Doctors and Nurses
Where Is the Momentum on Health Care?
Published July 20, 2009 @ 04:58PM PT
The forces of the status quo like to tell us care delayed is tantamount to care denied. That’s their argument against the hyperbolic rationing. But it’s also their political strategy -- reform delayed, they hope, is reform denied. On July 7, GOP Stategist Alex Castellanos wrote in a widely-distributed memo “If we slow this [legislative] sausage-making process down, we can defeat it.” Since then, the opponents of reform have chanted again and again the mantra, “Slow the process down,” including GOP Chairman Michael Steele using large portions of Castellanos’ memo verbatim (before laughably answering “I don’t do policy” before asked what his own plan is). If you watched the news over the last few days, you’d certainly get the impression that health care reform is slowing down. Does that mean reform is being defeated?
Well, it’s confusing. Right now, with both sides ramped up at full blast, the debate looks more like a melee – who has the momentum depends on where you look.
We know that the Senate Finance Committee continues to be bogged down with attempting to come up with new financing for health care reform to ensure it’s deficit neutral. It’s unlikely that they’ll follow the House’s surtax proposal, and their favored proposal of removing the tax exclusion for some or all of health benefits appears politically dead in the water. There’s been a bipartisan push to begin taxing the profits of insurance companies, but the money raised would only get us part of the way there. The Finance Committee still hasn’t given up on Olympia Snowe, Chuck Grassley, and maybe one other Republican vote to make this a bipartisan bill. We also know the Republicans are publicly crowing about blood in the water, from Sen. Jim DeMint’s description of health care as Obama’s “Waterloo” to Bill Kristol’s advice to “go for the kill.” This is all on the heels of CBO Director Doug Elmendorf’s comment that he didn’t see the long-term costs of health care bending sufficiently (a relatively boring pronouncement) being misinterpreted as him saying the health care bills under consideration were miserable failures that would bankrupt America and kick puppies in the face. (Whoops, simple mistake.)
Seen from that angle, it certainly looks bad.
But there’s another angle. For one thing, last week saw a comprehensive health care bill pass a Senate committee for the first time in at least a decade and a half. For another, two of the three House committees with jurisdiction over health care have already voted their bills out of committee. We never, ever got that far in the 1990s. Despite delaying tactics, hundreds of bipartisan amendments have been considered – so much that one committee pulled an all-nighter. The list of organizations who have endorsed the House bill in the past few days is daunting and includes the American Medical Association, the AARP and the American College of Surgeons – three organizations who I wouldn’t have bet money on. (Not would I have expected Kevin MD – not particularly a progressive voice on the blogosphere – to have also endored the bill.) House Energy & Commerce is still working through mark-up. Despite a more conservative-leaning make-up, they today rejected amendments to weaken or gut the public health insurance option. They’re expected to finish Wednesday or Thursday. At that point, we’ll have a House debate on a full package for health reform. When is the last time that happened?
I hate to sound like a Pollyanna, but if this is what being bogged down looks like, then heck, bog me down every week.
MSNBC’s Chuck Todd has the quote of the day: “I sometimes think we’re getting played here a little bit.” (h/t Media Matters)
At this moment, who has the momentum depends on your point of view. But it’s abundantly clear that there’s still plenty of baseball left to be played.
(Photo credit: House Committee of Education and Labor on Flickr.)
Will Massachusetts Kick Fee-for-Service to the Curb?
Published July 19, 2009 @ 07:46PM PT
The fee-for-service payment system for health care constantly affect the type and quantity of care we receive – often to our detriment. The financial incentive is towards providing more care, not better care. As I wrote before, “Whether the ‘service’ was successful or not, the doctor or the hospital gets the same ‘fee.’ Ditto whether the ‘service’ is necessary or not.” Now the state health care commission in Massachusetts has unanimously voted to end fee-for-service in the state – but what will take its place?
It’s fortuitous that this news broke in the same week as the federal debate on health care became so cost-control crazy. Massachusetts’ move is bolder than anything seen at the federal level thus far – but it also shows the downfalls, politically and policy-wise.
The plan is for a “global budget” per patient. As described in The Boston Globe, the move would compel “private insurers and the state and federal Medicaid program to pay providers a set payment for each patient that covers all that person’s care for an entire year and to make the radical shift within five years. Providers would have to work within a predetermined budget, forcing them to better coordinate patients’ care, which could improve quality and reduce costs.” This is very similar to the payment structure known as “capitation.” The idea is that if you pay up front for what should be all of the patient’s needs, the doctor or hospital will have financial pressure to keep you healthier so you use less of the allotted “budget.”
As an example, although presumably no one consciously wants a patient with a cardiac episode requiring hospitalization to not get better, there’s not much incentive to have the patient sit down with a nurse practitioner or a social worker to go over self-treatment to prevent readmission – there’s no fee for that service, only for the hospital visits. It’s bad for patient care but good for the bottom line if a patient has to come back in 30 days or fewer because they didn’t learn how to improve their condition. As such, hospital readmission rates in this country are completely unacceptable and wasteful. Under the global budget scenario, each return trip would be draining the capitated payment. Now hiring that N.P. or social worker to instruct the patient or follow-up a few days later has the potential to save a lot of money.
Massachusetts has come to this out of sheer financial necessity. With a huge state responsibility for health care because of Medicaid and the state universal health care program combining with the same economic recession hitting everyone else, they simply can’t afford the excesses of fee-for-service. But capitated payment has a spotty history. HMOs in the 1980s and 1990s operated under capitation, which soon developed its own excess – denying care so that more could be pocketed as a profit. The “global budget” is structured more like coordinated care – requiring the primary care provider to not just serve as a gatekeeper but also verify that patient care conforms with best practices.
It’s a bold move that will affect all Massachusetts patients not on Medicare or at the VA (Medicare patients will be operating in a system that’s primarily fee-for-service). It’s a real attempt at cost control. As such, it already scares the bejeesus out of some in the Bay State. Will the yearly cap on compensation be too low? Will it take into account not just foreseen healthcare costs, but unforeseen liabilities, like a catastrophic illness or injury? If doctors and hospitals decide to fight it, how long before the first reference to “rationing care” gets directed at the general public? Who will pay for the investments in technology and administration that would make administering a global budget possible?
Controlling costs is hard – particularly if we wish to avoid the cost-setting route most other countries utilize. But if Massachusetts moves forward and develops a system that saves costs and improves quality, it won’t be long before the “bold” because the commonplace across the country.
(Photo credit: Philocrites on Flickr.)
Why Does the House Push Off Full Reform Until 2013?
Published July 15, 2009 @ 08:01PM PT
It is the single most frequently asked question I get about the new House bill, HR 3200: why doesn’t it make its major push to expand coverage until 2013? The top two bullet points on the House bill’s summary call for the creation of a Health Insurance Exchange and a public health insurance option. Yet according to a document obtained by The Treatment’s Jon Cohn, those elements won’t be open for business until Year Four. What’s going on here? And what can we expect to get right off the bat to make the health care we currently have better for the insured and uninsured alike?
My own guess is that we’re looking at two real problems of U.S. health care at work – one policy based, the other political.
The policy reason for delaying before opening up a Health Exchange where the uninsured and small businesses alike could purchase standardized, transparent and comprehensive plans – and where all businesses would be able to purchase plans by 2015 – reflects the state of our workforce, and the experience of Massachusetts. Giving everyone coverage does not guarantee there are adequate physicians, health care providers and facilities. In fact, we know there’s not -- shortages, particularly in primary care, are noticeable even today. Massachusetts, for all of its physician density, had rather lengthy wait times for a doctor’s appointment even before it pushed its reform. But once hundreds of thousands of people suddenly had coverage and began calling around, it could no longer be ignored.
The same is true of the U.S. as a whole – particularly if the legislation pushes primary care and prevention as much as the House bill, we’re going to hit a real snag waiting for enough primary care providers to tend to the 37 million+ who suddenly have coverage. Looking at the accomplishments scheduled for 2010-2012, they focus disproportionately on provider development: eliminating the SGR fix in Medicare; increasing primary care reimbursement for Medicare and Medicaid; more funding for the National Health Service Corps for primary care; and jump-starting the programs designed to increase our supply of doctors and nurses are all Year One (2010) priorities. Even the items unrelated to workforce development all have to do with delivery system reform. Community health centers get their investment right away, since they’re going to be important in the delivery of care in rural and out-of-hospital settings. Administrative simplification by regulation and Health IT start up right away. Programs to ramp up preventative care start right away. In fact, the delivery system reforms are the only piece of the puzzle that would all get accomplished in year one! Given the years that it takes to develop primary care doctors and even nurse practitioners, that still won’t be enough time. But any head start is a necessary one to prevent a dysfunctional disconnect between supply and demand.
What Impact Will Dr. Benjamin Have on Health Care?
Published July 13, 2009 @ 05:01PM PT
Today, President Obama nominated Dr. Regina Benjamin to be Surgeon General. A lot of time is going to be spent figuring out how she figures into the health care reform debate. The blunt answer is she won’t have a lot to do with whether we get a bill passed or whether the bill is as strong as we can possibly make it.
And actually, her potential contribution to the quality of care is this country could be far greater than that.
Clearly the White House wanted to kick start a renewed focus on health care by the President by putting such an impressive woman forward. Since so much of her life has been consumed with providing care for the uninsured and underinsured, regardless of ability to pay, she’s a stand-in for the “can do” spirit that was so absent from the last week of Congressional hand-wringing. Obama made this blatant in his remarks, saying she represents “doctors and nurses who give and care and sacrifice for the sake of their patients; those Americans who would do anything to heal a fellow citizen.” Just being on the stage, she brings a number of issues to the forefront – care for the uninsured, the importance of primary care and prevention (she’s certified in family medicine), the disparity of care for rural communities like her own Bayou La Batre, and, yes, a physician workforce that doesn’t yet look like America – according to the American Medical Student Association, “Racial and ethnic minorities comprise 26% of the total population of the United States, yet only roughly 6% of practicing physicians are Latino, African American and Native American.” Becoming the first African American woman to be President of the state medical society of Alabama is an impressive achievement in and of itself.
But this is a health care reform headline for a day – an opportunity for Obama to reassert that there is a plan, there is a schedule, and we’re going to get this done. I’d expect Dr. Benjamin to talk a lot on TV about health care reform, make some nice speeches, and have zero impact on the final shape of the bills moving through the House and the Senate.
But there’s a life to health care reform even after a bill gets passed. If we manage to get a robust bill passed with significant insurance regulation, limits on out-of-pocket cost, the definition of a standard benefits package throughout the country, and a “college try” expansion of coverage, that would be a historical accomplishment. But the work of making us healthier and making our health care cost less through a better delivery system only starts there.
If Dr. Benjamin is confirmed as surgeon general, she’ll be able to talk about primary care and prevention from a personal experience that a neurosurgeon from CNN couldn’t match. As Dr. Benjamin proved today, these issues aren’t just a good idea academically – fighting chronic disease is quite literally in her DNA:
Public health issues are very personal to me. My father died with diabetes and hypertension. My older brother, and only sibling, died at age 44 of HIV-related illness. My mother died of lung cancer, because as a young girl, she wanted to smoke just like her twin brother could. My Uncle Buddy, my mother's twin, who's one of the few surviving black World War II prisoners of war, is at home right now, on oxygen, struggling for each breath because of the years of smoking.
The health of our nation will only improve if we can recruit and train even more primary care physicians than we have now – something that Dr. Benjamin, as a beneficiary of the National Health Service Corp, a chronically underfunded federal program that pays for medical student education in exchange for years of service in an underserved area, knows first hand. It will require non-hospital ways of distributing that care, especially in rural areas – something that Dr. Benjamin, as the founder of the Bayou La Batre Rural Health Clinic in Alabama. And it will require a real voice for patients in our health care system. As health care blogger Duncan Cross knows all too well, health care too often becomes about everybody but the patient. So it’s hopeful – at least – to hear the President describe her self-professed mission statement as: “The one thing I want to do is make sure that this Surgeon General's Office gives voice to patients, that patients have a seat at the table; somebody is advocating for them and speaking for them.”
They may just be well-intentioned words. But if she’s confirmed and if she turns them into deeds, Dr. Benjamin could have an even more dramatic effect on our health care system than any member of the Senate Finance Committee.
(Photo credit: hot_tea on Flickr.)
Medicare Payments: A Second Front on Health Reform
Published July 05, 2009 @ 02:01PM PT
The health care reform bills in Congress aren’t the only game in town. The Wall Street Journal reported on Thursday that payment reform in Medicare is also underway, through the Centers for Medicare and Medicaid Services, the agency that sets rates for Medicare Physician Fee Schedule. Primary care reimbursements will go up – a step long overdue. Given the fact that Medicare is the Big Dog of payors, and any reforms they adapt tend to get quickly implemented by private insurance, there’s hope that primary care will soon be better compensated across the board. But it will do so by reducing the total reimbursements for some specialties. This could be a positive step for medicine, or it could unleash a flurry of lobbying, hand wringing and destructive rhetoric. CMS may be opening a second front on the fight for health reform.
The details are not for the technically squeamish. CMS sets the payment rates for over 7,000 services and procedures, so tracking who is likely to get paid what is beyond confusing. It’s not like the release comes out and says, “We expect radiologists to get a 10% pay cut.” I’m relying heavily on the analysis of blogger and ER attending Shadowfax to help me make sense of it all. The short version is that some of the most lucrative scans, tests and consultations are being reduced in rate to something closer to what a primary care doctor would get charged for a similar consultation. As you can imagine, this hits those specialists who utilize scanning technology the most. Shadowfax explains:
Hardest hit among specialists are Radiation Oncology, Nuclear Medicine, Interventional Radiology, Cardiology, and Radiology, all of which see >10% decreases in direct compensation. This may in fact be understating the impact, in that the compensation will also be cut for certain diagnostic procedures such as echocardiography (-42%), coronary angiography (-24%), as well as the payments for CT, MRI and PET scans, and radiologists often (though certainly not always) own the equipment being used to perform the scans.
The cuts aren’t coming willy-nilly. Rather one of the arguments for limiting these payments is based on the cost of keeping up the equipment and how often it’s in use. The old payment scale presumed many of these scanners are only in use 50% of the time, so they should be compensated higher in order to break even. The reality is many of them are in use 90% of the time, and have become cash cows for providers and hospitals, leading to a perverse incentive to order still more tests and procedures, often “just in case.” Whether the decision is conscious or unconscious, the fact that such procedures are so lucrative unquestionably leads to overtreatment, and increased health care costs that don’t lead to better health.
The AMA Neither Supports Nor Opposes the Public Plan
Published July 03, 2009 @ 03:10PM PT
I didn’t really want to write about the American Medical Association at all after the president’s speech a few weeks ago. As Harold Pollack notes in a recent blog post, “I’m struck by extent that the AMA seems stuck in a narrow interest-group model that represents a shrinking segment of the medical profession.” But I’ve received so many emails about a recent CNN report on new AMA president Dr. J. James Rohack, that I’m writing this one post just to clarify what happened.
It’s fair to say that the AMA is in support of health care reform in a very general way. It is not accurate to say they support a public health insurance option. CNN got it wrong.
The official AMA position, as reported by the Daily Dose and others, was voted on at their convention in Chicago. It supports a broad definition of “health system reform” but explicitly leaves out any mention of a public plan. The Daily Dose article provides some fascinating context as to the parliamentary maneuvering that went on during June 17. After the controversy of the previous two months, where the AMA seemed increasingly against a public plan and then softened that position to say they were against a public plan that forced Medicare providers to participate, the shock of the day was that they passed a resolution in support of the public plan! But then-president Dr. Nancy Neilsen essentially took the podium to say, “Not so fast, bub!” She made an appeal to not peg their support of reform to one policy, and as a result they soon they passed an amendment to that resolution to punt on the question of a public plan.
This was basically a vote of “We want reform – but we’re not going to tell you what kind.”
Fast forward to the CNN interview with Dr. Rohack from July 1. Most of his comments were strongly pro-reform, but vague on details. The only thing he seemed die-hard against was, “expanding Medicare coverage for senior citizens into a broader general public plan” – not a shock, since the AMA has been the sworn enemy of single-payer since the days of FDR. (For colorful commentary on the AMA’s intransigent past, check out this column by Nicholas Kristof.) But how could they then be for a public plan similar to Medicare if they're dead-set on Medicare for All? The confusing quote in the article which prompted the misleading headline says that the AMA supports “an ‘American model’ that includes both ‘a private system and a public system, working together.’” But that’s not a public plan – that’s the National Health Exchange as envisioned by the House bill or the state-level Gateways envisioned by the Senate Health, Education Labor Pensions Committee. The “private system” is the current insurance marketplace. The “public system” is the Exchange. Dr. Rohack makes it clear he’s looking at the Federal Employee Health Benefit Program and wonders why Congress doesn’t just expand that. The FEHBP is the model of a transparent marketplace, but it’s all private insurance. The public plan, if it makes it through the process, would be one option among many private options. But the marketplace itself is not the same as the public plan.
So it was either the reporter or the editor who missed the boat on this one. The AMA still seems to be living by the mantra of “We don’t want to get pinned down” or as Dr. Nielsen put it, “The AMA did not close doors. The AMA said we will evaluate all alternatives in keeping with our principles.” (What they’re saying in private is anyone’s guess.)
So pro-health reform in a fuzzy, hard to define way? Sure. Pro- an expansion of public coverage either through single-payer or a public health insurance option? Nope. Pro- a “level playing field” flavor of the public plan, like the one suggested by Sen. Schumer and the HELP committee? Remains to be seen, but actions speak louder than words. I wouldn’t be singing the AMA’s praises just yet.
(Photo credit: this lovely piece of the AMA's history with health care reform is by exakta on Flickr.)
MedPAC Provides Solutions, Congress Looks the Other Way
Published June 21, 2009 @ 10:07PM PT
In President Obama’s letter to the Senate, he expressed support for expressed support for making the recommendations of the Medicare Payment Advisory Committee (MedPAC) more than easy-to-ignore suggestions. As such, it’s worth looking at their latest report (issued last week) and imagining what could be if Congress were required to vote on the whole package. What would happen this year if MedPAC ruled the world?
Right off the bat, they once again recommend that Medicare Advantage plans be capped at 100% the payment for a normal Medicare recipient – an area of fat (Medicare Advantage averages 114% per enrollee without producing better health outcomes) that has also been targeted by the White House and, in theory, Congress for years, although no one’s made that cut happen yet.
They encourage a rethinking of residency programs. Currently, the overwhelming majority of residencies for newly-graduated physicians are done in a hospital inpatient and outpatient environment. They’re great for teaching those skills, but a lot has been left out of the equation – skills like complex coordinated care where doctors work as part of a multi-specialty team, or learning the cost-effectiveness of procedures as well as the raw skills to execute them, or seeing what patient care is like in non-hospital, community settings. Unremarkably, the areas that prove the hardest to change in Medicare and where some physicians offer resistance are precisely in these areas. Learning the skills in residency, the theory goes, will make physicians more willing to try pilot programs that improve efficiency and lower costs.
They also heavily target is physician self-referral for imaging services. The report recognizes that there would be good reasons why a physician or a practice would have an MRI or CT scan on the premises, as it allows for a quicker and more efficient diagnosis – a very good thing when time is of the essence. But we also know there’s a problem here, and an inherent conflict of interest. As the report notes, “Between 2002 and 2007, the volume per beneficiary of imaging services paid under the physician fee schedule grew nearly twice as fast as all physician services.” Even more interesting, more frequent self-referral for imagine services has a correlation to more use of resources in treatment just in general. MedPAC doesn’t have a recommendation on how to fix this, but wants to look at restructuring image service payments to take into account how much technology has advanced (i.e., it’s not as expensive to do these tests as it used to be) as well as what’s a clear temptation to do more MRIs if you happen to have an MRI machine.
I’m barely scratching the surface. From cover to cover, MedPAC is filled with interesting solutions to simultaneously save costs and reward quality. Some of these paradoxically require spending more money on the things we don’t do enough of. Some of them involve cuts on programs that haven’t shown their worth. None of them have, to date, survived resistance from the lobbyists of the various industries: Medicare Advantage is the poster-child for spending money for no reason, but the insurance lobbyist has fought off cuts; hospitals like to keep residents working full time in the hospital, thank you very much, and are resistant to change; and anything that changes the perverse incentives for physicians to be tempted to run up the score with more imaging scans will draw the ire of medical device makers and physicians. We have an overabundance of ideas for cutting costs and improving care, thanks to MedPAC. But until these recommendations have any teeth, Congress is likely to conveniently look the other way.
(Photo credit: Corporal Cacophony (ClintJCL) on Flickr.)
