The Users' Guide to the Health Reform Galaxy

On health, and health care, everywhere

As you know, we like to keep busy over here at RWJF and so I've got two posts to offer you today, cross-posted from elsewhere.  First we have our president and CEO, Risa Lavizzo-Mourey, posting on the Health Care Blog about last week's release of county-by-county health rankings, for all 50 states, and then we share a post from our Pioneering Ideas blog, related to a report released on Monday about hospital-acquired infections and the costs in lives and dollars.   

* * * *

Thanks to a new set of reports, we now know that where you live matters to your health.  People who call Prince George’s County Maryland home are twice as likely to die prematurely from disease as their neighbors just across the line in Montgomery County.  The data cut both ways.  People who live in the healthiest counties, such as Montgomery or Howard County Maryland have a two-to-three times better chance of living longer than people who live in less healthy counties such as Prince Georges or Baltimore.  

These important new facts aren’t just for the Washington area, because the same disparities are happening across the country. This story unfolds in 50 state reports – The County Health Rankings – that the Robert Wood Johnson Foundation just released with the University of Wisconsin Population Health Institute.   

The data tell a story of our health that doesn’t take place in the doctor’s office, but where we live, learn, work and play.  This story reveals multiple factors— beyond access to health insurance and medical care – that influence how healthy we are and how long we live.  Factors like whether we have access to healthy foods, safe places to be active, our level of education, the number of children living in poverty, and even the number of liquor stores on our block. 

Wrapping up the week with a shout-out and a few words

As this week’s host of Health Wonk Review, Brady Augustine at medicaidfirstaid.com suggests that “watching politics right now is like watching the intimate moments of a dysfunctional relationship. One person groping for the other in a very awkward way and the other disengaged with their back turned and suffering from the imaginary headache.” Noting the need for a “relationship rescue,” the latest edition features posts that support efforts to rebuild and repair reform. Included as a “formula for success” is Bruce Siegel’s post about the Aligning Forces for Quality initiative in Maine and its push for high-value health care.

And now, for something completely different.... 

With this next bit, we launch The Health Reformer’s Lexicon, a new weekly feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Sustainable growth rate (SGR)

The sustainable growth rate is Medicare’s formula for setting total payments to physicians. It was designed essentially to hold growth in physician spending in line with economic growth.

While the Medicare program pays individual doctors based on a fee schedule, the Congressional Research Service (CRS) notes that,

“The SGR system was established because of the concern that the Medicare fee schedule itself would not adequately constrain overall increases in spending for physicians’ services.”

And here is how CRS explains how it was supposed to work:

“… If expenditures over a period are less than the cumulative spending target for the period, the update is increased. However, if spending exceeds the cumulative spending target over a certain period, the update for a future year is reduced, with the goal to bring spending back in line with the target.”

Why it matters:  The SGR is often mentioned in association with another phrase widely used on Capitol Hill – the “doc fix” – so named because Congress each year votes to “fix” the payments to doctors instead of cutting them. Since 2002, Congress has voted not to follow the SGR formula because it has not wanted to cut physicians’ payments.

As a result, there is a growing gap between what physicians are actually paid and what the formula calls for, so much so that Congress would have to cut physician payments by more than 21 percent this year to bring spending in line with the formula. This politically dicey proposition created uproar on Capitol Hill, where a decision on the cut must be made before the end of this month, since cuts are scheduled to take effect March 1.

To address this upcoming deadline, both the Senate and the House recently passed a pay-as-you-go law, which would require the government to offset any new spending with cuts in existing spending or with revenue increases.  But with an eye toward the SGR issue, this measure also contains an exemption for new spending for doctors’ pay, at a cost of $82 billion, enough to avoid cutting the doctors’ payments for another five years.

As another alternative to temporarily address the problem, the Senate considered including a patch in its jobs bill to address the rate cuts; but recently removed the provision.

Roots: The SGR was created by the Balanced Budget Act of 1997. It replaced another formula called the Medicare Volume Performance Standard that set payment targets that were also exceeded.

Usage: Patches created under laws like pay-go only temporarily address SGR pay cut issues. When it comes to more permanent solutions, perhaps one of the more prominent uses of SGR is in H.R. 3961, which passed the House last November. The measure would resolve the “doc fix” permanently by changing the formula, at a cost of about $210 billion over 10 years, according to this Congressional Budget Office estimate.

Do we want to know what works in health care?

Bob Berenson of the Urban Institute and Beth Docteur of the Center for Studying Health Systems Change write about how comparative effectiveness and comparative effectiveness research, concepts that have been frequently referenced in recent health reform debates, could potentially affect the quality of health care that Americans receive.

Much of the debate about taking action on health care reform, particularly in recent times, has had the unintended effect of obfuscating the  ideas that might really help fix our health care, instead of giving us an objective basis to judge whether they’re any good.  That’s why politicians and talking heads can heatedly argue about ideas like public options and individual mandates  while the vast majority of the American public go through stages of hope, bewilderment and even outright fear about what they’re going to gain, or lose, under different versions of health reform legislation. 

To a certain extent, the loosely-based-on-fact rhetoric on health reform is understandable, given what a staggeringly complex beast American health care has grown to be—the Nine-Headed Hydra is nothing compared to the vast industry that costs us so much, delivers state-of-the-art care to some Americans, yet leaves so many others without access to good health care.  But as our national leaders continue to grapple with the details of the reform, we policy analysts and researchers still need to help by focusing some of our energies on clarifying what’s what in terms of key concepts and ideas that have dominated the health reform debate.  So, already, we at the Urban Institute, with RWJF’s support, have looked at how the quality of U.S. health care stacks up internationally, finding evidence to dispel some myths about supposed U.S. superiority; and we have also tried to shed light on so-called accountable care organizations, a concept that offers real potential but faces significant challenges, not least of which is achieving a consensus about what an ACO actually is.

Our latest policy paper is about yet another concept that has cropped up frequently in health reform debates, even before the stimulus funding—comparative effectiveness.  Comparative effectiveness is, simply, about how evidence from various kinds of research, might help inform the decisions of physicians, payers, and patients about which diagnostic tools and treatments work best for particular patients with particular conditions.  Comparative effectiveness is about the notion that if, say, you are faced with a decision about what to do about a new (and troubling) development in your heart condition, you might want your doctor, and yourself, to have access to the best available information that can help you make more “informed” decisions about your own care, consistent with your own values and perspectives.

While the notion of using information to make better decisions should be fairly uncontroversial, remarkably, in health care it is not.  Because comparative effectiveness is one of those concepts that, while innocuous on its face, raise all sorts of bogeys about potential misuse.  Patients and consumers, for example, are being scared by the view that the application of information about what works and doesn’t work in diagnosis and treatment options is a thinly veiled attempt to “ration” health care.  The truth of the matter is, much health care IS rationed already, according to the ability to pay for health care. But most people don’t see it quite that way, and are more apt to focus on what they might lose, rather than what they might gain, under a more rational health care system.  And some doctors view the use of comparative effectiveness research as a threat to their autonomy and ability to use their own judgment in treating individual patients, rather than as a tool to help them serve their patients better. Yet, as the policy paper points out, dozens of organizations representing physicians have strongly endorsed comparative effectiveness and want it to proceed expeditiously.

Our purpose, with our latest paper, is not to suggest that comparative effectiveness is either the silver bullet or the bogey in health reform—it is, like our other papers, an effort to explicate the concept so that policymakers make decisions based on what they can know, rather than make decisions based on distortion and myth.

While we're waiting....

Some blogs feature blurbs, others, treatises.  The latter can be well worth reading if you've got the time and you come away feeling smarter.  So I recommend the recent Health Affairs post by Timothy Jost called Getting Health Reform Done for the above reasons, and also because I'm jonesing for anything these days that sounds pragmatic rather than political.

And, while we're cooling our heels and waiting for Washington DC to dig out from the metaphorical snowdrifts of health reform debates, researchers at the Urban Institute continue their series of reports looking under the hood of the vehicles passed by the House and Senate to examine how legislation might affect critical issues.

In Health Care Spending Under Reform: Less Uncompensated Care and Lower Costs to Small Employers, the researchers zero in on the cost and coverage implications of the House bill from the point of view of both government and employers. Of particular import is what happens to the annual cost of uncompensated care – that is, “care that is either freely donated or results in an unpaid bill.”  The report concludes that the cost of uncompensated care would fall from $61 billion to $25 billion a year.  It estimates the $89 billion increase in costs to federal, state and local government from the expansion of Medicaid and subsidies to employers and individuals could be offset by as much as $27 billion due to decreased spending on uncompensated care. As for employers, net costs under the House bill would increase of 2.9 percent over the current system. Moreover, spending would differ depending on the size of the firm, with higher spending among larger firms and lower spending among smaller firms. 

In the second new report, How Would States Be Affected by Health Reform?, researchers look at the effect of the Senate legislation on people in individual states. Because coverage levels vary dramatically from state to state, any significant reforms would affect states differently.  Among the biggest beneficiaries are southern and western states, due to their low levels of Medicaid coverage, relatively large low-income populations, and higher rates of people without insurance.

Recess for better health

Jim Marks, senior vice president and director of the Health Group, encourages us to turn to the playgrounds to build prevention efforts and reclaim recess to help improve children’s learning and well-being. This post first appeared on The Huffington Post. As another way to improve children’s health, read Jim Marks’ thoughts about the importance of attacking “cereal killers” in the grocery store to help reverse childhood obesity here.
 
When it comes to improving the health of Americans, we normally talk about what happens in a doctor's office.

And when it comes to improving education, we usually focus on what happens in the classroom.

But what if we looked outside of the classroom and the doctor's office? In fact, what if we just looked outside?

It turns out that there's one place you can go to improve learning and health at the same time: the elementary school playground. A growing body of research suggests that playing games like kickball or four square at recess may be the secret to a successful school day and building a lifetime of health.

Kids today are getting fewer and fewer minutes on the playground for recess -- the average is now down to about 22 minutes each day. Facing pressure to meet academic and other requirements, many schools have cut back on recess and some have eliminated it entirely, thinking that this can help them with their academic mission.

However, this trend toward sacrificing recess may produce the exact opposite result and hurt academic performance. In fact, according to a new Gallup poll of elementary school principals, the vast majority surveyed linked having recess to academic achievement, and two-thirds reported that students listen better and are more focused in the classroom after they have had recess. Principals also overwhelmingly saw recess as key to their students' social development.

How Maine Used Its Clout to Press for Higher-Value Health Care

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, recounts how a big health care purchaser applied its considerable leverage to insist on public reports about hospital performance. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

What does a heavyweight look like in the fight for high-value health care? Take a look at how the state of Maine has used its muscle as the administrator of health plans for 34,000 employees, retirees and their families. It is an especially noteworthy story since the health care reform bills before Congress include a number of provisions to encourage the use of quality measures and value-based purchasing.
 
Maine’s State Employee Health Commission, responding to a call from the state legislature to contain health care expenses, developed a new health-benefits plan in 2006. No ordinary plan, its goals included engaging employees and retirees in the health care process, improving quality of care and encouraging providers to publicly report their performance information.

The upshot has been a value-based purchasing strategy based on public reports developed by the employer-led Maine Health Management Coalition, which works closely with the Robert Wood Johnson Foundation’s Aligning Forces for Quality grantee, Quality Counts, and the state government’s quality-improvement initiative, called the Maine Quality Forum.

Obama's Budget Includes Modest Increases for Public Health and Prevention

Jeffrey Levi, executive director of Trust for America's Health, writes about advancing the agenda of prevention and public health in tough economic times.

In a time of very tight financial constraints, we all need to be realistic about our expectations. In the context of a freeze on overall domestic non-defense/security discretionary spending, the Obama Administration did show its commitment to a strong public health system that focuses on prevention. Obviously, we'd love to see big increases for public health; however, this budget, combined with large investments about to be released under the American Recovery and Reinvestment Act (ARRA), will significantly increase the capacity of communities to respond to pressing prevention needs.

But the question of health reform still looms large. Unless we take action to improve the health of Americans, we'll lose an important opportunity to rein in health spending. Treating chronic diseases is
one of the biggest drivers of health care costs,  and until we focus more on prevention in a sustained and comprehensive way, we're never going to get these costs under control.