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The Ryan/Rivlin Plan

By JOHN GOODMAN, PhD

Congressman Paul Ryan (R-WI) and Alice Rivlin, former director of the Congressional Budget Office (CBO), have proposed an entitlement spending reform plan that is striking both for its boldness and its left-right-coming-together origins. There are a number of interesting parts, but I want to focus on the three most important:

  • Medicare would, for the first time, be transformed into rational insurance. Beginning in 2013, all enrollees would be protected by a $6,000 cap on out-of-pocket expenses; in return they would pay for more small expenses on their own.
  • After a decade, people newly eligible for Medicare would receive a voucher to purchase private insurance instead. The value of the voucher would grow at the rate of growth of GDP plus 1% (note: for the past four decades, health care spending per capita nationwide has been growing at about GDP growth plus 2%).
  • Medicaid would be turned into annual block grants to the states. The value of the block grants would also grow at GDP growth plus 1%.

Bottom line verdict: This is a good proposal that deserves serious attention. To guarantee its success, however, more needs to be done to (1) allow the private sector to control costs through economic incentives, competition and entrepreneurship and (2) allow young people to save for the growing share of expenses they will be expected to bear.

How Does This Plan Compare with the Affordable Care Act (ACA)? Given that Ryan has been previously attacked by Paul Krugman and others on the left because of his ideas about voucherizing Medicare, a natural question arises. How does the Ryan/Rivlin slowdown in Medicare spending compare to the health reform bill Congress passed last spring — a bill supported by some of the very people attacking Ryan?

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Is This Normal?

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By PAUL LEVYPicture 26

This is a story about consumer choice using publicly available information. Unfortunately, it is also about the power of suggestion as used by an incumbent provider organization.

The friend who sent me this note is a research fellow at one of the Boston teaching hospitals, so I guess he is more likely than most to do the kind of research he summarizes. Most people would have taken the referral advice offered without question. If they ever did ask to see a different doctor, most would never get past the “need” for asking for “special permission.”

Hi Paul,

I had a strange encounter, and I was wondering if you could tell me if this is normal.

A few months ago my primary care physician recommended I see dermatology for my eczema. His clinic recommended the names of two dermatologists within the same health care system. I looked up both dermatologist on healthgrades.com and found that their patients had given them luke-warm reviews. (There were many reviews, so this wasn’t a sampling problem). Also, I have been reading the medical literature about eczema, and knew there were a lot of recent advances, so I wanted somebody who had published and was familiar with the research.

I found another dermatologist, Dr. Caroline Kim. Her patients loved her (according to healthgrades.com), she had published articles in dermatology research (from scholar.google.com), and she trained at top institutions: Harvard Medical School and MGH. I made an appointment with her.

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“Don’t Litigate, Innovate.”

Robert Laszewski By ROBERT LASZEWSKI

What if a Republican governor and a Republican legislature had the ability to implement their version of health insurance reform and the federal government would have to pay for it? It’s a great idea. And I’m thrilled to say that a bi-partisan bill has already been introduced in the Senate by Ron Wyden, D-Ore., and Scott Brown, R-Mass., that would help facilitate exactly this end.

First, let’s review section 1332 of The Patient Protection and Affordable Care Act to realize how states are already — at least eventually — given the ability to innovate in this manner. Here is a simplified summary:

  • A state may apply to the Health and Human Services secretary for a waiver of all or any requirements with respect to the insurance exchanges, mandates, and subsidies with respect to health insurance coverage within that state for plan years beginning on or after January 1, 2017.
  • The secretary has to provide for an alternative means by which the aggregate amount of the tax credits and subsidies, which would have been paid on behalf of participants in the exchanges, would instead be paid to the state for purposes of implementing their own version of the law.
  • The secretary may grant a request for a waiver only if the secretary determines that the state plan will provide coverage that is at least as comprehensive as the coverage defined under the new law and offered through similar exchanges established by the states.

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Healthcare Messages Over the Internet: The Direct Project

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By BRIAN AHIER, RICH ELMORE and DAVID C. KIBBE, MD

The Direct Project announced today the completion of its open-source connectivity-enabling  software and the start of a series of pilots that will be demonstrating directed secure messaging for healthcare stakeholders over the internet.  The Direct Project specifies a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet.

Also announced:

  1. A new name – the Direct Project was previously known as NHIN Direct
  2. An NHIN University course, The Direct Project – Where We Are Today, to be presented by Arien Malec, November 29 at 1 PM ET, sponsored by the National eHealth Collaborative
  3. An extensive list of HIT vendors (20+) that have announced plans to leverage the Direct Project for message transport in connection with their solutions and services
  4. Presentations at the HIT Standards Committee on Tuesday November 30 where three or more vendors will be announcing their support for the Direct Project.
  5. A thorough documentation library including a Direct Project Overview
  6. Best practice guidance for directed messaging based on the policy work of the Privacy and Security Tiger team
  7. A new web site at DirectProject.org
  8. A new hashtag #directproject for following the Direct Project on twitter.

The Direct Project is the collaborative and voluntary work of a group of healthcare stakeholders representing more than 50 provider, state, HIE and HIT vendor organizations.  Over 200 participants have contributed to the project.  It’s rapid progress, transparency, and community consensus approach have established it as a model of how to drive innovation at a national level.

What is The Direct Project?

Today, communication of health information among providers and patients is most often achieved by sending paper through the mail or via fax. The Direct Project seeks to benefit patients and providers by improving the transport of health information, making it faster, more secure, and less expensive. The Direct Project will facilitate “direct” communication patterns with an eye toward approaching more advanced levels of interoperability than simple paper can provide.

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The Bond Markets and Health Care Financing

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By ROBERT LASZEWSKI Robert Laszweski

When will the Congress and the White House finally make the hard decisions in order come to grips with the federal deficit problem?

When will we finally deal with real health care reform and get the entitlements, and with them the private health care cost issue, under control?

My focus on trying to answer those questions has always centered on what’s going on in the health insurance market: When will costs simply become untenable and therefore force real change?

Watching “Meet the Press” a few weeks ago, it occurred to me I may have been missing the catalyst for real health care change.

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Engage with Grace at Thanksgiving

Since 2008 THCB has featured Engage with Grace at Thanksgving. We invite everyone to post this to their blog or Facebook page, and to link here with their status update. You can download a “blog ready” html version of this piece in .txt format to drop into your blog software by right-clicking and choosing”save link as” here. This post was written by Alexandra Drane and the Engage With Grace team.

For three years running now bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage with Grace are five questions designed to get the conversation about end-of-life started. We’ve included them at the end of this post. They’re not easy questions, but they are important.

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Could It Be That Patients Aren’t Any Safer?

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By ROBERT WACHTER, MDPicture 16

On the occasion of last year’s tenth anniversary of the IOM Report on medical mistakes, I was asked one question far more than any other: after all this effort, are patients any safer today than they were a decade ago?

Basing my answer more on gestalt than hard data, I gave our patient safety efforts a grade of B-, up a smidge from C+ five years earlier. Some commentators found that far too generous, blasting the safety field for the absence of measurable progress, their arguments bolstered by “data” demonstrating static or even increasing numbers of adverse events. I largely swatted that one away, noting that metrics such as self-reported incidents or patient safety indicators drawn from billing data were deeply flawed. Just look at all the new safety-oriented activity in the average U.S. hospital, I asked. How could we not be making patients safer?

I may have been overly charitable. This week, in an echo of the Harvard Medical Practice Study (the source of the 44,000-98,000 deaths/year from medical mistakes estimate, which launched the safety movement), a different group of Harvard investigators, led by pediatric hospitalist and work-hours guru Chris Landrigan, published a depressing study in the New England Journal of Medicine. The study used the Institute for Healthcare Improvement’s Global Trigger Tool, which looks for signals that an error or adverse event may have occurred, such as the use of an antidote for an overdose of narcotics or blood thinners. Following each trigger, a detailed chart review is performed to confirm the presence of an error, and to assess the degree of patient harm and the level of preventability. While the tool isn’t perfect, prior studies (such as this and this) have shown that it is a reasonably accurate way to search for errors and harm – better than voluntary reports by providers, malpractice cases, or methods that rely on administrative data.

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Thanks Giving

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By ROB LAMBERTSLamberts, MD

Thanksgiving is probably my favorite holiday.  Christmas is great, but the commercialization of it has largely spoiled it.  Thanksgiving seems to be the one holiday that has remained as it was when I was young: a time to be with family and friends, and a time to reflect on the good things in life.

Yet I know for a lot of my patients and readers, finding feelings of thankfulness is difficult or impossible.  I see pain and loss that is hard to understand.  Thanksgiving is looked at my most as a time to thank God for the good in life, but to those who suffer, God seems to have it out for them, or to be ignoring them completely.  To many, Thanksgiving is a sad reminder of happier times.

A boy in my children’s school died suddenly last week of an anemia caused by his body attacking his red blood cells.  It came suddenly, and it happened swiftly.  One day he was a normal 14 year-old kid, and a week later he was dead.

I have friends who are going through divorces, who have lost close family members, or who are dealing with inner demons that make celebration very difficult.

Some patients have physical pain so bad that they can’t even sleep, while others have only a few months to live.

Happy Thanksgiving?

So how do we deal with this reality?  How do we look at the our lives in light of those around us?  Should we feel guilty for our blessings?  Should we ignore those in pain?  Those are hard questions with different answers for different people.  But one thing I do know is that we should not ignore reality.  We can’t pretend life is a sit-com that will work out in the end.  That does an injustice to the pain of those suffering – perhaps more of an injustice than the pain itself.

Here are some of my personal observations regarding these questions.  They are in no way the complete answer (I am sure readers will add their wisdom to this), but it’s helpful for me to put them down.  I hope it helps some of you.

1.  I am most thankful for my giving.  The fact that I have been able to make a mark in people’s lives, to help them in their hard times, to be the person they needed when life was falling apart, is an incredible honor.  Any thing we possess can be taken from us, but what we have done for others is ours forever.  The simple fact that I can help people in their suffering lets me be thankful for what I have.

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