The Users' Guide to the Health Reform Galaxy

Looking back to move forward.

I have days when I can't remember what I had for breakfast, let alone what happened in the past eighty years with respect to health reform initiatives, but having flirted with being a history major for a while during college, I think that I came away from that experience thinking that history can, indeed, teach us something about today.  If history came in forms other than big, chunky books, more people might have time to learn those lessons.  So in the interests of condensing some historical lessons, here are two posts:  The New Republic's Jonathan Cohn's piece, here, and The Washington Post's Ezra Klein's piece, here.  Both pieces take issue with a Huffington Post piece by Marcia Angell, a noted physician and author, that argues that the House bill is not better than the status quo.

We have plenty of material to offer on the status quo, on the history of health reform in America, and on learning from our past successes and failures.  Take a look.

Reform's secret weapons: quality measures and the nurses who act on them

Valerie Overton, a nurse practitioner at the Fairview Rosemount Clinic in Rosemount, MN, writes about how nurses are helping clinics improve their quality scores and saving lives along the way.

Measuring and publicizing the quality of health care in communities is crucial to reforming our dysfunctional health care system because it forces doctors and hospitals to improve the care they deliver. A recent Wall Street Journal article showed how this is happening in my state, Minnesota, thanks to the efforts of an organization called MN Community Measurement (MNCM).

Nurses are key players in the reforms unfolding here. As the article rightly noted, doctors “started letting nurses call patients back in if the physicians forgot to order tests during a visit.”  But at Minnesota’s Fairview Rosemount Clinic, where I work, we don’t wait for Twin City-area women to come to us. We write them urgent reminders to get Pap, breast and colon check-ups as well as talk face-to-face about screening. 

Those calls can save lives. Just ask Jean Shanley and Amanda Franco.

What health reform looks like in the real world, right now

Susan DeVore, the CEO of the Premier healthcare alliance, writes about the lessons health reformers can learn from its efforts to drive quality improvement and costs savings in hospitals.

A year ago, 157 hospitals in the Premier healthcare alliance set out to see if they could deliver better care to save lives, while simultaneously saving money.

As it turns out, they can. And there is a lesson from this effort for Congress as it struggles to find practical solutions to improve health care quality and control spending. Cutting costs while improving care is the holy grail of healthcare reform. If we can bend the curve of healthcare costs, we stop the system from careening toward insolvency and make coverage more affordable.

Premier, an alliance of 2,200 not for profit hospitals, created QUEST (for “Quality, Efficiency, Safety and Transparency), in partnership with the Institute for Healthcare Improvement, to find ways to holistically improve healthcare. To participate, hospitals joining the collaborative agreed to transparently share data and results with one another; adopt tough measures; and then observe and implement new ways of providing care to enhance quality.

This wasn’t some academic study. We pulled performance statistics on deaths, costs and effective care. We then figured out what is driving deaths, errors and excessive costs, devising the best ways to prevent them and setting aggressive improvement goals. After just one year, we estimate QUEST saved 8,043 lives, or 14 percent fewer deaths than expected. At the same time, hospitals also saved $577 million, or $343 per patient discharge.

Where were you?

Mike Painter, senior program officer at RWJF, writes about the latest report released by RWJF on the adoption of electronic medical records.  He contributed a chapter in the report on quality measurement and how it relates to health information technology.

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. 

Of course, the news is sobering.  This third report highlights yet again that overall adoption of the electronic record is stubbornly, almost shockingly, low in virtually all clinical settings.  This current report also highlights that without focused attention, adoption of electronic health records might make disparities even worse.  Terrific. 

How important are individual mandates in achieving health reform?

Debra Lipson, a senior researcher at Mathematica, writes about individual mandates and health reform through the lens of reform efforts in Massachusetts and Maine.

Nearly every health reform proposal now under consideration in Congress has a provision that would require individuals to purchase health insurance coverage. For years, the notion of government requiring individuals to have health insurance was anathema. To those on the right, it smacked of government intrusion into personal affairs. The far-left opposed mandatory purchase of private insurance because they argued that it would perpetuate an overpriced, unfair system stacked against consumers.
 
Thanks to Massachusetts’ health reforms passed in 2006, we have experience with individual mandates and lessons about what it takes to make them work:  Adequate subsidies to make premiums affordable to those with low or moderate income. Penalties for non-compliance high enough to induce participation. Exemptions for those who demonstrate that premiums for available policies remain unaffordable, even with subsidies. Regulations that require insurers to issue plans to all applicants regardless of health status, and that limit the extent to which rates can vary based on age, gender, and other personal characteristics. 

Even with such provisions, not everyone gets covered. That’s because Massachusetts is unable to raise sufficient revenues to provide adequate subsidies to everyone who needs help paying premiums. This could well be the case with federal health reform. There is little appetite on Capitol Hill (at least in the Senate) for raising enough funds to subsidize families earning more than 300 percent of the federal poverty level. In addition, Massachusetts didn’t get around to serious health care cost control until this year, so premium rates remain high.

What we're reading about health reform

A number of posts in our blogging pipeline are still percolating, so I'll go to the time-honored blogging practice of pointing to other posts that I've read and liked (when I've had the time to actually read, and like, other blogs).  I thought Joe Flower's post on The Health Care Blog, about how the concept of free-market competition works in the health care context, was pretty interesting, especially since I know people who believe that factors like greater transparency of health care information on quality and value could potentially make dysfunctional health care markets, er, function the way they should.  And then there was Joanne Kenen's highlighting of Ceci Connolly's piece in the Washington Post about how whether current health reform bills will do enough to trim health care spending.  The article relates to a recent policy paper RWJF put out from the Urban Institute, on the topic of how to improve the delivery and efficiency of health care services, focusing on accountable care organizations.  If you haven't read the paper, you really should. This is one paper that's really worth reading (reading in the actual sense, not in the, skim-the-headlines-and-then-refer-to-it-knowledgeably sense).  It tells you everything you need to know about accountable care organizations, which is a concept that has been much in vogue in health reform discussions.

Some colleagues of mine suggested sprinkling a few pop-culture references here and there in this blog, to spice it up a bit and also, because pop culture is one of my favorite things, you know, along with working to ensure that all Americans get access to high-quality, affordable health care.  But my week's sampling of books, television shows, and magazines have so far failed to yield an interesting health reform insight, other than the fact that I read a novel where one of the characters was slowly declining into a serious mental illness and it was kind of interesting to read about his (fictional) interactions with the British national health care system.  Let me know if you've got anything to share on this angle.  (Example: "How a recent episode of Glee showed me that we really need to improve school-based health care.")

Talking about health care quality on the Hill

Anne Weiss, Team Director for Quality/Equality at RWJF, writes about a recent series of visits that took place in DC.

Earlier this week, I found myself walking the marble hallways of Capitol Hill, right at ground zero for health reform as the House and Senate were preparing final bills for vote.  RWJF’s Aligning Forces for Quality (AF4Q) grantees were visiting with their Congressional delegations on Capitol Hill, and I got to come along for the ride.  (For those who just came in, AF4Q is the Foundation’s signature effort to improve health care quality in 15 communities around the country.  You can learn more about AF4Q here) 

I’m not talking here about a casual “hey, I was in the neighborhood, so I thought I’d drop in and say hi” kind of visit, either.  Just imagine what it might take to nail appointments for 15 grantee teams with two Senators and at least one Representative for EACH team during a typically frantic 48 hours on the Hill.  Then factor in that we were there during a week when the national debate over health care reform was positively deafening (and so were the demonstrators on every corner, especially the guy who threatened eternal damnation for supporters or opponents of the public option, I forget which).  This formidable undertaking took months to plan and prepare for, so we were lucky to have all the support we needed from RWJF’s Project Connect, a project that helps RWJF grantees build relationships with their members of Congress and other policy-makers.  The Connect support is invaluable for lots of reasons, but two especially:  one, they know how to help grantees make the most of a few precious moments with very busy legislators and two, they kept us all safely on the right side of legal rules that prohibit RWJF grantees from lobbying.  Thanks to Project Connect, all 15 grantee teams arrived in Washington on Monday morning having thought about what they wanted to get out of the meetings, how to tell their stories effectively, and prepared to make their pitch in a hallway or on an elevator if required.

Reforming health care in rural America

Keith J. Mueller, PhD, director of the Nebraska Center for Rural Health Research and the Rural Policy Research Institute (RUPRI)’s Center for Rural Health Policy Analysis, writes about a new report prepared by the RUPRI Health Panel, Assuring Health Coverage for Rural People through Health Reform.

The benefits of living in rural America may be many, but enjoying stable, comprehensive health insurance is not necessarily among them. The 50 million Americans who live outside metropolitan areas are more likely to be uninsured or underinsured than their urban counterparts. In order to improve the health care of all Americans, regardless of geography, policy makers need to pay attention to these differences.

The challenges rural Americans face in obtaining health insurance are partly due to the structure of the rural economy. Simply put, jobs in rural communities are less likely to come with health benefits than those in urban America. Rural workers also pay more for health insurance plans than workers at urban businesses.

Trick or Treat

This week’s Health Wonk Review is hosted by Boston Health News and features Halloween health care horror stories, including our recent post from National Committee for Quality Assurance President Margaret E. O’Kane on the state of U.S. health care quality.  For more on the good, bad and ugly of the quality of U.S. health care, you can go trick or treating here, where you can take your pick from our slide deck of statistics, facts and messages about the state of health care quality today.

Shortage of frontline health-care workers poses challenge to reform

Maria Flynn, director of Jobs to Careers, writes that the millions of health care workers on the front lines are key to the success of health reform - but they have been mostly absent from lawmakers' discussions.

As representatives on both sides of the aisle battle over the fine points of health care reform, the debate focuses primarily on the scope and cost of proposed changes.  Few on the Hill seem aware that one of the greatest challenges to achieving affordable, accessible health care is the persistent and severe shortage of frontline health-care workers.

There’s no doubt that increasing the number of primary-care physicians and nurses is needed to improve care. But the five million health aides, medical assistants, laboratory technicians and other workers who make it possible for the nation’s hospitals and clinics to operate nearly round the clock are also in increasingly short supply and in need of opportunities to increase their skills and education.

Are accountable care organizations the answer to our problems?

Kelly Devers and Bob Berenson of the Urban Institute write about the latest policy brief by Urban and RWJF, which focuses on the concept of creating more accountable entities in health care.
 
In the often contentious health reform discussions, ideas that are good in theory often gain quick currency, but deserve closer examination as to whether they might actually work.  One such idea is the accountable care organization (ACOs).  Accountable care organization are entities—and we’ll clarify what we mean by “entities” in a second—that are intended to address one of the conundrums of our current health care system:  how to pay providers for high-quality, efficient care.  Under our current fee-for-service payment system, we end up paying for volume, not quality or value, that is better quality for the money we spend. In addition, many of the ways we deliver health care, especially for common chronic conditions like diabetes or heart disease, have become increasingly fragmented and cumbersome for both the provider and the patient.
 
To address these interrelated problems of provider payment and delivery, many health care leaders and experts have become increasingly interested in ACOs as a way to bend the cost curve, i.e., deliver higher-quality care to more people without contributing to our escalating health care tab.  ACOs are commonly understood to be local entities comprised of clinicians—primary care and specialty physicians, hospitals—that are responsible for delivering quality care and controlling health care costs in ways that current providers are not. 
 
However, the concept of what ACOs are and how they might work is still murky.  Therefore, in a new policy paper out today from the Urban Institute and the Robert Wood Johnson Foundation, we try to go to uncharted territory, and wrestle the ACO concept into the real world. 

What breakfast cereal has to do with health reform

Jim Marks writes about why the decisions we make in the cereal aisle of the grocery store are as important those Congress will make when it comes to health reform.

One of the greatest challenges we face in reforming our nation’s health system is reducing costs. We will never be able to afford a health system that provides all Americans with access to affordable, quality care unless we do all we can to prevent or greatly delay the onset of illness and their associated costs.

Reversing the epidemic of childhood obesity should be right at the heart of that effort, and addressing this crisis would avert untold suffering and enormous expense related to chronic conditions like hypertension and type 2 diabetes. (Don’t just take my word for it—check out this commentary in the New England Journal of Medicine). 

No single piece of legislation is going to cure all of the ills of our nation’s health system, which is why we need to look past the bills wending their way through Congress for solutions that are beyond medical care. True health reform will require action on Capitol Hill, in the White House, in doctors’ offices, in schools and communities throughout the nation—and in the cereal aisle.  Seriously.