Health Care.

I see by the media mouthpiece for Democrats, the New York Times editorial page, Democrats are growing desperate to get “comprehensive health reform” on the books before year’s end. The reasoning seems to be, if we don’t get in now, we’ll never get it, so we’ve got to ram it down the opposition’s throats, even if that opposition contains moderate and conservative Democrats.

Here, in part, and I quote, is the Time’s reasoning.

“Majority Rule on Health Care Reform,” Editorial August 27, 2oo9

“The talk in Washington is that Senate Democrats are preparing to push through health care reforms using parliamentary procedures that will allow a simple majority to prevail in their chamber, as it does in the House, instead of the 60 votes needed to overcome the filibuster that Senate Republicans are sure to mount.”

“Superficially seductive calls to scale down the effort until the recession ends or to take time for further deliberations should be ignored. There has been more than enough debate and the recession will almost certainly be over before the major features of reform kick in several years from now. Those who fear that a trillion-dollar reform will add to the nation’s deficit burden should remember that these changes are intended to be deficit-neutral over the next decade.”

“Delay would be foolish politically. The Democrats have substantial majorities in the House and the Senate this year. Next year, as the midterm elections approach, it will be even harder for legislators to take controversial stands. After the elections, if history is any guide, the Democratic majorities could be smaller.”

“The Democrats are thus well advised to start preparing to use an arcane parliamentary tactic known as “budget reconciliation” that would let them sidestep a Republican filibuster and approve reform proposals by a simple majority.”

“Republicans claim that they want to make medical insurance and care cheaper and give ordinary Americans more choices. But given their drive to kill health reform at any cost, they might well argue that these are programmatic changes whose budgetary impact is “merely incidental.”

“Another hurdle is that the reconciliation legislation covers only the next five years, while the Democratic plans are devised to be deficit-neutral over 10 years. The practical effect is that the Democrats will almost surely need to find added revenues or budget cuts within the first five years. “

“Another Senate rule, which applies whether reconciliation is used or not, requires that the reforms enacted now not cause an increase in the deficit for decades to come, a difficult but probably not impossible hurdle to surmount. “

“Clearly the reconciliation approach is a risky and less desirable way to enact comprehensive health care reforms. The only worse approach would , once the electorate has awoken to what’s at stake.”

“It is barely possible that the Senate Finance Committee might pull off a miracle and devise a comprehensive solution that could win broad support, or get one or more Republicans to vote to break a filibuster. If not, the Democrats need to push for as much reform as possible through majority vote.”

In other words, strike while the iron is hot, and the votes are there. Once the electorate has awoken to what’s at stake, the votes may not be there after the November 2010 election.

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“Since the days of Harry Truman, Democrats have wanted universal health coverage, believing that if other industrialized countries can achieve it, surely the United States can. For Democrats, universal coverage speaks to America’s sense of decency and compassion. Democrats also believe that it will lead to a healthier and more productive country.”

“The bipartisan trade-off in a viable health care bill is obvious: Combine universal coverage with malpractice tort reform in health care.”

Bill Bradley, former Democratic Senator from New Jersey, “Tax Reform’s Lesson for Health Care Reform, “ New York Times, August 30, 2009

Bill Bradley has it right – health reform without tax reform is dead. Perhaps it’s the lawyer in him, or maybe it’s the lobbying strength of Trial Lawyers, but President Obama has it wrong. He should stop talking about the “public option,” villainous health plans, and opposing “special interests,” and more about establishing medical courts – like bankruptcy or admiralty courts – with special judges to make determinations in cases of medical injuries to reward patients for the compensation they deserve.

No one, least of all doctors, denies medical injuries occur in these days of rampant hospital infections, invasive medical procedures, the rush to get people in and out of hospitals, and hazards high tech medicine, powerful anti-cancer drugs, and cross-reactions between multiple medications.

And no should doubt, as Senator Bradley says, that tort reform “ would lower health care costs, reduce errors (doctors and nurses oftren don’t report errors for fear of being sued, and guarantee all Americans adequate health care.”

There is another aspect to tort reform as well. Tort reform would help abort,and lessen, the next big, imminent health care crisis already upon us – lack of access to doctors because of the doctor shortage and increased demand for their services.

In my book Obama, Doctors, and Health Reform, I feature an interview with Louis Goodman, CEO of the Texas Medical Association. and President of the Physicians’ Foundation, which represents 650,000 practicing physicians in state and local medical societies.

In that interview, I asked:

“What do you regard as your greatest accomplishments at the Texas Medical Association?”

Here was his reply:

“Our 2003 tort reform effort would fall into the category of a major accomplishment for the state of Texas, and it’s now used as a national model. That reform put a cap of $250,000 for noneconomic damages for physicians, a $250,000 cap for hospitals, and another $250,000 cap for a second hospital or nursing home. This is referred to as a stacked cap, $250,000 for each party. The total is $750,000, but only $250,000 of that falls on the doctor’s side.

Most important, access to care was shrinking in rural and other underserved areas. But during this past year, the number of physician licenses increased from 2,000 to 4,000, and physicians are now settling and practicing in underserved parts of Texas, such at the Rio Grande Valley. Both primary care and specialist physicians are coming to Texas. The specialists aren’t restricting access to high-risk procedures for fear of liability penalties. Patients are getting better care and highly specialized procedures are being done. All of this is attributable to the tort reform legislation.”

Case closed.

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Every weekend, I select the three top articles, op-eds or videos that best enhanced my own understanding of health care reform in 2009. We’ve seen the number of stories on health care increase dramatically over the past few months. The number of quality stories, however, has remained the same. Instead, there’s a flood of process and politics, without a similar rise in intriguing new ideas or policies.

The first of my top three addresses this very topic:

1.) Washington Post, “A Missing Ingredient in Health-Care Coverage”

The Washington Post ombudsman gives a frank assessment of his paper’s health care coverage. Speaking as one who writes about health care every day, it’s extremely difficult to get the mix right. Many casual readers don’t understand how our health care system works now, let alone how the proposals floating around would or would not change it. It’s no surprise to anyone that the mainstream media tends to give short shrift to complicated discussions of real life implications and gravitate towards the loud, the bombastic, and the palace intrigues on reform.

Many have said that Post stories routinely assume a foundation of knowledge that they simply don’t have. Some said that they don’t understand basic terms like “public option” or “single payer.” They want primers, not prognostications. And they’re craving stories on what it means for ordinary folks and their families.

In my examination of roughly 80 A-section stories on health-care reform since July 1, all but about a dozen focused on political maneuvering or protests. The Pew Foundation’s Project for Excellence in Journalism had a similar finding. Its recent month-long review of Post front pages found 72 percent of health-care stories were about politics, process or protests.

“The politics has been covered, but all of this is flying totally over the heads of people,” said Trudy Lieberman, a contributing editor to Columbia Journalism Review, who has been tracking coverage by The Post and other news organizations. “They have not known from Day One what this was about.”

Read the whole article on WashingtonPost.com (h/t Matt Yglesias)

2.) Bill Bradley, “Tax Reform’s Lesson for Health Care Reform”

Judging from the behavior of Baucus’ “gang of six” bipartisan negotiators, the House Blue Dogs, and various Republican talking heads on Sunday morning shows, people have forgotten what “compromise” means. It shouldn’t mean taking a good provision and making it less effective to no real end. It also doesn’t mean capitulation. As former Senator Bill Bradley, who himself ran on a platform of universal health care as a presidential candidate, it should mean everybody gets something they want.

Since the days of Harry Truman, Democrats have wanted universal health coverage, believing that if other industrialized countries can achieve it, surely the United States can. For Democrats, universal coverage speaks to America’s sense of decency and compassion. Democrats also believe that it will lead to a healthier and more productive country.

Since the days of Ronald Reagan, Republicans have wanted legal reform, believing that our economic competitiveness is being shackled by the billions we spend annually on tort costs; an estimated 10 cents of every health care dollar paid by individuals and companies goes for litigation and defensive medicine. For Republicans, tort reform and its health care analogue, malpractice reform, speak to the goal of stronger economic growth and lower costs.

The bipartisan trade-off in a viable health care bill is obvious: Combine universal coverage with malpractice tort reform in health care.

(My two cents:  this continues to be one of the most inexplicable untold stories of the health care debate. If moderate Republicans told Harry Reid that they only way they’d vote for cloture on health care reform is if some malpractice provisions were included, do you think or a millisecond he’d say no? Why is trying to kill or delay health care outright better than accomplishing a long-held goal of the conservative movement?)

Read the whole op-ed by Bill Bradley.

3.) Nicholas Kristof, “Until Medical Bills Do Us Part”

It’s a story I’ve heard too many times. It’s a story that wouldn’t happen in any other first world country. And it’s a story that happens disproportionately to comfortable folks with what they presume are decent insurance benefits. But then, serious illness requiring expensive care develops, and they realize just how little security they have.

The hospital arranged a conference call with a social worker, who outlined how the dementia and its financial toll on the family would progress, and then added, out of the blue: “Maybe you should divorce.”

“I was blown away,” M. told me. But, she said, the hospital staff members explained that they had seen it all before, many times. If M.’s husband required long-term care, the costs would be catastrophic even for a middle-class family with savings.

Eventually, after the expenses whittled away their combined assets, her husband could go on Medicaid — but by then their children’s nest egg would be gone, along with her 401(k) plan. She would face a bleak retirement with neither her husband nor her savings.

Read the whole article on NYTimes.com

(Photo credit:  Why Tuesday? on Flickr.)

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Since the White House Office of Management and Budget and the Congressional Budget Office released the latest numbers on our budget deficit, we have predictably been treated to a host of opinions on why now is not the time for health care reform. This analysis has it backwards. We can’t afford not to reform health care. Doing so spells certain doom for the future of our federal budget.

The first misconception is that spending on health care has anything to do with this year’s deficit. If the president follows through on his pledge that he will not sign a health care reform bill that adds to the deficit, then health care becomes like the defense budget or the Department of Transportation or the existence of the National Oceanic and Atmospheric Administration – it’s paid for in the budget. The House and the CBO do not agree on whether the current bill is deficit-neutral or not, largely because the CBO prefers to count the $250 billion savings from reforming the Sustainable Growth Rate cut for doctors as a separate item since it’s in a separate bill. That’s an academic distinction – one they’ll have to work out before the bill passes. The layman’s version, as put by Ezra Klein, is that health care reform wouldn’t affect this year’s deficit the same way “my credit card bill doesn’t change if I decide to use the $20 on my dresser to buy a pizza rather than a movie ticket.”

The second misconception is that not reforming health care will help our federal budget picture. The exact opposite is true. A timely post on Healthcare Economist tells the tale:

From 1960 to 2006, GDP grew at 2.27% per year. Over this time period, GDP increased cumulatively by 174%.

From 1960 to 2006, national health expenditures (NHE) grew at 4.79% per year. Over this time period, NHE increased cumulatively by 721%.

This is our national health expenditure in total – public and private. This isn’t about whether public or private have been less sucky at controlling costs (they’re both bad, although Medicare and Medicaid have a slight edge over the private insurance industry), it’s about a system that is wholly unsustainable. Healthcare Economist links to a report by the NCAP that notes the argument between the CBO and the Medicare trustees as to whether, if our health care costs are unreformed, Medicare will eat up 85% or 61% of our federal budget in 50 years. This is like arguing whether you’d like to be slaughtered by the Aliens or Predator.

So we have a choice. The Medicare savings proposed in the House bill reduce Medicare spending in a way most beneficiaries would never notice – no more overpayments for Medicare Advantage plans, billions in discounts for prescription drugs, investing in measures proven to reduce hospital readmissions, etc. We’d reform health care and begin to reduce our long term health cost liability. Or we can do nothing, end this reform push, not try again for another 15 years, and face the fact that we’d have to make extreme cuts that would be immediately noticed by beneficiaries.

Put another way — we can reform health care through preventative care, or we can keep delaying until we need life-threatening surgery.

(Photo credit:  thatmushroom on Flickr.)

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In a prior post, the Disease Management Care Blog noted that the Obama Administration’s health care chops would depend on its response to the H1N1 (Swine Flu) virus. So far, it’s been lucky: a serious pandemic has yet to land on U.S. shores. With the coming arrival of fall, however, luck may be running out.

According to this New England Journal of Medicine article, planning is furiously underway. It looks like the patchwork of emergency rooms, public health clinics and primary care providers are being geared up to give the vaccine. Individual clinics are anticipating the coming demand based on the Centers for Disease Control’s (CDC’s) emerging two shot vaccine recommendations that assign priority to the pregnant, children, young adults and adults up to age 50 years with a chronic illness.

This may look good on paper, but the DMCB worries that this public health campaign is vulnerable to one of two extremes. One is high numbers of persons refusing to be vaccinated because of the fear of side effects. The other is high numbers of persons demanding the two shots and over-running our decaying primary care network. Over the last decade, most primary care sites have reduced overhead to a minimum and have neither the personnel or the resources to take on a new crush of persons demanding the two Swine Flu shots.

For more insight on this, the DMCB turned to one of its primary care colleagues, who, unlike the apparent healthcare experts writing in the New England of Journal, has a real grip on the reality of what could happen this fall:

‘I hear rumors that the government is going to pay for the vaccine but the cost of administering the shot (including storing the vaccine and covering the cost of the nurses to administer it) is supposed to be covered by private insurance. We haven’t heard if the insurance payers we deal with will provide first dollar coverage or if they’ll transfer some of that cost through a co-pay or other forms of co-insurance. We also still have no idea about the distribution channels and we don’t know how the vaccine supply will be shared with physicians’ offices, Department of Health clinics or pharmacies. Our small primary care office is terrified of the burden that will be imposed by having giving two more shots to our population with a short lead time. We already have full schedules for the fall season and will have difficulty processing the 1200+ extra contacts and associated paperwork. We are a tiny office that normaly gives 600-700 flu shots a year.’

By the way, the primary care physician had a particularly novel idea. It’s built on the common sense observation that lay people can be trained to give shots.

‘My solution: Train census takers to give shots or better yet, put a shot giver on every Fed Ex and UPS truck. Those guys are the best logistical wizards on the planet. You could even get a tracking number and find out where your flu shot is!! They know where everyone lives. My UPS guy knows that if I am not a work to drop by my house. Talk about a neural network.

Readers may think this is naive, but the DMCB points out that the circumstances of the coming H1N1 pandemic may warrant out-of-the-box thinking. This is the Obama Administration’s chance to show that it is different – that it is able to come up with non-FEMAoid approaches. Are there plans to involve the public schools? Why can’t Visiting Nurse Associations be contracted to set up vaccine stations in our nation’s post offices? Or maybe when the Administration isn’t pillorying the insurance industry, it is working with it to reduce the out of pocket financial barriers that patients may be facing?

And, in case sizable numbers of persons refuse to be vaccinated for H1N1, check out this thought:

How about a variation of the Cash for Clunkers Program. I call it Shekels for Shots program. At first glance, this may sound silly, but if a voucher not only provides first dollar coverage of the shot for particularly vulnerable persons, but gives them a meaningful cash rewards, the population will be vaccinated and we’ll have another stimulus!!

The DMCB says the traditional response to H1Ni so far does not bode well for the Administration. If the story being told above is typical of many other primary care providers, H1N1 could turn out to be the Obama Presidency’s Katrina.

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By Matthew Holt Seniors care about death panels (apparently) but they usually really care about drug prices and costs. Part of the political rationale for the Republicans passing Medicare drug coverage in 2003 was to deny the Democrats the ability…

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Sharona Hoffman, Professor of Law and Bioethics and Co-Director of the Law-Medicine Center, Case Western Reserve University School of Law, and Andy Podgurski, Professor of Electrical Engineering and Computer Science at Case Western, had written an important article on HIT that I highlighted in my March 2009 post “Let’s Deregulate Pharmaceutical Information Technology.”

In that article, entitled “Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems”, Harvard Journal of Law & Technology 2008 vol. 22, No. 1, they called for premarketing and postmarketing surveillance of healthcare IT, adverse events reporting, and tight regulation as in the medical device and pharmaceutical industries. They summarized and amplified their views in the short piece “Why Electronic Health Record Systems Require Safety Regulation“, Bioethics Forum, March 20, 2009.

In a remarkable new followup article entitled “E-Health Hazards: Provider Liability and Electronic Health Record Systems” available here, they expand their case in a highly organized and extremely well documented piece. The abstract is as follows:

In the foreseeable future, electronic health record (EHR) systems are likely to become a fixture in medical settings. The potential benefits of computerization could be substantial, but EHR systems also give rise to new liability risks for health care providers that have received little attention in the legal literature. This Article features a first of its kind, comprehensive analysis of the liability risks associated with use of this complex and important technology. In addition, it develops recommendations to address these liability concerns. Appropriate measures include federal regulations designed to ensure the quality and safety of EHR systems along with agency guidance and well crafted clinical practice guidelines for EHR system users. In formulating its recommendations, the Article proposes a novel, uniform process for developing authoritative clinical practice guidelines and explores how EHR technology itself can enable experts to gather evidence of best practices. The authors argue that without thoughtful interventions and sound guidance from government and medical organizations, this promising technology may encumber rather than support clinicians and may hinder rather than promote health outcome improvements.

They point out that:

EHR systems can facilitate access to patients’ medical records, improve the quality of care and the accuracy of treatment decisions, achieve cost savings, and promote clinical research. Without discounting any of these potential benefits, this article focuses on the risks of EHR systems and on liability concerns associated with their use …

The liability risks of EHR systems have received little attention in the legal literature. This new technology may bring with it novel responsibilities, burdens, and complexities for medical practices at the same time that it can potentially enhance health outcomes.

The liability risks are not just to hospitals, but to EHR users of all stripes. They find current efforts at HIT “certification” severely lacking in usefulness, and strongly support federal regulation of health IT due to the risks and dangers involved. The authors are opposed to vendor “hold harmless” and “defects nondisclosure” clauses, and have included in their article many well thought out solutions to the double-edged sword that HIT represents.

In summary, though, they believe that:

EHR systems cannot remain unregulated and largely unscrutinized. It is only with appropriate interventions that they will become a much-hoped for blessing rather than a curse for health care professionals and patients.

Download the article at this link. Read the whole thing.

I am in strong agreement with their positions. The unregulated free-for-all that has been the health IT marketplace, with dangerous and even outrageous practices I noted starting a decade ago, must come to an end as the market matures and as diffusion of this technology massively increases per the government mandates now in effect.

The rationalizations for problems, the excuses for defects and the starry eyed utopian exuberance about this technology (not to mention the conflict-of-interest and/or HIT lobby-driven irrational exuberance) must come to an end.

– SS

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In “This informaticist can’t escape clinical IT issues even on personal business“, I observed that I encountered HIT informational issues even in my own family matters, when least expecting them. I’ve had a few incidents since then, generally each time I’ve taken relatives to the hospital as a medical advocate.

It seems every time I step into a hospital as a medical advocate such issues arise, whether they be complaints from staff about IT, my mother being prescribed an IV antibiotic in the ED that an hour before I’d told the intake nurse she was severely allergic to, that fact being dutifully entered into the EHR – or as in the case below, outright errors regarding surgical procedures.

Either medical information errors follow me around, or they are more common than I realize, because I just spent a few days as a medical advocate for a very long and dear friend.

She had a suspicious thyroid nodule found at the time of exam for excision of a small breast carcinoma. She was set to have a thyroidectomy at a major NYC hospital with relatively advanced HIT capabilities and large endowments from very wealthy contributors, whose paintings hang in the lobbies (and where some high level informatics professionals are involved in clinical IT projects).

When I arrived the evening prior to surgery, my friend showed me her pre-op instructions. They were printed out in a neat and organized fashion, and she’d shown me the calcium supplements she’d purchased as the instructions advised.

“Calcium supplements?”, I asked…

The computer form, properly labeled with her name and ID and the name of the nurse practitioner she’d seen for preop evaluation, was quite improperly entitled “Preoperative instructions to patients undergoing parathyroidectomy.”

First thing I did in the morning was insist on seeing the surgeon in person. I wanted zero chance for error. Fortunately, the surgeon was familiar with her case and knew this was an error. Suppose, however, the surgeon was not so knowledgeable about the patient, or unavailable, or called away for some emergency and someone else filling in?

I do not know if the error was simple human error by the NP or someone prior who’d performed data entry, a wrong selection due to a mission hostile user interface in the setting of overwork, a computer error due to some cross-link between (to non biomedical personnel) two similar-sounding terms – parathyroid vs. thyroid – or some other cause.

Needless to say, if this error had resulted in an unnecessary and injurious parathyroidectomy and necessity for followup thyroidectomy on a postoperative area, and had been as a result of IT problems either totally or partially , it is likely the vendor would have been “held harmless” and the defect nondisclosed to other organizations.

(Anecdotally, on going to the bathroom, I also noted a group of residents on rounds energetically discussing what “template” was the correct one in which to enter patient data of some type. When I rounded years ago, I remember discussing medical issues…)

While I agree the likelihood of major IT contribution to this error was low, this was a reminder of just how problematic healthcare quality can be, even with advanced IT.

I think the solution is not to see IT as a panacea, and maintain adequate human involvement (with humans not overburdened feeding the bureaucratic machine) in safety issues.

– SS

Addendum:

One physician replied to this message as posted in a private medical informatics listserv with the following statement that I do not identify with:

“… Regarding the calcium supplement, since unplanned loss of parathyroid tissue is a recognized and fairly common event with thyroid surgery (relative tolerance depends on unilateral or bilateral dissection), you might have been better served by the “error” than its omission.“

Medical errors and indolence in correcting the problems can be as much a human attitudinal problem as IT-related.

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Q for Doctor is a clever system which uses the now-ubiquitous mobile to help doctors to schedule their appointments , so that patients don’t have to wait for ever. This is a clever idea, because it addresses the biggest pain point of patients – the fact that they have to wait and wait ( which is why they are called patients, according to a friend of mine !)

This is a great “proof of concept” model which shows how technology can be used to improve healthcare delivery – but I have my own doubts as to how well it will work in practise . I have learnt from personal experience that patients don’t always admire efficient doctors . Most patients in India are worried when there are very few patients in the waiting room. They feel that a “busy doctor” who makes them wait for hours must be a good doctor, because he is so busy ( though I feel this just means that he does not respect his patients can cannot manage his time well !)

This system is “Doctor driven” so doctors go ahead and be a part of the revolutionary system and change the way you are conducting your appointments forever. Give the most desired facility to your patients at no extra cost.
Without you registering in this system your patients can not take advantage of it. So go ahead, register and give your patients “Appointments on Finger Tips.“

Tags: mental health care, health care management, health care accounts receivables outsourcing, against universal health care, obama health care plan, health care administration, health care insurance, elderly health care, harvard pilgrim health care, health care costs

2. Don’t put all your eggs (and sperm) in one basket

Don’t count on your first cycle working. Sure, it could; plenty of people hit the jackpot on IVF #1. Statistically speaking, however, it’s likely that you’ll need more than one try, and it’s best to be prepared for that from the very outset.

Our doctor encouraged us to think of our first cycle in terms of a diagnostic run, a chance to see how my body would respond to the drugs, and how our embryos would develop in the dish, giving us information that would help optimize any further treatment if necessary. This excellent advice helped us face a bad outcome without destroying our future hopes. So when you’re making a treatment plan, save enough money, time, and stamina for a second cycle, and perhaps beyond. There’s no down side to being prepared. And, hey, maybe you will hit the jackpot. After all, you can’t win if you don’t play.

All patients considering IVF should read this post – it’s full of hard-earned
wisdom !

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I advocate incremental but not sweeping reform. Health reform is too big, too personal, too emotional, and too threatening to do otherwise. In my book, Obama, Doctors, and Health Reform, I predict President Obama will get about 1/3 of what he wants in the health reform bill he will end up signing.

But which 1/3? Here would be my six choices.

One, encourage competition across state lines to drive down costs. In this Internet age, I see no reason why data on various plans could not be readily available for all, and why all citizens should not have access to less expensive plans.

Two, end the ability to health plans to deny membership for pre-existing illness. This may raise premiums, but could be offset by wide access to cheaper plans in other states.

Three, have a guarantee that the plan would not increase national debt. This should be concrete guarantee rather than vague proposals about savings through prevention, EMRs, and coordinated care.

Four, a concrete proposal on tort reform. Without such reform, the physician shortage will escalate, and the costs of defensive medicine will continue to soar.

Five, tax breaks, or tax credits, for all citizens, including individuals rather than just for employees.

Six, the ability to choose a plan that fits every individual’s or family’s needs and health status rather than comprehensive plans with every conceivable standard benefit regardless of risk.

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“They’re predators. Who can really know what’s on their minds? Even though they’re raised in captivity ,and they love us, sometimes their natural instincts take over”.

Kay Rostaire, Big Cat Trainer, Sarasota, Florida, describing why a tiger attacked Roy Horn, of the Schneider and Roy Show, in Los Vegas

“A guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system”

David Goldhill, “What the Government Doesn’t Get about Health Care,” The Atlantic, September, 2009

When you ride a tiger it’s hard to dismount lest you get eaten. So says a Chinese proverb. The tiger is health reform. The trainer is the American health consumer. The health reform endgame is fast approaching. People riding the tiger must decide how to dismount without being eaten. The tiger is hungry. It will consume more and more people, money, and resources until the consumer tames it by training it to act differently.

The Narrator

I am a retired pathologist and long-time commentator on health reform issues. My work includes books – And Who Shall Care for the Sick (1988), Managed Care Memoir (2003), Voices of Health Reform (2005), Innovation-Driven Health Care (2007), and Obama, Doctors, and Health Reform (2009) – and a blog, medinnovationblog blogspot.com, with 955 entries since 2006. Some say pathologists know everything. but it’s too late. I maintain pathologists aren’t mere bystanders. We actively participate in clinical medicine and observe intermediate and final outcomes.

People Riding the Tiger

People riding the tiger include:

• President Obama, who has staked his legacy on health reform

• Democrats, especially Blue Dogs, who wish to remain in power

• Republicans, who seek to regain power

• America’s seniors and the disenfranchised, now covered by Medicare and Medicaid

• America’s 5000 hospitals, who remain at the center of community care

• America’s physicians, 900,000 of them, whose future rests on the outcome of health reform

• physician-led or affiliated organizations – the AMA, state societies, specialty societies, The Physicians’ Foundation, Sermo, MGMA, and integrated health organizations – who try to guide doctors

• American health plans, 1300 of them with their various agents, who desire to remain in business by administering health reform

• the pharmaceutical industry, who is said to have stuck a deal with the Obama administration to stay on the tiger

• the medical device industry, arguably the most innovative health care sector

• American businesses, large and small, whose economic futures depend on taming the tiger

• health information technology businesses, who in their various guises – EMRs, clinical algorithms, predictive models, data mining, and health 2.0 innovations – hope to create a rational dismounting glide path

• Health lawyers and malpractice attorneys, who need to promulgate fewer rules and regulations and who need to be reined in through tort reform

• all Americans, who are growing increasingly restive, distrustful, and skeptical about what governmental comprehensive reform might portend for them

Cracking the Whip

Consumers – patients- in conjunction with knowledgeable doctors, are beginning to crack the whip. After all, it is their health and safety, not the economic health of those riding the tiger that counts. The most important thing that has happened during this latest health reform tiger ride is reawakening of the survival instinct of patients. They have begun to recognize that their survival and restoration of a full life-style function are at stake.

The enduring lesson of the health reform movement is that consumers have a potentially powerful voice. They are unleashing that voice in town meetings as they press politicians riding the tiger on how they plan to dismount without harming consumers and drowning them and the nation in debt.
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Dr. Reece’s latest book, Obama, Doctors, and Health Reform is available on Iuniverse.com, amazon.com, barnesandnoble.com, and booksamillion.com, or can be ordered through your local bookstore.

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From the moment that Sen. Edward Kennedy passed away, we’ve been told by conservative blogs and talk radio to watch out for any sign of Democrats “inappropriately” using Kennedy’s death as a call to arms to get the health care bill he worked on for the last year of his life passed. Of course, “we shouldn’t play politics with this” is itself the oldest political trick in the book. In this case, however, it’s also as dumb a statement as one can make. Ted spent most of the last year of his life focusing on one cause and one cause only – universal health care. Remembering Ted Kennedy and not mentioning health care is like remembering Michael Jackson and omitting that he was a musician.

Having watched Sen. Kennedy’s funeral, the one moment that could possibly be interpreted as advocacy for health care reform this year was also one of the least political moments – the reading of his letter before his death to Pope Benedict XVI. Ted’s own personal, intimate words to the head of his faith were as follows: “I also want you to know that even though I am ill, I’m committed to do everything I can to achieve access to health care for everyone in my country. This has been the political cause of his life.” Likewise, you can peruse Ted’s public writings from this year, and discover they’re all on health care – from his op-ed “Health bill would fix what’s broken” in the Boston Globe to his front-page editorial for Newsweek, “The Cause of My Life.” Moreover, all of the decisions Ted made for what was sadly his final year in the Senate were entirely focused on health care – from resigning his seat on the Senate Judiciary Committee (missing entirely the confirmation hearings for Justice Sonia Sotomayor) to the closed-door sessions with all stakeholders in the health care industry that began last year, to his too, too few public appearances being the confirmation hearings for Tom Daschle as Secretary of HHS and the White House Summit on Health Reform.

The man was only working on one issue and one bill in the final year of his life, one he described as, “It is a cause that knows no boundary of party, region, or philosophy. It is a cause that can and should unite us all as Americans.” To mention the cause of his life is to politicize his death?

Hearing this false concern spring up, I couldn’t help but think of the death of one of Ted’s older brothers – John F. Kennedy. When new President Lyndon Johnson addressed both houses of Congress on November 27, 1963, there was no attempt to discuss the life of JFK in a neutral way, as if to pretend the battles he had fought all year were unimportant:

First, no memorial oration or eulogy could more eloquently honor President Kennedy’s memory than the earliest possible passage of the civil rights bill for which he fought so long. We have talked long enough in this country about equal rights. We have talked for one hundred years or more. It is time now to write the next chapter, and to write it in the books of law…

In short, this is no time for delay. It is a time for action–strong, forward-looking action on the pending education bills to help bring the light of learning to every home and hamlet in America–strong, forward-looking action on youth employment opportunities; strong, forward-looking action on the pending foreign aid bill, making clear that we are not forfeiting our responsibilities to this hemisphere or to the world, nor erasing Executive flexibility in the conduct of our foreign affairs–and strong, prompt, and forward-looking action on the remaining appropriation bills.

And you know what? That’s exactly what we did. It was not at all inappropriate, and it served as the fitting legacy of a great man. For men and women who have devoted their life to a cause like public service, it only diminishes their accomplishments to pretend the cause of their career is but inconsequential politics.

History is silent on the “appropriateness” of Johnson’s speech.  All it remembers is how a great injustice finally began to be solved.

(Photo credit:  thesmuggler on Flickr.)

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With health care, we keep saying the perfect shouldn’t be the enemy of the good. But as good as the bills moving through Congress are when it comes to expanding access, improving quality and giving us tools to finally begin to control costs, there are a few areas where the bills simply whiff. One of the worst is how little money is set aside to both improve the quality of education and increase the numbers of nurse practitioners and physician assistants for a health care system that’s desperate for them.

If we waved a magic wand and covered all the uninsured tomorrow, would we have enough doctors to provide care? The answer is yes and no. For specialists, unquestionably – orthopedic surgeons, radiologists, dermatologists and other specialties are in no short supply. But for primary care, where low reimbursement and high burnout rates have led to only half the available residency slots in primary care being filled each year by American graduates, the answer is no. Filling this gap are nurse practitioners and physician assistants – nurses who have been trained to do as much as 80% of the tasks associated with a primary care physician. At a time when we already have a primary care doctor shortage, having 75,000 PAs and about 140,000 NPs has helped get us through, particularly in high need areas, at community health clinics and in the medical home model of care. Just to mention it, primary care nurses also get paid significantly less than primary care physicians ($81,000 vs. $160,000 as posted on KevinMD), which help brings health care costs down. And a study in Health Affairs suggests patient satisfaction with the level of care given by NPs and PAs is high.

So why is there so little to promote NPs and PAs in health care reform? Let’s look at the House bill. There’s an expansion of the National Health Service Corps for primary care physicians, a new loan program also for primary care doctors, increased rates for primary care in Medicare and especially in the far-too low Medicaid rates. But nothing specifically directed to NPs and PAs. No funding for more of the nursing school instructors that we so desperately need, let alone for the relatively new specialized doctoral-level instructors required. No primary care bonuses to attract skilled nurses to get the extra training required. No money for community health clinics or medical homes using NPs and PAs as a cost-saver. The only time NPs are even mentioned in the House bill is to say they’re not disqualified from working at said medical homes.

Why aren’t we investing in more nurse providers, even just to get us through the current primary care crunch before the programs for physicians in the bills have a chance to work their magic? Difficult to say – but the American Medical Association seems pretty happy with them being left out. In their FAQ on HR 3200, they make clear, “we do not support nurse practitioners practicing independently, without at least regular consultation with a physician.”

It’s a big omission, and it doesn’t quite seem worth it.

(Photo credit  thebone on Flickr.)

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By RICK PETERS Last Friday morning, delirious, wasted, bone tired, driving home from the Emergency Room at 8AM in my beat-up little truck with only one speaker working. Amid all of us awash in the blogosphere thank the stars for…

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Mark Warner clarified his position on the public health insurance option a bit more on Wednesday night (emphasis added):

Last night, at John Bell’s fundraiser, Senator Warner said to a group of people that, in the end, he would not vote against health care reform containing the public option. I didn’t report that immediately for two reasons: 1) I wasn’t there when he said it, but heard it secondhand; and 2) I wasn’t sure if it was on or off the record. Well now, after just getting off the phone with Senator Warner’s office, I can confirm that this is correct information – in the end, the public option is not a “make or break” for Warner one way or the other and he WILL vote for a health care reform bill with a public option in there. Good news.

This led Chris Bowers to posit that there needs to be a new category on our chart tracking where Senators stand on the public health insurance option – “Won’t vote against.” It also brings our total to 45.

His logic goes like this:

At this point, finding another six Senators who will not vote against a health care bill with a public option is almost as good as finding another six Senators coming out in favor of the public option.  We should have enough supporters of the public option in the Senate to force a vote on it.  If we can just find another six Senators who might not advocate for the public option, but who will not vote against it when the time comes, then we still have enough support to pass it through the Senate.

After reaching 45 supporters last week, not only had the whip count stagnated, but the death of Senator Kennedy actually moved it back to 44.  With Senator Warner’s statement, we can consider ourselves back to 45. I will put Warner in a new category “won’t vote against,” showing that he is not exactly a supporter, but that where he is will be good enough for now.

Perhaps most importantly, I think that the way Blue Virginia got Senator Warner on the record can be replicated for other wavering Senators, allowing us to get to 50 as early as next week.  At this point, instead of looking for supporters of the public option, maybe we should just be asking Senators to say they won’t vote against a bill with a public option in it.  Not only is that an easier statement to make, it is very close to what Senators like Baucus, Carper, Tester and Wyden have already said. With those four votes, we would really be on the brink.

Health Care for America Now and Democracy for America, plus local bloggers, will be following up with Senate offices next week to see if more Senators “won’t vote against” a public health insurance option. In the meantime, we’ll add Warner to the full list.

While we wait for more clarifications, make sure the Senators still on the fence hear from you:

• Send a fax to Mark Begich, asking him if he supports the public option!
• Send a fax to Jon Tester, asking him if he supports the public option!
• Send a fax to Tom Carper, asking him if he supports the public option!
• Send a fax to Ron Wyden, asking him if he supports the public option!
• Send a fax to Kent Conrad, asking him if he supports the public option!
• Send a fax to Mary Landrieu, asking her if she supports the public option!
• Send a fax to Blanche Lincoln, asking her if he supports the public option!
• Send a fax to Ben Nelson, asking him if he supports the public option!
• Send a fax to Bill Nelson, asking him if he supports the public option!
• Send a fax to Mark Pryor, asking him if he supports the public option!
• Send a fax to Joe Lieberman, asking him if he supports the public option!
• Send a fax to Evan Bayh, asking him if he supports the public option!
• Send a fax to Olympia Snowe, asking her if she supports the public option!
• Send a fax to Robert Byrd, asking him if he supports the public option!

The full chart on where Senators stand on the public health insurance option is available after the jump.

Likely Supporters

Likely Opposition

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NEWS

Reid’s views on overhaul taking shape - Las Vegas Sun

He supports public option to provide competition, and hints he’s against conservatives’ tort reforms

Health Compromise to See Changes Before Vote, House Dems Say – Wall Street Journal

Two senior House Democrats said an agreement struck with centrist Blue Dog Democrats in late July on a public health insurance option might be altered before a health-care bill reaches the House floor.

Grassley: No Longer Sure Bipartisan Health Deal Possible In September – Kaiser Health News

Republican Sen. Charles Grassley of Iowa indicated Thursday he was no longer sure whether negotiators can reach a bipartisan deal in September, citing mounting public concern about excessive government spending and soaring federal deficits.

Mark Warner WILL NOT Vote Against Public Option – Blue Virginia

Last night, at John Bell’s fundraiser, Senator Warner said to a group of people that, in the end, he would not vote against health care reform containing the public option. I didn’t report that immediately for two reasons: 1) I wasn’t there when he said it, but heard it secondhand; and 2) I wasn’t sure if it was on or off the record. Well now, after just getting off the phone with Senator Warner’s office, I can confirm that this is correct information – in the end, the public option is not a “make or break” for Warner one way or the other and he WILL vote for a health care reform bill with a public option in there. Good news.

Obtained: The RNC’s Health Care Survey - Washington Independent

I just chatted with Raymond Denny, the 64-year-old La Center, Wash., man who received the RNC’s “2009 Future of American Health Survey,” which alleged that President Obama’s health reform plans might discriminate against Republicans. Here’s the survey question.

Dealing With Being the Health Care ‘Villains’ - New York Times

Max Shireman says that when he looks in the mirror he does not see the monster the politicians have made him out to be.

OPINION

GrassleyWatch: What Does He Not Understand About ‘Fully Paid For’? - Think Progress

Yesterday, Sen. Chuck Grassley (R-IA) — the ranking member on the Senate Finance Committee and a member of the so-called bipartisan ‘Gang of Six’ negotiations — joined the growing chorus of Republican lawmakers who are using the adjusted deficit numbers to argue for a smaller health reform package.

Grassley Claims Large Deficit Compels Him to Embrace Budget-Busting Status Quo - Matt Yglesias

Senator Chuck Grassley continues to cast about for pretexts to spike health reform and please his party leadership so he’s hit upon an unusually nonsensical reason.

I Can Has Health Care? – AFL-CIO

You’d have to be living in a cave, or in a willful veil of ignorance, not to know how people in this country are suffering in our broken health care system. If you have health insurance through your job, that’s one more reason to be desperately afraid of losing that job (with unemployment at 9.4 percent, no less;), if you get it as an individual or a family, you have to worry that your insurance company will find a reason to dump you the minute you need it most (whether you’re insured through your job or on your own, your health care costs are exploding. Then, of course, there are the 47 million people without insurance in the United States.

Town Hall Attendee Confronts McCain: ‘Why Don’t I Have The Health Insurance You’ve Got!’ – Think Progress

Over this past month, it has become a customary sight at town halls across the country to witness angry protesters mouthing right-wing talking points against health reform. But yesterday, in a town hall forum in Phoenix, Sen. John McCain (R-AZ) was confronted by an attendee who voiced passionate anger in support of health reform.

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I fear two things as a young health policy researcher: health care costs that grow faster than the economy and the flashing red light on my phone.

"You’ve got voicemail" triggers a series responses in my brain: "You’ve got work," quickly followed by the gut fear of "You screwed up," topped off with a dash of "Why weren’t you at your desk," anxiety.

The last time I entered the last two digits from the years the Cleveland Indians won the World Series into my phone, I was expecting a request for PowerPoints. What I got was "Chris."

Chris is a nurse in middle America. She’d seen slides from an event my boss participated in about health reform, and wanted to talk. She was worried about Medicare financing. And she had some thoughts about who the uninsured really were, and hoped I’d call her back to discuss.

Given the tone of the health care debate this summer, I called Chris half-expecting to be told I was some sort of actuarial anti-Christ — a faceless bureaucrat bent on killing her Grandma or cutting Medicare.

Instead I was a reminded of why we’re doing this.

Chris, it turns out, lives in a western Ohio community so conservative that the local newspaper once protested against a public library on the libertarian grounds that if a person wanted a book they could buy it. I’m sure that many of Chris’s neighbors are fearful and even angry after all the health reform misinformation they’ve heard all summer. But Chris sees everyday how our system works, and doesn’t work. Health reform doesn’t scare her. It’s the alternative of doing nothing that’s got her worried.

We talked briefly about some Medicare cost projections she’d seen. They painted an unsustainable picture of Medicare’s finances and future. Like most facts and figures in public policy, they’re true enough, depending on the assumptions you’re willing to make and the point you’re trying to prove.

Numbers are important, but frankly the case for health reform right now doesn’t need yet another fact or figure as much as it needs people like Chris.

Chris has been a nurse for many years and presently works in hospice. She also teaches a class on medical ethics. She’s seen patients suffer needlessly and watched friends and family members be offered treatments that would cost a lot but she, as a nurse, believes would not reverse the inevitable. The controversy over "Death Panels," makes her furious, but not for the reasons Sarah Palin intended.

Chris has insurance through her husband’s employer. It’s good, but it’s expensive, and she worries about how her college-age children will able to pay for health insurance when they get out of school. She’s tired of a system where no one knows the real costs or benefits of care. She’d like a few less MRIs and a few more face to face discussions between patients and their doctors and nurses about what’s best for them.

Chris’s 25-year-old son practically breaks down in tears when the real health care debate appears to be derailed by misrepresentations. Chris’s son has friends in their twenties who forgo their medications for illnesses such as multiple sclerosis and infectious diseases because they have no health care and they can’t afford the emergency rooms.

Chris knows health reform needs to happen, but she worries that it won’t, and she’s frustrated by the people who can’t see past partisan ideology to examine the problems and come up with solutions.

Fortunately for Chris, there are people working seriously on health reform who want many of the same things. Unfortunately, these people don’t hear enough from people like Chris and the majority of Americans who share her concerns and hopes for health reform. Gun-toting protesters make cable news. Chris makes a phone call to a stranger who seems like they might listen. It’s these calls that matter, and it’s these questions that the President, Congress and health reform need to answer.

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The Congressional Budget Office, and their estimates for the costs and savings that will come from different health reform proposals, is often the source of frustration for some in the health reform debate.Earlier this week, Jon R.Gabel wrote an op-ed in the  New York Times, taking a closer look at some past CBO numbers, and found their record for predicting the costs of health reform ito be less than perfect…

In the 1980s, Congress reformed Medicare payment to hospitals. Rather than fee-for-service, Medicare paid predetermined amounts based on the patient’s medical problem, leading to shorter stays in the hospital, lower administrative costs (less paperwork) and a reduced utilization of costly diagnostic services. The CBO said this would cost $60 billion from 1983 to 1986 — but total spending ended up at only $49 billion. Rather than admitting lots of moderately ill patients and discharging them quickly, as the CBO predicted, hospitals instituted stronger programs for reviewing admissions and admitted fewer patients.

The CBO also underestimated savings from the Balanced Budget Act of 1997 and more recently, overestimated the cost of the Medicare Modernization Act of 2003. The savings in the early nineties were greater than the CBO predicted, 50 percent higher in 1998 and 113 percent greater in 1999. In 2003, the CBO predicted Medicare Part D would cause prices to rise as patients demanded more drugs, driving spending up to $206 billion. It turned out actual spending was 40 percent less.

Why is the CBO zero-for-three in predicting the impact of major health reform initiatives? According Gabel,

The Congressional Budget Office’s consistent forecasting errors arose not from any partisan bias, but from its methods of projection. In analyzing initiatives meant to save money, it helps to be able to refer to similar initiatives in the past that saved money. When there aren’t enough good historical examples to go by, the estimated savings based on past experience is essentially considered to be unknown. Too often, "unknown" becomes zero — even though zero is not a logical estimate.

The office also struggles when trying to predict the impact of multiple initiatives at once, says Gabel. Medical malpractice reform and comparative effectiveness research might not yield significant savings on their own, but combined, they could drive down costs by making doctors feel more confident about prescribing procedures that are scientifically proven to be effective, and less worried about getting sued for not prescribing dozens of unnecessary tests. Gabel concludes:

The budget office’s cautious methods may have unintended consequences in the current health care reform effort. By underestimating the savings that can come from improved Medicare payment procedures and other cost-control initiatives, the budget office leads Congress to think that politically unpopular cost-cutting initiatives will have, at best, only modest effects. This, in turn, forces Congress to believe it can pay for reform only by raising taxes, which then makes reform legislation more difficult to pass.

The Congressional Budget Office’s integrity is beyond questioning. But the record shows that it has substantially overestimated the cost of health care reform three times out of three. As Congress now works on its greatest push for reform in generations, the budget office needs to revise the methods it uses to make predictions about costs.

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