The Health Care Blog – Page 888 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The Case for Comparative Effectiveness Research

Jul 13, 2009• 7

By RAHUL PARIKH, MD

When I was a kid growing up in Los Angeles, there was this local TV show my dad used to enjoy watching called Fight Back with David Horowitz. Basically, Horowitz, a TV reporter and consumer advocate, used to put the claims a manufacturer made about their products to the test—whether it was if Samsonite luggage could withstand abuse from a Gorilla or Bounty really was the “quicker picker upper,” it was on its show and ended up either endorsed or debunked by it. It was Consumer Reports come to life, if you will—pitting products against one another to see which one was worth putting down some hard earned dollars for.

Now, over 30 years later, we in medicine are just getting around to doing the exact same thing that Horowitz was with retail way back in the 1970s—comparing the claims made by drug and device makers about their products.

Nursing Homes Get Old for Many With Disabilities

Jul 13, 2009• 12

By JENNIFER LaFLEUR

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ST. LOUIS — Melody Ping never thought she would be trying to moveout of a nursing home. She lived in a St. Louis apartment for 19 years and worked as an
accountant until two years ago, when she lost her job. Ping, who has
multiple sclerosis, couldn't find new work. When her unemployment ran
out, she ended up on Medicaid in a nursing home.

Ping, 51, is among tens of thousands of people nationwide who want to
live on their own, but instead remain in nursing homes, rehab centers
or state hospitals, often at a higher cost to taxpayers because of a
historic bias toward institutional care.

Ten years ago today, the U.S. Supreme Court said that
bias amounted to discrimination. Now, as disability advocates
celebrate the anniversary of that landmark ruling, they worry the Obama
administration is backing away from a pledge to give more people with
disabilities the option to live at home.

As a senator, Barack Obama co-sponsored the
Community Choice Act, pending legislation that would give
Medicaid recipients equal access to services in the community and not
force them into institutions. But the administration recently said it would
not address the issue as part of its proposed health care
overhaul.

Musings on Payment Reform

Jul 12, 2009• 38

By CHARLIE BAKER

Charlie Baker is the president and CEO of Harvard Pilgrim, a nonprofit health plan that covers more than 1 million New Englanders. Charlie is a regular contributor to THCB, where he has authored posts on national health reform (See: “Is Massachussetts a Model for National Reform?” and related issues facing the healthcare sector. (For example: “Shifting Costs From Public To Private Payers“). His posts also appear at his own blog, Let’s Talk Health Care.

This week Charlie confirmed a longstanding rumor, announcing that he will be giving up his position at Harvard Pilgrim at the end of July to run as a GOP candidate for governor of Massachusetts. You’ll find more about his campaign on his web site, CharlieForMA.com.

The Commonwealth of Massachusetts – along with a number of other states (including New Hampshire and Maine) and the federal government – is kicking around a number of ideas concerning payment reform. The argument goes something like this – since the current health care system, led by the gigantic Medicare program, pays primarily on a fee for service basis. This “do something” payment model encourages clinicians and hospitals to do “more” for patients than they might do otherwise, if they weren’t encouraged to “do something” to get paid. Add to that the fact that fee for service – again led by Medicare – pays more for new technology than it does for existing technology, and less for primary care, and you have the primary ingredients in the recipe that’s driven our system to be technologically driven, volume driven, fragmented and very expensive.

In Massachusetts, the group that’s working on payment reform seems to think the solution to this problem is to move everyone away from fee for service and into something that’s being called, “global budgets.” Put simply, global budgets are a new and improved form of capitation. Let me be clear on this one – I’m actually a big fan of both. I believed in capitation when I worked in state government, and I worked for a medical practice (Harvard Vanguard Medical Associates) before I came to Harvard Pilgrim that was built on global budgets.

And before I go any further, I would offer up the cover story in this month’s issue of Health Leaders Magazine – titled “Bundling By Decree” as a solid a representation of the pros and cons of this debate as it winds its way through the national discussion around health care and payment reform. This article is primarily about bundling payments around episodes of care, but the issues it raises – in both directions – apply in either context.

With that said, I wonder about whether or not global budgets, at least in the short term, are the answer to our health care cost and quality problems. For some provider organizations, global budgets work – but they work in large part because those particular clinicians believe in them, and want to practice in environments that are based on them (like Harvard Vanguard/Atrius HealthCare). But that represents a fairly small slice of the practicing clinician community – I’m guessing 10-15 percent. Maybe 20. It’s also not clear to me that this issue, above all else, drives our cost/quality problem, since many other countries that spend a lot less than we do on health care and have solid clinical results use fee for service payment systems too.

As far as I can tell, those other countries that spend less than us on health care do two things differently than we do. First, they spend less on each service than we do – sometimes a lot less. They also have robust primary care systems. This, in particular, is just the opposite of our approach. Our payment policies – and as a result, our medical education system – have been disinvesting in primary care for years.

In the short term, I’m not sure global budgets solve this disinvestment problem. First of all, it’s financial and operational whiplash for a system that’s been running on fee for service for years. That, all by itself, will take some getting used to. It’s also not clear that Medicare or Medicaid – which make up 50-60 of the payments to providers to begin with – would also adopt global budgets. If they don’t, having private sector payors using global budgets and the public sector payors using fee for service is just about the worst outcome I can think of for providers and their patients. The mixed messages these two payment models would send about what matters and what’s important would be virtually undecipherable.

This makes me wonder if our short term approach shouldn’t focus instead on changing the message all payors send under the current fee for service system to providers by improving the way we pay for primary care. No one thinks we can possibly deliver integrated, coordinated care if we don’t send some signals to the medical and medical education community that primary care matters. If a young medical student can make $250 an hour in primary care – or $1,000 an hour in dermatology – or $2-3,000 an hour in cardiology or orthopedics – how hard do you think it is to get that person into primary care? The answer is it’s wicked hard – and the declining number of students going into primary care coming out medical school for the past decade is proof positive of that. We used to be 50/50 primary care / specialty care. Now we’re 70/30, and some of the anecdotal information suggests that kids coming out of U.S. medical schools are now running 15/85 primary care/specialty care.

Think about it. No one disputes the fact that primary care has a key role to play in care management and care coordination – especially as the Baby Boomers get older. The state’s Payment Reform Commission says global budgets will take three to five years to implement – and expects that every doctor will be using an EMR as one of its requirments for success. Will this approach really grab today’s medical students and practicing clinicians and say – ”HEY! It’s time to invest in primary care!” In the short term, I think we’re more likely to get more capacity, faster, into primary care by boosting, on a relative basis, the fees paid to primary care providers by the private plans, Medicare and Medicaid.

Over time, maybe everybody gets to global budgets, but in the meantime, I think we need to do more to support primary care.

Behind the Curtain: Wendell Potter on the Industry’s Management of Care and Reform

Jul 10, 2009• 11

By BRIAN KLEPPER

Stop what you're doing and take out a half-hour to watch this week's superb Bill Moyers' 3-part show, especially the extended interview with Wendell Potter, former CIGNA VP Corporate Communications, for a frank, insider's discussion of how major health plans have worked over the last decade.

Also be sure to watch Moyer's very brief final commentary, describing a dinner that was planned by the Washington Post to connect lobbyists with high-ranking officials working on the health care reform process. His conclusion: we won't get anywhere with health care or any other national problem until "the money-lenders are tossed out of the temple and we tear down the sign they've placed on government, the one that reads 'For Sale.'"

Fantasy League Baseball — Beltway Series Edition

Jul 10, 2009• 12

By MICHAEL MILLENSON

Bob Laszewski’s Health Care Affordability Model has the same connection to the reality of the current battle over health care reform as a Fantasy Baseball League does to the actual outcome of a major league baseball game; i.e., none.

Actually, while those who play Fantasy Baseball – might we call them “baseball wonks”? – are affected by what happens in the real world to the players they have selected, they have no illusions of reciprocity. Laszewski is a brilliant analyst whose examination of the various political proposals for health-care reform have become a “must-read.” But in making his own proposal, Laszewski, a strategy consultant based in Washington, has managed to completely ignore the fact that reform is an intensely political process.

“The Health Care Affordability Model…could be attached to virtually any health care reform plan now on the table,” he writes.

No, it couldn’t. Just like managing a Fantasy Baseball team has no connection to managing real major league players. Given Laszewski’s timing, his proposal is somewhere between almost irrelevant and completely so. Which is not to say his ideas are wrong.

Has Harry Reid Torpedoed Reform?

Jul 10, 2009• 13

By ROGER COLLIER

Health care reform ran into new BIG trouble this week with a series of comments from Senate Majority Leader Harry Reid.

On Tuesday, Reid leapt into the middle of reform negotiations, telling Senate Finance Committee Chairman Max Baucus that Democratic leaders had major concerns about the draft Senate Finance bill’s proposed taxation of some health benefits and the exclusion of a strong public plan.

The immediate result was the effective suspension of bipartisan negotiations on the Senate Finance draft, with Republican Senators Chuck Grassley and Orrin Hatch both saying that bill markup would have to be delayed indefinitely until the conflict was resolved.

Yesterday, Reid tried to soften his comments in conversation with Senate Republicans, but later indicated that taxing health care benefits was still unacceptable, leaving Senate Finance members wondering how else to help pay for the trillion dollars (or more, perhaps much more) that they estimate as the ten-year cost of reform.

Reid’s comments reflect the findings of a series of straw polls in which various senators’ constituents were asked if they supported taxing health care benefits (Surprise! They didn’t want any new taxes), as well as an aggressive union-led campaign against the idea.

Reid’s intervention may very well have torpedoed reform. It leaves Senate Finance with few choices for funding reform, and virtually none that are likely to attract any bipartisan support.

Even if Senate Finance members are able to find other funding solutions, killing taxation of health care benefits will remove from the Senate Finance draft one of the very few provisions that might have resulted in slowing of overall health care cost increases. Leaving tax deductibility of benefits in place will continue to encourage the belief in those lucky enough to have generous employer coverage that health care is “free,” and in turn pander to providers eager to invest in high-priced resources that increase costs for everyone else. Meanwhile, Reid’s insistence on a strong public plan as an alternative cost control mechanism is likely to end support from moderate Republicans and centrist Democrats and to generate huge (and well-funded) opposition from insurers and providers. And, as the Clinton administration discovered sixteen years ago, any slowing of legislative momentum can be fatal to reform.

Roger Collier was formerly CEO of a national health care consulting firm. His experience includes the design and implementation of innovative health care programs for HMOs, health insurers, and state and federal agencies. He is editor of Health Care REFORM UPDATE.

Op-Ed: Health Care Re-invention and Personal Responsibility More Critical to Reform than Government Intervention

Jul 10, 2009• 21

By DR. STEPHEN KARDOS

Stephen Kardos

President Obama should be commended for addressing the challenge that’s facing our nation’s health care system. While Democrats and Republicans agree that the health system is broken (since 1975, per person annual health spending has grown 2.1 percent faster than overall economic growth per person¹), there is no clear agreement on the next steps that need to be taken to fix the problem.

President Obama has offered the idea of implementing a national health care plan; however, in its current iteration, his plan doesn’t address what’s broken with the system. Instead of flooding the system with 46 million more insured persons and spending $1.2 trillion over the decade, Obama should look to the hard evidence that indicates a third of all health dollars currently spent each year (more than $750 billion) are wasted. That lump sum should be brought back into the system to care for the uninsured and reduce the national deficit at the same time.Continue reading…

Head of Investigations Unit Resigns

Jul 10, 2009

Dca-logo BY TRACY WEBER

The head of investigations for California’s Department of Consumer Affairs has resigned, continuing the fallout from a Los Angeles Times – Propublica investigation into lengthy delays in disciplining nurses accused of egregious misconduct.

According to a spokeswoman for the California State and Consumer Service Agency, the decision by Lynda Swenson to quit was tied to revelations by The Los Angeles Times and ProPublica about problems at the Board of Registered Nursing. Most investigations of errant nurses are handled by the Division of Investigation, which Swenson headed.

Why Congress Should Consider Bob Laszewski’s Health Care Affordability Model

Jul 9, 2009• 40

By BRIAN KLEPPER

ALP_H_BK_0010 Over the last few months, I have become increasingly disheartened over the prospects for meaningful health care reform.

First, the process is terribly conflicted, and it shows. In the first quarter of 2009, the Center for Responsive Politics reported that the health care industry contributed $128 million to Congress. Now that the tide has turned, this has gone mostly to Democrats who, as it turns out, are just as receptive as their Republican predecessors.