors: startups, major businesses, nonprofits, public health, health care delivery system, federal and local government, and academia.

On June 9th, 2011 at the National Institutes of Health, in partnership with the IoM, we will be holding our 2nd Annual Health Data Initiative Forum (or, as I like to call it, our second annual Health Data Palooza!). Continue reading…

Ryan’s “vouchercare” is a false choice

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Paul Krugman spends time today ripping Paul Ryan once more. Ryan’s plan is to limit government spending way off into the future (starting with people who are now 55) by giving them a flat Medicare voucher and then telling them to try it on for size in the individual insurance market. The joke is that there is a rational way to try to introduce some consumer-choice competition into Medicare. Essentially there are two alternatives to dealing with the mess that is Medicare. One–try to manage Medicare spending both with a global budget (the IPAB) and with specific restrictions on care that’s delivered that’s wasteful or unnecessary (via changes in FFS payment). That’s essentially the route the ACA goes. Two, give recipients a voucher that lets them choose between competing entities that can’t charge more than the value of the voucher and actually are mandated to compete on the correct things (outcomes, service, etc) like they do in Holland and in Alain Enthoven’s theories. That’s rational managed competition under a global budget, and the winners in that would look more like Kaiser and Group Cooperative than today’s insurers. Ryan’s idea is just to subsidize the dysfunctional private marketplace and to repeal the minor restrictions the ACA puts on health insurers while he does it–a sure-fire recipe for disaster.

There is of course another alternative. Just to let Medicare continue to spiral out of control on both costs and the quality of services it provides, and Ryan’s plan basically does that without a safety net

Some of My Best Friends are in Private Equity

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By PAUL LEVY

Like moths to a flame, private equity investors are quick to pounce on those sectors of the economy that have the potential for higher than average returns. Such investors also have an appetite for the higher risk that accompanies those sectors. In this manner, private equity can serve a useful role in capital formation for the economy. It also helps money managers who want a portion of their portfolio to be in that part of the risk-reward spectrum.

Health care is a fertile field for private equity. You might not think so because of concern about rising costs, but as someone once said, “One person’s costs are another person’s income.” Let’s look at it this way. First, more people will have access to insurance to pay for diagnosis and treatment because they will be newly eligible for private insurance under the national health care reform law. Second, demographic changes in society are producing an ever-increasing demand for health care services. Longer lifespans and the aging population offer a growing number of people with cancer and the other diseases that are more likely to occur with age. The number of Medicare beneficiaries is projected to rise from 46.6 million today to 78 million in 2030. (It was 40 million in the year 2000.)

It is with this background that we should consider the growing interest by private equity in proton beam facilities. You have heard before about my real concern about the cost impact of rapid expansion of the number of such facilities.

I want to expand on that today and give you a sense of how the dollars work in this kind of investment. I have pointed out how the Medicare rate-setting process contributes to its profitability. Let’s look at this in very rough form.Continue reading…

An Obama-Gingrich-Ryan Ticket on Health Policy Reform

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By SENATOR DAVID DURENBERGER

Newt Gingrich has to be one of the most interesting figures in recent political history.  His soul lives at the intersection of public policy, politics and history.  Because he has been on so many sides of history and policy, political insiders greet his entry into the presidential primary campaign as “Harold Stassen-ish.” I am among them, having entered the Senate the same time Newt entered the House 30-plus years ago.  I don’t know Republican House Budget Committee chair Paul Ryan, but I admire his leadership talent and regret his decision not to run for the Senate from Wisconsin.  It would raise the level of health policy discourse substantially in that “august body.”

Barack Obama is undoubtedly making presidential history.  Given the many policy challenges he has had to take on since January 20, 2009, plus the one he chose to take on – health policy reform, aka PPACA, there’s no question he is in a unique place in history today.  But, it is the Republicans – the “Party of No” on Obamacare – that are carrying the day on bringing health policy in line with health reform on the ground in the U.S. today. Obama’s PPACA sets historic national policy goals.  Ryan and Gingrich articulate the policy means to the ends of the new law.

Public health insurance programs like Medicare and Medicaid should begin now to reward success in meeting access, quality, and value goals where they exist in communities and systems across the country.  On their way to converting to private insurance and “premium support” subsidies when, and only if, genuine competition comes to the insurance marketplace. Along with the information consumers of insurance and healthcare need to make value judgments to purchase.

Obama could encourage this now because he has the new law on his side.  He has a budget/debt ceiling impasse which could make it possible. Unfortunately, he doesn’t know it; and it appears those in his administration charged with implementing PPACA, haven’t figured out how to do it. Bogging down in waivers and new rules and regulations which set the new law up for “socialistic” ridicule, and the president for a messy political campaign which will not, as Gingrich suggests, “lead to a national discourse” on the future of health care policy and politics.Continue reading…

What Dr. Oz Learned From His Cancer Scare

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By DAVIS LIU, MD

Dr. Mehmet Oz recently had a piece in Time titled “What I Learned from My Cancer Scare” in which he became the more humbled Mr. Mehmet Oz.  As noted previously here, Dr. Oz last summer had a colonoscopy at age 50 and much to everyone’s surprise had a precancerous colon polyp.  He was advised to follow-up again for a repeat test in 3 months.

As the Time magazine piece noted, he didn’t return for 9 months despite repeated reminders from his doctor.

From this experience, he essentially stumbled upon what has been challenging American medicine and primary care.  How do we enable patients to do the right thing and get the screening tests done and treatments necessary to avoid premature death and maintain a high quality of life?  As a highly trained professional, Dr. Oz knows the risks and benefits of not doing a preventive screening test.  As a doctor, he knows all of the secret protocols and codespeak we use when calling patients or asking them to see us in the office for important matters.  As a doctor, he also understood the importance of a repeat colonoscopy to ensure no more colon growths.

Yet he didn’t return for 9 months.  Why?

None of us want to deal with our mortality.  Having a screening test means there is a possibility that the test may be abnormal and now we must confront it face to face. Skipping the test means to be blissfully ignorant, even if it is the wrong thing to do.

Also, as Dr. Oz noted, many individuals, particularly those who are otherwise healthy with no family history, feel that many of these tests or interventions don’t apply to them.  Trust me, I know.  As a practicing primary care doctor, do you know how hard it is to convince someone to get screened for colon cancer?  Get vaccinated for pertussis, influenza, or pneumonia?

Continue reading…

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