The Users' Guide to the Health Reform Galaxy

What does 'protecting choices in health reform' really mean for us?

(This post comes from Uwe Reinhardt, a health economist at Princeton University, who spoke at a press briefing last week, Consumer Choice in Health Care: How Could Reform Affect Our Choices? How Could We Make Better Choices? The briefing was sponsored by the Alliance for Health Reform and the Robert Wood Johnson Foundation. To view a webcast of the briefing, click here.)

In comparison to people in other countries, including my native Germany, Americans place much more value in having choices in health care. But they don’t do a great job of explaining what they mean by choice.  The way I see it, there are three main categories of choice in health care: 1) choice of health insurance plans 2) choice of providers and hospitals and 3) choice of treatments and therapies.

Lots of attention is paid to #2 and #3, but in some ways choice of insurance plan dictates our current level of choice more than anything else.  It seems bizarre to me that the U.S. health care system is set up so that your health insurance plan dictates what doctors you can see and what treatments or therapies will be covered. We are essentially telling people, “You can have this choice, but once you choose your health insurance plan, you will have less choice of doctors and treatments.”

If you're going to pay for performance, measure what matters

(Today's post comes from Francois DeBrantes, CEO of Bridges to Excellence, who also heads up the PROMETHEUS payment demonstration currently being supported by RWJF.)

The “pay-for-performance” movement has become a powerful force in healthcare reform. In P4P compensation models, providers are rewarded for meeting specific quality and efficiency measures. But how do you know those measures are the right ones?

At Bridges to Excellence, we support P4P as a necessary shift away from traditional fee-for-service payment. We believe, if done right, it’s an effective way to drive quality up and costs down. However, a recent study we conducted suggests that P4P programs don’t always measure the processes that matter most.

We analyzed the clinical and financial value of 62 commonly used, generally approved quality measures for ambulatory care. They covered conditions like coronary artery disease, heart failure, diabetes mellitus, osteoarthritis, asthma, and more. The measures were selected by an expert panel, and most were endorsed by organizations like the National Quality Forum, the Ambulatory Care Quality Alliance, or the National Committee for Quality Assurance.

Yet, for all that expert backing, we found that fewer than one-third of these measures had a truly significant clinical and financial impact. Many had some clinical value, but only a handful combined a real financial benefit as well. True, these results may simply reflect the growing pains of a relatively young movement. But if P4P programs don’t get the measures right, we may only be replacing one highly inefficient compensation system with another.

Public health nurses help make prevention actually happen

By Susan Hassmiller

In this year’s run at major health reform, I find it encouraging that the debate has widened, rather than narrowed.  Meaning, policymakers are not just discussing how to reform our health care system—they are also discussing how policies that affect people’s lives inside and outside the care system can help make us healthier.  Therefore, the concepts of “prevention” and “public health” are finally becoming more familiar—even to the public, as a recent poll showed that voters ranked prevention as the top health reform priority.

But if health reform legislation truly ends up shifting the paradigm of how we think about health and health care—if we start seeing policies that emphasize prevention as much as the disease—then we will also need to figure out who will be doing what under the new paradigm.  In all of the discussions about the proposed ideas for paying for and delivering health care, there is very little discussion about how the health and health care workforces might need to adapt along with these changes.

What's possible for bipartisan health reform

By Andy Hyman

It’s been almost a week since former Senate Majority Leaders Howard Baker, Bob Dole, and Tom Daschle, released a report outlining their vision for a bipartisan approach to health reform.  So it’s a good time to reflect on the initiative, as well as some of the press coverage it’s received. 

First, some background.  The three Leaders, along with former Senate Majority Leader George Mitchell, came together in 2007 to form the Bipartisan Policy Center (BPC) in order to find bipartisan solutions to intractable policy issues. (Senator Mitchell resigned from the BPC in March 2009 when President Obama appointed him his Middle East envoy.)   Early in their partnership, the four Leaders selected health care as their signature issue, and with RWJF as its sole funder, the BPC launched the Leaders’ Project on the State of American Health Care.  They brought Chris Jennings and Mark McClellan in to direct the project, and after more than a year of study, public engagement through four policy forums across the country, followed by intense negotiations, Senators Baker, Dole, and Daschle on June 17 announced a compromise that would achieve the goals they identified at the start of the initiative: a health reform plan that would be budget neutral, achieve cost savings, improve quality, and ensure that all Americans have affordable health insurance coverage.  A summary of the recommendations can be found here.

Staving off the buzzkill

Whether it was the prospect of more rain, or the Politico article on the divisive business of health reform legislation, either way, last week did not end on a promising note.  I continue to think that the CBO might have been a little more pointed about the "important caveats" part of their preliminary analysis of the Senate HELP bill, but maybe they were just, you know, testing the waters to see if anyone's paying attention.  (Yes, they are, but is it the right sort of attention?)  Anyway, I still think it's far too early to call the game--because stuff is still happening and the public still seems to be on the side of health reform, even if they are getting increasingly worried about the tab.  

For those of you are getting a little bummed out by the slog (and remember, it could just be the weather)--try a little humor.  

How are consumers feeling about health care?

(Here's a post from Lynn Blewett, who directs the State Health Access Data Assistance Center (SHADAC)at the University of Minnesota.  SHADAC is analyzing data for the new RWJF Index, a monthly survey that evaluates consumer confidence in American health care.)

Researchers at SHADAC have been working with the Robert Wood Johnson Foundation to develop a new monthly Health Care Consumer Confidence Index.  Today we have released the inaugural report featuring baseline data and the change as measured in May, and I invite you to view the results here.

The RWJF Index is a new research venture for us.  We've typically focused on research from the state perspective; this index is a national measure that does not provide state-level estimates.  But we feel that this is an important measure for our mixed audience:  health policy analysts, health services researchers, and policy-makers.  Why?  First, the index provides an indicator of the health access concerns of the American people.  At a time when health reform is so prominent in Washington D.C., and the states, we feel it's important for policy-makers to have a reliable indicator of the barriers people face in accessing health care and their future concerns about whether they will lose coverage.

The State of Meaningful Use

By Mike Painter

Is it possible that the State Department is technologically bolder than the HIT Policy Committee?  On Tuesday, that committee convened by the Office of the National Coordinator as required by the American Recovery and Reinvestment Act released some initial recommendations on the definition of "meaningful use" of health information technology.  Then yesterday, the New York Times in an above-the-front-page-fold article reported that the State Department recognized an internet blogging service could change history—right now.  Compare that report about the State Department to the HIT Policy Committee’s recommended vision for the role of patients and families.  The committee envisions that someone would eventually “provide access for all patients” to populated personal health records and some self-management tools by 2015—about six years from now.  It’s not that this vision is bad; it’s just so underwhelming.  Let’s see—the State Department thinks that the Iranian people might be using Twitter today to regain control of their nation—and in our multi-billion dollar ultimate vision for the patient’s role with health information technology we’re still talking about “providing” a couple of interesting tools to patients by 2015.  Is it me, or are we possibly missing a powerful health reform player here—the consumer?

So, as you can see, I listened to this meeting on “meaningful use” and came away with some distinctly mixed impressions. 

Can the future of health care be scored?

Yesterday, the Congressional Budget Office released a preliminary analysis of the Affordable Health Choices Act, the draft legislation on health reform released by the Senate HELP committee.  Although the cover letter to Senator Kennedy was couched in the language of caveats—there’s even a section called, “Important Caveats Regarding This Preliminary Analysis”—an article in the New York Times offered this observation from the the preliminary analysis, “As the president spoke at the annual conference of the American Medical Association in Chicago, it became clear that one of the major health plans on the table would cost at least $1 trillion over 10 years yet leave tens of millions of people uninsured.”

How, exactly, did this become clear?  It’s true, these deficit and uninsured estimates stuck out as the headlines of the CBO’s preliminary analysis, but as the CBO also stated, these figures did not represent a complete cost estimate of the proposal, nor was it an estimate of all of the components of the proposal, just the ones related to health insurance, nor was the legislative proposal itself complete. 

Acceleration

I asked a colleague what he thought about the advent of the first draft legislation on health reform from the Senate HELP committee, and he answered, "Well, now it's clearer which oxen can be gored."  It's not just the legislative language that's telling us that, however, it's also the saturation of the airwaves by our President and other national leaders, arguing for or against certain aspects of reform legislation.  And my, things are getting livelier.  During times like these, I depend upon the echo chamber of the blogosphere to help me get a grip on current events, especially when I feel ill-equipped to do it for others, and here are a few that I've liked, recently: 

For a "stop and think" perspective on some of the meta-issues in health reform, I liked the latest post on the Health Policy and Communications blog.  

For President Obama's latest, delivered in front of docs, I spent some time on the Wall Street Journal blog, reading the prepared text and thinking about how he is trying to wrap many, many brains around some hard realities of our health care woes, but, you know, in a soothing way.

Connecting all of the dots for patients: the key to high-quality care

(This post comes to us from Matthew Press, M.D., a RWJF Clinical Scholar and internist in Philadelphia who recently spent time observing a program started by an RWJF Community Health Leader.)

An increasingly popular target for lowering costs and controlling quality in health care is the reduction of hospital readmissions.  The Obama administration announced that readmissions are a priority in their reform efforts, and the momentum to tackle this issue was bolstered by Stephen Jencks, M.D.’s recent New England Journal of Medicine article that showed that around 20% of Medicare patients are re-hospitalized within thirty days of discharge.  Another problem area currently under the health reform magnifying glass is the regional variation in health care costs.  Risa Lavizzo-Mourey’s recent post discussed the Dartmouth Atlas Project’s research in this area and Dr. Atul Gawande's New Yorker article on the subect, which has been much in the news as of late.

What do these two hot-button issues—readmissions and practice variation—have in common?  The solution to improving both may lie in making our health care system more interconnected.  In a webinar following the release of his study, Dr. Jencks commented that effective transitions between inpatient and outpatient care are hindered by the fact that, in our current system, providers often practice in individual silos, effectively cut off from one another.  As a result, continuity of care breaks down, putting patients at greater risk of readmission.  Likewise, Gawande said in a New Yorker interview that one of his observations about the higher health care cost city he visited (in contrast to the lower-cost city) was the degree to which health care is fragmented there.

The national and local health care perspectives, coming together

(President Obama touches down in Green Bay, Wisconsin today, to take part in a town-hall style meeting about health reform.  Ceci Connolly of the Washington Post offers some context to the event in her article today, here, and today's blog post will take that context one step further, since the state of Wisconsin is one of the 15 regions in this country that's currently taking part in RWJF's effort to improve healthcare quality at the national and local levels.  To talk about that effort and how it relates to health reform, today’s post comes to us from Bruce Siegel, M.D., M.P.H., director of the Aligning Forces for Quality National Program Office and the Center for Health Care Quality at the George Washington University Department of Health Policy.)

The health care reform landscape is littered with articles speculating that there is a better shot at reform legislation passing this year than in 1994 because of an increased willingness among stakeholders to pursue the common good of controlling costs, getting more people access to care and improving the quality of care they receive.

As a physician and advocate, I can say that I’m hopeful that all of this speculation proves true. Regardless of what happens on Capitol Hill this year – when the details are done and the last vote is counted – I still have reason to look on the bright side.

It's the waste, stupid.

(Today Mike Painter, who has written for us before on health care quality and value, now takes a look at the issue of health care spending and waste in the health care system, and references analysis conducted using the PROMETHEUS payment model.  RWJF is sponsoring a lunch briefing in DC today to give stakeholder groups an overview of the PROMETHEUS model and other payment reform approaches, and the webcast of this event will be available in the next few days on this site.)

A recent Wall Street Journal editorial strongly challenged the notion that there is enormous waste in American health care.  In the article the editors acknowledge that dramatic variation in health care spending exists across the country—but point out that the precise reason for that variation remains uncertain.  They also note that much of the data about regional variation comes from the Dartmouth Atlas—and that work, they point out, is limited in that it only examines Medicare data.  And they cite work from Richard Cooper at the Wharton School that directly challenges some of the Dartmouth Atlas conclusions—essentially arguing that the Dartmouth observed regional variation is actually simply an artifact of Medicare.   They conclude that “Dr. Cooper’s assault on the Dartmouth Atlas is controversial but compelling. He argues that the less-is-more theory is based on the flawed premise that when a region's outcomes did not improve as spending increased, the difference is simply classified as ‘waste’ – even if it isn't.”

And yesterday, at a Brookings Institution-sponsored conference on comparative effectiveness, Peter Orszag, mentioned prominently in the WSJ article, initiated the beginnings of a response to the editorial—noting that he did not believe that the Wharton research was correct.

Cramming for the exam

I thought I had lots to say today about what Robert Pear characterized as a "fight" about health care spending (I would have characterized it as a bit of a debate, myself) but who am I kidding?  I've got a lot of studying to do, because of this, and am seeking any and all input on what this means, of course.  I think I could save myself some trouble if I just waited for the one unified bill that could rule them all, but that's the thing about this health reform frenzy:  you're always worried about missing something important.

Back tomorrow.

Prevention now for a healthier future

(Today's post comes to us from Al Quinlan, president of Greenberg Quinlan Rosner Research and Bill McInturff, partner and co-founder of the firm Public Opinion Strategies, in conjunction with a new poll released today by the Robert Wood Johnson Foundation and the Trust for America's Health.)

Quit smoking.  Eat right.  Exercise more.  For years, you’ve heard this from your family, your doctors, your teachers, your friends.  Now, you can hear it on pretty much any street corner in the country. A recent survey we conducted provides compelling evidence that Americans have rejected “sick care” and are demanding that we work to keep people healthy in the first place, rather than treating them once they get sick. 

Can politics be taken out of health reform?

A while back, I wrote about using the budget reconciliation process to enact health reform legislation, and the point of the post was not to give everyone a civics lesson, but more to highlight what using that particular process signaled in terms of politics.  While leaders from both sides of the aisle can agree on the basic goals of health reform--getting more Americans health insurance, helping them lead healthier lives--it's the how we will get to those goals that has killed past efforts.  And the challenges of navigating the political process go well beyond R and D divisions, there are also stakeholder rivalries to worry about--whether the docs and pharma and the insurers will play along or fight, and whether the consumers will ever get a real say in the matter.

In addition to the budget reconciliation option, there's also the idea--straight from President Obama himself--of juicing up the Medicare Payment Advisory Commission (known as "MedPac") so this body of commissioners has the actual authority to do some major overhaul work of Medicare instead of deploying the more subtle methods of influence available to them.  Maggie Mahar of the Health Beat blog did a bang-up job of talking about what this could mean for getting health reform done, so I'm not going to re-invent her wheel--just click here for a link to her post on the subject.

And now we're hearing that President Obama wants to take an even stronger role in helping to get health reform legislation passed, which, given the fact that he's been unambiguous from the start about what a top priority this is for him, should be interesting to watch. 

Measuring the right attributes of health care, to get to better care

(This post comes to us from Chris Queram, the president and CEO of the Wisconsin Collaborative for Healthcare Quality, which leads the Wisconsin Aligning Forces for Quality initiative.  Chris is also a member of the Quality Alliance Steering Committee.)

In a recent Wall Street Journal op-ed, Peter Orszag, the director of the Office of Management and Budget, asked a question that many of us in the trenches of the movement to measure and report on the performance of health care providers have been asking for years: “How can we move toward a high-quality, lower-cost system?”

Put another way, how can we get care that is better and more affordable at the same time? There are many answers to that question, of course, but I want to advocate here for the path we’re taking in Wisconsin: linking quality and cost in our efforts to measure what happens inside our health care system. This pairing of measures is the critical tool for understanding where to focus our attention to reduce costs and increase the overall value delivered by the system. Consequently, understanding the efficiency of health care providers should be in the vanguard of national efforts to measure and report on health care performance.

Paying for health care, one soda at a time

By Marjorie Paloma

In these tough economic times, many cities and states are increasing sales and property taxes to fill budget shortfalls. Earlier this year, Congress passed a  62-cent-per-pack federal tax increase on cigarettes to fund an expansion of CHIP. So it shouldn’t come as a surprise that Congress is considering a tax on soft drinks to fund health care.

Taxes are ordinarily used to raise revenue, but some taxes, like tobacco and alcohol taxes, are also designed to change behavior. Over the last ten years, we’ve learned a lot about the impact of taxing tobacco.  Through the Substance Abuse Policy Research Program, we’ve funded 14 studies examining a variety of issues related to cigarette and other tobacco product taxation and pricing  The studies look at issues ranging from the effect of cigarette taxes on the economy and jobs to the impact of cigarette prices on how much a person smokes. The research clearly demonstrates that higher taxes on cigarettes and other tobacco products and the resulting higher cigarette prices lead to significant reductions in smoking and other uses of tobacco.  In other words, an increase in the cigarette tax equals a health win that reduces smoking and saves lives and a financial win that raises revenue and reduces health care costs. So can the same be said for a tax on soda?

All bets are ON when it comes to raising the quality and value of U.S. health care

(This blog post comes to us from Arnold Milstein, M.D., M.P.H., Chief Physician and National Health Care Thought Leader at the consulting group Mercer Health & Benefits, and Medical Director of the Pacific Business Group on Health.  He is a Congressional MedPAC Commissioner and an advisor to the White House on health reform.  His perspective does not necessarily represent the perspective of any of these organizations.)

In politically diverse discussions of federal health reform, there is convergence of the political right and left that reducing per capita health care spending growth is feasible and instrumental to insurance coverage expansion.  There is also a shared sense of political necessity, as public fear of loss of lifetime assets due to a costly illness or injury spreads upward into politically-enfranchised lower middle class households.       

Motives differ for curbing health care spending growth: the right seeks reduction of entitlement programs and the left seeks universal health insurance coverage.  Increasing the efficiency of U.S. health care delivery serves both purposes.

New Deal 2.0: Wellness for All

(Today's post comes from Dr. Maya Rockeymoore Cummings, President and CEO of Global Policy Solutions, a social change strategy firm based in Washington, DC. and Director of Leadership for Healthy Communities, a national program of the Robert Wood Johnson Foundation.) 

It is perhaps ironic that our country is at the precipice of creating a national healthcare system a full 74 years after President Franklin D. Roosevelt first tried to get universal healthcare passed as a part of the original Social Security Act of 1935.  While many people today aren’t familiar with this important history, FDR’s efforts provide important guidance for today’s healthcare reform debate.
 
Experts agree that rising rates of preventable chronic diseases are driving higher annual medical expenditures. That is why national leaders are seeking to make prevention and wellness a core component of healthcare reform. However, the proposals that have been most discussed will not provide vulnerable populations—those who experience the most sickness and death as a result of preventable chronic diseases—with equal access to prevention and wellness services.