The Users' Guide to the Health Reform Galaxy

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.

Teaming Up to Improve Care of Diabetes Patients in Minnesota

As Congress and the president figure out their next steps on national health care reform, we want to continue shining a light on local laboratories of reform. Here, 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, writes about the effort to encourage high-performing health care providers in the Land of 10,000 Lakes.

Quality reformers have a mantra: You can’t improve what you don’t measure. But in Minnesota, the local team that the Robert Wood Johnson Foundation tapped to manage its Aligning Forces for Quality initiative, also knows you can’t lose weight by just standing on the scale. You have to act on what you learn.

The Foundation’s grantee, Minnesota Community Measurement, operates the scale. Its HealthScores project gathers performance data from Minnesota health plans as well as 300 medical clinics statewide. But it is part of a multi-pronged action team that is driving change in Minnesota by helping providers improve on their performance and then rewarding them when they do.

Prevention - An Impetus for Moving Health Reform Forward

Jeffrey Levi, executive director of Trust for America's Health, writes about how strong public support for expanded disease prevention programs could help jumpstart the legislative process. This column first appeared in Huffington Post.

As we turn the page to the next stage of debates around health reform, we should remember there is a whole lot in the current Senate and House bills that is popular, already in close agreement, and could be the impetus for moving forward.

The prevention and wellness sections of the bills could help do just that.

A public opinion survey released in November 2009 by Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation (RWJF) found that disease prevention is one of the most popular parts of health reform. In fact, 71 percent of Americans favor an increased investment in disease prevention.

Investing in disease prevention receives majority support from across the political spectrum (85 percent of Democrats, 59 percent of Republicans, and 68 percent of Independents) and across the country (72 percent in the Northeast, 73 percent in the South, 71 percent in the West, and 69 percent in the Midwest), according to the poll, conducted by Greenberg Quinlan Rosner Research and Public Opinion Strategies.

Making health care quality information easier for patients to grasp

Chris Queram, president and CEO of the Wisconsin Collaborative for Healthcare Quality, describes an "all-or-none" measure for reporting on the quality of diabetes care. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

Last year alone, the number of people with diabetes in Wisconsin jumped by a quarter, to more than 400,000. The Wisconsin Collaborative for Healthcare Quality, where I work, is taking a new approach to fighting this epidemic.

Managing a chronic disease like diabetes can be tough for patients — besides taking steps to live a healthy lifestyle, there are the regular medical tests for blood sugar and cholesterol, not to mention feet exams and other important checkups.

The Collaborative, which the Robert Wood Johnson Foundation supports as part of its Aligning Forces for Quality initiative, decided to simplify matters by developing an “all-or-none” measure for diabetes. This method has been catching on as reporting on quality has become more extensive and more complicated.

Consider the Joint Commission, which accredits and certifies more than 17,000 hospitals and other health care organizations:  It measures care for acute heart-attack patients nine ways. It has five measures for pneumonia.

Measurement experts started asking whether it wouldn’t be far better to simply tell patients if a clinic or hospital meets a specific set of quality measures rather than making the patient sort through a long list of measures, some of which their doctor or clinic may meet and some of which they may not.  Hence the “all-or-none” name for this innovative and patient-centered approach.

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.

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. 

$650M for community prevention is milestone on road to reform

Jeff Levi, executive director of Trust for America's Health, writes about how stimulus funds  for community prevention will create a laboratory for what might be achieved with health reform.

The Administration’s announcement Thursday that $650 million in stimulus money will be made available for community prevention and wellness programs is a defining moment for public health in America. It is also an important down payment on the road toward real health reform that will help make Americans healthier.

With two-thirds of Americans overweight or obese and one in five Americans still smoking, this initiative, called Communities Putting Prevention to Work, is tackling two of the biggest health crises in the United States head on.  It will help reduce rates of preventable diseases and give millions of Americans the opportunity to live healthier, higher quality lives. Evidence-based community prevention programs have shown success in improving nutrition, increasing physical activity, and preventing tobacco use by making healthy choices easier choices forAmericans.

What is unique about this initiative is its scale. The program, funded through the American Recovery and Reinvestment Act, will earmark funds for approximately 30 to 40 communities around the country and to states to build or expand upon programs that prevent chronic disease and obesity by addressing physical activity, nutrition and tobacco use. Potentially, it will direct as much as $10 to $20 million to larger cities, representing one of the great advances for prevention programs that this country has seen in decades.

The program will give strong priority to communities that suffer a disproportionate share of preventable chronic diseases and where leaders are able to assemble a communitywide consortium of partners, including the local and state health departments, schools, businesses, community and faith-based organizations, health plans and health centers. At the end of the day, these programs will be the laboratory for showing what results we can have if we invest more heavily in wellness and prevention.

At the end of the day, these investments will be the laboratory for showing what results we might achieve if we invest more heavily in wellness and prevention.

We are convinced they will have a big payoff. In 2008, Trust for America released a study, Prevention for a Healthier America, which found that for every $1 spent on proven community-based disease prevention programs, the county could net a return of $5.60 in health care costs within five years.   On Monday, we’ll release a Compendium of Proven Community-Based Prevention Programs report, along with the New York Academy of Medicine, featuring a range of evidence-based, disease prevention programs that have shown results for improving health and reducing costs.

Finally, this initiative through the American Recovery and Reinvestment Act is a milestone towards the recognition that health reform must start with prevention in order to be successful.   We must take this as a down payment towards the creation of a dependable annual funding stream to allow hundreds of additional communities around the country to benefit from these programs. The future health and wealth of our country demands we improve the health of Americans, not just how we pay for our care.

At yesterday’s briefing, I asked HHS Secretary Kathleen Sebelius where prevention programs ranked on her priority list for health reform legislation.  She replied that it was at the very top – as it was for both the First Lady and President Obama.  Between now and the end of the year when legislation lands on the President’s desk to be signed, I believe it’s the role of the public health community to cement that support, from Congress as well as from the Administration.

To learn more about the Communities Putting Prevention to Work initiative, visit http://www.hhs.gov/recovery/programs/cdc/chronicdisease.html

 

'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.

 

Massachusetts looks at the health and health care equation

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

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

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

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