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Health Care Reform’s Deeper Problems

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By BRIAN KLEPPER and DAVID C. KIBBE

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Congress’ health care reform debate has highlighted how American governance is broken and the difficulty of addressing our national problems.

Take, for example, whether health care is in crisis at all. Conservative commentators argue that America’s health system is fine, that our excellent care simply costs more than other countries’ poorer quality, and that most uninsureds can afford coverage. They ask why we should revamp a great system for the two or three percent of Americans who get less.

This misrepresents reality, though. Care and outcomes are often superior in other developed nations. In America, the ranks of the uninsured and under-insured have skyrocketed, from insurance costs that have grown four times general inflation for a decade. Health coverage is employers’ most unpredictable major cost, a threat to their businesses’ competitiveness, and they have increasingly offloaded costs onto employees. So while  the marginalized uninsured are an important problem, declining coverage for the mainstream is the greater worry. Most know that, even with insurance, any major health problem can spell financial ruin.

As businesses and individuals have been priced out of health coverage over the last four years, commercial health plan enrollment has plummeted by as much as 20 percent, or about 36 million people. The Kaiser Family Foundation reports that 40 percent who lose group health coverage probably become uninsured.

Fewer people buying coverage means less money to pay for health care products and services, so the industry is experiencing an unprecedented financial decline. With reforms looming, it has fiercely advocated for universal coverage, which would provide stable funding for a larger patient population. Meanwhile, the industry has opposed changing business mechanisms that encourage waste, even though experts agree that one-third or more of all health care cost is unnecessary or inappropriate. But this raises an important question. Why not spend less by recovering wasted dollars, and then improve access?

The industry has pressed its goals through lobbying, which lets special interests exchange campaign contributions for policy influence. The non-partisan Center for Responsive Politics reports that, between January and June, the industry gave Congress more than $260 million. One lobbyist commented, “A person can reach no other conclusion than this is a quid pro quo [this for that] activity.”

The funds have gone mostly to Democrats, the party in power now, and are producing their contributors’ desired results. The current proposals expand coverage, but do little to reduce cost, failing to heed any of health care’s management lessons from the last 25 years. For example, they won’t re-empower primary care, which other nations have found will maintain a healthy populace for half the cost of our specialist-dominated approach. They fail to make care quality and cost transparent, which would let health care finally work as a market, and help identify the best health care vendors. They continue to favor fee-for-service reimbursement, which rewards delivering more products and services rather than rewarding results. And they all but ignore our capricious medical malpractice system, which most doctors say encourages defensive practice.

These problems and their solutions are structural, and are well understood within the industry. If reform does not pursue these structural approaches, health care will continue to drag down the larger economy. Our current problems will remain and intensify, at enormous cost.

Out of this experience, the American people should become aware of a couple of harsh truths.

First, so long as Congress willingly exchanges money for influence, American policy will favor special interests rather than the public interest. We’ll be unable to meaningfully address our national problems: energy, the environment, education, and so on.

Second, so long as partisans distort the truth to discredit their opponents, rather than focusing on our very real problems, America’s future will continue to be compromised.

Which is to say that we have deeper problems than an inability to fix health care.

Brian Klepper, PhD is a health care analyst based in Atlantic Beach. David C. Kibbe MD MBA is a physician and Senior Advisor to the American Academy of Family Physicians.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians. Brian Klepper PhD is a health care analyst.

More by these authors:

U.S. v. Europe — What’s Your Risk of Dying?

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By MERRILL GOOZNER

Want to have some fun with numbers? Check out a brand new “Death Risk Rankings” website, which was sent my way today by Dr. Paul Fischbeck of Carnegie Mellon University in Pittsburgh. He and his colleagues have compiled data and made a user-friendly interface that allows you to compare the risk of dying within periods of time at various ages of various causes. It also allows the user to set variables like sex and race as well as age. Very cool.

So what did learn in my first pass through the data?

If you’re a 50- to 59-year-old man (guess how old I am), your chances of dying in the next ten years are better if you live in the U.S. than in Europe: 7.8 percent versus 8.2 percent. However, all of the difference was due to a single factor: the higher rate of cancer deaths in Europe, which is undoubtedly due to the much higher rate of smoking.

But the situation is completely reversed if you’re a 50- to 59-year-old woman. For late middle-aged women, the chances of dying in the next ten years is much higher in the U.S.: 4.7 percent versus 3.9 percent. Cancer death rates are almost exactly the same in the two regions, but U.S. women over 50 are much more likely to die of heart disease, diabetes, infectious diseases and respiratory diseases — in short, everything that a good health care system that stresses prevention can help.

And did you know that if you reach age 80, your chances of dying in the next year are about one in ten? I was initially disturbed by that number. But after thinking about it for a few moments, I realized that if I were 80, I’d probably think those were pretty good odds. Moreover, if I still have the energy to play 18 holes of golf at age 80, I’ll probably think I have a pretty good chance of beating them. And if I didn’t have the energy to play 18 holes, who’d want to live anyway?

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. His most recent book, “The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs ” (University of California Press, 2004) has won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. You can read more pieces by Merrill at  Gooznews.com, where this post first appeared.

There Will Not Be Health Care Reform in 2009…

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By ROBERT LASZEWSKI

…without Republican leadership.

I will suggest that there is an opportunity for the Republicans to
score a huge political and policy win. It can be done in a bipartisan
way and it can be done in a way that does not sell out the core
principles that either Republicans or Democrats believe in.It would require a new effort—a clean sheet—this time initiated by the Republicans.The
Republicans have won August. No doubt about it. But they have “won,”
not because they actually did anything to deserve the win—they pretty
much sat back and let political gravity do all of the work.Now what? Do Republicans really think they can sit back and do nothing for three or four more months and come out “winners?”At this rate, this health care debate is headed for a stalemate that will not do the country, nor either party, any good.

Continue reading…

The HIT Deluge Part I: The Need and the Opportunity

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By GLENN LAFFEL

Glenn

There was a time–not too long ago, in fact– when it seemed safe and reasonable to define health information technology narrowly: the acronym encompassed the management of health information and its secure exchange between patients, providers, and insurers.

For many providers, the definition seemed to compartmentalize HIT. It was for someone else, perhaps the Ivory Tower crowd, but not for me. The nearly 90% of practicing physicians in the US that don’t use an EHR for example, might have sensed that someday they’d have to log on, but not any time soon.

And as for all that stuff about telemedicine and consumer driven health care, that made good topics for CME courses, but again, it wasn’t immediately relevant.

That began to change 15 years ago when nascent quality reporting initiatives began forcing physicians to deal with clinical performance data and the systems used to collect, analyze and display it.

It accelerated when patients began showing up in their offices with Internet-derived reprints of journal articles they hadn’t read themselves, and with pay for performance systems in which insurers tied a chunk of their income to the frequency with which they screened people for colon cancer and kept their diabetics’ HbA1c levels below 7.0.

But nothing in the past could have prepared physicians to deal with the overwhelming flood of HIT that inundates them on a daily basis today, a flood that threatens to sweep away long-established professional codes of conduct and disrupt the very processes by which care is rendered, doctors communicate with patients, and health systems interact.

The Obama administration’s push to disseminate EHRs via Medicare bonus payments for those who demonstrate “meaningful use” beginning in 2011, is but a tiny component of the Deluge.

Equally if not more important is the recent explosion of social media, a phenomenon whose unprecedented, indiscriminate growth has spared no sector of our society and taken health care by storm.

The newest generation of physicians has grown up with Facebook and Google, with Twitter and YouTube. They “get” the technology, but don’t always understand how its use affects their efforts to forge identities as medical professionals.

And for the rest of us, forget it. What in the world is all this stuff, and how dare we use it without getting burned by the fire?

Consider the following examples, which illustrate how the deluge affects physicians at every stage of their careers:

1) In his second week as a medical intern, Dr. Jain receives a “friend request” from an Erica Baxter on Facebook. Years ago, while he was a medical student, Jain helped deliver Baxter’s baby. Now she wants to reconnect. Is she simply a grateful patient interested in sharing news about her child, or does she have other motives? Jain clicks “confirm,” granting Ms. Baxter access to his network of friends, his personal photographs and blog, and the scrawls of others left on his wall.

2) Dr. Margolis, a middle-aged pulmonologist, receives about 120 emails per day. The assortment spans the range of her busy life. There’s an email from her oldest child who needs to be picked up at 6:30, not 5:30. Her dentist has an opening this afternoon and wants her to come in for a permanent fitting on her crown. Her secretary wants her to see a patient whose breathing difficulties have taken a turn for the worse.

And then there are emails from Dr. Margolis’ patients. Some are annoying, some can be handled by the nurse practitioner, and some reflect downright emergencies.

Problem is, Dr. Margolis is way too busy to read 120 emails per day. She’s lucky if she gets through half of them. She has a thousand unread emails in her inbox, many of which arrived weeks ago. She worries some may contain time-sensitive information regarding a patient.

3) Dr. Tapscott, in his late 60s and nearing the end of a satisfying career in family practice, is convinced by front-office personnel to begin using an electronic health record. “That $44,000 in bonus payments sure would help make ends meet,” he reasoned to himself at the time.

But the EHR implementation doesn’t go well. He has trouble getting the hang of the thing and believes the machine puts a barrier between himself and his patients. He expresses displeasure to his staff, one of whom leaves in a huff. Five months and tens of thousands of dollars later, he ditches the system.

Physicians have faced emerging ethical challenges before. Their struggle to develop professional identities is as old as the profession itself. And this isn’t the first time they’ve have had to incorporate new medical innovations into their daily lives, but the HIT deluge multiplies these challenges several fold, and creates myriad new ones, many of which remain vexing even to deep thinkers in the field.

Something has to be done to support physicians as they confront the HIT Deluge.

Thankfully, that’s possible and within our abilities to do so, at least for the most part. In subsequent posts of this series, we’ll explore the Deluge in detail and draw conclusions about what we need to do.

Glenn Laffel is a physician with a PhD in Health Policy from MIT and serves as Practice Fusion’s Senior VP, Clinical Affairs.

Faces of the Fallen

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By ALICIA SAMUELS & ANDREA CARLSON GIELEN

Andrea Carlson Gielen

What do Hillary Clinton, Pope Benedict XVI, Barbara Mikulski and Sonia Sotomayor have in common? Falls. (And no, this is not a joke). In fact, falls are far from a laughing matter. Approximately 20,000 Americans die each year from falls (Katharine Graham, the former publisher of the Washington Post who died from a fall in 2001, is one notable example).

While the falls of these high-profile leaders made headlines, the bigger picture- falls as a public health problem- went largely unnoticed. It’s estimated that seven million people are treated for fall-related injuries each year in our nation’s emergency rooms, and the cost to our healthcare system is nearly twenty billion dollars annually.

If these numbers don’t grab your attention, take a minute and think about what’s going to happen as a result of our aging population. One in three adults 65 and older falls each year and every 35 minutes someone in this population dies as a result of their injuries, making falls the major reason for injury-related death, injury and hospital admission for older adults. A public health crisis of this magnitude won’t come cheap: by 2020, the annual direct and indirect cost of fall injuries is expected to reach $54.9 billion.

Contrary to popular belief, “slips, trips and falls” are not unavoidable. Because of the disproportionate burden of falls among those 65 and older, a large body of research has been devoted to developing and evaluating fall prevention interventions. As a result, we now know that older adults who exercise regularly, have their vision checked, undergo medication management, and who have access to home hazard assessment are less likely to fall in their homes. Moreover, studies have uniformly indicated that falls-prevention services result in a net cost savings for older adults at high risk of falls.

Unfortunately, falls prevention currently receives little attention in clinical practice. In fact, it’s easier to cite what Medicare doesn’t cover than what it does. Falls screening is not part of the Medicare Part B Preventive Services package, nor is it included in the “Welcome to Medicare” exam upon enrollment. Participation in strength and balance programs and home modification assessments for those at high risk are also sadly left out.

Much focus has (rightly) been directed at how healthcare reform can lead to better prevention of chronic diseases like diabetes and cancer, however the lack of attention to falls and other injuries is alarming. By neglecting injury prevention strategies, opportunities to contain costs and improve outcomes- two key goals of healthcare reform- are missed.

We wish full and speedy recoveries to these distinguished leaders. Let us use their experiences as a call to action to help the millions of others who suffer needlessly every year by incorporating falls and other injury prevention strategies into healthcare reform.

It would be a huge misstep to let this critical issue fall through the cracks.

Alicia Samuels, MPH, is the director of communications for the Center for Injury Research and Policy at the Johns Hopkins Bloomberg School of Public Health. Ms Samuels has nearly a decade of public health communications and research experience, including six years at the national home office of the American Cancer Society in Atlanta, GA.

Andrea Carlson Gielen, Sc.D., Sc.M., is professor and director of the Center for Injury Research and Policy at the Johns Hopkins Bloomberg School of Public Health. Dr. Gielen has almost three decades of public health experience, including as a public health practitioner and an academic researcher directing federally funded studies of health behaviors and behavior change interventions. She is the author of more than 120 articles on health behavior, health education, and the prevention of injuries and violence. In 2002 Dr. Gielen was awarded with a Distinguished Career Award from the American Public Health Association’s Public Health Education and Health Promotion Section.

Donald Light sticks it to PhRMA and Tauzin, again

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By Matthew Holt

Over the years PhRMA must be getting pretty sick of Univ of Medicine and Denistry of New Jersey Professor Donald Light. He’s made a cottage industry of pissing on the commonly-trumpeted propaganda that only American drug research is effective, and that high prices for drugs in the US cross-subsidize lower prices elsewhere in the world. And in Health Affairs this week he does it again. Essentially Light shows that the added R&D spent in the US compared to Europe doesn’t give much bang for the buck, and that not many breakthrough drugs have been created anyway—something that PhRMA knows all to well as it looks at its shrinking pipelines.

In global NCEs, European research productivity was about the same as U.S. productivity in the first period but increased by 30 percent in the second period (1993-2003), while U.S. research productivity declined 26 percent (Exhibit 3). In first-in-class drugs, European relative innovativeness moved from well behind the United States in the first period to well ahead in the second. These are the most commercially and therapeutically important types of new chemical entities.

Now personally I think that, in an era in which all drug research is pretty much international, the basic premise of the argument about which system does more effective drug research is pretty silly. But of course it’s a one-two punch. And the upper-cut that would leave pharma staggering if it didn’t have control of the microphone is this quote from Light:

Congressional leaders and others concerned about high prices of new patented drugs will be heartened by this analysis, because lower European prices seem to be no deterrent to strong research productivity.20 A previous analysis using industry-based data showed that pharmaceutical companies recover all costs and make a good profit at European prices.21 Europeans are not “free riders” on American patients–another myth promoted by industry that assumes that countries are separate R&D/market silos that should each pay for themselves.

Given that Billy Tauzin at PhRMA has already cut a deal with the Obama Administration (albeit one that seems to be unofficially official), none of this matters very much. But it’s good to see that it might just be possible to reduce the very high margins earned by big Pharma without necessarily ending scientific advancement as we know it.

CODA: Read Michael Cannon’s amusing take on PhRMA’s Billy Tauzin’s performance here.

SXSW–Vote for me, or those other guys!

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By Matthew Holt

So in Austin every year they have this SXSW conference. Indu goes every year and raves about it. Last year Jay Drayer from CareFlash put me on a panel (but it didn’t get selected). This year he has a different group. But don’t worry, Feelgoodnow.com has proposed a panel entitled Sick Clicks: The Evolution of Health Online that will feature me and other buds including Susannah Fox, Associate Director of Digital Strategy at the Pew Internet & American Life Project,Catherine Ulbricht, founder of Natural Standard and Jay Parkinson, founder of HelloHealth.com.

The bizarre thing is that SXSW is a democratic event and you have to vote for it. So please go vote for us here. And if you want to vote for Jay Drayer’s motley crue, well they’re here (and they’re pretty damn good too…)

Commentology: Healthcare in the UK

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Anonymous

Rod Unger writes:

I am, if you like, Joe the Plumber living here in the UK just to the North of London. I have no particular political mandate in terms of the NHS (more of this later). I don’t work for the NHS or have any other such vested interest. Nor do I have any knowledge or contact etc with any of the Pharmaceutical companies. Hence I am Joe the plumber. I am just an ordinary man in the street. Before going any further there is one other thing I would like to state as a prequalification. You have to understand the British mentality (as a generalisation). Many, many years ago we thought it proper and decent to be modest. This then slightly altered to us becoming a nation of moaners and pessimists! Unlike Americans who have (as a generalisation) a wonderful “can do” mentality and optimism.

The NHS is one of the most wonderful things about an excellent lifestyle we have here in the UK. Our weather is better than often reported. (Check out the stats if you don’t believe me) We are full of invention, fun and excel at many world wide industries and sports. But the NHS is one of the best things about the U.K. It is not run by the Pharmaceutical companies who only want to maximise profits. It is not run by lobbyists for their own benefit. It is run for the nation. It is not perfect and you will here the moaners going on about the small percentage of problems (big in number small in percentage). No government ever since the NHS as introduced has ever even considered doing away with the NHS. This is not a political issue in the UK. The NHS is supported by all parties and by everyone. Quite a few people do have private insurance as they can afford to pay for non essential matters or to jump queues. But even they in an emergency will be taken straight to an NHS hospital and receive an excellent service. There will be no queues and no questions asked!

I personally know many people who live in Spain, Portugal etc etc and they all come back to the UK for the NHS. Indeed my own parents lived in Portugal for 12 years when the retired and moved back to the UK at the age of 76!! just for the NHS. Since being back they have used the NHS on a regular basis (they are now 88) and we all have nothing but praise for all parts of this massive organisation. All their care, medications etc etc is free.

About 4 years ago my son was diagnosed with a serious ling term mental disorder. We use the NHS every day. He takes medication every day and will have to for the rest of his life. All this is free and the staff are fantastic

We do live in different societies. It is not for us to advise you as to what is best for your country but do not denigrate or criticise the NHS it is fabulous on a world wide scale. Yes there are problems not least of all trying to move this huge organisation in to the modern technological age plus coping with a huge influx of people from foreign countries many of whom cannot speak English. This has put a massive strain on the resources available, but still the staff provide a fabulous service.

Don’t believe the propaganda from those wishing to feather their own nests. It is too important

Best Wishes

Rod Unger

Data drives decisions? Crowd-sourcing as the future of research

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By Matthew Holt

So, I get back from lounging on the beach in Hawaii to find that two strands of the THCB and Health 2,0 worlds have connected! At the Health 2.0 Conference we’re going to be hearing from 23andme, PatientsLikeMe, Pfizer, MedHelp, Within3 and more about the role that crowd-sourced data has on the future of decisions and discovery.

And then in the NY Times today there’s an excellent article all about this called Research Trove – Patients Online Data. And the author is THCB alumna Sarah Arnquist, who is now in Africa studying health care in Uganda.

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