The Users' Guide to the Health Reform Galaxy

Are health insurance mandates constitutional?

Mark A. Hall, professor of Law at Wake Forest University, a Robert Wood Johnson Foundation Investigator Award winner in 2004 and a leading expert health care law and policy, writes about the emerging legal controversy over a federal health insurance mandate.

Legislation moving through Congress would mandate insurance coverage for all legal U. S. residents earning more than approximately $16,000 a year. In response, some legal scholars are now posing a new question: Is a mandate constitutional?

There is no precedent for requiring citizens to purchase insurance simply because they live in the U.S. Therefore, several respected attorneys are arguing that compulsory health insurance is unconstitutional. Arguing in last week’s Washington Post and here and here, David B. Rivkin, Jr. and Lee A. Casey, partners at a Washington law firm who also served in the Justice Department under presidents Ronald Reagan and George H.W. Bush, now say the mandate is unconstitutional. Their reasoning is not only unconvincing, it is deeply flawed, as I argue more fully here.

Shining a light on some dark insurance practices

Hilary Haycock, a director at Harbage Consulting, a Washington, D.C.-based health policy consulting firm, writes about extending greater protection to consumers in the health insurance market.

At a recent town hall forum on health care reform in Montana, President Obama cast some light on one of the darker corners of the health insurance market by telling the story of Robin Beaton of Waxahachie, Texas. In case you missed it, here is a quick recap:

Beaton lost her health care coverage after discovering she had breast cancer. Why? The insurance company cancelled the policy after it found a minor discrepancy in her policy history regarding a visit to the doctor for acne.  The upshot was awful.  Without coverage, Beaton delayed treatment for five months, during which time the tumor tripled in size. Eventually, her health coverage was reinstated after intervention from her Congressman, Joe Barton (R-TX).

EFFEKTIV

David Colby continues his summer reading series on health reform.

With all this summer reading, everyone may need to make a trip to IKEA for a new bookshelf.  They have a great line of bookshelves that even have the perfect name for a wonk like me, EFFEKTIV.  But finding the right product is just the first step.  Somewhere between opening the box, making neat piles of nuts and bolts and reading the instructions (which I never do first), you realize that the best of ideas – or products – can fall flat if we don’t think through how to implement them.  IKEA has made everything (relatively) easy to build.  With health reform, it’s a bit more complicated. 

Although we’re still in the thick of debate over reform, at RWJF our attention is already turning to what happens next. If a robust reform package passes Congress, there’s going to be a lot of legal and regulatory work to get the policies up and running. It’s simultaneously exciting and daunting to think through how some of the ideas being bandied about could be implemented. How could insurance be subsidized? How could mandates be administered? How could health insurance markets be restructured? Fortunately, there’s some good research to light the path:

First, check with legal

A series of eight papers from the Georgetown University O'Neill Institute for National and Global Health Law identifies the legal issues surrounding health care reform. Experts agree that understanding these issues is the first step in implementing whatever reforms are decided upon. Topics covered include the role of ERISA, insurance discrimination, whether mandates are constitutional, legal issues regarding insurance exchanges, and others. There’s a lot packed in this series, but a pithy introduction report puts it in context and provides an overview of the issues that is just right for summer reading.  

20 ways to get the job done

A top-tier study panel assembled by the National Academy of Public Administration and the National Academy of Social Insurance last month released a report recommending 20 solutions to help implement ideas being discussed in reform legislation. The two-year project identified administrative functions that need to be performed regardless of the health system in place, and assessed how these functions might be implemented under reform scenarios. For each function, the panel defined the choices, summarized what is known about them, and drew conclusions. It’s good stuff.

Be careful what you wish for, the idea of reform is the easy part

This paper from Mathematica Policy Research looks at Maine’s early experiences in trying to implement its Dirigo Health Reform Act, which aimed to make affordable health care coverage available to every Maine citizen, slow the growth of health care costs, and improve the quality of care in the state.  The study focuses specifically on two provisions designed to expand coverage for adults in the state, as well as how the program is financed.  Based on analysis of administrative data and interviews with key stakeholders in the state, the researchers document Dirigo’s successes and challenges in the early stages of implementation. These are important state lessons that could apply to implementing potential federal reforms.  

*  *  *  *

As you enjoy the fleeting days of summer and gear up for what comes next, there’s still time to look through the papers and reports I’ve recommended these past four weeks. This is research that was made to be used, not to gather dust on a bookshelf, although if you need a new bookshelf, maybe I’ll see you at IKEA.  The Swedish meatballs are on me!  For a special treat try the lingonberry drink.

Just the facts ma'am

David Colby writes about the importance of sorting out fact from fiction in the health care reform debate.

In order to fix what is inarguably a broken health care system, reform efforts should be driven by research and data.  Sadly, as we all have seen and heard over the past month, the facts of health reform are too often getting lost in a pile of myths and fear. 

I unfortunately watched from a front row seat in Washington when the last round of health reform became derailed by panic and politics.  As someone who has dedicated my professional career to data and research, it pains me to see cold hard facts and painstaking research drowned out by whoever is speaking loudest or last.  So with Sergeant Joe Friday of Dragnet fame ringing in my ears – “just the facts ma’am,” – I’m doing my part to not let that happen again. 

Health reform requires a civil, enlightened discussion.  Much is at stake.  So when it happens, it is worth calling out. And it happened last week.

To help contribute to the dialogue and set the facts straight, the journal Health Affairs hosted a series of panels in Washington last week to discuss "Fact vs. Fiction: Key Issues in Health Reform.” I had the chance to speak at this Foundation-sponsored symposium that focused on three issues: the government's role in health care, implications of slowing the rate of growth in Medicare spending, and end of life issues.  If you’d like to see what the panelists had to say about whether the government has a role in health care; what happens if you really try to reduce the growth of Medicare; or why counseling on advance directives is not “death panels,” check out the full symposium on C-SPAN.  Or read the related health policy brief.

As a private philanthropy our role in the health reform debate is to provide our leaders and policy makers with the resources, tools and research they need to support a health care system that achieves coverage and improves the quality, value, and equality of health care for all Americans. And that’s a fact.

Is public health the answer to our problems?

Michelle Larkin writes about the role public health policies and research can play in health reform.

In years past, health reform discussions have focused mostly on providing quality, affordable health care to all and not much on public health and prevention. The past few months suggest that our policymakers now recognize that a strong public health system focused on disease prevention and wellness is something that should be considered as part of a comprehensive health reform plan. 

So, why the increasing attention on public health and prevention?  Well, some of it might just be common sense.  Preventing people from getting sick in the first place makes a whole lot more sense than trying to make them better after they are ill. And since our nation’s public health departments play a critical role in delivering population-based prevention services, it makes sense to ensure they are well-equipped to rise to the challenge of keeping their communities healthy. It might also be that we know more now about how public health works – and we are increasingly able to demonstrate the value of public health and prevention. Sure, there remains quite a bit of discussion on the value of prevention and there is still more focus on clinical prevention over population-based approaches, but most public health practitioners and researchers would agree that progress has been made.  

Do we really have the best health care in the world?

Bob Berenson of the Urban Institute writes about the quality of care in the United States as compared to other countries.

The rhetoric about health care reform has heated up and thickened over the summer months, and it is now more critical than ever to discern what, exactly, is at stake in these health reform debates.  If people are getting increasingly passionate in their support for, or opposition to, health care reform, then there must be quite a few perceptions circling around out there about things that we want to gain out of reform, as well as perceptions about things we are fearful of losing. 

So what, exactly, do we stand to lose if health care reform happens?  We could lose the appallingly high number of uninsured Americans, for one thing.  (Is that a problem for anyone?)  And, there’s also a perception that we could lose the care that we have—based on a belief that America has the best health care in the world, and that we are headed for surefire doom if we adopt a system similar to Canada’s or England’s.   (Never mind that proposals to transform us into Canada and England aren’t even on the table—fact seems to be beside the point these days).

Well, a team of researchers, headed by myself, actually took a look at the evidence for whether the United States does have the best health care in the world.  A new issue brief out today talks about what we found.

The opposite of that bridge to nowhere

Mike Painter writes about how payment and measurement changes can make care better, ultimately, for patients.

An elderly family member recently received a devastating cancer diagnosis.  She gets her care in California from a team of health professionals in a large integrated delivery system.  We’re supposed to be reassured that her care team is working together in seamless accountability—dedicated solely to the best possible outcomes for her, right?  Unfortunately, that’s not entirely the case.  She, of course, has a primary physician and a surgeon.  She had a hospitalist who managed her inpatient post-operative complications.  She has a number of oncologists. 

Guess what?  None of these five or six physicians were communicating with each other about her care until family members prompted them to do so.  She didn’t really have much, if any, choice in selecting her specialists.  She had minimal, if any, information about the performance of the various professionals she suddenly needed. 

The upside and the downside to caring about the facts

  Brian Quinn writes about polling with respect to research and politics.

When you buy a car, do you:

a) Base your decision on objective factors, like fuel economy and reliability?
b) Buy one that fits your persona?
c) Choose a color that you like?
d) Base your decision on the recommendation of a friend, family member or coworker?
e) All of the above?

If you’re like many people, the answer is probably e), and the weights that you assign a), b), c) and d) may vary according to who you are, what day it is, and maybe even what you had for breakfast.

In other words, people’s opinions and actions, on any range of topics and decisions, are almost always driven by a host of factors.  Some of these factors do have an empirical basis—you can’t really argue with a fuel efficiency rating on a car, for example.  But there’s a whole bunch of other factors in there that don’t have an empirical basis, not to mention that most of us don’t know very much about cars and aren’t in a position to make educated decisions about a). 

Massachusetts on my mind

David Colby continues his summer reading series on health reform.

Hopefully, many of you are relaxing this month at one of the nation's real beaches. I'm spending most of August in the backyard, maybe with my feet in an inflatable pool.  While the closest I’ll get to Cape Cod is the potato chips I’m eating, Massachusetts is on my mind. I’m sure when President Obama arrives on Martha’s Vineyard later this month he’ll get plenty of advice from the locals on how Massachusetts managed to pass health reform and whether it’s working or not.

There’s a lot to be learned from Massachusetts – the first state to pass comprehensive health care reform and guarantee insurance coverage for all its residents. With that in mind, the following are a few select reports about what happened in Massachusetts (and how it happened… and why it happened … and what it means …) that offer particularly salient lessons:

How is reform affecting real people in the Commonwealth?
This overview of the aftermath of reform in the Bay State on affordability and access was authored principally by Sharon Long and published earlier this summer in Health Affairs. It shows that while coverage has expanded dramatically, cost controls and reforms of the health care delivery system must also be key parts of comprehensive reform efforts if they are to be successful. If you are on the beach read RWJF’s short summary or if you are in your backyard check out the article from Health Affairs. 

Massachusetts and the cost conundrum
Early this year, researchers John Holahan and Linda Blumberg prepared a compelling brief that summarizes the state’s reform accomplishments, addresses head-on questions about whether the costs will climb over the long run to unsustainable levels, and suggests several options for addressing long-term costs.

The employer fear factor
A number of concerns are being voiced in Washington about what would happen to employers and employer-sponsored insurance if reform passes.  Jon Gabel and his colleagues conducted a survey of the state’s employers to examine these issues.  Their report decisively debunks the theory that employers in Massachusetts would quit offering insurance (especially small employers and/or low-wage employees), therefore pushing them into new public programs they may also be eligible for.

The implementation playbook
John McDonough, one of the founding fathers of Massachusetts’ reforms, put this paper together last summer to provides a thorough overview of all that Massachusetts accomplished in the immediate months after legislation passed: establishing new coverage programs; merging small-group and nongroup insurance markets; creating an insurance "Connector;" determining affordability and penalty standards for an individual mandate; and launching employer responsibility requirements. If and when national reform passes, these lessons on implementation will be just as important as anything we’ve learned from Massachusetts on the policy side.

Useful research and good reading for beaches and backyards alike. Find out why there is much more happiness with health reform than in Red Sox Nation this summer. I hope you enjoy and learn from them. Until next week … stay cool!

Last but not least, "meaningful use" for patients and consumers

This is the third and final post in a three-part series on the implementation of the health information technology (HIT) provisions in the stimulus package, which called for "meaningful use" of HIT for those who give and get care.  This series was written by David K. Ahern, Judith M. Phalen, and D. Matthew Brothers.

In Part I of this series, we argued that the definition of ‘meaningful use’ should go beyond the matrix of outcomes, goals, and objectives developed by the federal government’s HIT Policy Committee to address the specific behaviors needed by healthcare’s agents (e.g., providers, consumers/patients, payers) to achieve the stated goals.  In Part II, we discussed the ABCs of behavior change –antecedents, behaviors, consequences – that must be in place in order to move providers toward a 21st century healthcare system.  Here, we will examine the role of the ABCs for patients and consumers (words we will use interchangeably here) in making the meaningful use of HIT a reality.

'Death panels?' What really happens in end-of-life discussions

Diane E. Meier, a geriatrician at Mount Sinai Medical Center in New York and director of the Center to Advance Palliative Care, explains how advance-care planning empowers patients.

Despite persistent falsehoods alleging that pending health reform legislation would create panels to decide which patients were worthy of living, the facts surrounding the debate are clear – and they clearly disprove these misrepresentations.

The provision in question would compensate physicians for offering their Medicare patients an opportunity to engage in  conversation about their preferences for care under future conditions of serious illness - this is advance-care planning. My patients are uniformly fearful of being overtaken and harmed by the health care system, and their greatest concern is that they will lose control over their lives and their options once caught up in it. They have read about hospital infection rates and medical errors, and they have watched and worried as friends and loved ones with serious and chronic illnesses try to negotiate the fragmented and confusing health care system.

My patients want to know that their goals, values and hopes will be the primary considerations when healthcare decisions need to be made. They are frustrated by how little time most of their doctors can devote to talking with them and how rushed these encounters have become. They hesitate to ask questions about their illness because they are afraid to take any extra time that might burden their busy doctor, who is always harried, always behind, and always has a waiting room full of other patients.
The reasons for these time pressures are clear. Physicians do not have time to devote to patient/family counseling because these so-called cognitive services are so poorly compensated that few can afford to provide them. Doctors are paid for doing things to patients – X rays, chemotherapy, procedures, surgery – but we are paid almost nothing for talking with our patients.

This is what these conversations are like in the real world of doctor and patient.  So that the patient's voice and values remain front and center when serious medical problems arise, I ask them the following question: "Who would you trust to help me make health care decisions on your behalf if you were unable to make your own decisions? This person can be a family member but does not have to be, and they will only be asked to represent you if and when you are unable to represent yourself."  Most of my patients appoint one or more of their children, or their spouse, but some prefer to spare their family this burden of responsibility and appoint a friend or other counselor. 

Secondly, although most of us really do want all the facts about what is happening to our bodies, some of my patients prefer to sustain a certain level of denial.  That's fine, but I need to know how they would like me to handle information and shared decision-making.  I say, "Some of my patients like to know all the details about their medical condition and their treatment options, and others prefer a more general outline, or ask that I discuss treatment planning with a family member.  Which kind of person are you?"  Roughly 90% of my patients respond that they do want to know everything, but a substantial minority do not. If I try to force unwanted information on this group of patients, they will no longer trust me and are unlikely to feel safe in my care. Hence, I will honor their request that I confer with their family when medical decisions need to be made, though I will check in frequently to see if they are ready to learn more as time passes.  

Lastly, I ask my patients one more, very important, question.  "If you ever got so sick that your brain was permanently injured to the point where you could no longer recognize or interact with your loved ones -  the kind of condition that Terri Schiavo had or what typically happens in the late stages of Alzheimers’ dementia - in this situation some of my patients say they would want care focused only on assuring their comfort and not on prolonging their existence in this state; but others tell me they would want everything possible done to prolong their existence no matter what the quality of their mental functions or ability to connect with others.  Which kind of person are you?"  

Again, the clear majority opt for comfort measures when they reach this state of loss of self. But a consistent minority are either so fearful of death or so convinced that a miracle will restore them to health that they tell me to "do everything to keep me going, no matter what."  Whatever they say, I write down in the medical record as a guide for when (not if) serious medical problems arise.  The patient's wishes and goals are my guide as I work with other doctors and family members to try to come to the best plan of care.  Whenever possible and with the patient's permission, we have these conversations together with family and surrogate decision makers.  That way, when the family decision makers are faced with wrenching and painful medical choices for a very ill loved one, as they inevitably will, they know what the patient's wishes are, and they take great comfort in their ability to honor them.

Family decision makers who know what their loved one - the patient – wanted, and who are able to advocate for these wishes and goals, are better able to heal after their loss and are less likely to undergo complicated or prolonged bereavement periods.  Of course, these conversations are not mandatory, but I have yet to encounter a patient who is not tremendously relieved by the chance to talk out some of their deepest worries and fears about what might happen to them in the future and how we will work together to face these situations.  I have this kind of discussion with all my patients, early in my relationship with them, just as I discuss getting a flu shot, or wearing seat belts, or using sun block outside.  It is a routine part of good primary care.  It is not rationing. It is not euthanasia.  It is not a death panel. These are outright lies.

Actually compensating doctors to speak with patients about their illness and its implications is a small effort to restore the balance back towards our patients and away from the financial pressures in our medical marketplace. It recognizes that conversations between doctors and patients about the patients' illness, the patients' goals, the treatment alternatives and their pros and cons are time consuming and require skill and expertise. It is a misnomer to call these "end of life" conversations. These conversations are needed throughout the typically multi-year course of a chronic illness (such as cancer or heart disease or emphysema) and are not limited to the "end" of life.

The real truth is that we doctors don't know who is actually at the end of life until only a few weeks before death in most cases. Advance-care planning  is a small step towards restoring power and control to the objects of all this effort and expense – the patient.

 

Learning from Massachusetts

Sharon Long, a senior fellow in the Urban Institute’s Health Policy Center and economist by training, writes about the Massachusetts health reform initiative. 

What the health reform debate needs is more discussion firmly grounded in facts and data. And that’s what took place at an Alliance for Health Reform briefing held on Monday (where I had the opportunity to speak). Event materials are available here, but in this post, I thought I’d try to parse out the lessons learned in the three years since Massachusetts began implementing health reform—and sum up how those lessons might address some of the concerns about national health reform that were asked of Monday’s panel.

The facts: Our research at the Urban Institute shows that health reform in Massachusetts has accomplished much of what it set out to do. Nearly everyone in the state has health insurance; more people have access to care; and care has become more affordable. Expanded insurance hasn’t crowded out employer-sponsored insurance coverage—instead, the individual mandate has increased enrollment in employer-sponsored insurance plans.

Our surveys found that, over the last three years, health insurance coverage among working-age adults in Massachusetts increased to 96% (well above the 80% on average in other states), with 90% reporting having health insurance coverage for at least a full year. We found that increases in health insurance were most pronounced among adults earning less than 300 percent of the federal poverty level. Among that group, there was a 17 percentage point increase in people having health insurance for a full year so that now 92 percent of lower-income adults report having health insurance.

Dewey Decimal and the financing of reform

David Colby shares another round of summer reading tips with the RWJF blog.

Continuing with our series of influential – and downright interesting –summer reading, this week I have gathered a mystery, a thriller, an unexpected romance and a vintage tale that shed some light on the big story of the season: how to pay for federal health reform. Following are a few of the reports we’ve recently released that help put the cost of reform in context, while also expanding our understanding about potential financing options.  

Understanding How We Can Pay for Reform
Some call it a mystery, but I like the pictures (just a glance at the charts alone tells a crystal-clear story of how much reform can save American health care). A team from the Urban Institute showed that a combination of revenue options that are currently being discussed would provide more than enough money to fill the gap between the cost of reform and the savings resulting from it.

Getting Past the $1.6 Trillion Sticker Shock
This short thriller from respected policy analysts John Holahan and Linda Blumberg puts the cost of health reform in its proper perspective and should be passed around among everyone who cares about health reform.

Financing Ideas with Bipartisan Support
Everybody loves a good romance, especially when it’s bipartisan. In June, former Senate Majority Leaders Howard Baker, Tom Daschle and Bob Dole showed once again why they are statesmen deserving of all our respect when they released a set of policy recommendations they hammered out together in a bipartisan manner. While most of the recommendations focus on how to provide quality, affordable health coverage for all Americans, included are options for developing a workable, sustainable approach to health care financing.

Options for Financing Health Coverage Expansion
Here’s an oldie but goodie. Back in 2003, we asked Jack Meyer and Elliot Wicks (as part of their leadership of the Covering America project to consider financing options for expanding insurance rolls. This paper presented a framework for describing and assessing the alternative ways to finance health coverage for the uninsured (tax credits, increased ESI, expanded public programs, etc.) that is still very relevant and shows the tradeoffs inherent in each. 
 
In addition to these reports, be sure to check out the health reform section of our website, where we have many other papers on specific aspects of financing reform. One recent addition includes a primer from the experts at Health Affairs on the pros and cons of taxing employee health benefits.  

The path between the rock and the hard place

Arnold Milstein writes about the unnecessarily hard choice impeding health reform.  The views he expresses here do not represent those of any organizations with which he is affiliated.

Some Congressional observers are gloomy about the prospects for health reform legislation that could get most people covered. Bedeviling the current political debate is a belief that a “pay-go” Congress committed to debt control must make a choice between extending expanded health insurance coverage and avoiding unpopular tax increases or indiscriminate Medicare fee cuts.

The perception of an inescapable trade-off is flawed: there is a technically achievable and politically viable path between the rock and the hard place.  That path is incentivizing greater efficiency in how we deliver care without sacrificing quality improvement or biomedical innovation.

The future of CHIP: What if it goes away?

Jocelyn Guyer is the co-director for the Center for Children and Families at Georgetown, writes today about children's health insurance provisions in draft health reform legislation and blogs regularly at Say Ahh! A Children's Health Policy Blog.

It is becoming increasingly clear that Congress may well dismantle the popular Children’s Health Insurance Program (CHIP) as part of broader health reform. Children and their families have much to gain in health reform, as my colleagues and I have written about elsewhere, but this is a change worthy of its own discussion. It is a big deal. CHIP is widely viewed, and rightfully so, as one of the most resoundingly successful health coverage programs adopted in recent years. Along with its larger companion program, Medicaid, CHIP has helped to drive down the uninsured rate among low-income children by a third over the past decade.  Right now, 14.1 million children are expected to be on the program in 2013, the year when key elements of health reform would go into effect.

With all of the other debates going on in health reform, the question of the future of CHIP is only now garnering some attention.  Senator Rockefeller expressed displeasure over the prospect that the program might disappear in a New York Times article a few weeks ago, and, just last week turned the heat up even further on the issue, calling it a “crime” according to Roll Call’s CongressNow.

The devil's in the details, but the direction's in the data

David Colby writes about using evidence to take action.  This post originally went out as an RWJF content alert yesterday to subscribers on the Coverage and Health Reform lists.
 
This is a watershed moment in America’s long struggle for far-reaching health system reform. Pressure is building in Washington for profound improvements in how we finance and deliver health care.

What’s the big difference with this round of reform efforts? This time lawmakers and policy experts are guided by a tremendous body of evidence and data-driven knowledge that takes the guesswork out of what’s wrong with health care and how to fix it.

Much of the evidence comes from the Foundation’s partners in the health policy research community. If politics is the art of the possible, then research is the art of the solvable.

Apply primer. First.

Make no mistake:  we're in the middle of a message war right now.  There are a lot of people pushing hard for health reform during the recess and there are groups and voices populating the airwaves that are just as determined to push back.

I really can’t—especially on this blog—pick sides in the message wars.  Although, I did spend some time studying the First Amendment in law school, and I’m a big believer in freedom of speech and religious freedom (you go Pilgrims!), and I ended up believing that the First was more about protecting fundamental rights on how we think and live as citizens of America, and not so much about letting people be rude as all get-out whenever they please.  Call me prissy, but my parents taught me that interrupting and heckling someone while they’re speaking is rude; I realize that principle may not apply to activism, per se, but are some of the tactics being deployed out there really necessary? 

What if Benjamin Franklin ran the Congressional Budget Office?

Jim Marks writes about CBO scoring of prevention in health reform.  This post also appeared on The Huffington Post today.

While Congress is now its August recess, the country will continue to grapple with a health reform package that is likely to be significantly different from the earlier versions. Among the catalysts for the ongoing debate was the Congressional Budget Office (CBO) estimate of the projected price tag of over $1 trillion for the original proposal that almost ground the prospects of real reform to a halt. 

The CBO was established 25 years ago to “provide Congress with objective, non partisan, and timely analysis to aid in economic and budgetary decisions….” It has turned out to be a powerful voice in the discussions of many important bills.

Within its roles and responsibilities, however, lies a very significant limitation:

According to CBO’s cover letter to the original scoring report “Health Care Reform and the Federal Budget”, “the CBO does not provide formal cost estimates beyond the 10-year budget window because the uncertainties are simply too great.”

Let me repeat that, according to its mandate, the CBO does not look at any return on investment beyond 10 years.

Have we forgotten about mental health care in health reform?

Nancy P. Hanrahan, Ph.D., R.N., writes today about mental health services and health reform.  She is also a Robert Wood Johnson Nurse Faculty Scholar.

As the final health care reform proposals take shape, there is one important topic that has not been given a fair hearing—the need for mental health care reform.  Thanks to the parity law, all reform proposals will carry a provision for covering mental health care services at levels equal to coverage for medical care, a great improvement over the existing system.  But increasing coverage only addresses one of the many problems associated with the way mental health services are organized and delivered in our system. Communication between general health care providers and mental health care providers is unnecessarily complicated. The current health system carves out and fragments mental health and substance use care.  Patients with serious mental illnesses find the system demoralizing and impossible to understand and therefore stay away and do not get the help they need. For these reasons, simply increasing coverage without changing the way we provide mental health care will severely limit the success of health care reform.  It’s not at all clear that this message is getting through to our representatives on the Hill.

Our "Aha" moment: what Maine learned from PROMETHEUS

Elizabeth Mitchell is CEO of the Maine Health Management Coalition in Portland, ME and writes today about new ways to think about paying for health care.

As Congress looks to add exact greater value for the $2.3 trillion spend the U.S. now spends annually on health care, it should keep a simple maxim in mind: You get what you pay for.

A 2006 article in The New York Times gave a vivid illustration of the perverse effects our current payment system can create. The article noted: “Insurers, for example, will often refuse to pay $150 for a diabetic to see a podiatrist, who can help prevent foot ailments associated with the disease. Nearly all of them, though, cover amputations, which typically cost more than $30,000. Patients have trouble securing a reimbursement for a $75 visit to the nutritionist who counsels them on controlling their diabetes. Insurers do not balk, however, at paying $315 for a single session of dialysis, which treats one of the disease's serious complications.”

Part II: Putting meaningful use into action for providers

This is the second in a three-part series of posts on the implementation of the health information technology (HIT) provisions in the stimulus package, which called for "meaningful use" of HIT for those who give 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, BA is the Program Associate.

In Part I of this series, we argued that the definition of ‘meaningful use’ should go beyond the matrix of outcomes, goals, and objectives developed by the federal government’s HIT Policy Committee.  We believe it should also determine what those who get, give, and pay for care – healthcare’s agents – need to do in order successfully achieve better health outcomes for all.  In this post we examine these questions:  What behaviors must be adopted by healthcare providers (and how can we reinforce them?) so that they will move lock-step towards an evidence-based, effective, and efficient healthcare system? And, what interferes with the good intentions of those who are trying to do the right thing?