The Users' Guide to the Health Reform Galaxy

Regulators need to step up enforcement to protect consumers

Peter Harbage, of the DC-based health policy firm that bears his name, writes that federal and state regulators must do more to enforce the law, if proposed new consumer protections are to be effective. We published another post on this topic, by Hilary Haycock of Harbage Consulting, which can be found here.

In the current health reform debate, President Barack Obama as well as many Senators and Members of Congress have repeatedly promised to end rescissions, the practice of insurance companies cancelling coverage for policyholders who get sick.  While this is a line guaranteed to generate applause from audiences fired up about insurance company bad acts, little attention has been paid to the federal law that should have been protecting consumers from such practices since 1996.  A recent report we released with the support of the Robert Wood Johnson Foundation aims to understand why that law has failed to change the individual insurance market, and what lawmakers can do to ensure that any new regulations created by health reform are more effective.

Rescissions occur because private health insurers have a strong financial incentive to sell their product to a healthy population.  The better the risk pool, the better the profit.  This leads insurers to underwrite their products—that is to evaluate the risk of the person or family purchasing insurance and issue or price the product accordingly.  In the case of a high risk applicant, the insurer will likely refuse sale of the product.  Once covered, if an individual subsequently becomes sick, the insurer may re-review the original application to find any preexisting conditions that may have been missed during underwriting.  If this process of post-claims underwriting finds new information, the insurer can rescind—or take back—coverage leaving the individual uninsured.  While it is believed that rescission happens on a limited basis, it can be financially and physically devastating to those who lose their coverage.   

Where's the magic with electronic medical records?

Mike Painter writes about health information technology and when might be the right time to assess its impact on health care quality and cost.

Last week a new article from The American Journal of Medicine entitled, “Hospital Computing and the Costs and Quality of Care:  A National Study” by Himmelstein, et al. appeared in my Twitter stream.  In fact, Brian Ahier (@ahier), whom I and about 3300 other tweeps like me follow, sent me a DM asking for thoughts.  In that article the authors sort of breathlessly conclude that current hospital computing has minimal impact on quality and no impact on cost.  Shocking.   Actually, it’s the kind of gotcha article that really grates—the kind that isn’t particularly helpful to anyone as the authors seem intent on drawing sweeping conclusions from pretty limited data. 

For starters, how can we draw any conclusions about the impact of widely adopted, meaningfully used electronic records until they’re, well, widely adopted?   As research by  Ashish Jha et al. highlighted in Chapter One of the recently released 2009 RWJF HIT Adoption report (results from that research also published in April NEJM) show that only 1.5% of hospitals have a comprehensive EHR system—and only another 8% have a so-called basic system.  I’m not sure how one can draw important conclusions about national hospital computing given such an unbelievably low national rate of adoption. 

More importantly, though, most do not think that simply adopting, even widely, a technology would ever magically on its own improve quality or lower costs.  I’m not sure why these authors seemed to say otherwise.  The point as many have noted over and over again is for health professionals to adopt and then USE (remember our year long discussion regarding meaningful use?) the technology FOR improved quality, including improved efficiency.  As I discuss extensively in Chapter Five of the 2009 HIT Adoption Report, one important use of the technology will be, for instance, automation of performance measurement and public reporting.   The automation enabled by widely adopted, meaningfully used EHRs will hopefully accelerate the creation of results oriented information—information that will facilitate payment reforms as well as improvement.  We absolutely cannot do the kind of payment reforms that the nation needs without creating measures from the automated collection and aggregation of clinical data.  Bundled payment reforms, like the Prometheus model for example, will not work without this kind of automation—and to get to that automation we need widespread adoption and meaningful use of the technology.  But the adopted technology is only an important step.

We are still nowhere near that kind of use in an environment of ubiquitous electronic records.  Given that small fact, to conclude that there is “evidence” that hospital EHRs “don’t” improve quality or lower costs seems pretty silly.  That’s like saying a stethoscope should, but shockingly doesn’t, improve the quality and cost of care just because an intern buys one and hangs it around her neck. 

The authors end their article asserting that predictions about cost and efficiency improvements from widely adopted EHRs “are premature, at best”.  To me that statement is pretty disingenuous, at best.  What’s premature is expecting magic transformation when folks are just getting the tools out of the box—and trumpeting the lack of that magic transformation as if it’s evidence.

 

'Cost of Dying' on 60 Minutes looks at human and financial toll of system

It's worth taking a look at “The Cost of Dying,” which aired Nov. 22 on CBS News’ 60 Minutes and explores the extraordinary amount of money spent on medical care at the very end of people’s lives.

In 2008, Medicare paid $50 billion for doctor and hospital bills during the last two months of patients' lives – with as much as 20 to 30 percent deemed to have had no meaningful impact, Steve Kroft reported.

Dr. Elliot Fisher of Dartmouth Institute for Health Policy and Clinical Practice noted that as many as one-fifth of Americans end up dying costly deaths in intensive-care units because "it's the path of least resistance" - the easiest way for doctors to manage them.

But the report is at its most powerful tackling the human costs of such a system.

Families cannot imagine there could be anything worse than their loved one dying," said Dr. Ira Byock, who heads the palliative care program at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, NH. "But in fact, there are things worse. Most generally, it's having someone you love die badly-dying, suffering, dying connected to machines."

Rhetoric of consumer choice may be a double-edged sword

1. Jessie Gruman is the founder and president of the Center for Advancing Health, an independent, nonpartisan Washington-based non-profit policy organization that seeks to increase people's engagement in their health and health care. She writes here about the long-term impact of the rhetoric of consumer choice that has dominated discussions of health reform.

For all the heated debate about “consumer choice” in the health reform debate, the bill that emerges will be unlikely to result in more or better options for most of us: as of the end of last week, it appeared that a maximum of 6 million people will have a shot at coverage by a public option.

But the aftereffects of this hot rhetoric fuel our sense that we are both entitled and obligated to make choices about our health care in much the same we are entitled and obligated to exercise our prerogatives about our kids’ breakfast cereal.

Even before the debate over health reform, we were importuned by our employers, our health plans and the government to be informed and responsible consumers of health care. For years, they have worked to instill the idea that some choices are best made by us: for example, decisions about treatments where the outcomes may be indistinguishable but the side effects differ, decisions about which hospital to use, and decisions about reducing risks to our health.  

We are urged to make these choices based on the belief that we will generally act in accordance with scientific evidence and in our own interest: we’ll go to the hospital with the highest ranking; we’ll quit smoking, get a colonoscopy every ten years, choose watchful waiting over surgery when a test shows a high PSA level and become parsimonious in our doughnut consumption. 

Recommended reading, on top of all that other reading

There's been an interesting debate brewing about costs and efficiency in health care.  Here's the latest salvo from Jack Wennberg and Shannon Brownlee, published on the Health Affairs blog.  As Jack points out, it's not that people can really object to the Dartmouth Atlas data, per se (although some certainly do keep on trying to poke holes in the research itself), it's more that they object to what actions can possibly happen in an effort to address unwarranted variations in cost and quality of health care.  It would be interesting to keep track of all the controversies that have cropped up during this national health reform discussion and someday point out which fears came true and which ones didn't.  I guess it's impossible to try and re-shape an industry that makes up so much of our country's economy without kicking a few hornets' nests along the way.

Preparing for health reform in the states

Alan Weil, executive director of the National Academy for State Health Policy (NASHP), discusses what states will need to implement health reform legislation.

As federal health care reform takes final shape on Capitol Hill, it is natural to start looking towards the future. Even though the details of reform are not yet settled, it is vital to consider just how states will actually implement reforms being proposed in federal health reform legislation and what kind of support they will need.

In July 2009, the NASHP senior staff met with our state leaders to identify the most critical issues state health policy officials expect to face over the next several years. We found that, despite the many ways states vary, for the most part their leaders have similar policy goals. In fact, there were five consistent priorities that emerged from our discussions: 1) connecting people to services; 2) promoting coordination and integration in the health system; 3) improving care for populations with complex needs; 4) orienting the health system toward results; 5) and increasing health system efficiencies.

Majority of Americans believe prevention will make us healthier and wealthier

Al Quinlan, president of Greenberg Quinlan Rosner Research, talks about why prevention is one of the most popular elements of health reform.

When it comes to health care reform, one thing is clear: Americans want prevention to play a central role in shaping a new direction for our health care system.

Our latest poll shows strong support for increasing our investment in prevention. When we asked people whether we should invest more in preventative care, 71 percent said we should invest more, as opposed to 23 percent who said we should not.

Even when people learn the potential pricetag with respect to health reform, they support the investment as a way to make people healthier and drive down health care costs in the long run.

Reasonable minds

I had a thoughtful discussion with my father last night about health reform and what was right and wrong with health care in this country.  He and my mother were practicing physicians in this country for over thirty years; retired now, they had just returned from a trip to South Korea, and my father shared observations about what his physician friends in Korea have experienced under that country's system of national health care, and compared these observations to his experiences as a doctor in this country. 

My dad and I sometimes find ourselves on different ends of the political spectrum, but last night, we talked only about the issues and what we agreed needed to be fixed about America's health care.  We disagreed on a couple of points, but we ended the conversation agreeing on what I thought was the important thing:  that many things about America's health care do need to be fixed, and we both hope that they will get fixed, through national and local action.  And then he said to me, "I'm glad you're working on these issues."  Which was a HUGE statement, coming from him, given that it's taken him years to understand what my jobs have been about (there seem to be only four jobs in the Korean culture:  doctor, lawyer, teacher, and business owner.  Anything else is a mystery.).

I start with this story because we're at a point in the health reform debate where the rumblings and grumblings about this provision or that provision have been on the rise again.  I believe that people are certainly entitled to feel very strongly about different aspects of health reform, but I just don't think that disagreement about any one point should kill the entire enterprise of making our health care better.  It seems like there are a lot of reasonable people out there, from all walks of life and of all political stripes, who can agree about the big things that need to be fixed about America's health care, and that what these reasonable minds agree on should ultimately guide the debate.

So I'm ending this week by pointing you to a few of those reasonable minds:  Drew Altman of the Kaiser Family Foundation writes a rather brilliant column called "Pulling It Together," which actually does pull things together, namely, he helps pull together some important themes in the health reform debate, and this was his most recent column, on the third school of thought about controlling health care costs, and then here's a worthwhile Kaiser Health News interview with one of the true gurus of quality, Dr. Donald Berwick of the Institute for Healthcare Improvement. 

Looking back to move forward.

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

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

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

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

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

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

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

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

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

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

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

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

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

Where were you?

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

I distinctly remember the first time I heard the title, “National Coordinator for Health Information Technology”.  It was 2004.  That’s, of course, the year that RAND released its important national report card highlighting the overall mediocre state of health care quality.  You know the one that told us “it’s a flip of a coin.”  I was an RWJF Health Policy Fellow working on the Hill with then Majority Leader Bill Frist’s health policy staff.  There was a flurry of staff activity regarding the president’s pending executive order pushing adoption of the electronic health record and creating a new federal health information technology, dare I say, czar. . . . But what to call this new position?  To be honest, when I initially heard folks say the words, “national coordinator for health information technology,” my first thought was, “Well, that’s a mouthful.”  My second was “It sort of sounds like a character from that TV show, ‘The Love Boat’”.  But I kept those smart remarks to myself and quite quickly got on board—and, to be honest, never looked back. 

At RWJF in 2005, several of us worked with then National Coordinator, Dr. David Brailer, on a partnership effort between the Office of the National Coordinator and RWJF.  With this project we extended a grant to Dr. David Blumenthal, then in Boston, to create a series of national reports that would track the national adoption of the electronic health record over several years as the nation progressed toward wider and wider adoption.  This week we’re issuing our third report in that series. 

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

How important are individual mandates in achieving health reform?

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

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

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

What we're reading about health reform

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

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