Does the New Senate Health Care Bill Get the Job Done?, Conclusion

by Tim Foley

categories: For Profit Insurance, National Health Exchange, Obama and Congress

Published November 20, 2009 @ 10:05AM PT

In part 1, I looked at joy with some of the provisions in the new Senate bill to make coverage more affordable, and shouted “Woohoo!” In part 2, I looked at some other less impressive policies and shrugged, “Meh.” But the fun times must come to an end.

I had three big “Aw Crap!” concerns while skimming through the new Senate bill. These aren’t just qualms. To my mind, they’re major problems. We’re talking “Tom Hanks is on the phone with Houston and they need to put a square peg into a round hole in order to get breathable oxygen in the Apollo 13 module” problems.

The simplest is the most inexcusable. The Senate bill delays opening the Exchange, providing individuals and families with these very affordable subsidies insurance plans, and creating a public option to bring some competition to private insurance -- all of that is delayed until 2014. Why? To get a better CBO score -- that’s all. We’ve hit the real failure of our health care debate this year square in the mouth once again: “more affordable” in terms of a prettier price tag for the federal government can only come at the expense of “more affordable” in terms of making coverage affordable to Americans.

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Senate Health Bill: Less, Later, and Holy Complexity Batman (P1)

by Gillian Hubble

categories: Obama and Congress, Public Plan

Published November 20, 2009 @ 06:00AM PT

The wait is over, the latest bill is out. If I had to sum up the difference between the Senate and House healthcare reform bills in three words, it would be ‘less’, ‘later’, and ‘holy complexity, Batman’. Fine, that last one is not a word, but it is accurate. Considering I’m comparing a 2,074 page Senate bill to a 1,990 page House bill, that’s saying something. Yes, HR 3590, the Patient Protection and Affordable Care Act (lots of info at this link), is an interesting exercise in playing with numbers and perceptions even compared to HR 3962. However, there are also some very good aspects to the bill. We’ll cover the good here, and the rest in Part 2.

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Does the New Senate Health Care Bill Get the Job Done?, Pt 2

by Tim Foley

categories: National Health Exchange, Obama and Congress, Public Plan

Published November 19, 2009 @ 12:37PM PT

In evaluating the new Senate bill, I’m defining “get the job done” not through how well it does on creating the tools for serious cost control (Ezra Klein is your man for that), nor am I defining success as winning the enmity of health insurance companies, although Wall Street clearly hates this bill -- in and of itself reason to be optimistic about its effect for Main street!  No, for right now I'm solely looking at the bill through the lens of whether it does enough to make health insurance affordable both to those who already have it and those currently uninsured who would get it under the Health Exchange.

In Part 1, I shared my relief at some strong changes Sen. Harry Reid had made to his predecessor bills from Senate Finance and Senate Health, Education, Labor and Pensions, causing me to say, “Woohoo!” But there are other elements of the bill that should help keep coverage affordable for the vast majority of Americans, even if they're less spectacular.

Under “Meh,” we have one bad idea from Finance that’s been kicked to the curb, provisions for Medicaid which, after much ado, are exactly where we thought they’d be, and Reid’s compromise “state opt-out” public option, which is slightly worse than we thought it’d be, although it's less because the idea is unsound and more because we're making it compete with one arm tied behind it's back.

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The Prescription for Revolutionary Healthcare Delivery Reform*

by Gillian Hubble

categories: Comparative Effectiveness Research, Doctors and Nurses, Hospitals and Health Systems, Medicare and Medicaid

Published November 19, 2009 @ 06:00AM PT

*Sorry, it's not the Senate bill!

Hidden among the 1990 pages of HR 3962, there are some provisions to tinker around the edges of healthcare delivery and bend the cost curve to a minor extent. There are Medicare payment bundling and pay for performance pilot programs, comparative effectiveness research, and of course Medicare rate cuts. The combined Senate bill should have similar features. In truth, no one expects these strategies to have a big impact over the long term. As the photo translates, “Without theory, no revolution.” But what if we used the aggressive pursuit of four goals to revolutionize US healthcare delivery and bend the cost curve? A recent Health Affairs article explores what it would take to reach these far-reaching goals:

1. Improve the science of healthcare delivery

The US must prioritize developing a science of healthcare delivery, which is currently a black box. Patients with the same condition are treated in many different ways, depending upon the physician. Rarely does that physician do much research to determine what the most effective and cost-effective treatment might be. For example, many years ago I worked in two cardiac rehabilitation practices on opposite sides of town. The patients in each practice were on completely different blood pressure medications, depending upon which pharmaceutical reps visited which side of town! Less than 10% of the patients had their hypertension adequately controlled.

Electronic health records (EHRs) also aren’t typically deployed to help analyze the link between care and outcomes. They must support the incorporation of patient-reported health status and ongoing outcomes. I can tell you from long experience in EHR deployment that clinical decision support aids like these are “maybe some days” that are quickly forgotten once the EHR goes live. Focus shifts elsewhere. EHRs must be rolled out intelligently and progressively to enable safe, quality, scientific care.

2. Foster the expansion of organized systems of care

This goes back to the coordinated care model, where there is one accountable organization that coordinates comprehensive care to the patient for a bundled payment. Adhering to high-quality clinical processes, achieving high-quality outcomes, and providing a high-quality patient experience are rewarded with bonus payments (pay for performance.) This will rein in excess utilization – otherwise known as the quantity of care juggernaut – while improving the quality of care, especially for the chronically ill, who account for 60% of Medicare spending. It’s a model that will require a learning curve and frequent adaptation.

3. Establish informed patient choice as the standard for elective surgeries, tests, and procedures

The devil is in the details on this one. When they sign an informed consent, patients routinely don’t know what they are signing up for, and may not actually want what’s offered if they could actually understand it. This increases care costs and can lead to malpractice suits. Centers for Medicare and Medicaid Services (CMS) needs to develop standardized approaches to informing patients, not just obtaining their consent. States need to redraft their informed consent laws to focus on informed choice as the standard of practice. Finally, CMS needs to reimburse physicians for time spent on shared decision-making, reward high quality as in #2, and require hospitals and ambulatory surgery centers to support it if they wish to be Medicare and Medicaid providers.

4. Constrain undisciplined growth in healthcare capacity and spending

If we could slow Medicare spending growth by even 1% it would save $1 trillion over the next 15 years. Imagine the impact on healthcare spending as a whole. This goal relies on both carrots and sticks. The carrot is preferential treatment for superstars in #2 through pay for performance programs. The opposite also applies. Areas like McAllen, TX, where per capita spending has gone through the roof, are penalized. Even if only highest-cost hospitals are targeted, it might rein in out-of-control hospital construction (a record-breaking $50 billion worth in 2008) to more rational and population-based levels. Shrinking reimbursement in these areas would encourage more providers to transition to the coordinated care model with its quality-based performance incentives, or even just encourage hospital mergers to reduce unnecessary capacity.

Additionally, we don’t need more physicians generally; we need more primary care physicians. Specifically, we need more well-trained primary care physicians in under-served areas. Shifting residency slots to rural, understaffed, and the best teaching hospitals would fill that need. Finally, and of extreme importance, we need to fill in the big utilization cost black hole. For all the outrage over the Dartmouth Atlas Medicare spending findings, did you know there is no similar index for private health plans? That’s right: we have no idea of the overall healthcare spending patterns across the US. Just imagine the graft and waste going on under the radar. I’m betting there are a lot of cockroaches under them floorboards.

Photo srbyug // CC BY 2.0

Does the New Senate Health Care Bill Get the Job Done?, Pt 1

by Tim Foley

categories: For Profit Insurance, National Health Exchange, Obama and Congress

Published November 19, 2009 @ 01:05AM PT

Senate Majority Leader Harry Reid scheduled a press conference for this Thursday to formally unveil the long, long, LONG-anticipated full Senate bill. Which of course means it all leaked semi-intentionally Wednesday night. (Man, I’m glad the Senate isn’t in charge of keeping state secrets… oh wait…)

The initial reporting will largely focus on the sheer scope of reforms in the bill and the superficial price tag as scored by the Congressional Budget Office -- $848 billion over 10 years while reducing the deficit by nearly $130 billion. Democrats will champion the expansion of coverage to 94% of Americans and how the cost-controls in the bill reduce the deficit even more past the 10-year window. Republicans will blast the sheer length of the bill (2,074 pages, which honestly seems like a bargain considering the complexity of the issue) and their usual nonsense about government takeovers, death panels, and how cutting a single dollar from Medicare waste will make the Virgin Mary cry. And of course those not content to actually talk about reforming our morally and economically bankrupt health care system will get drawn into sideshows about Reid reverting to the same abortion language we’ve talked about all year, or the titillation of something we’ll all come to know as “the Botox tax.”

But before the madness of political punditry overtakes us, allow me to focus on one key question that will unquestionably get lost in the shuffle. Does this new Patient Protection and Affordable Care Act do enough to put quality health care coverage affordable to low- and middle-income families? At the end of the day, if we haven’t made standard, comprehensive coverage within reach of the pocketbooks of working families in America, we just haven’t gotten the job done.

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5 Steps to Get Americans on Board With Health Reform

by Gillian Hubble

categories: For Profit Insurance, Hospitals and Health Systems, Medicare and Medicaid, The Uninsured and Underinsured

Published November 18, 2009 @ 06:00AM PT

The latest AP poll repeated the same tired trends in public healthcare reform sentiment. We are generally for it, until pollsters start presenting aspects as trade-offs. Once they hit one that resonates with one of us, we will promptly be against reform. We really can’t help it. As Change.org members regularly point out, we’re not a country that values solidarity, social worth or even basic human rights when they interfere with profits and self-interest. The United States is the nation of Me, not of Us. So, given we are unlikely to change our basic fabric any time soon, how do we get the public on board with meaningful healthcare reform?

I have the solution, and all it takes is 5 simple steps in public education. Before any of our brethren is allowed to answer another popular opinion poll regarding healthcare reform, they will be required to dig up one simple piece of information and digest 4 more. Follow these steps, and I predict a 99% "for healthcare reform" rating in the next poll.

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How to Shame Senate Healthcare Obstructionists

by Gillian Hubble

categories: Doctors and Nurses, Enemies of Reform, Obama and Congress, State and Local Efforts

Published November 17, 2009 @ 06:00AM PT

Remember Rachel Maddow announcing a 3-prong Democratic strategy to get healthcare reform passed last month? The audacious “shame them, demote them, and do an end run around them” strategy seemed lifted right out of the Tea Party sensationalistic playbook. The basic approach was to 1) do good while shaming those Congressional representatives who would deny their constituents affordable healthcare, 2) relieve obstructionist Democrats of their committee chairmanships, and 3) use reconciliation as an end run around Republican obstructionism. Well, we haven’t heard much about demotion and reconciliation lately, but the shame part is full steam ahead.

Yes, we’ve asked thousands of times for his removal, but Joe Lieberman’s Senate Homeland Security and Governmental Affairs Committee Chairmanship seems sacred to his Democratic Senate brethren. Even though Lieberman is an Independent, his obnoxious pro-filibuster stance against anything to do with a public option deserves a quick and decisive amputation from his leadership position. Ain’t going to happen, apparently.

Perhaps it’s because, if they are anything like their House counterparts, Senate Democrats knowingly have a tremendous amount of conflict of interest in their policy positions (see Change Congress’ video on Lieberman and Evan Bayh for examples.) Did you see that Genentech managed to insert its pre-scripted language into the House “debate” register via 42 Representatives? It was bipartisan representation too – 22 Republicans and 20 Democrats parroted Genentech’s positions. That’s disgusting.

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