The Users' Guide to the Health Reform Galaxy

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.

The secrets of Massachusetts' success (including bigger carrots and smaller sticks)

Robert Restuccia, Executive Director of Community Catalyst, writes about the less-talked-about lessons from Massachusetts-style health reform.

Massachusetts as model – it’s a common claim in health policy circles. With the lowest rate of uninsured residents in the nation – just 2.7 percent – it’s clear to those watching that Massachusetts’s mix of Medicaid expansions, sliding scale subsidies, private insurance reforms and individual mandate are working to expand coverage and have served as the template for national reform. 

But there are other, less obvious lessons from the Massachusetts experience that have not really filtered into the political and policy discourse in Washington.  Here are a few of the most important.

There are good policy and political reasons for putting coverage expansions ahead of cost containment

Massachusetts made the strategic decision to tackle health coverage before cost containment – making it easier to keep all players at the table.  Despite bold words to the contrary at the start of the process, the Congressional leadership and the Obama Administration too are finding it hard to arrive at a consensus on significant cost containment while still keeping the industry backers of coverage expansion at the table.  But Massachusetts is using the pressure from the cost of its coverage expansion to jump-start a more serious debate about cost containment than ever before.

Faster is better

The current health reform is not the first time Massachusetts attempted to enact a near-universal coverage program.  In the late 1980s under Governor and soon-to-be Presidential candidate Michael Dukakis, Massachusetts enacted a major health reform proposal with an employer “pay or play” as its central element along with a number of other smaller programs.  Today those smaller programs, implemented almost immediately after reform passed, are still going strong, while the employer pay or play, which was not scheduled to go into effect for several years after passage, was first delayed and then repealed as the political and economic environment shifted.

What Congress Can Do To Boost Health Care Quality

Margaret E. O’Kane, president of the National Committee for Quality Assurance (NCQA), an independent, non-profit organization whose mission is to improve the quality of health care, writes about NCQA’s new report, The State of Health Care Quality 2009. You can also read an interview with O’Kane here.

Just as the health care reform process is speeding up, NCQA has found that progress on important measures of health care quality has slowed down. After 12 years of steady and often remarkable progress in performance, the report we released today documented relatively little improvement in most areas of care during the past year by the nation’s health plans. These findings underscore why provisions to improve quality must be part of any health reform package.

Because reform will most certainly bring more individuals into Medicare and Medicaid programs, it was especially disconcerting to see that for the third year in a row, we found that performance of health plans serving these public programs failed to improve on key quality measures. In fact, Medicare Advantage plans made statistically significant improvements on only five of 36 measures (14 percent). The results for Medicaid plans were somewhat better, but still there was a statistically significant gain on only 18 of 50 measures (36 percent), and most of these were small. Results in the commercial plan sector were slightly better, with improvement on 22 of 51 measures (43 percent).

What Massachusetts docs think about health reform

Gillian K. SteelFisher, a research scientist at the Harvard School of Public Health, writes about a recent poll she and her colleagues conducted with physicians on health reform in Massachusetts, highlighted today in the New England Journal of Medicine.

With the passage of the 2006 health insurance law, Massachusetts has made significant changes in health insurance coverage and now can claim the lowest uninsured rate in the country.  As the debate on health reform in Washington, D.C. unfolds, policymakers at the national level have turned their attention to the state’s health reform; in fact many of the Congressional proposals currently on the table include elements from the Massachusetts plan.  In this process, there have been some criticisms of the reform, with suggestions, for example, that the reform has made it more difficult for people to access care.

We already know from past research that the reforms hold majority support among the public, but what about physicians who are on the front lines of care and directly see the potential impacts of that reform?
To address that question, my colleagues and I polled more than 2,000 Massachusetts physicians.  Our goal was to assess their perceptions in three areas: their overall support for the legislation, their views of its impact on their own practice, and their views of its impact on health care across the state.

Could health courts provide an answer on medical liability?

What should have been a heads-up on a news item last week is now a look-back--the idea of malpractice reform has occasionally bubbled to the surface of the health reform debate, it's a topic that certainly many docs feel quite passionately about, and RWJF's Pioneer portfolio has examined an approach to address the problem involving health courts.  You can read more about this work, and find a CBS Sunday Morning News piece on the project, if you click on over to our Pioneer blog, here.

Bills would boost quality by shining a light inside the health-care system

Debra Ness, co-chairman of the Consumer Purchaser Disclosure Project (CPDP) and president of the National Partnership for Women & Families, writes about provisions to improve health care quality in pending legislation.

And now there are five. With its vote this week, the Senate Finance Committee reported out the final of five reform bills that hold the potential to transform our broken health care system.

It has been a long road getting here. The National Partnership, for one, has worked for 15 years with a wide range of consumer and patient groups to shine a light on the need for improving the quality of health care, getting costs under control and expanding affordable coverage.

I’m encouraged because the Finance Committee bill builds on the momentum we’ve seen over the past several months to make some sorely needed improvements to our health care system – things that will help Jane Citizen and her family get the care they need. Chief among them are key insurance market reforms that take great strides towards protecting Americans’ health coverage — making it illegal for insurance companies to raise rates based on a pre-existing condition or gender, denying coverage based on health status, and dropping people who get sick.

The long and winding road to reform

Peter V. Lee, co-chairman of the Consumer Purchaser Disclosure Project (CPDP) and executive director for national policy of the Pacific Business Group on Health, writes about provisions to improve the quality of health care in pending reform legislation.

We’re seeing important movement on health care reform front, as the Senate Finance Committee moves its version of a bill to now be part of the debate. Whether or not we manage to get one bill that everyone can agree on, there’s no doubt that some have found the long wrangle in Congress over health reform depressing. But call me an incurable optimist—after looking at all of the different versions of the bills floating around, I’ve taken heart in the fact that while none of the bills are perfect, they all contain good provisions that could help improve the quality of health care and make care more affordable.

For instance, there is very good language in each of the three proposals – in the Senate Health, Education, Labor and Pensions Committee, Senate Finance and House "Tri-Committee" – on measuring and reporting quality. They call for setting national priorities with processes that engage consumers, employers and other stakeholders; make sure the patient’s perspective is at the center of measurement efforts; and require more information on how patients fare. The proposals also focus on comparative-effectiveness research so patients, doctors and insurance-purchasers know which treatments really works.

Success of smoking bans showcases role of prevention

Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, writes about the implications of the Institute of Medicine report concluding that smoking bans reduce heart attacks.

In the effort to combat the epidemic of heart disease, we often focus on changing individual behaviors related to smoking, diet and exercise.

But a landmark report released today by the Institute of Medicine underscores a major environmental factor – the deadly impact of second-hand smoke – and by so doing, spotlights the role of community-based prevention in keeping Americans healthy.

The IOM report concludes that smoke-free laws reduce the number of heart attacks and save lives.  It also finds conclusive evidence that secondhand smoke causes heart disease, including heart attacks – the No. 1 killer of Americans -  and compelling evidence that even relatively brief exposure to secondhand smoke can lead to a heart attack.

These pronouncements, reached by one of the most prestigious scientific authorities in the United States, send a clear message to elected officials:  As we debate how to reform our health system and rein in costs, we must recognize the key role of prevention. Strategic investment in disease prevention and population health can save lives, strengthen families and the workforce - and reduce health care spending.

CBO's scoring window: why it matters

Michael J. O’Grady, PhD, a senior fellow at the National Opinion Research Center at the University of Chicago, writes about the Congressional Budget Office and how it scores proposals.  The CBO recently issued a price tag for the Senate Finance bill on health reform that is being voted on right now.

The current debate our country is having about overhauling our health care has highlighted the sometimes challenging interaction between the worlds of budget policy and health policy.  One such interaction is the issue of scoring windows.  The Congressional Budget Office (CBO), the official scorekeeper of reform proposals, typically projects spending for a 10-year period.  However, on September 14, Senator Kent Conrad (D-ND), Chairman of the Senate Budget Committee, requested that CBO provide a twenty—year estimate of the Senate Finance Committee bill.  He was right to do so, and here’s why.

First, let’s talk about why CBO moved from the original 5-year window to the current 10-year window.  The shift occurred for a number of reasons.  The Budget Committees began looking at a longer time horizon.   In the FY 1994 Budget Resolution Congress established a 10-year budget “point of order” in the Senate.  Then in 1995, Speaker Gingrich introduced a seven year balanced budget plan, adding further momentum to estimate budget impacts beyond the five-year window.  By 1996, CBO released its first 10-year budget baseline.

Health reform: the really short version.

As we gather our thoughts for the upcoming week, I couldn't resist a quick mention of this feature from the Huffington Post, which involved a shout-out for health reform haikus.  One of the haikus selected is by Diane Stollenwerk, project director for the Aligning Forces initiative in Puget Sound, Washington.

Who knew that the complex topics of health reform could be boiled down to the austerity of the 5-7-5 syllable framework?  Now anything seems possible.

(And, fair warning:  one of the haikus contained, er, strong language, so those with more delicate sensibilities, please don't take a look.)

Let's learn some health reform lessons at home

Lynn Blewett, director of the State Health Access Data Assistance Center (SHADAC), shares more lessons from the Massachusetts experience with health care reform. 

As the federal reform moves forward, we’ve heard many different ideas about how to improve access to health insurance coverage, bend the curve of growing health care costs, and improve the efficiency and quality of health care services.  Washington policy-makers are grappling with uncertainty about how these reform strategies will work and what the unintended consequences might be.  Wrestling with this type of ambiguity is inherent in most policy-making, but it’s particularly challenging when the stakes are as high as they are for health reform.  After all, Congress doesn’t often attempt to reform one-sixth of our economy in one legislative session.

One way to resolve the uncertainty about reform strategies is for policy-makers to look and see how other countries have designed their health care systems.  However, the US is so different from other countries culturally and historically, it’s often impossible to simply transplant reform ideas from outside the US and have the same impact.   We aren’t entirely out of luck, though.  We do have home-grown evidence based on what works.  This evidence is provided by the states, who have been implementing many innovative reforms with some very promising results.  States are demonstrating that reforms can lead to effective, efficient American health care with increased access to coverage. 

How do we spur competition in the health-care marketplace?

Elliot Wicks, a senior economist with Health Management Associates, writes about how to achieve competition in the health care marketplace through health insurance exchanges.  A perspective on the public insurance option, by Karen Pollitz of the Health Policy Institute at Georgetown University, immediately follows.

If we can take the liberal Democrats at their word – that their reason for insisting on a public plan is not to achieve single-payer by stealth but rather to ensure that health insurers have to truly compete on the basis of price—at some point they should probably stop insisting. The key to achieving real competition is structuring the health insurance exchanges properly.

A public option is not a magic bullet to bring down premiums. In the first place, the public option would be available only to people who buy through the insurance exchange – that is, people who buy coverage with the help of federal subsidies, some other individuals buying on their own rather than through their employers, and some small employers. All the people who are covered by self-insured employer plans would be excluded from the competition provided by a public plan. They constitute nearly 60 percent of people with employer coverage. But these large employers can pretty much take care of themselves. All they are buying from insurers are administrative services; the employer assumes the risk associated with the medical expenses their employees incur. They wouldn’t be eligible for the public plan, and they don’t need it because they already have market clout with insurers.

Following the money: doing health care better at less cost

Thomas Bodenheimer, a physician and professor at the UCSF School of Medicine, and Rachel Berry-Millett, a University of California medical student, preview an upcoming Synthesis report on care management.

As much as we all aspire to an ideal state of health, there are some people who are sicker than others in the United States.  Approximately 10% of patients consume 70% of health care expenditures.  In this group are the patients who have multiple chronic conditions, many medications, frequent hospitalizations, and limitations on their ability to perform basic daily functions. 

Health care spending for people with five or more chronic conditions is 17 times higher than for people with no chronic conditions. With the projected growth in the Medicare population in the next decade and the far higher prevalence of chronic conditions among this group, the cost of caring for this population threatens Medicare’s future viability. A real way to “bend the curve” is to improve the care and coordination of people with multiple chronic conditions.

Recent research that we conducted for the RWJF Synthesis Project showed us that this challenge may, indeed, be possible to address.  We preview the research in a new NEJM perspective, and our full Synthesis report will be available in a few months. 

What Massachusetts teaches us about emergency departments and reform

Derek DeLia and Joel Cantor of the Rutgers University Center for State Health Policy write on the possible impact of health reform on emergency department utilization.

A popular idea in the healthcare reform debate is that enrolling more Americans in health insurance coverage will decrease emergency department (ED) use and with that alleviate other health system ills like excessive costs and ED overcrowding. A recent paper by Sharon Long and Karen Stockley on Massachusetts’ recent healthcare reform adds to a growing list of studies that cast serious doubt on this idea.  Despite the state’s remarkable progress in covering the uninsured, its ED utilization patterns look very unremarkable. Although no pre-reform data are provided, the paper is consistent with prior studies summarized in our July 2009 Synthesis Report suggesting that expanded coverage alone will not decrease ED use.

Designers of the Massachusetts reform effort understood from the beginning that covering the uninsured would be only the first step. Accordingly, the state is now moving into the second phase of its reform effort with a greater focus on healthcare delivery and reimbursement. Now is a good time for Massachusetts (and the nation) to assess the role of the ED in a reformed system and how to define its “appropriate” use.

Lessons from Massachusetts about the impact of health reform

Sharon Long of the Urban Institute writes about how health reform might change--or not change--the health insurance many people have.

I suppose I was naïve, but I really thought we’d be making progress on health reform this fall. Instead, we’re still mired in contentious debate based as much on fear as facts. One concern is the possibility that health reform could undermine employer-sponsored health insurance coverage—the backbone of the US health care system. Massachusetts, which has mounted an ambitious initiative with many of the same features currently under consideration at the national level, offers a real-world case study of what health reform can mean for employer-sponsored insurance (ESI) coverage.

The bottom line? ESI was not weakened once health care reform took hold in Massachusetts, which now enjoys the country’s lowest rate of uninsurance. Indeed, ample evidence suggests that the 2006 health care reform law significantly boosted ESI coverage, countering the trend toward lower ESI coverage in the rest of country.