Uwe E. Reinhardt: U.S. Health Care Prices Are the Elephant in the Room - NYTimes.com

A good overview and reminder of the health care price issues we face in this country.  First there is the problem of transparency, we have no idea what anything costs.  But it goes farther than that, even if we know what something costs, the individual patient/consumer has no bargaining power to impact that price.  Other countries have successful models to deal with these issues, but if I mentioned what they are I'd be called a heathen communist.  (You know, like that communist country Japan...)

Uwe E. Reinhardt: U.S. Health Care Prices Are the Elephant in the Room - NYTimes.com:

Salesmen in the Surgical Suite - NYTimes.com

In most industries an aggressive sales staff is an asset.  In medical care it costs lives.  Yet one more reason why our health care problems will not be fixed by the "free market".

Salesmen in the Surgical Suite - NYTimes.com:

The filtering of medical evidence has clearly failed

A stark reminder that not all evidence-based treatments are truly evidence based.

The filtering of medical evidence has clearly failed:

Patients should decide what the end of life is like, study says - latimes.com

While I think  we should be engaging in these conversations simply because it helps the patient.  The fact that it saves money is an added bonus making it criminal that it's not happening more.


Patients should decide what the end of life is like, study says - latimes.com: "Studies have shown that when a patient’s desires are taken into account, death is less likely to occur in an intensive care unit, physical distress is reduced, and death comes no sooner, they wrote."

**UPDATED** DHS: extra cost to feds of Arkansas "private option" will be little to none | Arkansas Blog

 The Arkansas Department of Human Services released a report - or at least the executive summary of a report - on how the costs for their "private option" Medicaid expansion will not lead to extra costs for the Feds.  Many (including me) remain skeptical.  Nonetheless, it's worth paying attention as other larger states consider jumping on the bandwagon.  Linked below is an excellent analysis of the report and the issue in general (the article includes a link to the actual release).

**UPDATED** DHS: extra cost to feds of Arkansas "private option" will be little to none | Arkansas Blog:

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Hospital Ratings Are In The Eye Of The Beholder - Kaiser Health News

It's hard for patients/consumers to base decisions on metrics when the metrics don't agree.

Hospital Ratings Are In The Eye Of The Beholder - Kaiser Health News: ""We've alternatively been labeled the least safe hospital in Maine and the safest hospital in Maine," said Dr. Douglas Salvador, vice president of quality at Maine Medical Center in Portland."

Healing the Hospital Hierarchy - NYTimes.com

Great column discussing doctor-nurse relationships. This relationship is a crucial part of our health care delivery system that will need to be part of overall reform efforts.  The team approach is often discussed as part of the solution; utilizing appropriate level practitioners to deliver care.  The author provides a stark reminder that this is not an insignificant task - hierarchies built up over 100 years will not be changed with the flick of a pen.

Healing the Hospital Hierarchy - NYTimes.com:

ACP: 5 excuses physicians and patients should question

We all know that ultimately, it's changing the delivery of health care that  is needed to bend the cost curve.  I've written before about the Choosing Wisely campaign, a very important initiative to help patients choose appropriate care/testing.  Unfortunately we know that any attempt to change the status quo is bound to be met with resistance.

This excellent column addresses some of that resistance.  Yul Ejnes the the Immediate Past Chair, Board of Regents, American College of Physicians discusses five excuses not to follow the Choosing Wisely guidelines.

ACP: 5 excuses physicians and patients should question:

Note that with this post I'm returning to my health care blog.  For the past several years I've been posting on Facebook instead.  Given my imperfect nature I was finding sometimes I'd also share on LinkedIn and/or Twitter and sometimes not.  I'm now using twitterfeed.com to automatically share across platforms.  We'll see how this works...

Helpful resources

A tremendous amount is being written about the new health care reform law.

People have a lot of questions on what is really in the law and when things will change.  In the spirit that more information is always better than less, below are three helpful links providing information on the details of the bill.

H.R. 4872, The Health Care & Education Affordability Reconciliation Act of 2010-Section by section analysis 


Higher level summary of the bill


Implementation timeline

Why You Should Care About Health Care Reform

Health care in this country is in crisis – below we’ll take a high-level look at why this is the case.   Books can (and have) been written on the details of the situation, however by staying at a high level and not getting bogged down in details, we’ll review why the current situation is unsustainable and why this matters to each and every one of us.

One useful way to examine the problem is to separate the issues into two categories; the current state and the future state (or what’s to come).

The current state category includes issues such as:

• The number of people in the country who do not have access to adequate health care (access)
• The quality of care provided to those that have access (quality)
• Amount of money the country spends on health care given the return compared to other countries (cost)

Of course this is an oversimplification, the three issues are tied together and all have sub-issues (as we said, books have been written about the complexities).  However it gives us a way to briefly see the impact of the problem by looking at how these three areas directly impacts each of us: 

• Access –Do we want to live in a society where people die because they do not have enough money?  We each have a moral imperative to see that all individuals are guaranteed access to lifesaving treatment, regardless of their economic circumstance
• Quality – Although on an individual basis many of us are happy with our doctors, that does not mean we are necessarily getting the care we need.  Below we’ll look at the concept of unwarranted variation – how many of us are getting either not enough or too much care (controlling this would free up enough money in the system to cover everyone)
•  Cost – Even those of us with insurance are at risk of incurring costs we can’t pay.  From rising deductible and out-of-pocket costs, to our plan not covering the services we need, to the plan having benefit limits that mean it stops paying when we most need the coverage:  The current state of costs is so bad that the majority of bankruptcies in the US have medical costs as one of the contributing factors.  And as we’ll see in the next section, the precarious position we are in now is only going to get worse

The concept of “unwarranted variation” is useful in understanding some of the problems inherent in our current system.  It is defined as differences in healthcare service delivery that cannot be explained by illness, medical need, or the dictates of evidence-based medicine.   It can be caused by shortfalls in three areas:

• Effective care and patient safety – services of proven clinical effectiveness, such as using lipid lowering agents in patients with coronary artery disease not being administered to all appropriate patients
• Preference-sensitive care - treatment for conditions that have significant trade-offs in terms of risks and benefits for the patient. The choice of care should be, driven by the patient’s own preferences but this is often not the case
• Supply-sensitive care - care which is strongly correlated with healthcare system resource capacity and is generally provided in the absence of medical evidence and clinical theory.  In other words, if there are twice the number of back surgeons in a city, that city will have a higher rate of back surgeries

Unwarranted variation results in too much treatment, too little treatment and the wrong treatment.  Improving on these areas will free up a vast amount of resources that can be put to more appropriate use. 

The current system has additional causes of mistreatment including fraud and defensive medicine – both of these also utilize resources that could be better used elsewhere.

We’ve seen that for a variety of reasons, we are in the midst of a crisis.  Yet many of us don’t feel impacted by the situation, if we have insurance, are relatively healthy and don’t look too closely at the details, we may think everything is fine.  Even if this were true (which we’ve seen above is not the case) the current situation is not sustainable.

Experts use the concept of “medical trend” to talk about how the situation will change.  Among other uses, the trend number helps dictate how much insurance costs increase each year.  Medical Trend is comprised of three components:

·         Change in cost for existing services

·         Change in use of existing services

·         New services/technologies being used by the health care system

Let’s take a look at each of these individually:

Change in Costs is more than just overall inflation:

·         The medical component of the consumer price index is often used to represent this component

·         In certain populations (private insurance plans) it is also necessary to take into account negotiated rates or contracting when examining this component (a plan may negotiate a price different than the “public” price)

·         This is often considered the “least troubling” of the components – if overall medical cost changes only mirrored overall inflation rates there would not be a “cost crisis”

Change in use of existing services is due to several factors:

·         Demographic shifts - E.g. aging population – We are faced with older individuals making up a greater proportion of the population – this will increase overall costs since individuals use more services as they age

·         Changes in practice patterns - E.g. number of MRIs done - Between 2000 and 2004, the number of MRIs performed is the US rose 60% (too high to be accounted for by demographic shifts)

·         Changes in population morbidity - E.g. change in the presence of a condition that requires treatment – Over a 10 year period (1995-2005) the percent of Americans aged 45-64 with diabetes went from 6.2% to 10.2%

New Services/technologies keep coming:

·         First there were x-rays, then CAT scans, then MRIs.  New technology is constantly being introduced

·         New technology at its best represents an advance that will save more lives, but even in these cases there is a cost

·         Often these new services or technologies are add-ons, not replacement for existing ones.  That means more resources are being utilized

·         When these services and technologies are introduced, there is often a rush to use them – even if their use is not warranted

So where does this leave us? 

Each year, more resources are devoted to health care at a rate of growth that is not sustainable.  Costs have been increasing at multiples of the overall rate of inflation, leading to health care costs taking an ever increasing percentage of GDP as well as an increasing percent of government expenditures being devoted to Medicare and Medicaid.

Employers are not able to sustain their contribution levels resulting in increased premiums, deductibles and co-pays for most individuals.  As premium costs continue to rise, more and more employers will drop coverage. 

Ultimately this means that more and more of us will have to forego lifesaving care.

We are in crisis, with both a current state that is unsustainable and future trends that will only exacerbate the situation.  The only possible conclusion is that reform is needed now on multiple fronts.

While the measure currently before congress is not perfect, it is deserving of our support and puts us on the road to “curing” health care in this county.  

More evidence on the need for evidence based medicine

We always knew that as a country we did too many medical tests.  We even had some idea that in addition to wasting money, some of the tests could be harmful.  However, if the point needed reinforcement we have it with the study released recently stating that there are 15,000 extra cancer deaths a year due to CT scans.

We need to remember that there are ramifications to all actions – Asking for that extra test, or a Dr recommending that extra test – doesn’t just increase costs to the system, it could be killing you. 

So how do we appropriately limit tests?  One way is through the use of treatment protocols.  Some think protocols or "cookbook medicine" is a bad idea, just an excuse to limit care.  However, the reality is that sometimes there is a right way and wrong way to treat a condition.  A Dr. does not need the freedom to prescribe a CT scan for a sore throat, because there is no possible way that will lead to improved care.  

Are there potential pitfalls involved?  Yes.  Safeguards must be put in place to ensure that insurance companies do not use protocols as a way to limit needed care.   But in order to expand health care to all we need to be cutting the waste out of the system.  One piece of the puzzle that will both save lives and save money is to eliminate unnecessary testing.

Compromise – not always pretty, but it moves the ball forward

They say a true compromise is one where neither side is happy…  Although as of this writing we’re still waiting on details of the deal that eliminates the public option from the Senate Health Care bill, it seems clear no one will be jumping with joy.

While it would be easy to rant about not getting what we originally hoped for in health reform, we need to remember why this journey is so important…  The millions of people who don’t have coverage and so don’t get adequate health care, the tens of thousands forced into bankruptcy by out of control health costs (that most of them thought they had coverage for), and the unknowable (but significant) number that die needlessly every day because of our health care (non) system.

With that in mind, if giving up the public option (for now) means we’ll expand access to health care, then we have to live with it for the sake of those who will not live without the positive changes the compromise will bring.

Health Care Vigil

The Maine Council of Churches is sponsoring a Health Care Vigil on Tuesday, December 8 at 4:00 PM in Lobsterman Park in Portland Square, on the corner of Temple and Middle Streets in Portland. For more information, take a look here.

A look back, a step forward

With Saturday night’s historic vote to allow Senate debate on their health care reform bill, it’s a good time to look back on how we got here, and think about the path forward.


The New York Times published a great interactive chart showing the history of health care reform:
A History of Health Care Reform - For almost a century, presidents and members of Congress have tried and failed to provide universal health benefits to Americans.

It reminds us that for almost 100 years, we’ve been trying to get this done. It also makes us think of all those people who went wanting when their lives could have been so different. But past is past, and while the bill taking shape in Washington will not accomplish everything we had hoped, it will represent a vast improvement over the status quo. (I know the final bill has not taken final shape yet, but general framework of making health care available to more people and starting to reign in the unsustainable cost increases is clear.)

There is so much that can still go wrong given the poisonous partisan atmosphere in Washington. Extremists on both sides of the aisle will claim that the bad things in the bill outweigh the good (and if you’ve watched TV in the past few days you’ve seen commercials hammering home their points). But we can’t fail again! Just because the bill doesn’t help everyone and fix everything, does not mean it’s not worth passing.

We must pass a bill this session. The time is now. It won’t be perfect, but it will be a step forward.

As if we needed more proof that the health care situation in this country is unacceptable

The Associated Press: Study: Injured uninsured more likely to die in ER

Uninsured patients with traumatic injuries, such as car crashes, falls and gunshot wounds, were almost twice as likely to die in the hospital as similarly injured patients with health insurance, according to a troubling new study.

The findings by Harvard University researchers surprised doctors and health experts who have believed emergency room care was equitable.

Health Care Reform and Abortion

No one ever said health care reform was going to be easy. But does it have to be quite so hard? Last week in the final days before the house passed the “historic” legislation, an issue we thought was settled once again reared its ugly head: How would abortion be handled by plans offered through the exchange.


The answer was going to be that the funds would be segregated, no government subsidy would pay for abortion (even though it is a legal procedure in all 50 states); coverage would be paid out of the individuals’ share of the premium. Ironically, this construct is similar to how catholic schools get money; the money only pays for the sectarian part of the education, not the religious part. (If one of these mechanisms is a gimmick, aren't both of them?)

Suddenly in the final days before the vote, that answer was no longer acceptable. Thus the Stupak amendment came to pass.

Following is an excerpt from Prescriptions: Abortion Puts Some in Congress in a Bind


By By KATHARINE Q. SEELYE

Robert J. Blendon, a professor of health policy at Harvard, said the choice between trying to stop an erosion of abortion rights and trying to improve health care for women pitted “what are described as two fundamental human rights — the right to universal coverage and the right of access to reproductive services — against each other.”

“They aren’t just policy trade-offs,” he said. “And that’s why this is so wrenching.”

This issue isn’t going away. As outlined in this Reuters’ analysis by Ed Stoddard there are no easy solutions but lots of potential damage: ANALYSIS-Abortion exposes divisions among U.S. Democrats

What do I think? As I'm writing this on Sunday afternoon (11/15/09) I’m not sure. Some Democrats are saying they won’t vote for a final bill that includes the Stupak amendment – is that the right response? I vehemently believe in a women’s right to choose, that part of me says don’t vote for the bill. I also vehemently believe that we must pass some form of health reform this year to expand coverage and start to rein in costs – to not do so will be to miss an historic opportunity and result in a continuation of unnecessary deaths. All I can say today is I’m saddened by the forces in this country that continue to work towards division instead of compromise.

The sad thing is that this is completely normal

The article talks about a lobbyist supplying the same text to Democratic and Republican congressmen for inclusion in the congressional record. This happens all the time... And we wonder (or maybe we've stopped wondering) why it is so hard to do the "people's" business in Congress.

In House, Many Spoke With One Voice: Lobbyists?
By ROBERT PEAR
Published: November 15, 2009
More than a dozen lawmakers? statements on the health care debate were ghostwritten by lobbyists working for Genentech, a biotechnology company.

Sorry I haven't posted in a while

To be honest, I was upset about last week's election (Maine Prop 1) but didn't want to write anything bitter. Now that some time has passed, I'm just left with a feeling of disappointment in the voters for being taken in by the fear mongering of the opposition.

But life goes on, and it’s time to turn our attention back to health care. In the next few days I'll have more to say about some of the ongoing issues (we can't let the quicksand that is the abortion issue in this country derail health care reform) but for today, just a link to an article about my adopted state talking about how hard this all is (and to me highlighting why we need fundamental change).


From today's NY Times:  Maine Finds a Health Care Fix Elusive

Health Care and Marriage Equality

Both of these issues are getting a lot of play here in Maine. Health Care maybe even more so than in the rest of the country due to the importance of our Republican Senators’ (Snow and Collins) potential support of a Democratic bill. Marriage Equality because after being the first state to pass legislation allowing gay marriage that was NOT court mandated, an election fight is underway as opponents try and pass a people’s veto to repeal the legislation. I’ve written about both issues separately, today I want to talk about what they have in common.

The answer to what they have in common comes from the following two part question: Who do you identify with and who can you identify with? You might think about your family, your church, your group of friends, your school, your town, your country. Another way of asking this is how do you define your pack? Years ago, Hillary Clinton wrote about it taking a village, but again, what is a village? How are we defining our community? Regardless of how we answer today, the two issues represent part of the struggle to get to the point where we extend the definition of our reference group to all individuals.

As we developed, we started to learn to get past thinking only about ourselves. It has been noted by many that the path of our growth as a society has been our ability to identify with larger and larger groups. First it was our family, then our tribe, then our village and so on. Now we no longer fear every stranger that comes down the road; however, there is still more progress to be made.

The civil rights movement can be viewed as extending our view of the group we identify with to people of all races. Seeing a larger group as deserving of the same legal protections and rights that some already had. The battle for gay rights (and gay marriage) is a continuation of that struggle to yet another segment of the population. As we come to recognize that ultimately the key group we belong to is mankind we realize that everyone deserves the same protections and rights.

As with recognizing that all individuals deserve the right to marry, we must recognize that all individuals deserve access to health care. Again, the definition of ourselves as being part of the group of all individuals is key. It leads to recognition of the shared responsibility to take care of each other. Keep this in mind as the debate rages on in Washington. The discussion should only be about the details, the goal of affordable access to care for everyone must be taken as a given.

As always I encourage you to share your comments below.

Medicare Advantage – spending more was NOT the idea

A good article this morning on Medicare Advantage plans and how they are part of the health care legislation debate: Medicare Advantage tussle at heart of overhaul - Health care- msnbc.com: "Medicare Advantage tussle at heart of overhaul".

 

A key fact getting lost in the conversation is that these plans were originally created to SAVE the government money over traditional Medicare. Let’s take a look at the governments own definitions from the Medicare website (http://www.medicare.gov/choices/Overview.asp):

The Original Medicare Plan – This is a fee-for-service plan that covers many health care services and certain drugs. You can go to any doctor or hospital that accepts Medicare. When you get your health care, you use your red, white, and blue Medicare card.

The Original Medicare Plan pays for many health care services and supplies, but it doesn’t pay all of your health care costs. There are costs that you must pay, like coinsurance, copayments, and deductibles. These costs are called “gaps” in Medicare coverage. You might want to consider buying a Medigap policy to cover these gaps in Medicare coverage. You can also add prescription drug coverage by joining a Medicare Prescription Drug Plan.

For more information on the Original Medicare Plan, visit the Original Medicare Plan section of this website.

Medicare Advantage Plans – Available in many areas. If you have one of these plans, you don’t need a Medigap policy. These plans include:

• Health Maintenance Organizations (HMO),
• Preferred Provider Organizations (PPO)
• Private Fee-for-Service Plans
• Medicare Special Needs Plans
• Medicare Medical Savings Account Plans (MSA)

These plans may cover more services and have lower out-of-pocket costs than the Original Medicare Plan. Some plans cover prescription drugs. In some plans, like HMOs, you may only be able to see certain doctors or go to certain hospitals to get covered services.

Click here for more information on Medicare Advantage Plans.

 

Originally, Medicare Advantage plans were conceived to save the government and plans money. By contracting with private managed care plans, the government would pay less (95%) than for standard Medicare beneficiaries but the members would get enhanced benefits because of course (note sarcasm) private industry could be more efficient.

That intent did not last in the face of special interest lobbying as the payment threshold for Medicare Advantage plans rose compared to traditional Medicare. Some more background from the Kaiser Family Foundation Medicare Fact Sheet, May 2009 (http://www.kff.org/medicare/2052.cfm):

For many years, payments to Medicare HMOs were generally set on a county-by-county basis at 95% of Medicare FFS costs in each county because HMOs were thought to be able to provide care more efficiently than FFS… Medicare Advantage plans are currently paid more, on average, than FFS costs in their area. According to MedPAC, payments to Medicare Advantage plans per enrollee in 2009 will average 114% of FFS costs for the counties where Medicare Advantage enrollees reside.

Again the original intent was lost, so now we are faced with disparate Medicare plans with only a subset of seniors receiving enhanced benefits (due to greater government expenditures – not due to the efficiency of the private plans). To try and preserve these enhanced plans makes no sense. If we want to make the decision to spend the 114% of current traditional plan expenditures on all seniors, so be it. However, to continue to spend money desperately needed elsewhere just because certain industry lobbyists have perpetuated these plans (with ever increasing expenditures) makes no sense. Just because some seniors by the luck of the draw have ended up in these rich plans is not a reason to preserve them and is not equitable.

Robert Reich on the public option

The public option is getting lots of discussion right now (part of the "how" of health reform).  This short video explains its necessity much better than I could, please take a look. 

Robert Reich on the public option

Health Care security for all – The why of health care reform is a moral issue

The “why” of health care reform is being overshadowed by partisan bickering over the “how” of reform. Certainly how we provide health care to everyone is important, but the discussion gets lost when we lose sight of why we as a nation are again walking down this path.

Very simply, health care is a moral issue. Every man, women and child, regardless of circumstance, deserves acceptable health care.

In 1935 we as a nation made the decision to provide economic security to our seniors through Social Security. Thirty years later, we made the decision to expand security for seniors by providing health care through the creation of Medicare (a very successful government run health care option, but more about that another time). Now in 2009 we are (again) at the brink of providing health care security to everyone. This time we must be successful.

The social contract between people and government can be simply put as people obey the rules and in return are provided security. Originally, security meant that a person had the right not be killed by invading armies. We like to think that we are making progress as a society, that we are better off than those that came before us. To that end, the definition of security has expanded over time, in addition to the examples above, we have decided not to let people go hungry and for the most part, we ensure that people have a roof over their head.

It is past time that we all agree to define being secure as having basic health care. Each of us has a moral compass, whether derived from religion or elsewhere, most of us make decisions based on that compass every day. The direction our collective compass should be pointing is clear, it must point to health care for everyone. While we certainly need to figure out how to provide it efficiently and effectively (the how) it must be done and done now.