The Health Care Blog

The Best Health Care Idea All Year

By ROBERT LASZEWSKI

Out of almost nowhere has come momentum for a proposal to create a bipartisan entitlement and tax commission to draft proposals to control the long-term costs of Social Security, Medicare, and Medicaid. The idea would require the Congress to quickly vote the recommendations up or down via a super majority vote.

The idea isn't new--proposals for a such a commission have been around for a longtime.

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Medicare’s Biggest Change in 40 Years on the Horizon?

By Vince Kuraitis

Earlier this week CMS issued a typically cryptic Announcement indicating that they were shelving the Medicare Medical Home Demonstration (MMHD) and instead would focus on the recently announced Multi-Payer Advanced Primary Care Initiative (MAPCI). My blog post from Tuesday provides details and asks the question “What does all this mean?”

Medicare’s Biggest Change in 40 Years?

CMS’ Announcement about the rise of MAPCI and the fall of MMHD struck me as highly significant…but all the pieces didn’t fit. I’ve spent a fair amount of time emailing and talking with colleagues this week…and the big picture is emerging…and it’s really BIG.  My working hypothesis is that Medicare is on the verge of its biggest change in 40 years:

• Medicare was created as a centralized, monolithic payment model.  It’s been one size fits all, and that size is created in Washington DC. There has been little tolerance of regional administrative variability, and the ironic result has been high variability in regional costs and quality.
• Medicare seems poised to do a 180. It’s signaling movement toward supporting state-based, multipayer initiatives — where Medicare is at the table and influential, but not in control.  It’s a recognition that health care is local and that unique solutions will be needed in different regional markets. The Obama administration is demonstrating strong support for the Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) as important building blocks in this transition.

…and while this shift could be solidified by national health care reform legislation, it doesn’t seem to be dependent on such legislation. Success will measured at the level of individual state MAPCI’s.

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Dave Durenberger on Lieberman

By Matthew Holt

Former Minnesota Senator Dave Durenberger, a thinking centrist Republican (remember them?) puts out an occasional newsletter full of gems. This is today’s zinger:

The Senate has a better bill than the House, but it also has a 60-vote requirement which empowers the odd-ball "if not my way, the highway" members - like Joe Lieberman claiming that something like a public insurance plan violates his "conscience." I guess I don't understand Conservative Judaism.

Intermountain Healthcare -- Proof That U.S. Hospitals Can Improve

By MAGGIE MAHAR

I urge everyone to read this story by David Leonhardt in this Sunday’s (November 8) New York Times. (Thanks to HealthBeat reader Lisa Lindel for spotting it. )

Leonhardt profiles Intermountain Healthcare, a network of hospitals and clinics in Utah and Idaho that President Obama and others have described as a model for health reform.

Leonhardt concludes:

“If you simply looked at Intermountain’s overall results — the good outcomes and low costs — you might be tempted to dismiss them as a product of the environment. Utah has the youngest population of any state, as well one of the lowest rates of alcohol and tobacco use. More than half of the state’s residents are Mormons. This homogeneity creates a noticeable sense of community, even a sense of mission, among many Intermountain doctors and nurses.

“The places that spend far more on medical care and get worse results — south Texas, south Florida, New York City and its suburbs — don’t have those advantages. They tend to have more diverse populations and a more diverse set of medical needs. None of these places is ever likely to reduce its costs, or raise its life expectancy, to Utah’s levels.

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Certification versus Meaningful Use

By John Halamka

Recently, clinicians have asked me "why should I implement my organization's preferred EHR when I've found a less expensive vendor that promises meaningful use?"

This illustrates a basic misunderstanding of the difference between Certification and Meaningful Use.

The certification process will be codified in a December 2009 Notice of Proposed Rulekmaking (NPRM) and will define the process for certifying electronic health records including modular and open source approaches. (The Standards for data exchange will be codified in a December 2009 Interim Final Rule and become law immediately.) We know that ONC will specify certification criteria and that NIST will oversee certification conformance testing which will be performed by multiple organizations. However, we will not have the final certification criteria or the defined process until Spring after a period of comment on the NPRM.

Meaningful Use is about electronic documentation to enhance quality/efficiency and actual data exchange among payers, providers and patients. The definition of meaningful use will be codified in a December 2009 Notice of Proposed Rulemaking. We will not have the final meaningful use criteria until Spring after a period of comment on the NPRM.

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The Federated Health System of America

By GLENN LAFFEL

After a spy plane confirmed the Soviet Union was building launch platforms for first-strike ballistic missiles in Cuba in October, 1962, President John F. Kennedy convened his Joint Chiefs of Staff and cabinet members to help him decide how to respond.

Kennedy managed the diverse input he received, including surreal, saber-rattling rants from Air Force General Curtis Lemay, and eventually resolved the crisis. It was the closest we ever came to nuclear war.

But the consensus-based, inclusive leadership style JFK used to resolve the Cuban Missile Crisis doesn’t seem to be working as well for President Obama as his Health Reform Express barrels towards an unknown final destination.

Take the latest cockamamie plans for the public option, for example. As the House and Senate struggle to cobble together some semblance of a bill, we hear that the end result is likely to contain a public option along with a rider that allows states to opt out of it if they so choose.

This ridiculous compromise is the byproduct President Obama’s decision to let Congressional group-think generate a legisltative package that (a)could pass Congress and (b)he could sign. In making this decision, Obama sacrificed his principles before the altar of political success.

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Spotlight on Health 2.0: The Patient Is In, from SF 2009

Every week we bring you a new video from Health 2.0! This week we're featuring The Patient is In, a session focusing on how Health 2.0 tools are making a difference for patients.

To see more videos from past Health 2.0 conferences, or to purchase the entire conference DVD sets from '07 & '08 click here. 2009 DVD sets will be available shortly, please check back for updates.

Where were you?

By MICHAEL PAINTER, Senior Program Officer - Robert Wood Johnson Foundation

I distinctly remember the first time I heard the title, “National Coordinator for Health Information  Technology”.  It was 2004.  That’s, of course, the year that RAND released its important national report card highlighting the overall mediocre state of health care quality.  You know the one that told us “it’s a flip of a coin.”  I was an RWJF Health Policy Fellow working on the Hill with then Majority Leader Bill Frist’s health policy staff.  

There was a flurry of staff activity regarding the president’s pending executive order pushing adoption of the electronic health record and creating a new federal health information technology, dare I say, czar. . . . But what to call this new position?  To be honest, when I initially heard folks say the words, “national coordinator for health information technology,” my first thought was, “Well, that’s a mouthful.”  My second was “It sort of sounds like a character from that TV show, ‘The Love Boat’”.  But I kept those smart remarks to myself and quite quickly got on board—and, to be honest, never looked back. 

At RWJF in 2005, several of us worked with then National Coordinator, Dr. David Brailer, on a partnership effort between the Office of the National Coordinator and RWJF.  With this project we extended a grant to Dr. David Blumenthal, then in Boston, to create a series of national reports that would track the national adoption of the electronic health record over several years as the nation progressed toward wider and wider adoption.  This week we’re issuing our third report in that series.

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Tell the FDA the whole story, please

By SUSANNAH FOX

I scan menus for keywords (fig, parsnips, salmon...) and it turns out I scan Twitter the same way, looking for anyone who is talking about my favorite topics (data, consumers, information quality...)

So when I saw Jonathan Richman's tweet the other night, I couldn't resist it:

Anyone ever seen data on the overall accuracy of medical information found online? Need help for some final stats for #fdasm

Short answer: No.

Long answer:

The Pew Research Center's Internet & American Life Project has been reporting on the social impact of the internet since 2000, when "information quality" on health websites was a big part of the conversation. It was the era of wagging fingers, scolding patients for straying too far outside their boundaries, and Pew Internet data was ammunition.

We released our first report about the internet's impact on health & health care in November 2000. The Medical Library Association (MLA) contacted us, asking for research looking at how consumers decide which sites/sources to trust. With their help we created a set of questions asking first if respondents went online for health info, then asking if they look for the source and date of the info they find (the two key quality indicators according to the MLA).

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Are We Too Small to Succeed?

By DON LINDSTROM

The logic behind the government bailouts in the financial and automobile industries goes like this:  some institutions are so large and interconnected that their failure could collapse the entire economy.  They are considered to be too big to fail.    
 
The notion of too big to fail implies its opposite, that some individuals and businesses are too small to succeed.  Of course, that includes most Americans.

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Modest step in the reform journey shows the idiocy of our political system

By Matthew Holt

It does seem to take a health care bill to remind us all how incredibly screwed up the political process is in these here United States. The Medicare Modernization Act was railroaded through by Tom Delay and friends using all their charm and finesse. And last night the House passed its version of the health reform bill. It includes employer mandates, exchanges, subsidies, public option and taxes on those earning more than $500,000 to close the cost gap. And CBO in its wisdom says that it doesn’t increase the deficit.
But it didn’t pass by much. 40 Democrats opposed it. These were the Blue Doggers who needed some political cover to be able to say in 2010 that they were against the bill before they were for it. Their expected course of action is that a less liberal bill comes back from final conference with the Senate which they can support. Apparently out there in purple state land uninsurance and egregious health plan behavior are not a problem—at least not compared to the desire of the people to protect the incomes of those earning over $500,000 a year.

But in order to stop even more Democrats opposing it at the last moment Pelosi had to let some previously unheard of Congressman called Stupak become the mouthpiece of the Catholic Bishops who decided that they needed to impose their views about reproductive medical care into the debate. Cynics like me may wonder about the validity of views on that issue from a bunch of old men who’ve allegedly never been married or had sex with a woman, and whose main contribution to child welfare over the past few decades has been to ignore and assist in flagrant abuses of it by their colleagues. But no matter, over recent days they started putting pressure on various Democrats to tighten restriction on Federal funding of abortion.

Someone with greater interest and attention to detail than me will surely figure out which Democrats were against the bill for “deficit reduction” reasons and which were against it because they feared that a mob of frenzied newly pregnant women were awaiting their federal subsidies so that they could expressly sign up via the exchange for health plans that offered abortions. But Pelosi obviously decided that to get the latter groups votes was easier than the formers, and allowed a completely non-sensical abortion of an amendment about abortion that seems to be completely unworkable. So as part of the final bill the Stupak amendment (which is only 2 letters away from describing itself accurately) will prevent insurers offering plans that cover abortions to people buying them through the exchange with subsidies.

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We the Consumers

By MARGALIT GUR-ARIE

There has been much talk lately about the Consumer movement in health care. The health insurance industry has given us the Consumer Driven Health Care (CDHC), which has gained much traction in the marketplace in the form of high deductible insurance plans, where the Consumer, having "skin in the game" now, is expected to make informed decisions on how to spend his or her money on health care services. The Consumer is empowered and in control of health care expenditures.

And then there are the various Consumer advocacy groups demanding an end to the paternalistic approach to the practice of medicine. Doctors should relinquish control to the Consumer. Consumers should actively manage their care by obtaining and controlling their medical records. Consumers should be informed by the medical establishment of the latest evidence-based best practices, timely research and costs of treatment. The Consumers will then make an informed decision aided by a myriad of peer and professional information available on the internet. 

That’s a lot of new responsibilities for most of us who have no idea how much a visit to the doctor costs and even less of an idea whether or not we need that stent, assuming that we even know what a stent really is. Well, since we are Consumers now, not just passive patients, let's see how we stack up to our brand new responsibilities.

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Johns Hopkins Medicine and the Health Care Debate

By Greg Rienzi, Staff writer for the Johns Hopkins Gazette

While concepts for health care reform volley back and forth in Washington, D.C., and around the nation,  Johns Hopkins has quietly but meaningfully injected itself into the debate.

Johns Hopkins Medicine has been working with a group of 12 academic medical centers to explain the key role of these institutions in the delivery of health care to millions of Americans.

The group —which includes Emory University, Mount Sinai Medical Center, UCSF Medical Center, the University of Pennsylvania and others—is focusing on a number of issues, including a proposal to create “Health Care Innovation Zones” that would offer support for providers working with stakeholders in their regions to redesign a more patient-centered delivery of health care.

Since last spring, Johns Hopkins Medicine executives have met with a large number of White House officials and members of Congress and their staffs to make their views known.

Edward D. Miller, dean of the medical faculty and CEO of Johns Hopkins Medicine, and Ronald R. Peterson, president of The Johns Hopkins Hospital and Health System, have kept close tabs on the health care debate and say they worry that it’s missing the two most important targets: workforce issues and delivery systems. The two leaders, who have spoken publicly on the subject in a variety of news outlets, say they believe that having more people insured is a good start but that incentives in the current payment system need to be changed.

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Pay (Only) for Health Care that Works

Charles Silver & David A. Hyman

Health care is expensive partly because governmental payers and insurers foot the bill for large quantities of medical services that are ineffective, unnecessary, or unproven.  According to a RAND report, studies of clinical efficiency “indicate that one-third or more of all procedures performed in the United States are of questionable benefit.”  

When state and federal governments set the minimum terms for insurance coverage, this problem is likely to worsen. Governmental decisions reflect the political power of providers (who want to sell more services), the sympathy felt for patients (who want to consume more services and have other people pay for them), and the desires of bureaucrats (who generally want to maximize their budgets and their importance).  These interests coalesce, causing governments to aggressively mandate coverage of services that may or may not be necessary.  

The health reform proposals pending in Congress require all Americans to have insurance coverage.  The problem with this “individual mandate” is that Congress (or some other regulator) will have to decide the minimum amount of insurance Americans can carry.  The need to set this requirement is an open invitation to aggressive lobbying by health care providers.  Wanting to ensure that the minimum benefit package covers their services, providers will spend millions on advertisements and campaign contributions to persuade legislators and regulators that more coverage is better.  Lobbying from providers and supportive patients explains why many states already mandate coverage of elective services like in-vitro fertilization, massage therapy, and visits to athletic trainers.  Concerns about the efficacy and cost-effectiveness of treatments are washed away by a stream of campaign contributions, and sad stories about patients who can only obtain the “necessary” services if the insurer will pay for them.  The result is a one-way ratchet toward richer (and more expensive) benefit packages. 

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Op-Ed: Why "free market competition" fails in health care

By JOE FLOWER 

In trying to think about the future of health care, thoughtful, intelligent people often ask, “Why can’t we just let the free market operate in health care? That would drive down costs and drive up quality.” They point to the successes of competition in other industries. But their faith is misplaced, for economic reasons that are peculiar to health care. 

More “free market” competition could definitely improve the future of health care in certain areas. But the problems of the sector as a whole will not yield to “free market” ideas – never will, never can – for reasons that are ineluctable, that derive from the core nature of the market. We might parse them out into three:

1. True medical demand is wildly variable, random, and absolute. Some people get cancer, others don’t. Some keel over from a heart attack, get shot, or fall off a cliff, others are in and out of hospitals for years before they die.
        Aggregate risk varies by socioeconomic class and age – the older you are, the more likely you are to need medical attention; poor and uneducated people are more likely to get diabetes. Individual risk varies somewhat by lifestyle – people who eat better and exercise have lower risk of some diseases; people who sky dive, ski, or hang out in certain bars have higher risk of trauma.
        But crucially, risk has no relation to ability to pay. A poor person does not suddenly discover an absolute need to buy a new Jaguar, but may well suddenly discover an absolute need for the services of a neurosurgeon, an oncologist, a cancer center, and everything that goes with it. And the need is truly absolute. The demand is literally, “You obtain this or you die.”

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Back to Basics: Toward a Core Set of Relevant and Portable Personal Health Information

By DAVID C. KIBBE

In the cacophony of health IT issues, products, and goals that compete every day for our attention, it is easy to lose sight of the profound value that could come from the universal availability of a simple core set of relevant and portable personal health information in digital format. 

If everyone in the country who wanted one, and if every doctor or nurse taking care of a patient needing one, had access to a digitally formatted set of current health data about the person in question, we as a country would benefit at many levels.  I am talking about basic information -- such as demographics, a problem and diagnosis list, a list of medications, allergies, recent vital signs (blood pressure, weight, etc.), and information about the most recent health care encounters. Individuals would get more continuous care and better coordinated care decisions.  Payers would pay for fewer duplicated or unnecessary tests and procedures.  Doctors would face less risk of error when making decisions in the ER.  Researchers would give us better feedback on populations of patients, e.g. those with diabetes, to improve care and care processes.  And the whole of society would benefit from a real-time, steadily enhanced knowledge database about what works to promote wellness, health, and to lower health care costs.

Achieving these benefits could come from many different methods of storing and transporting a Continuity of Care Record.  A piece of paper in PDF or Word format is better than no data at all; a computerized text file on a USB device is better than paper; an HTML web page at an always-available URL is better than a text file; and a computable, machine-and-human-readable XML file compliant with a standardized XML schema is still better.  But any and all of these are preferable to the current default for millions and millions of health care visits: no-information-at-the-point-of-care-or-decision.  Zip. Nada. 

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Health 2.0 and AccessDNA

Each year at Health 2.0, we present Launch!, a debut of new products and services to the Health 2.0 community. This year we were able to hear from many great companies, including AccessDNA, a new site that generates personalized genetics reports that help you identify which genetic tests could be right for you. I had the opportunity to chat with Jordanna Joaquina, Director of Genetics and Co-Founder, about the site and genetic counseling. 

Here's the interview.

For an introduction to AccessDNA, check out Lee Essner's demo at Health 2.0: 
 

On the road--ACHE Social Media, NCI, Healthcamp NYC, Blogging networking LA

By Matthew Holt

My time off for good behavior is at an end and today I get back on a plane for four fun conferences and a party.

Wednesday I’m keynoting the ACHE Social Media in Healthcare meeting in San Antonio, TX and then will be moderating a couple of panels, one with two leaders in social media from outside health care and one with several hospital execs. Much more here, and well worth checking out if you’re an ACHE member or may want to become one.

Thursday & Friday I’ll be at the NCI Informatics for Consumer Health Summit. It’s an invite only meet but it’s being webcast (although for some reason the bit I’m doing with Doug Goldstein of iConecto is private…perhaps we have something extremely valuable to say? Here’s where you can get the webcast although it’s not quite apparent to me exactly how you get a log-in (I do know it’s open to everyone)

Friday night I’ll be in Washington at a party at my friend Maggi Cary’s house. If you know me or Maggi and want to come, drop me an email.

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Spotlight on Health 2.0: Launch! from SF 2009

Every week we'll be bringing you a new video from Health 2.0! This week we're featuring Launch!, an introduction of new tools and services to the Health 2.0 community.

To see more videos from past Health 2.0 conferences, or to purchase the entire conference DVD sets click here.

A “Third School” of Cost Containment?

By BILL KRAMER

Is there a “Third School” of reformers that could help us resolve the long debate about how to contain health care spending?  Drew Altman’s recent column describes the history of the debate between the “Regulators” and the “Marketeers”, and he suggests that a new school of thought – the “System Reformers” – is in the ascendance.  According to Altman:

The Systems Reformers believe that the best way to bend the cost curve is not through external market incentives or regulatory controls, but from the inside out, by creating a smarter health care system with the information base, new delivery models and payment incentives that will improve quality and lower costs. . . .

The Systems Reformers' paradigm is reflected in the "bending the curve" elements of the health reform legislation currently in Congress, which mostly come in the form of pilot projects and experiments. These include tests of ideas like Accountable Care Organizations, "pay for performance" and "bundled payments," as well as efforts to create a smarter, evidence-based health delivery system through comparative effectiveness research.

He describes the Systems Reformers’ approach as a  “third leg of the stool of cost containment strategies.”

While Altman is right about the importance of the Systems Reformers’ ideas, I don’t consider this to be a new paradigm. 

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Time to put aside the intellectual disputes for now

By Matthew Holt

It’s always fun to see my friends beating each other up in public....and if you read down in the comments on the post published yesterday you’ll see a significant dispute between Maggie Mahar and the Klepper/Kibbe/Lazsweski/Enthoven team (who I'm calling the Four Horsemen from now on). But I think that right now we need to change what we're talking about.

I'm with Maggie in that there is potentially more in terms of changing the payment system in the current bills than nothing, but it's not that much more than nothing. However, pressure from the the Four Horsemen and their fellow travelers on payment reform may increase that section of the bill as it gets worked out on the floor and in the Congress conference committee. Their pressure will also serve notice that aware, sensible people are looking at the issues of payment and delivery reform.

And at the least, the proposals in the bill don’t make the current delivery system any worse (other than the exemption from taxes for self-insured groups which clearly discriminates against integrated systems and must go).

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Saving Health Care, Saving America

By BRIAN KLEPPER, DAVID C. KIBBE, ROBERT LASZEWSKI and ALAIN ENTHOVEN

So far, Congress' response to the health care crisis has been alarmingly disappointing in three ways. First, by willingly accepting enormous sums from health care special interests, our representatives have obligated themselves to their benefactors' interests rather than to those of the American people. More than 3,330 health care lobbyists - six for every member of Congress - contributed more than one-quarter of a billion dollars in the first and second quarters of 2009. A nearly equal amount has been contributed on this issue from non-health care organizations. This exchange of money prompted a Public Citizen lobbyist to comment, "A person can reach no other conclusion than this is a quid pro quo [this for that] activity."

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CMS Reinstates Paying for Avastin Used Off-Label for Macular Degeneration

MERRILL GOOZNER

Medicare has reinstated payment codes for eye specialists who use Genentech's Avastin to treat wet macular degeneration. A tiny amount of Avastin, which is sold for cancer treatments, successfully treats the condition at about $100 per shot. Genentech also sells Lucentis, which is basically the same drug but has gone through the clinical trials that led to Food and Drug Administration approval, at $2000 per shot.

Sen. Herb Kohl (D-WI), chairman of the Senate Aging Committee, pointed out in a press release today that "even seniors who have insurance often cannot afford the high co-payments associated with Lucentis. Patients should have a choice between these drugs, both of which have been proven effective," he said. He estimated the change could save Medicare $1 billion to $3 billion a year.

The National Institutes of Health is currently funding a trial comparing the two treatments. Results won't be known until 2011.

Atul Gofigure: Why McAllen Should Have Mattered in the Health Reform Debate

By JEFF GOLDSMITH

Back in June, Atul Gawande, a Harvard trained surgeon, published a riveting article in the New Yorker   about the physician community in McAllen Texas. If ever an article was strategically timed to influence the nation’s health policy debate, this was the one. His story was accompanied by a graphic showing a patient as an ATM machine.  President Obama read it and put it on his staff’s reading list.  Yet, it’s depressing how little impact Atul’s article has had on health reform.   

Atul’s purpose was to explain a major policy conundrum: why some communities manage to spend as much as triple on Medicare services as other communities. McAllen’s physicians practice some of the most expensive medicine in the United States, second only to Miami, and spend seven thousand dollars per Medicare beneficiary more than the national average. Peter Orszag has said that eliminating this type of variation could cut Medicare expenses nationally by as much as 30% and actually improve the quality of care.

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A Bill of Rights for Health Care Reform

By KIM BELLARD

Our nation's Founders created a pretty good system of government by starting from what they wanted to achieve, exemplified by the Bill of Rights, so perhaps we would be wise to base health care reform on a similar footing.  Instead, Congress is doing its usual muddled process to produce legislation that is likely to make no one very happy, but at least tries to minimize the number of people made very unhappy.  As is too often the case, it is easier to create straw men to attack than to address the real problems.

Insurance companies seem to be everyone's favorite target to demonize, but the “evil” health insurance industry is like the various other players in the health care system: responding to the numerous and often perverse incentives in the current system.  There are bad things done to people by insurance companies -- as there are done by doctors, hospitals, government, and just about every other player in the health care system.  There are both angels and demons working in health care, but mostly it is just normal people.  Perhaps ninety-nine percent of the people working in the health care system try to do right by the people they serve, but “doing right” may not mean the same thing to different people.

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