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The Fall of Berwick?

• 26

By MAGGIE MAHAR

When President Obama named Dr. Donald Berwick to head the Centers for Medicare and Medicaid (CMS) last March, I wrote this:

“Most who know Berwick describe him a ‘visionary’ and a ‘healer,’ a man able to survey the fragments of a broken health care system and imagine how they could be made whole.  He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. health care.”

To understand what I meant, view these clips from the film, Money-Driven Medicine, where Berwick speaks about the need for healthcare reform. Soft-spoken and charismatic, Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it could be.

And now, it appears that we are going to lose him. Thursday, 42 Senators delivered a letter to President Obama demanding that he withdraw his support for Berwick to head CMS. The Boston pediatrician and co-founder of the Institute for Health Care Improvement (IHI) had received a temporary appointment in July while Congress was on vacation. President Obama re-nominated him in January. But Berwick still needs to be confirmed by the Senate, or he will have to leave his post at the end of this year.

With 42 out of 100 Senators firmly opposed to him, it appears that Berwick’s supporters won’t be able to muster the 60 votes needed to clear the Senate floor. Reportedly, Senate liberals already have given up. According to Politico.com’s Brett Coughlin: “At a meeting with Senate staffers Friday, health care lobbyists and advocates were told that there will be no confirmation hearing and that they’ll soon be discussing ‘next steps’ for CMS.”    If this is true, Berwick is now a lame-duck CMS director without power—as of today.Continue reading…

The Urgency of Medicaid Reform

• 12

By AVIK ROY

Austin Frakt has penned a reply to a recent piece I wrote on Medicaid for my health-policy blog on Forbes, The Apothecary. Austin is a guy who takes the time to address opposing points of view, to his credit, and I’ve enjoyed my back-and-forth with him over time. But while I’m grateful for Austin’s attention to an issue of high import—the degree to which Medicaid harms the poor—he didn’t respond to the core concerns I raised in my post.

For those who haven’t been following the debate on Medicaid outcomes from the beginning, let me offer a brief summary.

How Medicaid Harms the Poor: The Debate (So Far)

Last summer, on my old blog, I put up a series of posts highlighting the findings of a study published in Annals of Surgery by a group of surgeons at the University of Virginia, entitled “Primary Payer Status Affects Mortality for Major Surgical Operations.” The study evaluated 893,658 major surgical operations occurring between 2003 and 2007, stratified by primary payer status, on three outcomes endpoints: in-hospital mortality, length of stay, and total costs incurred.

Despite the fact that the authors controlled for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid fared poorly compared to those with private insurance, Medicare, and even the uninsured. Relative to those with private insurance, Medicare, uninsured, and Medicaid patients were 45%, 74%, and 97% more likely to die in the hospital post-operatively. The average length of stay for private, Medicare, uninsured, and Medicaid patients was 7.38, 8.77, 7.01, and 10.49 days, respectively. Total costs per patient were $63,057, $69,408, $65.667, and $79,140 respectively.

Despite Austin’s initial criticism that this was merely one study, and therefore not representative, the poor performance of Medicaid beneficiaries is well-established in a very large body of medical literature. What was striking about the UVa study was its large sample size; that it controlled for a highly validated set of background health and social factors; and its finding that Medicaid beneficiaries not only underperformed those with private insurance (and dramatically so), but also those who lacked insurance.

Given that a core feature of PPACA is its large expansion of Medicaid to those with higher incomes than current beneficiaries, I argued that it was far from clear that this expansion would improve health outcomes, and in fact was likely to harm them by crowding out the more-efficacious private sector. Furthermore, I argued for the clinical benefits of migrating Medicaid over to a premium-support or cash-assistance model, which would allow Medicaid recipients to benefit from the superior quality of care delivered by private insurance. As I’ve said all along, “There is, doubtless, a level of poverty at which Medcaid is better than nothing at all. But most people can afford to take on more responsibility for their own care, and indeed would be far better off doing so.”

Continue reading…

The GOP’s Health Policy Cynics

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By MICHAEL MILLENSON

The health care community is discovering to its shock and dismay that it’s not simply traditional Republican conservatives who have taken control of the House of Representatives, it’s a new group of cynics.

Conservatives, like liberals, have a more-or-less coherent set of ideas. They use political power to push preferred policies, whether related to health care, housing or a hundred other possible issues. William F. Buckley Jr., one of the fathers of modern American conservatism, “had a way of … making conservatism a holistic view of life not narrowed to the playing fields of ideology alone,” as one admirer put it.

Although cynics may claim conservative credentials, their view of government is really nothing more than a quarrel about its cost. It brings to mind Oscar Wilde’s immortal phrase, “The cynic knows the price of everything and the value of nothing.”

The contrast between the two viewpoints was on stark display at two recent marquée meetings, AcademyHealth’s yearly policy conference and the sprawling Health Information and Management Systems Society — HIMSS — Health IT Conference and Exhibition.

AcademyHealth’s “Running of the Wonks” (my term, not theirs) is a magnet for researchers and policy mavens who are inured by long experience to most political rhetoric. Yet at the general session featuring a bipartisan dialogue among congressional staffers, the harsh rhetoric from the GOP participants stunned the crowd. The new federal health law, it seemed, was evil incarnate, and the rhetoric of “repeal and replace” was wielded with a fundamentalist zeal.Continue reading…

Health Insurance Doesn’t Necessarily Mean Better Health

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By JIM MARKS, MD MPH

A new study in the influential policy journal Health Affairs gives added credence to the idea that much of what drives health falls outside of the realm of medical care. In fact, this must-read study points out what so many of us know: that simply providing someone a health insurance card is not enough to make them healthy.

What better place to test this theory than in Canada – our northern neighbor with a publicly financed universal health care system. Researchers looked at nearly 15,000 Canadians in the nation’s health system who were free of heart disease and tracked them for at least a decade.  Not surprisingly, people disadvantaged by little education and low income, used the health care system more than those with higher incomes. But more importantly, this increased use of services had no discernable effect on improving their health or cutting their death rates – the ultimate bottom line – when compared with others with higher education, higher income and LESS usage of health care.

Almost all of the debate about health care here has been about how many Americans will be covered, for what care, and at what cost. The results of this Canadian study are clear. It may be helpful to have insurance to get care, but the United States cannot expect that giving people medical care will diminish differences in health outcomes or the likelihood of an early death among disadvantaged people. The authors explicitly warn against relying on universal coverage to eliminate inequalities in health.Continue reading…

Why Consumer-Driven Health Care Will Fail

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By DAVIS LIU, MD

The creation of consumer-driven health plans (CDHPs), health insurance policies with high deductibles linked to a savings option and with more financial responsibility shouldered by patients and employees and less by employers, was completely inevitable. The American public likes to have everything, whether consumer electronics or other services, as cheap as possible. With escalating health care expenses rising far more rapidly than wages or inflation, it’s not surprising employers needed a way to manage this increasingly costly business expense.

In the past, companies faced a similar dilemma.  It wasn’t about medical costs, but managing increasingly expensive retirement and pension plan obligations. Years ago, companies moved from these defined benefit plans to defined contribution plans like 401(k)s. After all, much like health care, the reasoning by many was that employees were best able to manage retirement planning because they would have far more financial incentive, responsibility, and self-motivation to make the right choices to ensure a successful outcome.

How did that assumption turn out anyway?

Disastrous according to a recent Wall Street Journal article titled Retiring Boomers Find 401(k) Plans Fall Short.

The median household headed by a person aged 60 to 62 with a 401(k) account has less than one-quarter of what is needed in that account to maintain its standard of living in retirement, according to data compiled by the Federal Reserve and analyzed by the Center for Retirement Research at Boston College for The Wall Street Journal. Even counting Social Security and any pensions or other savings, most 401(k) participants appear to have insufficient savings. Data from other sources also show big gaps between savings and what people need, and the financial crisis has made things worse.Continue reading…

The Ultimate Sacrifice

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By JOHN MAA, MD

An estimated 60% of American bankruptcies result from overwhelming medical costs. My uncle’s tale illuminates the dual tragedy of suffering catastrophic illness and being uninsured.

The 2008 recession claimed my uncle’s job, health benefits, and assets, except for a small inheritance. By 2009 he found work (but not health coverage) as a consultant.

One day he noticed that his eyes were yellow. He emailed a photograph, and I immediately recognized jaundice. I calmed him by suggesting benign causes such as hepatitis, gallstones, or liver cirrhosis. But I secretly dreaded a liver or pancreas cancer, given his recent weight loss and itching.

Laboratory and x‐ray tests, which he charged to his credit card, all suggested cancer. His doctor in New Jersey indicated urgent surgery was necessary. An appointment was unavailable for weeks at the county hospital, and private surgeons wouldn’t see him without a cash deposit. Time was ticking. Cure was already unlikely, and delays were allowing the tumor to grow. He decided to travel to the West Coast to expedite surgery.

My uncle arrived around midnight, glowing yellow; he had worn sunglasses to avoid frightening other airline passengers.Continue reading…

Third Place Health Care

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By EVAN FALCHUK

Media reports on misdiagnosis continue to mount.

A recent study on patients with Alzheimer’s found that half had been misdiagnosed.  Half.

Another headline blared “4 out of 10 patients being misdiagnosed.”  The article encouraged patients to “see another doctor” if they are worried about their diagnosis.

You know what it makes me think about?

Starbucks.

Why?

Because the way Starbucks revolutionized coffee drinking shows a way forward for health care.

Starbucks realized that since our lives focus on two places – home and work – most of us don’t have a “third place” to go.  A place where we can be free of everyday distractions and take care of ourselves.  Starbucks set out to create that “third place,” by making its stores comfortable, inviting places.  It works.  “Third place” makes customers’ lives better – and Starbucks has almost 20,000 stores to prove it.

It’s time for a kind of “third place” in health care.Continue reading…

Doctors Love iPads. What Does it Mean? What Does it Mean?

• 21

By VINCE KURAITIS

After attending HIMSS 11 the largest annual health IT conference of the year, John Moore reported that “nearly every EHR vendor has an iPad App for the EHR [electronic health record], or will be releasing such this year.”

Doctors love iPads…not surprising? But, how might you explain this?

There are at least two different possibilities:

  • Coincidence Theory
  • Conspiracy Theory

The Coincidence Theory

So doctors want to access EHR software through the iPad…what’s the big deal?

Apple has built a great new hardware platform with the iPad. There’s nothing else like it in the marketplace.  While other companies are building competing tablets, Apple’s has been the only viable option in the market for over a year.

The iPad is intuitive, easy to use, reasonably priced, easy to carry around, and has a lot of apps that have been developed for the platform. People — not just doctors — love the experience of using an iPad.

Doctors just happen to be one group of zillions buying iPads. Why wouldn’t they? Doctors are smart, affluent, and many are opinion leaders. Doctors like cool new technologies just like anyone else.

Doctors also are mobile. They want to access EHRs in different exam rooms, from the hospital, from their homes. The iPad is the perfect hardware platform to take with you as as a doctor goes about their day.

Why are nearly all EHR vendors making their software work on the iPad?

Because doctors are demanding it.

The Conspiracy Theory

The iPad is Apple’s Trojan horse to create new revenues in an industry in which the company has had minimal presence — health care.

Apple has developed a very appealing hardware platform in the iPad. Recognizing the market strength and lock-in to their walled garden they are creating with consumers, Apple is targeting key market segments to create new revenue streams and business models. Health care is the next target for Apple’s aggressive smarts.

Continue reading…

HIT Trends Summary for February 2011

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By MICHAEL LAKE

This is a summary of the HIT Trends Report for February 2011.  You can get the current issue or subscribe here.

Innovations in provider and patient solutions. DrFirst announced that it acquired AdherenceRx to integrate e-prescribing and care management. This is an innovative combination that helps smaller practices and EMR vendors that support them.

Emdeon is repositioning as a HIE, while combining its web EMR with LabCorp, and working with AAFP on benchmarking.  It is stepping up its game with a SaaS EMR, access to de-identified clinical data and major national partners.

Epocrates completed its IPO this month banking on its future mobile EMR.  It has the opportunity to leverage its industry-leading brand and reach into its new EMR for small practices.  The company will now need to execute on its new vision to keep Wall Street satisfied.

And smartphone health apps leader, iTriage, gets appointment scheduling by acquisition. This is innovative in that it makes scheduling from the provider point of view asynchronous.  It replaces the real-time phone conversation.Continue reading…

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