That Was The Week That Was* - Issue 2

A look back at the week's health policy news with a focus on ACA implementation

Welcome to the second edition of this newsletter.  You'll note that this one is a bit different - I've taken some very helpful feedback and shortened it considerably.  As much as I found all the articles in the last one interesting, not everyone has the time to plow through so much content.  So this week we take a more focused look at what went on.  Please continue to provide comments and feedback, as you see, this is still very much a work in progress.

The top story this week has to be the approaching enrollment deadline.  As I write this on Friday morning, there are a little less than 11 days to go. 

Let's start with where we are now - we saw "enrollment" hit 5 million this week: Health law enrollment hits 5 million with 2 weeks to go.  To-date I have objected to the focus on enrollment targets, but with the approaching deadline, it's inevitable that they will be reported and discussed.  So bowing to the inevitable I'll include them here.  Note that the "consensus definition" of enrollment has become those who selected a plan on a marketplace (be it Federal or State).  This does not take into account how many have gone ahead with the last step of paying their first month's premium.  Estimates vary from 75% to 90% as to how many take the final step.  We won't know the answer to that one for another couple of months.

How many of you remember Nate Sliver?  He is the blogger who came to prominence during the last presidential election by correctly predicting 49 of 50 state results (others did even better, but he is the one who got the coverage).  This open enrollment period seems to have led to a "new Nate Sliver" - and he thinks that contrary to what was being forecast at the beginning of March, not only will enrollment reach 6 million, it will blow past it to 6.2 million:  This guy knew when Obamacare enrollment would hit 5M before anyone else. Now he’s predicting 6.2M.

Regardless of the final number, it seems clear that overall the ACA will not collapse under its own weight:  Benefit Experts Agree With Obama That ACA Has Enough Enrolled.  But remember, this is really a 50 part story, while the national figures will get the attention, each state has its own insurance market and there will doubtless be a few that will have a tough time going forward.

So that's where we are, and a prediction of where we're going.  But with 11 days left, how are we going to get there?  Since March madness has begun, the only way to say it is we'll get there with a "full court press".  The Administration is using basketball in its attempts to "stuff the basket" (ok, I'll stop now):  Obamacare meets March Madness.  But not just basketball - The President was on Ellen this week talking Scandal, House of Cards and the ACA: President Obama On Ellen talks ACA (sorry, that clip is just the ACA segment).

For those looking for a handy basic introduction to enrollment, this piece is helpful: The Sign-Up Deadline Is March 31: A Consumer Guide.  And for those wondering when Ezra Klein (formerly of Wonkblog) would resurface, here is a handy explanation of the individual mandate including why it's needed provided by his new site:  Obamacare's individual mandate in two minutes.

Also under the category of momentous dates, Sunday marks the fourth anniversary of the bill's signing: Obamacare turns 4: Will anyone notice?

While it would be easy to just focus on this open-enrollment period, time marches on.  Looking forward the Administration has released new guidance regarding plans that will be offered for 2015: White House Tightens Health Plan’s Standards After Consumers Complain.  One of the big issues, both here in Maine and nationally, is the "narrow networks".  As we know, while the concept isn't new they've become much more prevalent.  The new standards begin to address them, and for further information, here is an industry based look at the concept:  Are your networks too narrow?.    When discussing networks its always worth repeating the ramifications of going outside them:  Warning: Opting Out Of Your Insurance Plan's Provider Network Is Risky.

The Administration has also said that those sub-standard plans that should have been cancelled last year but weren't can stick around another two years: Obama administration wants fewer people to get insurance cancellation notices. 

Of course, in addition to what the plans cover we also have to think about what they cost.  While individuals receiving financial assistance will be somewhat protected from rate increases (the percent of their income they are asked to contribute don't change, so if the plan rate goes up the subsidy will go up) long-term if the subsidies get too expensive something will have to change.  Right now, 2015 rates are anybody's guess - and everybody is guessing:  The Latest Obamacare Doom Prediction—and What to Think About It.

Looking toward next week, the Supreme Court once again here's an ACA case.  This time centered on the birth control issue for private employers: Everything You Need To Know About The Supreme Court Taking On Birth Control.

Shifting focus away from the ACA, the issue of health disparities was in the news this week.    Two excellent reviews of some of the issues involved and the scope of the problem:   Income Gap, Meet the Longevity Gap and Q&A: How States are Tackling 'Health Disparities'.  Also some thoughts on how it needs to be addressed by the provider community: Screening for poverty should be included in the medical curriculum.

We'll end with a look forward.  Maine's own Patent Centered Medical Home pilot received some focus: Our View: Pilot program focuses on health, not sick care: A team-based approach to medicine is starting to help Mainers but needs more time to develop.  This follows a few weeks of stories calling into question the efficacy of the Medical Home concept due to a recent study that failed to find the promised cost savings.  My take is that these pilots are still very much a work in progress.  The theory is sound but we haven't yet figured out how to make them work as well as they could.  It's not a simple issue, here is a helpful look at the issues involved:  Redesign the medical home to thrive in the real world.

Thanks for reading!

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Funded by support from the Maine Health Access Foundation

*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer  album "That Was The Year That Was"

That Was The Week That Was*

A look back at the weeks health policy news with a focus on ACA implementation

Mitchell Stein

March 14, 2014

March, 14 2014

Welcome to the first edition of this newsletter.  As always seems to be the case these days, lots going on so let's dive right in.  We'll start with this release of new enrollment figures and move on from there. 

ENROLLMENT

In my initial review of the enrollment data (available at the end of this document) I noted that opponents of the law would try and make something of the drop off in enrollment between this report and the last one.  And while that's certainly happened, we've also seen some interesting analysis saying there was no drop-off:

First the numbers

Obamacare Enrollment Now Up to 4 Million

Next, enrollment numbers as Rorschach test

Obamacare Enrollment Proves Whatever You Want It To

But wait, how many days were there in February?

Obamacare Enrollment Didn't Slow Down in February: Attention, critics: February has 28 days.

So the numbers didn't really show a slowing of enrollment

Health Exchange Enrollment Remains at 75 Percent of Target (enrollment chart by state)

But realistically, going to be touch to hit 6 million by the end of March

Analysis: Obamacare enrollment to miss target that HHS wishes you’d ignore

And  finally, we need to remember that these numbers are those who have selected a plan on a marketplace, not those who've paid their first month's premium (so not really "enrollment" numbers)

So how many have paid ACA premiums?

CONTINUING EFFORTS

Even before the numbers were released with the March 31 deadline approaching the final press had begun.  

One of my favorites was the President heading to alternative media

Obama goes ‘Between Two Ferns’ (Video)

Which actually seems to have helped

‘Between Two Ferns’ video leads to 40 percent more visits to HealthCare.gov

And of course here in Maine, naked men get people's attention

Nudity, humor used to get youth sign up for health care in Maine

THE REGULATIONS - SOME CHANGE SOME DON'T

The biggest date that won't change is the end of open enrollment - still March 31 and given how emphatically it was stated hard to see it changing

Health Mandate Won’t Be Delayed, Sebelius Says

One of the positive changes is that the cost-sharing subsidy funding will no longer be subject to the sequester cuts (the premium subsidies never were going to be)

Reversing course, the White House protects an Obamacare subsidy from sequester cuts

And an understandable break on MLR for insurers increased costs due to the rollout "glitches"

Insurers May Get Cost Break Thanks To Rocky ACA Rollout

THE PREVIOUS NON-PARTISAN EFFORTS ON THE DOC FIX JUST TURNED PARTISAN

The Doc-fix is the efforts to eliminate the annual problem of Medicare's physician payment system.  With health care cost inflation at historic low, now was the time to make a permanent fix.  However the House Republican's have attached the non-partisan fix to a postponement of the individual mandate for five years. Something they know won't get past the Senate and the President

Obama threatens to veto GOP 'doc fix' bill

Not to mention the negative impacts of delaying the mandate

CBO: Five-Year Individual Mandate Delay Means 13 Million More Uninsured, Higher Premiums

So negative that the American Medical Association who has lobbied (hard) for a fix for years rejects tying the two issues together

Doctors renounce GOP's permanent 'doc fix'

And a reminder how important - and problematic - the mandate is

Obamacare's Mandate Is Complicating Life for Both Parties

AND THAT'S NOT ALL CONGRESS IS UP TO

They passed three laws this week that span the spectrum from good to unnecessary to bad.  Note that it is unclear if any of these will make it to the Senate and then the President's desk.

The potentially good one (or at least harmless one) in the mix would allow employers to not count veterans when calculating their number of employees.  The idea is that firms would have an incentive to hire more veterans (Hire More Heroes Act, H.R. 3474).

The unnecessary one states that volunteer firefighters and emergency responders are not employees and so don't have to be offered health insurance.  The problem is they are already not considered employees per the most recent Federal guidance on the issue (Protecting Volunteer Firefighters and Emergency Responders Act, H.R. 3979).

And finally, the most troubling one would let people avoid buying health insurance under Obamacare if they could cite a religious reason.  There are many questions regarding if this is enforceable or if it would just allow anyone to say they don't want to buy health insurance.  Note there is already an exemption for those part of an established religion with objections making this bill either dangerous or redundent  (Equitable Access to Care and Health (EACH) Act, H.R. 1814).

House OKs religious exemptions to having a healthcare plan

ENROLLMENT ISSUES

As we near the end of the enrollment period, some good reminders for those who work on these issues but great reminders for the public who does not.

Yes you do need health insurance

When Health Costs Harm Your Credit

And if you don't get it, it will cost you

You Might Pay A Lot More Than $95 For Skipping Health Insurance

Understanding what is income can be complicated

A Reader Asks: Would An IRA Withdrawal Count As Income For Exchange Subsidies?

And not all enrollment issues have been solved:

Advocates Press For Insurance Subsidies For Domestic Abuse Victims

POLLS

As with the enrollment numbers, poll results can also serve as a Rorschach test.

You can take good news, like a drop in the number of uninsured
Survey: Uninsured rate drops; health law cited

For those of us who support the law, we can take a realistic look at the positives and negatives
Five takeaways from Gallup’s poll on the uninsured

But don't expect everyone to take that approach
Don’t Expect Conservative Media to Cover This New Obamacare Poll

Support continues to creep up (remember, in CNN's poll the oposition to the law includes those who say it doesn't go far enough)
CNN Poll: Support for Obamacare slightly edges up

Signs of increased support come from more than one poll with this one showing 64 percent of Americans now supporting it outright or backing small changes
Americans Stick With Obamacare as Opposition Burns Bright

MEDICARE

Mostly unrelated to the ACA but of note is that proposed changes to Medicare prescription drug coverage were pulled back by the administration

White House Withdraws Plan Allowing Limits to Medicare Coverage for Some Drugs

While the ACA mandated changes to Medicare Advantage reimbursement continue to have an impact

Medicare Changes Prompt Enrollees to Reconsider Plans

For a refresher on the issue, this older item may be useful

Planned Medicare Advantage Cuts Get Mixed Reaction in Maine

SYSTEM REFORM

In the long run, it is reforming the overall system that will free up the resources to provide access to all.  Here is one reminder of the scope of resources that may be reclaimed

How to Shave $1 Trillion Out of Health Care

And a reminder that change is hard and we must constantly be on the lookout for those unintended consequences

Injured Who Lived Near Closed Trauma Centers More Likely To Die

NEW RESOURCE

And finally, our friends at the Robert Wood Johnson Foundation have created a new website Financial Help for Health

New Website Features Tools and Information for People Who May Be Able to Save Hundreds of Dollars Per Month in the Health Insurance Marketplaces

Thanks for reading!

---

Funded by support from the Maine Health Access Foundation

*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer  album "That Was The Year That Was"

Enrollment Recap (originally published 3/12)

To me the biggest story around the enrollment report release yesterday was that it was not a big story...   

Doing a scan at 6 AM, it did not make the CNN front page or Google News top stories.  That said, some great coverage here in Maine around all of your efforts (see below).   And of course it wasn't completely ignored by the national media - and you can be sure that the law's opponents will try and make something of the drop-off in enrollment.  

The national press takes the drop-off in February to mean the Administration won't reach the "new" goal of 6 million by the end of March.  My take is we really have no idea how busy the end of March will be.  Massachusetts saw a tremendous spike at the end of their first deadline - but I'm leery of making any predictions based on one data point.  As we all move through the final push, please remember that while aggregate numbers are important, every individual who signs up for coverage is one less person at risk - and that means a lot.

And now some numbers and links.  Note that in the detailed report released by HHS yesterday.  There was basically only one number for Maine - reflected in this chart:

	Monthly Enrollment	Cumulative Total
Oct	NA	NA
Nov	1,741	1,741
Dec	11,963	13,704
Jan	6,807	20,511
Feb	4,901	25,412

Maine health officials trying to sign up immigrants, hard-to-reach populations

More than 25,000 Mainers have signed up for health care coverage through ACA

Maine beats Affordable Care Act enrollment target

National coverage:

Obamacare enrollment drops off in February

Health Care Enrollment Falls Short of Goal, With Deadline Approaching

Providing the right amount of healthcare

Less is more.  A lesson that can't be repeated often enough.

Providing the right amount of healthcare: "But a growing number of studies show that more healthcare is not always better and the more expensive drug or treatment option is not necessarily the right choice.  In fact, sometimes more care – specifically care that you don’t need – can be harmful for your health, and expose you to unnecessary risks."

The worst kind of guideline in prostate cancer screening

A thoughtful discussion of the ACP guidelines for screening of prostate cancer.  An important reminder that when treating a patient (as in life) sometimes the answer should be "no".

The worst kind of guideline in prostate cancer screening: "First, when as a profession did we decide that we had an ethical obligation to offer interventions that cause more harm than good? When we offer an intervention that is on the whole detrimental, are we not sending our patients a mixed message? "

Proton Beam Therapy Heats Up Hospital Arms Race - Kaiser Health News

We've talked about this before, as have many others, all apparently to no end.  Building these machines helps no one.  It improves the hospitals bottom line by selling a more expensive service that may sound good but time and again has proven to be no better than existing, cheaper technologies.

Proton Beam Therapy Heats Up Hospital Arms Race - Kaiser Health News: ""We don’t have evidence that there’s a need for them in terms of medical care. They’re simply done to generate profits."

The higher costs of proton services ultimately trickle down to taxpayers, employers and consumers in the form of higher health insurance premiums. "

Will high tech innovations actually improve health outcomes?

Will high tech innovations actually improve health outcomes?:

We've talked about this before, but yet another reminder that we know how to better care for people, we just are not doing it yet.

"If you really want to see the future of medicine, skip TEDMED and head over to Camden, New Jersey"

“There is a bias in medicine against talking to people and for cutting, scanning and chopping into them. If this was a pill or or a machine with these results it would be front-page news in the Wall Street Journal. If we could get these results for your grandmother, you’d say, ‘Of course I want that.’ But then you’d say, what are the risks? Does she need to have chemotherapy? Does she need to be put in a scanner? Is it a surgery? And you’d say, no, you just have to have a nurse come visit her every week.”

Poverty as a Childhood Disease - NYTimes.com

Another reminder, true health policy needs to be about more than just fixing a broken leg, it needs to address underlying issues that can impact one's health for the rest of their lives...

Poverty as a Childhood Disease - NYTimes.com: "These remind us that — more so than in my mother’s generation — poverty in this country is now likely to define many children’s life trajectories in the harshest terms: poor academic achievement, high dropout rates, and health problems from obesity and diabetes to heart disease, substance abuse and mental illness."

More US babies die day they are born than any industrialized country, report shows - Vitals

Still think we don't have a health care/public health crisis in this country?

More US babies die day they are born than any industrialized country, report shows - Vitals: "The U.S. is a worse place for newborns than 68 other countries, including Egypt, Turkey and Peru, according to a report released Tuesday by Save the Children."

Under Obamacare program, doctor visits would become data points

Perhaps the most important non-access related element of the ACA was the creation of PCORI.  Over time, their research has the potential to transform the way medicine is practice.  Research that is long overdue.


Under Obamacare program, doctor visits would become data points: "“Right now, were spending trillions on health care and 99.9999 percent doesn’t contribute anything to medical knowledge,” says Farzad Mostashari, national coordinator for health information technology at Health and Human Services. “That’s the real vision, that we actually take routine care, the heallth care happening in the real world, and have that contribute to knowledge.”"

We still have a health-care spending problem - The Washington Post

Disappointing but not surprising news.

We still have a health-care spending problem - The Washington Post: "most of this slowdown, 77 percent, has been due to years of a weak economy, which causes people to put off health services when they can and prompts employers and states to reduce health spending"

Want to cut health costs? Show doctors a price tag.

Want to cut health costs? Show doctors a price tag.:

It's the little things... the big things help too but don't underestimate the impact of small steps like this.

"Keep in mind, nothing changed for the doctors. The hospital would not penalize them for ordering more expensive tests; the costs would just get billed to the insurance provider. Still, the simple display of information suggests that “physicians can act in a cost-conscious manner even without direct incentives.”"

When your surgery goes wrong, hospitals profit

When your surgery goes wrong, hospitals profit: "“Part of what we have been trying to unravel is why some of the simple quality control measures that we know work are very slow to penetrate,” Gawande told me in an interview. “This puts in perspective how weak the incentives are [to improve quality]. Complications produced massively higher profits.”"

Hospitals In 5 States Clamp Down On Delivering Babies Before 39 Weeks – Capsules - The KHN Blog

Some low hanging fruit in our health care system - we know that babies born at 37 and 38 weeks are at a higher risk of death and other problems.  None-the-less an estimated 10-15 percent of US babies born every year are delivered early without medical cause.  This work shows that many of those elective early births can be delayed.

Hospitals In 5 States Clamp Down On Delivering Babies Before 39 Weeks – Capsules - The KHN Blog: "A study published Monday in the journal Obstetrics & Gynecology showed a group of 25 hospitals in five states were able to cut their rates of elective early deliveries from nearly 28 percent to under 5 percent in one year. "

Dying - avoiding the conversation is not the answer

I try and write about different aspects of health care (all of which can stand to be improved); Access, quality and cost is one of the traditional paradigms I use.  But today I want to briefly focus instead on a topic that transcends those categories, how our health care system deals with death.  This topic is incredibly important to me for two reasons - First, I have been through the passing of my parents and in-laws - four unique deaths that each taught me different lessons; and second, the use of the term "death panels" in the health care debate that made it even harder to have these vital conversations.

I'm no expert, but I do know that as we approach the end, or even better before we approach the end, we should as patients think about these issues.  Additionally, our providers should be prepared to help guide us through the process.

For your consideration, I share three recent articles.  Note that the first two link to additional classic articles on the topic that I encourage you to click through to.  The third article is a bit of a primer - just knowing what you want to do with respect to codes when you go into the hospital goes a long way towards addressing these issues, or at least helps start the conversation.

A duty to guide patients through the process of death: "Even in theses extremely devastating cases, We can still make a huge difference in the lives of our patients in the way in which we help them handle their own death."



Are physicians more afraid of death than the general population?: "If we aspire to become effective escorts to the patients whom we are privileged to shepherd in our medical ministries, then we might consider revising Luke’s well-known proverb to read: “Physician, emotionally heal thyself.”"


5 essential concepts to know about code status: "a few important and often unrecognized considerations that patients and their families should be aware of when discussing code status with their healthcare team."

The Republican plan for replacing Obamacare doesn’t replace Obamacare

Clear analysis of what the choice between the two approaches really comes down to.

The Republican plan for replacing Obamacare doesn’t replace Obamacare:

"...Or, to put it differently, Obamacare is trying to solve the problem of too little insurance. The Republican ideas are trying to solve the problem of too much insurance."

Now can we move on and work on how to implement the thing in the best possible way?

It's our duty as physicians to avoid needless tests

It's our duty as physicians to avoid needless tests: "But it’s not just the fact that our duty as citizens should force us to be good stewards of health care resources. It’s our duty as physicians to avoid needless tests that could add to potential morbidity."

Another voice in the growing chorus to "Choose Wisely".

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:

'

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.