The Users' Guide to the Health Reform Galaxy

Say we get some sausage--then what?

By Mike Painter

sausage (sô´sǐj) n. A highly seasoned minced meat usually stuffed in casings of prepared animal intestine.

Congress is obviously in the thick of the sausage-making. The August recess is pending. Bills may or may not be moving. The legislative process, especially at this point, is not particularly pretty or, to be honest, as thoughtful as we all might hope. It is the process, though, right? There was essentially no way around something like this intestine stuffing, especially in an effort to fix health care—such a large sector of the American economy. And in spite of the messy work and depending on the day, the observer and the poll, it nevertheless seems likely that something will come out of the kitchen, right?

It is also probably safe to say, though, that any reform law is not going to be the panacea—the ultimate health and health care fix. Instead, if a law indeed passes, it’s clear that we’re going to spend the next five, 10, 15 years adjusting, backtracking, redesigning and working toward better care. In other words, the implementation is going to matter, and it’s going to matter a lot.

On July 30 in Washington, D.C. at the Hart Senate Office Building, the RWJF-funded High-Value Health Care Project led by Mark McClellan of the Engelberg Center at Brookings hosted a panel discussion focused on just that—the implementation. Specifically, Mark, Carolyn Clancy of AHRQ, John Tooker of the American College of Physicians, Steve Findlay of the Consumers Union and Jim Chase of Minnesota Community Measurement talked to a large Capitol Hill audience about what it will take to make health care deliver sustainable high value.

Looking back while moving forward

Sheila Kee,  associate commissioner for the New York State Health Department for the Western Region, gave a talk this past Tuesday on the past and the future of health reform in America at an event I attended in Buffalo.

Some background on the event itself:  at RWJF, we’re supporting this initiative called Aligning Forces for Quality, which has assembled some pretty impressive teams in 15 regions across the country to improve health care and to set some good examples for the rest of the country.  So this year, we asked all of the Aligning Forces community teams to sponsor a local convening event, to reach out to health care stakeholders across the region, educate them about what Aligning Forces is doing, and get them to step on board.  The whole premise of Aligning Forces depends on working with people who give care, get care, and pay for care, and these events were designed to get more of those people who give care, get care, and pay for care, involved.

Fear of financing: How can we pay for health reform?

Linda Blumberg, PhD, is a senior fellow at The Urban Institute and writes today about paying for health reform.

As we move into the dog days of summer – and the eighth month of congressional discussions about health reform – the voices of gloom are starting to get louder:  “There aren’t enough cost savings in health reform,” they say. Or, “There aren’t any viable ways to pay for it.”

I was part of a team that yesterday released a detailed analysis of savings to the government if various reform ideas are implemented. It showed that the savings would be huge – enough to finance the lion’s share of the cost of comprehensive health care reform. It also showed that a combination of revenue options would provide more than enough money to fill the relatively modest gap between the cost of reform and the savings resulting from it.

Yet still, so many are afraid of financing.  

The costs of rising obesity

Risa Lavizzo-Mourey, President and CEO of RWJF, cites the high cost of the obesity epidemic in America as she argues for investing in building healthier communities.

A new study released yesterday that demonstrates the clear link between rising rates of obesity and increasing medical costs is alarming, but not unexpected.  Right now, America's health care system is set up to focus on treating people after they already have a health problem, and that’s a sure way to drive expenditures up.  We must shift our focus to preventing people from getting sick in the first place, which will save us money in the long run.

Obesity is the driver of so many chronic conditions—heart disease, diabetes, cancer—that generate the exorbitant costs that are crushing our health care system. What’s worse is the quality of life for people living with these illnesses.

The obesity epidemic isn’t just an adult epidemic, it’s booming among our kids. Today, more than 23 million children and adolescents in the United States—nearly one in three young people—are either obese or overweight, putting them at higher risk for serious, even life-threatening health problems.  The costs are only going to continue to rise.

Reform in our health financing and delivery systems is not the only answer to rising health care costs, we must have prevention.  We must change public policy and local environments in ways that make all communities healthier—especially those that have the highest rates of obesity and the fewest resources.  All Americans deserve to enjoy the benefits of good health.

In the coming months, as Congress works to enact meaningful health reform legislation, I strongly encourage comprehensive reform that addresses the delivery of care, but also makes wholesale changes to how we address wellness and prevention in this country.

 

Reading tea leaves, and what could happen next

I jog a lot but have never once been inspired to run a marathon, basically because I think 26.2 miles is an awfully long distance to drive, let alone cover on my two little legs, but if I was a marathoner, I kind of think that this point, where we are right now on the prospect of health reform legislation, this point is maybe like the 20th mile or so of a person's first marathon.  Right now, the terrain still feels familiar--we've covered this ground before, in our training runs--but we are bracing ourselves for that last grueling slog to the finish line, the distance that has been heretofore far unknown to us, despite all of our preparation.  The President's urging us all to keep going, the August deadline for legislation from Senate Finance is all but shot, and his budget director has administered what appears to be a gentle admonishment to the CBO, a place that he, lest anyone need reminding, once managed himself.  I can't quite figure out if I'm reading too much or too little into this:  Orszag stated that the CBO might have overstepped because it estimated long-term savings without an analytical basis for doing so, even though it might be in his boss's interest to cite those savings while selling a health reform package that many are arguing is too expensive.  Does arguing against the long-term savings also mean, by implication, that the long-term costs estimated by the CBO should also be viewed dubiously? 

Again, this may just be muscle fatigue talking.

On another note, trying to make a 2009 deadline for health reform legislation leaves very little time for folks to wonder what the post-legislation world might actually look like.  The folks from Massachusetts have some experience to offer the rest of the country on what happens when you try to get nearly everyone covered, especially on the payment and delivery side of the equation, but there are also some important discussions about implementation that came out of the health information technology provisions in the stimulus package. 

So today we're going to start a series of posts on that subject, especially on defining "meaningful use" of health information technology for those who give care and get care.  This series was written for us by a team of people at The Health Information Technology Resource Center (HITRC) at Brigham and Women's Hospital in Boston, which provides technical assistance to RWJF’s Aligning Forces for Quality program. David K. Ahern, PhD is the Director, Judith M. Phalen, MPH is the Associate Director, and D. Matthew Brothers, is the Program Associate.

Making Health Reform Work

Paul N. Van de Water, a senior fellow at the Center on Budget and Policy Priorities, talks about recommendations to implement change successfully.

With health care reform legislation taking shape on Capitol Hill, few members of the policy community and the news media have yet considered one of the most important questions: what do we do once a bill is enacted? Unfortunately, the details of implementing and administering health care reform are among the stickiest and most important details of the entire debate. Fortunately, a new report sponsored by my colleagues at National Academy of Public Administration and the National Academy of Social Insurance, with the support of the Robert Wood Johnson Foundation, recommends 20 solutions that will help Congress and the administration address this conundrum. (Full disclosure: I directed the study).

As we began developing and exploring our recommendations, our diverse, bipartisan panel agreed -- regardless of how health reform is achieved – that we would presume a goal of expanding access to affordable, high-quality health care, with the ultimate aim of universal health coverage. But the panel does not endorse any particular plan for achieving that objective.

How'd they do that - and how can we do it elsewhere?

John Lumpkin writes about how we might provide better care for less money based on the experiences of 10 communities that have done it successfully.

 

 

I want to start this post with a quick exercise in the geography of health care spending. So to start, please spend a minute with our interactive map of U.S. Medicare spending by clicking here, and then hit your return button.

Back with me? Now ask yourself: Why are some areas of the countries a lighter shade of green than others? If you answered, “because they spend less money on Medicare than the darker green areas,” you are right.

Now ask yourself, “How do they do that?”

That was the question posed to health care leaders from 10 of the light green areas on the map who were invited to a symposium I attended yesterday in Washington called, “How Do They Do That? Low-Cost, High-Quality Health Care in America.”

Feelings....

We are now at a stage of the health reform debate where all small and large gestures are saturated with political significance.  And during this time, everyone with a stake in the reform discussion is trotting out their dollar figures:  $1.6 trillion.  $700 billion.  $155 billion.  $80 billion. 

I'm going to confess something:  I have no real understanding of how much money $1.6 trillion really is.  Even my fairly fertile imagination has difficulty imagining what that dollar amount looks like, circulating through various systems, whether it will make some people better, some people worse, how it might make some people richer, some people poorer, etc.  But working in communications, I also grasp the larger point:  it's not really about the actual dollar amount, per se.  It's about how a particular dollar amount makes one feel, and act, when it comes to being for or against certain types of changes to our health and health care systems.  Is it big?  Well, it's all big.  The problems are expensive, and the solutions are also likely to cost something, over the near term  So how big is it?  You tell me.  How big am I supposed to think this number is?

Beyond the $1.6 trillion sticker shock

John Holahan, director of the Urban Institute's Health Policy Center, writes about the recent CBO budget estimate of the Senate Finance Committee's health plan and puts the cost estimate into context.

The Congressional Budget Office (CBO) recently estimated the cost of the Senate Finance Committee’s health plan to be $1.6 trillion. That eye -bulging estimate led the committee to stop dead in its tracks and begin to develop a new plan that would cost closer to $1.0 trillion.

So is $1.6 trillion a lot of money?  In most contexts, it truly is. But in the context of the health reform debate the number needs to be better understood. My colleague Linda Blumberg and I recently sought to put the $1.6 trillion estimate into perspective. Let’s look at the facts:

A spoonful of sugar helps the medicine go down

I sometimes feel like it would be better to not follow what's happening with national health reform, rather than keep up, even though it's anathema to those of us who work on these issues to appear uninformed on the issue (or mis-informed).  The bloggers and the mainstream media that have been covering this issue, day-by-day, minute-by-minute, have left me with what appears to be a severe case of emotional whiplash.  One day, health reform is imperiled! and the next day, it's back on, the Senate passed a bill!  The President gets stern with Congress and tells us that inaction is not an option, but people keep on knitting their brows about that aggressive timeline for action we were promised and how much is this going to cost, oh dear.

Oh, it's so hard to know whether to feel hopeful or dispirited on any given day, so every once in a while we find ourselves leaning on a piece for inspiration alone.  One of my colleagues circulated this one, here, about a former RWJF president and visionary leader.  Another one that I keep returning to is this one, by Donald Berwick, about thinking more radically about what patient-centered care really means.  You can see some of the comments posted in response to the article, which appeared in Health Affairs, on the Health Affairs blog here.  Any other profound pieces you've come across, please feel free to post in comments.  We all need a little lift, now and again. 

Show some sympathy for Ira Magaziner and Hillary Clinton

Harold Pollack, a University of Chicago professor and a former RWJF Scholar in Health Policy Research, takes a fresh look at past health reform efforts. 

At this writing, the Senate Finance and HELP (Health, Education, Labor and Pensions) Committees are wrangling over competing bills. HELP has released a 615-page version that, of necessity, leaves countless details to be determined later.

The House has a similarly humongous document, assembled by multiple committees. Both houses are struggling to assemble the required financing to manage intricate linkages across levels of government, facilitate new health information technologies, encourage preventive care and much, much more. All sides anxiously await Congressional Budget Office scoring that can make or break particular provisions in the bill. The Democratic Party struggles to unite a coalition that includes diverse constituencies ranging from disappointed single-payer advocates to centrist constituencies that favor market-oriented solutions and stringent cost controls. Things are moving forward, but it is a hard, hard climb.

I don’t know how this difficult process will end. I do know one thing: Many of us who favor health reform should take back some of the self-righteousness and scorn with which we condemned the Clinton Administration’s efforts to achieve the goal of restructuring our health care system.

Regina Benjamin's story as a morality tale for reform

The symbolism was unmistakable:  At a moment when doubts were growing about President Obama's ability to deliver on his promise to reform America’s health care system, he nominated as Surgeon General  a small-town Alabama doctor, who has spent her entire career ministering to the poor and uninsured, sometimes taking pints of oysters as payment.

Dr. Regina Benjamin represents “what’s best about health care in America - doctors and nurses who give and care and sacrifice for the sake of their patients,” Obama said.  “When people couldn’t pay, she didn’t charge them. When the clinic wasn’t making money, she didn’t take a salary for herself.”

Close the revolving door at our hospitals

Bruce Siegel, director of RWJF's Aligning Forces for Quality, a national effort to improve health care quality in targeted communities, writes about reducing readmission rates.

Many of our hospitals, we were reminded last week, aren’t very good at following up in order to make sure that heart attack and heart failure patients won’t have to be admitted again shortly after being discharged.

The reminder came from a new study based on data from the Centers for Medicare and Medicaid Services that found that one in four heart attack patients and one in five heart failure patients are back in the hospital within 30 days of their discharge. The study confirms what people in medicine know: avoidable hospital readmissions are a serious and widespread problem. And as the health reform debate continues to unfold in Washington, it is a powerful reminder of how poor quality health care robs the system of precious resources that could be used to expand access to care. As a study reported earlier this year in the New England Journal of Medicine found, unplanned rehospitalizations cost Medicare alone more than $17 billion in 2004 – one reason why Congress and the Obama administration are weighing incentives to induce hospitals to lower readmission rates.

Prevention might be a cure for more than just health care costs

Last week's developments on health reform were mixed:  the President urged Congress to keep plugging away at health reform legislation, as he traveled to Italy; the Blue Dog Democrats set their jaws on the possible price of health reform; and in the meantime, people just kept on doing stuff to improve health care anyway, like the Centers for Medicaid and Medicare Services quietly adding information on hospital re-admission rates to its Hospital Compare web site.  Even though it’s not easy to use, this web site can tell you how hospitals do on things like, uh, patients dying, and how hospitals do on factors like people showing up again at their doors, within the 30-day window after they exited.

Matthew Miller also wrote an article last week on Fortune.com about how investing in prevention won’t save us any health care dollars.  In this article, he calls prevention the “faux panacea” in the health reform debate, and points to the paucity of evidence that exists for whether prevention will end up costing us less, or more, over the long run.

Matthew Miller’s article makes some interesting points, but mostly in response to people who were foolish enough to make some sort of sweeping claim that investments in prevention would solve all of our health care economic woes. 

Massachusetts looks at the health and health care equation

Former ABC News correspondent Carole Simpson, who serves as a commissioner for the RWJF Commission to Build a Healthier America, explains why promoting health is key to reform.

We are not alone.  While our Commission to Build a Healthier America was studying alternatives to expensive medical care to improve the health of our citizens, so, too, was the New England Health Institute (NEHI) with funding from The Boston Foundation.

On June 30—after a 2-year study—NEHI released the results of its findings and recommendations in a report titled, Healthy People in a Healthy Economy: A Blueprint for Action in Massachusetts. Two hundred interested health care providers, policy makers and others attended the event at The Boston Foundation’s headquarters.

The report emphasizes that the economic downturn is making it more difficult to fight the double threat in Massachusetts of “rising health care costs combined with a rising tide of preventable chronic illness.”

Recommended reading

I did a gallop around the health care blogs today, something that I ought to do on a daily basis, but I just...don't.  Reading the news and the blogs really does take a LOT of time.  There's so much  information flying around about health reform, so much commentary and blurb-ing, that I can't quite figure out whether I'm keeping up or not, and it's not easy to hold my attention for very long these days.  But I actually read, from start to finish (wait for applause) two pieces that were very much on the long side, but made me feel like I knew more after I was done reading.  One's a pretty comprehensive review of where we're at with health reform, to be found on the Health Care blog here.  The other's a June 18th (oldie-but-goodie in blogging time) roundtable discussion on the Health Affairs blog between Bob Berenson, Elliott Fisher, Bob Galvin, and Gail Wilensky that's a great wrap-up of all the wrap-ups that have taken place after the Atul Gawande article on health care costs and quality.    

I was also intrigued by an article on the New America Foundation's blog about Consumer Reports endorsing "choice-friendly" insurance plans.  When Consumer Reports created a consumer index for "hospital intensity ratings" based on Dartmouth Atlas data, there were some who heaped scorn upon this endeavor, the main argument I think was that consumers might not be able to act upon this sort of information as well.  But maybe waiting around for consumers to be ready is not the answer.  Maybe it's a trial by fire--pull them into the discussion about good and bad health care, and all of the things that dictate access and quality, whether they're ready or not. And maybe CR just wants to keep on trying.

Regulating tobacco is a step towards better health care

RWJF President and CEO Risa Lavizzo-Mourey discusses the recent legislation on tobacco regulation as part of the broad roadmap to health care reform.

As I watched President Obama sign the Family Smoking Prevention and Tobacco Control Act in the White House Rose Garden, I shared a deep feeling of pride with many public health champions on hand for the ceremony and hundreds of others who fought long and hard for this moment. We share a profound sense of the impact this landmark public health law will have on our nation's health. The bill will prevent more than 2 million of our nation's young people alive today from starting to smoke, saving some 700,000 of them from premature deaths related to smoking.

I also see a roadmap for what prevention can do for health reform. As we grapple with the devil in the details, let's keep our eyes on the prize -- helping all Americans lead healthier lives with a good quality of life.

Healthier ingredients for health reform

By Jim Marks

Yesterday, I was involved in the RWJF and Trust for America's Health release of our annual F as in Fat report on obesity in the United States.  This year's findings were particularly interesting.

In addition to going over the usual things about which states were the fattest for adults and children, for the first time it showed how much more obesity there is among 55- to 64-year-olds versus those already eligible for Medicare.  The wave of disease and costs to come dwarf what we're spending now, and some researchers, like Ken Thorpe, have already been finding that obesity and chronic conditions were major drivers of Medicare spending increases during the 1990s. 

America is being weighed down by the obesity epidemic.

Getting to the bottom of regional disparities in health care spending

Sharon Arnold, vice president at AcademyHealth and the director of RWJF’s Health Care Financing and Organization initiative, writes about what we need to know before we can act.

Of all of the questions facing policymakers and experts on health reform, none is perhaps as difficult as the prospect of controlling health care costs.  Most analysts and policymakers agree that health care costs are growing too rapidly, but more importantly, research also shows that we are perhaps not getting a sufficient return on value for the dollars spent on health care.  Seminal work from researchers at Dartmouth has demonstrated that there is significant geographic variation in health care spending by Medicare, and that health outcomes in high spending areas do not appear to be better than outcomes in lower spending areas.