The Users' Guide to the Health Reform Galaxy

Leaving this health reform thread, now.

Maybe Jonathan Cohn has started a trend.

When we began RWJF’s health reform blog, a little over a year ago, we knew we were joining a crowded space.   But the health reform debate touched on so many of the issues that this foundation works on that not joining the conversation would’ve felt, to us, profoundly weird. 

We learned a lot from doing this blog.  It wasn’t the first blog launched from the RWJF mother ship, but it still taught us some new things about blogging in general.  Like, we knew that a ton of our grantees and partners were actively participating and informing the discussions and debates about health reform.  We know this because we were suddenly insanely busy (even more so than usual) putting out a ton of analyses and information from RWJF grantees and partners, and the blog enabled us to put add another layer of thoughtful commentary on top of the high volume of stuff coming from the RWJF fire hose.   However, we also learned that our grantees and partners, for the most part, traffic in groundbreaking research or demonstration projects, and not a lot of them have the time to quickly dash off a conversational, insightful piece.  Only a few had added blogging to their formidably impressive skill sets, and the competition for their thoughts was fierce. 

Nonetheless, we thought it was worth the try to get our own health reform blog going—and we got some good stuff.  We heard from our grantees and staff on a wide range of topics covered by the health reform debate.  We tried to stick, whenever possible, to plain English, so that our few thousand readers would be less confused, perhaps, about particular aspects of the health reform debate.   And now we’re come to a crossroads, and we’re ready to turn in another direction.  This is definitely not the end of RWJF’s blogging days—our Pioneering Ideas blog is still alive, well, and kicking—but we are calling it over for the Galaxy blog.   During the debate leading up to the passage of the law, we joined the conversation in so many ways.  But now the law is passed, and we’re gearing up to join other conversations, and will continue to inform others, with thoughtful and timely analysis and commentary.

Before I turn out the lights, some parting thoughts:

RWJF recently sent out the annual message from our President and CEO, Dr. Risa Lavizzo-Mourey.  This year, her message focused on what just happened, with respect to health reform, and what needs to happen, with respect to health reform, in the years to come.  In RWJF’s ongoing quest to explore the frontiers of interactivity and social media, this year, she invited readers of the President’s Message to submit “one-minute essays,” quick thoughts about what was on people’s minds with respect to health reform.

A ton of responses came through in response to the invite.  And while these responses were meant for Risa alone, she did share some key take-aways with some of us here from the hundreds of e-mails received.  Many respondents shared concrete, thoughtful, detailed responses that showed how people are already thinking several steps ahead about how to implement different provisions of the law.  And, she heard some anxiety in the responses, as well.  Anxiety about what’s in the health reform law, and how whether certain provisions will be implemented well, and successfully, and anxiety about what wasn’t in the law, and whether some important issues in health and health care will simply fall off the radar screen, forever.

I’ve heard a lot of anxiety about the health reform law, too, and can probably rattle off a list of my own worries to add to the mix.  But there are times when I wonder:  gosh, have we become a nation of hand-wringers, or what?  Are we all carrying a Woody-Allenesque flag about our own particular neuroses with respect to health reform?  (“How are states going to handle this?”  “Will people ever understand the benefits of the law?”  “What about public health/addiction/nursing/affordability/mental health/etcetera, etcetera?”)   The Patient Protection and Affordable Care Act, in many ways, is like one ginormous Rorschach ink blot for us all:  we interpret its many provisions according to our own perspectives and experiences, and we project our many hopes and fears onto the law because its passage was, truly, an extraordinary event. 

But I think the wide range of reactions and feelings about the new health reform law tells us another thing, too, and it is this:  a person’s health is shaped by so many different factors.  We as human beings present a vast array of health and health care opportunities and challenges:  where we live, what we eat, where we work, how we think, our genetic make-up, our insurance status, the care we receive, whether we like our doctor, whether enough doctors and nurses live in our neighborhoods, what we read on the Internet….all of these factors can shape a person's health and well-being in this society.  There are so many people out there who care about these different factors.  There are so many people in this country who want to try and influence these factors in ways that actually help people live healthier lives and get the care they need, rather than live sicker and die younger through successive generations. 

This, to RWJF, is what health reform is about.  Health reform has never been about one law, however momentous.  It’s what we do.  It’s our mission.

With that, I thank everyone who contributed to this blog, and everyone who read it, and all of the people at RWJF and elsewhere who took the time to keep it up and running.  It was fun while it lasted—now on to other things.

 

Health Reformer's Lexicon: Federally Qualified Health Centers

The Health Reformer's Lexicon is a weekly feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Federally Qualified Health Centers (FQHCs)

The Centers for Medicare & Medicaid Services provides the following definition:

FQHCs are “safety net” providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless.

Under the supervision of certified medical professionals, like doctors and psychologists, FQHCs offer primary care and preventive services, such as screenings for cholesterol, visual acuity and hearing; prenatal care; immunizations; and mental and nutritional evaluations.

Funded through the Health Centers Consolidation Act, FQHCs must be public or private nonprofit organizations. To receive the designation and qualify for grant funding, they must meet a number of other requirements.

Care can be provided in a number of settings: at health centers, at patients’ homes or elsewhere in the community, and must be provided to all patients regardless of their ability to pay for it.

FQHCs Payments are determined using a sliding fee scale. And as our Health Reform GPS also notes,

… because of their location and high level of treatment of the uninsured, FQHCs receive special payment rates from Medicare, Medicaid and CHIP and are eligible for special supplemental payments from exchange-participating health insurance plans. 

Why it matters: Federally qualified health centers provide care to millions of uninsured, underinsured and non U.S. citizen populations. As access to care expands through health reform, so too will the need for safety net providers. To do so, the federal government will need to work closely with the states to connect people to services and address the primary care workforce shortage.

According to a Health Affairs article, it is estimated that FQHCs will provide care for twenty million people in 2010, about 40 percent of whom will be uninsured. 

Roots: The Economic Opportunity Act of 1964 called for “neighborhood health centers,” which spurred the creation of the first two centers–one in the Mississippi Delta and the other in Boston–in 1965. These early models were based on similar ones in South Africa and also inspired by the American civil rights movement and a growing need to address national poverty issues.

The federal government continued to increase its support for health centers, and eventually created a reimbursement designation–the Federally Qualified Health Center benefit, in 1991. 

More recently, thanks to the support of President Bush’s Health Center Initiative, federal grants for FQHCs increased from $1.1 billion in 2001 to $2.2 billion by 2009, and the number of patients who received care doubled in number. 

Where the term appears: The Patient Protection and Affordable Care Act calls for the establishment of “Teaching Health Centers,” which include FQHCs; it also calls for support to help address the primary care workforce shortage, especially in rural and underserved areas.

The bill also contains $11 billion in funding for health centers, over a period of five years, starting in 2011. According to the National Association of Community Health Centers,

$9.5 billion of this funding will allow health centers to expand their operational capacity to serve nearly 20 million new patients and to enhance their medical, oral, and behavioral health services. $1.5 billion of this funding will allow health centers to begin to meet their extraordinary capital needs, by expanding and improving existing facilities and constructing new sites.
 
Previous Lexicon entries include:
- Value-Based Purchasing
- High-Risk Pools
- Bundled Payments

From a doctor's point of view: making billing better, for better care

James E. Bailey, M.D., M.P.H., is a practicing internal medicine physician, director of the Healthy Memphis Data Center and a professor of medicine at the University of Tennessee Health Science Center.  In this post, he riffs on a topic covered by a recent RWJF-supported study, about how streamlining billing procedures will increase efficiency and help improve the quality and cost of health care.

Between the recession and new health reform law, Americans have been thinking a lot about what health care costs. I’ve heard many stories of patients and their families suffering because of the cost of getting care. I also know many primary care doctors and hospitals that do their best to provide everyone the care they need most are finding it difficult to keep their doors open. Again and again, I’ve seen how the health care people receive is often of poor quality, despite its high, and rising, cost. Sadly, Americans end up getting expensive, sometimes even dangerous procedures they don’t need while their most essential health care needs are overlooked.

The health reform debate tended to focus on big, divisive issues—and rightly so. Real change in our health care system will require hard choices to be made by everyone. But there is another big issue—not quite as divisive but nonetheless worth our attention—which is the system’s misuse of time.  Any physician can speak of large amounts of time—and frustration—spent dealing with administrative issues such as billing. As a doctor, I want most to spend my time with my patients. And so every minute I spend on administrative tasks is one less minute I have for seeing patients. And instead of an efficient system that empowers doctors to best do their work, we’ve created a time hog that dictates the priorities of our practices, inhibiting us from doing what we are called to do as physicians—provide care for those who need it.

This is why reform efforts must address issues like the simplification of billing and paperwork. A new study from RWJF's Changes in Health Care Financing and Organization initiative, “Saving Billion of Dollars—And Physicians’ Time—By Streamlining Billing Practices” suggests that it is possible to streamline the billing process, increase the quality of care and eliminate some unnecessary costs. The study examines the U.S. system of billing third-party payers for health care services, arguing that the system of third-party payment is excessively cumbersome, complicated and costly. We spend about twice as much on the billing bureaucracy in America than in any other country in the world.  While it is unlikely that we will be able to eliminate third-party middlemen from the system any time in the near future, there is much that can be done now.

Health Reformer's Lexicon: Bundled Payments

The Health Reformer's Lexicon is a weekly feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Bundled payments

The RAND Corporation defines bundled payments—also known as “episode-base payments”—as “a single payment for all services related to a specific treatment or condition … possibly spanning multiple providers in multiple settings. Providers would assume financial risk for the cost of services for a particular treatment or condition as well as costs associated with preventable complications.”

The Robert Wood Johnson Foundation and George Washington University’s Health Reform GPS project adds: “In contrast to fee-for-service payments, which can encourage a high volume of treatment, ‘bundling’ is thought to encourage more cost-effective care.”

(Bundling payments first requires categorizing different types of medical cases. These categories are known as diagnosis-related groups, or DRGs, which Medicare uses to bundle reimbursements to hospitals for inpatient care.)

Why it matters: A root cause of many of the U.S. health care system’s most profound problems—including soaring costs and uneven quality—is the fee-for-service payment system, which encourages overuse of health care services and fails to reward value. Among the alternative options, bundled payment schemes are attractive because they give hospitals and physicians incentives to coordinate care and to provide it more efficiently. Tied to evidence-based medical practice, bundling also promises to increase the value of our health care system—producing better outcomes for patients—in a fair and equitable way.

Roots: Physicians at the Texas Heart Institute introduced bundled payments in 1984 for cardiovascular surgical procedures. A 1987 study found that the Health Care Finance Administration could decrease its costs by more than $192 million (13 percent) under Texas’ payment plan. Since then, as U.S. health care expenditures have ballooned, health reformers have continued to advance the idea of bundling as a way to reform the fee-for-service payment system. The Balanced Budget Act of 1997 established new payment systems for most types of post–acute care services; independent initiatives such as PROMETHEUS Payment have worked on the practical design and implementation of evidence-informed case rates; and President Obama championed bundling in the recent health care reform debate.

Where the term appears: The final health reform bill calls for the creation of a national Medicare pilot program by the beginning of 2013, which will develop and evaluate bundled payment systems for acute inpatient hospital services, physician services, outpatient hospital services and post–acute care services for episodes of care that begin three days prior to hospitalizations and last an additional 30 days following discharge.
 
Under the new law, the government must also set up Medicaid pilot projects by 2012 that will use bundled payments to pay for episodes of care that include hospitalizations.

The Centers for Medicare & Medicaid Services is already experimenting with bundled payments through its Acute Care Episode demonstration, with sites in Texas, Oklahoma, Colorado and New Mexico.

And recently, several major health care providers in California announced plans to use bundled payments to pay for hip and knee replacements beginning in August. The lump-sum fee will cover a full range of medical treatments from surgery to 90 days of recovery.
 
Previous Lexicon entries include:
- Flexible Spending Accounts
- Value-Based Purchasing
- High-Risk Pools

Health Reformer's Lexicon: High-Risk Pools

The Health Reformer's Lexicon is a weekly feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: High-risk pools

High-risk pools are private, self-funded health insurance plans that serve high-risk individuals with costly pre-existing medical conditions such as cancer or HIV/AIDS.

Why It Matters: As the National Association of Health Underwriters explains, most Americans get their health insurance in group-purchasing arrangements—typically through their employers or the employers of family members—but some people do not have access to this type of coverage and need to buy their own insurance independently.

Unlike in the group health insurance market, however, insurers in most states traditionally have been allowed to deny coverage to individuals with serious pre-existing conditions. That’s because when you buy insurance individually, you’re essentially a “group of one.” The health insurance company has to determine how likely it is to take in more premium dollars from you than it pays back in benefits—and if it appears that the odds are you will get sick, then it is in the insurance company’s financial interest to avoid taking on the risk you represent.

(There have also been widely commented-upon incidents in which insurance companies have found reasons to rescind people’s coverage after they get sick.)

For this reason, many states offer some form of risk pool that individuals can buy into.

Roots: High-risk pools were first implemented in Minnesota and Connecticut in 1976, according to the Kaiser Foundation, and now operate in 34 states, providing insurance to nearly 200,000 people.

Where the Term Appears: The recently passed health reform law established a national high-risk pool program to insure individuals with pre-existing conditions from now until 2014, when the law’s broader provisions for expanding access to coverage begin to kick in. Getting this temporary program up and running is one of the first things that HHS Secretary Kathleen Sebelius has been tackling. She recently sent a letter to governors and state insurance commissioners asking whether they are interested in creating high-risk pools. Some states have responded that they need more time to decide.
 
Previous Lexicon entries include:
- Individual Mandate
- Uncompensated Care
- Value-Based Purchasing

Health Reformer's Lexicon: Value-Based Purchasing … and the latest from Health Wonk Review and Grand Rounds

The Health Reformer's Lexicon is a regular feature that examines key words, terms and phrases in health reform and explores their meaning and orbit.

Today’s term: Value-based purchasing.

According to the Agency for Healthcare Research and Quality, “the term basically refers to any purchasing practices aimed at improving the value of health care services, where value is a function of both quality and cost.” AHRQ continues: “It can be helpful to think about value as the result of quality divided by cost: Value = Quality ÷ Cost. This equation shows that value increases as quality increases, holding expenditure constant.”

The term is commonly associated with specific reforms such as pay-for-performance and discrete initiatives aimed at improving outcomes for a single disease or fraction of the population. But many health care experts argue value-based purchasing must be construed more broadly if it is to be an instrument of systemic reform. For example, the Urban Institute’s Robert Berenson and New America Foundation’s Len Nichols, writing in the Health Affairs blog, offer this definition: “Value-based purchasing uses a variety of tools to try to obtain the right kind and mix of services, of desired quality, at a reasonable cost.”

Why it matters: Susan DeVore, the CEO of the Premier healthcare alliance, has put it this way: “Cutting costs while improving care is the Holy Grail of health care reform.” And in the search for that Holy Grail, many health care policy experts believe value-based purchasing will be a critical tool.

Our current health care system, structured as it is around a fee-for-service model of reimbursement, rewards doctors and hospitals for the volume of services they provide, not the value of the care they deliver for patients or populations. This causes a host of problems, not least of which is overuse of health care services.  In the long run, health care reform can only be successful if the system rewards providers for giving patients the right care at the right time in the right way.

Roots: The concept of value-based purchasing has been gaining currency since the late 1990s as health care researchers and stakeholders have been systematically examining the design, implementation and outcomes of new purchasing strategies to replace fee-for-service.

Where the term appears: The newly enacted health care reform law establishes a hospital value-based purchasing program in Medicare to pay hospitals based on their performance on certain quality measures. The new law also calls for plans to be developed to implement similar value-based purchasing programs for skilled nursing facilities, home health agencies and ambulatory surgical centers.

Previous Lexicon entries include:
- Individual Mandate
- Uncompensated Care
- Flexible Spending Accounts

Meanwhile, in other news …

In this week’s Health Wonk Review on the HealthBlawg, David Harlow mentions our recent post on the definition of uncompensated care, joking that “Titanic doesn't even begin to capture the immenseness of the galaxy” when it comes to this topic. Also, the latest edition of Grand Rounds highlights Catherine Hess’ recent post on children’s health insurance coverage.

What just happened? Still processing.

I spent some time with the actual pages of PPACA this week (in my opinion, you can either pronounce it to sound like a town in upstate New York, or adopt a slight stutter), because I was getting the uneasy feeling that just reading those nifty summaries and implementation timelines that everyone's circulating might not be enough (this reminds me of how I try to resist opining on movies based on just reading the reviews).  I had to track down the one person at RWJF who had been brave enough to print out the entire law, plus the reconciliation amendments; then I started cautiously sifting through the table of contents to see what I could find.  It is not a task for the fainthearted.  Secretary Sebelius announced a "help desk" to guide Americans through the law but I always feel some obligation to learn on my own before I start bothering those nice people someone puts at my disposal to help me somehow muddle through.  Clearly, this is going to take some time.  But I found one thing to be oddly comforting as I wended my way through pages of text; it took me years of working at RWJF to truly understand that health results from so many different ingredients, including, but not limited to, personal health behaviors, environment, housing, insurance status, and the quality and type of care one receives.  It's impossible, once you really steep yourself in what it takes to make people healthier and get them the care they need, to believe that any one solution will do the trick for any one problem.  And so, as I was trying to dip my toe just a wee bit into the PPACA waters, I did think to myself, "Oh.  They got that."

Health Reformer’s Lexicon: Individual Mandate

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Individual mandate

Similar to the way that auto insurance is required for all drivers, the individual mandate is a provision that requires all Americans to carry health insurance.

Why It Matters: Supporters of the concept believe that the mandate will lead more people to obtain health insurance and push the U.S. closer to universal coverage.

As Laura Meckler of The Wall Street Journal explains,

The thrust is to get everyone into the health-insurance pool so that healthy people, who are cheap to cover, help balance out the sick, who are expensive.

Opponents believe the mandate is unconstitutional and claim that it encroaches on individuals’ personal rights. Others fear that individuals may not be able to afford it.

Roots: The concept originally surfaced in the early 1990s. It was included in the Health Equity and Access Reform Today Act of 1993.

In 2006, Massachusetts introduced an individual mandate that penalizes people who do not have coverage. As a result, the state now has the lowest rate of uninsured residents in the nation – at 2.7 percent, and an increase in the number of people covered under employee-sponsored insurance, but is currently struggling to rein in the overall cost of health care.

Where the Term Appears: The individual mandate appears in the health care bill, which was signed by President Obama earlier this week. According to the language in the bill, the mandate will:

Require U.S. citizens and legal residents to have qualifying health coverage.

Individuals without coverage will be subject to pay a tax penalty that will be phased-in over four years starting in 2014. Certain qualifying individuals will be considered exempt from having to pay these fees.

Exemptions will be granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, if the lowest cost plan option exceeds 8% of an individual’s income, and if the individual has income below 100% of the poverty level.

Although similar, the reconciliation act presents a slightly different tax penalty structure.

Previous Lexicon entries include:
- Accountable Care Organization
- Meaningful Use
- Patient Centered Medical Home

Reactions

Yesterday, I was picking up my children from their afterschool program, and two of the teachers who run the program pulled me aside and said:  “Uh, do you have a few minutes?  We were wondering if you could tell us about health reform—like what, exactly, was in that bill that just passed, and how it will affect us.”

I was astonished.  These teachers know where I work (you have to include that info on the enrollment forms for the program) but I had no idea they knew anything about the Robert Wood Johnson Foundation or, for that matter, what my job is here.  (Which recently changed.)   But getting past my astonishment about the questions, I was also struck by how straightforward and simple their desire was:  they wanted to know more about the health reform legislation.  And, they wanted to know if their lives would change.  In today's 24/7 media spin cycle, you’d have to be deaf, dumb, and blind to not be aware that something was going on related to America’s health care, in the last 14 months, but clearly, so much of what happened with respect to the health reform debate was challenging for the ordinary citizen to understand, especially in terms of what was at stake, for different people.   

I don’t think I have an opinion on whether it’s a good or a bad thing that the bill became law without greater understanding from people like these teachers about what was actually in the bill, even though there are many who would argue one side or another of that question.  First of all, I’ve seen enough policy sausage-making to know that no matter how much you try to get people to understand what’s at stake, and no matter how much you invite comment and input from different perspectives, you’re still gonna get accused of leaving people out.  And it seems reasonable to assume that there was no intentional, diabolical plan to leave people like these teachers out of the debate; it’s more that that health care reform is, by its very nature,  a highly complex topic, and as far as I can tell, many efforts were made to engage different groups, but America’s collective attention span for understanding this issue was a limited commodity, crowded by earthquakes and Tiger Woods. 

A major step forward for better health and health care

When the Robert Wood Johnson Foundation opened its doors as a national philanthropy almost 40 years ago, it appeared that health reform was right around the corner. It looks like history will record 2010 as the year our nation finally turned the corner towards providing coverage for millions more Americans, fixing our broken health care system, and helping us all live healthier lives.

While the Foundation can’t and doesn’t advocate for legislation, we have been advocates of covering all Americans and improving the quality of our health care system from our very first day.  We are driven by our mission: to improve the health and health care of all Americans.  This is a mission that stands the test of time and has guided our efforts over the past four decades to: Cover the uninsured; Improve the quality, value, and equality of health care; Prevent disease and promote healthier lifestyles; and, strengthen public health, and at the same time address the root factors that influence our health so much. 

Today, major health reform legislation will become law.  No legislation is perfect, and I’m not going to get into the specifics of what the legislation does and doesn’t do.  What I can and will say is that this legislation marks a historic milestone on the road to better health and health care, meets the core coverage principles endorsed by the Foundation, and addresses many key areas on both sides of the health and health care equation.

But, just as covering the uninsured alone won’t solve what’s ailing the health care system, the legislation will only be one part of the story—a stop on the long journey we are all on together.  And the destination is not yet in our sights.  The high numbers of uninsured, the staggering rates of childhood obesity, the broken systems of health care and public health that still need re-building—these problems will not vanish with the President’s signature.  It’s a long journey with few rest breaks and plenty of road blocks yet to come.  But it is these achievements along the way that keep us going and get us one step closer to realizing the full promise of our philanthropy and our nation.

The Galaxy Welcomes the Wonk Review

 
Photo used under Creative Commons from j9sk9s

This month, we health care wonks and basketball fans each have our own version of March Madness. As the 2010 NCAA Men’s (and Women’s) Division 1 Basketball Tournament play begins this afternoon, policymakers are hurtling toward what may well be the last round of health care reform. (This week, we at the Foundation are also giving primetime spotlight attention to health insurance coverage issues, as part of our 8th annual Cover the Uninsured Week.)

Like the health reform debate, the NCAA basketball tournament is full of make-or-break, game-changing moments. In the nineties, we watched Chris Webber’s infamous time-out call that led to the end of Michigan’s “Fab Five”, and Christian Laettner’s “buzzer-beater” shot that led to Duke’s ultimate glory. Two years ago, it was “Mario’s Miracle” three-point shot in the last few seconds of regulation game time that led to Kansas’ big OT win against Memphis.

Today, I present you with the latest Health Wonk Review (HWR) – the March Madness edition. For those who may not know, the HWR is a bi-weekly collection of top scoring posts from the health policy world. So with a nod to the tourney’s artful, alliterative lingo – think “Final Four” and “Sweet Sixteen” – we review the health wonk game from the following angles: Players’ Pool, Fans’ Favorites, Referees’ Records, Coaches’ Corner, Commentators’ Color, and the League’s Landscape.

As this edition’s sideline reporter, here’s the highlights reel from the health reform blogosphere.

Players’ Pool
Each team roster is full of players with different styles of game. At the New Health Dialogue blog, Joanne Kenen writes about respecting each player’s perspective for palliative care treatment. 

John Goodman selects a few chronic disease management projects that might deserve the “Most Outstanding Player” award for their work over at his Health Policy Blog.  He takes a shot at RWJF in the elbow, but we're not calling a foul: hard elbows are a part of the game.

Fans’ Favorites
Joan Alker is cheering for team Medicaid in her latest post at the Say Ahh! Children’s Health Policy Blog. Alker notes that Medicaid provides both children and adults access to care, and suggests that increasing reimbursement rates would help us expand the system. 

As ultimate cheerleaders, we cross our fingers and hope that this will be the year our Cinderella team (or cause) rises to the top. This loyalty sometimes clouds our judgment (and perhaps our bracket choices). But over at Managed Care Matters, Joe Paduda asks fans to take a moment and step out of their fantasies, to consider the consequences of expanding coverage now while controlling costs later.

And while there is little doubt that EHRs were the crowd pleaser at this year’s Healthcare Information and Management Systems Society conference (aka HIMSS10), Peggy Salvatore at Healthcare Talent Transformation believes that fans need more guidance on the role of Health IT in future gameplay. 

Referees’ Records
While on the subject of EHRs, EHR Blogger Glen Laffel tells us that a new official, the FDA, wants a bid in the regulatory shuffle to ensure that systems are safe. Glen suggests that too much officiating can cause an upset, and argues that ONC should remain the head official to evaluate the safety and efficacy of EHRs.

Fred Lee at Health Care Hacks reports on a series of fouls (aka medical errors). Doctors who studied patients over the age of 65 found that patients who did not receive referrals were less likely to receive recommended follow up treatment. Unlike game refs, the researchers stray away from finger pointing to assign blame, and instead insist that doctors and patients play nice and work together as a team to produce better outcomes.

Health care leaders must be careful not to abuse home court privileges (an advantage the NCAA team prevents by not allowing teams the chance to play on their own turf). Roy Poses at Health Care Renewal reminds us about the dangers that conflicts of interest present in the health care arena by reviewing the details of a deal between a for-profit medical school and a NY-based hospital corporation.

And while game official Anthony Wright issues a technical foul to Anthem on its proposed rate hikes over on Health Access, referee Louise Norris at Colorado Health Insurance Insider finds Anthem at midcourt in insurance rates in Denver and calls for play to resume.

Coaches’ Corner
In the words of Rick Pitino, (the man who first introduced me to the world of college basketball in the nineties with his fast-breaking, full-court pressing Kentucky Wildcats,) “Excellence is the unlimited ability to improve the quality of what you have to offer.”

When assessing the quality of care provided in nursing care settings, the INQRI Blog coaches examined past plays and their results (aka processes and outcomes). They also reviewed patients’ feedback, noting the importance of including patients’ voices in improving care delivery models. *editor’s disclaimer: INQRI is a program supported by the Robert Wood Johnson Foundation

David Harlow over at the HealthBlawg thinks that educators need to go back to the books. According to the results of a recent study produced by the Lucian Leape Institute and the National Patient Safety Foundation, faculty need to spend more time in the classrooms consistently teaching students important “chalk talk” lessons about patient safety.

Commentators’ Color
And now it’s time to step into the play booth. Over at InsureBlog, Henry Stern provides us with a play-by-play summary of his recent interview with Rep. Joe Wilson. The Congressman discusses coverage mandates at the state-level, stimulus funds and the reconciliation process.

On the Disease Management Care Blog, Jaan Sidorov outlines his must-picks to implement pilot Accountable Care Organization models. According to Jaan, we need to select pilots that have physicians who have “a track record of exposure to the ‘systemness’” of disease management programs and patient-centered medical home settings, and thus experience with patient engagement and care management.

And Workers’ Comp Insider sportscaster Tom Lynch takes us from hoops to the world of baseball to recount former athlete and soon-to-be retired Sen. Jim Bunning’s latest actions at bat, with regard to COBRA benefits and the Sustainable Growth Rate.

Finally, we close out the commentary section with Sens. Tom Harkin and Mike Enzi, who weigh in with their thoughts on the Health Affairs Blog about the latest national and local efforts to battle obesity.

League’s Landscape
In the beginning, the NCAA men’s basketball tournament featured just eight teams. In today’s championship battle, we have 65, (plus constant chatter that the NCAA may add more teams to the mix). Similarly, as our health care market expands, we must continue to look at ways to restructure the system to ensure that we are providing high-quality, cost-efficient care.

When considering ways to rebuild the system, we must look to the individual teams (aka states), who often provide invaluable insight for national reformers. RWJF Senior Program Officer Brian C. Quinn and Lynn A. Blewett, director of the State Health Access Data Assistance Center, share findings on our blog from a recent report that highlights the growing challenges states face in meeting the needs of the middle class. As they write, “Just 66 percent now receive insurance through their employer, a drop of seven percentage points since 2000”. As part of our Cover the Uninsured Week, we aim to foster discussion to expand coverage across all states.

Austin Frakt from The Incidental Economist also examines local-level data, and gives us a detailed look at the history of the relationship between Medicare Advantage payments and traditional fee for service Medicare costs. He suggests that we restructure benchmark rates to control costs.

In another post on payment reform, Chris Langston at health AGEnda writes, when it comes to providing care, we can’t assume that “what IS, is what OUGHT to be.” If physicians are not currently providing recommended care, they will report less time spent on treatment, which will lead to lower Medicare reimbursement fees, and another reduction in the amount of care provided. 

As sports fans and health reform analysts, we’ve waited all season for the Big Dance. And now that we’ve made our predictions and selected our best picks, we sit back to watch the game unfold.

Thanks for letting me call the shots for this edition of HWR. Don’t forget to tune-in on April 1 to the next edition over on the Health Technology News blog, as host Rich Elmore breaks down the latest health policy rebounds, slam dunks and results.

The economic squeeze on the American middle class

Brian C. Quinn a senior program officer at the Robert Wood Johnson Foundation and Lynn A. Blewett, Director of the State Health Access Data Assistance Center (SHADAC) write about Cover the Uninsured Week.

The inner researcher(s) in us don’t generally get excited about spending days working on national awareness campaigns. But for the last eight years, Cover the Uninsured Week has provided an exciting opportunity for RWJF and SHADAC to explore interesting trends in health insurance coverage. This year, with families across the country struggling through the second recession in the last decade, it seemed natural for us to look into how those economic downturns have affected health insurance coverage.

The resulting report – Barely Hanging On: Middle-Class and Uninsured –released today, chronicles coverage trends in all 50 states from 2000 to 2008.  The findings? The first decade of this century has been marked by declines in employer-sponsored insurance coverage, greater costs to employers and employees for individual and family health insurance policies and significant erosion in private coverage.   Coupled with this we find significant declines in median incomes across the US.  This raises increasing concerns for the affordability of coverage for the middle class and a continued increase in the numbers of uninsured in nearly every state.

One finding that hits home for millions of people: America’s middle-class is bearing the brunt of these trends. Middle-income earners – families making roughly $45,000 to $85,000 a year – became uninsured at a pace faster than those who made more money, as well as those with lower incomes. In total, 13 million middle-income earners were uninsured in 2008 – about 2.4 million more than in 2000.

As the cost of health insurance premiums rose by 56 percent for family coverage (adjusted for inflation), many employers stopped offering health insurance coverage, shifted the increase in costs to employees in terms of higher premiums or changed the criteria for employees’ eligibility. By 2008, more than one in five people who work in firms that offer health insurance weren’t eligible for the benefit. For those employers who still paid the bulk of their employees’ insurance premiums, rising costs have been passed on to workers, likely causing some workers to drop their work sponsored coverage. In all, 21 percent of employees who worked for firms that offered employer-sponsored insurance (ESI) in 2008 did not accept or “take up” the offer.  Among the middle class, just 66 percent now receive insurance through their employer, a drop of seven percentage points since 2000.  

ESI has long been the mainstay of health coverage for middle-class families, who typically do not qualify for government insurance programs. Among middle-income Americans, only about half of the decline in employer-sponsored coverage from 2000 to 2008 was offset by increased enrollment in government insurance programs. For people who earned less money, declines in ESI were even steeper, but those numbers were almost completely offset by increases in coverage through government insurance programs like Medicaid and SCHIP. The result is that it’s the middle class that is going without.

America’s middle class is being squeezed to the point that they are barely hanging on. Overall, the average cost an employee paid for a family insurance policy rose significantly by 81 percent from 2000 to 2008, while median household income fell significantly by 2.5 percent (adjusted for inflation). Clearly, hard-working families are at the brink.

We are concerned about the erosion of ESI and the continued growth in health care coverage costs.  In this economic crisis, we know that business owners can’t afford to shoulder more of the burden of health care costs.  Yet, at the same time, state are facing unprecedented budget shortfalls and are not able to meet the need of  laid-off workers and the members of the once-middle class who are now uninsured.   If nothing is done to stave off these trends, it could spell doom for our nation’s middle class, our health care system, and ultimately the future of our economic recovery.

During this 8th Cover the Uninsured Week, people across the nation will hold events and have discussions about what to do about this national crisis. We’ve certainly done our part to build awareness. Now it’s up to the people to take action.

America's uninsured: still matters.

I know this is going to make me sound old (truth hurts), but I can clearly remember the first Covering the Uninsured Week, eight years ago.  It was one of the very first issues I worked on at RWJF and one that I'd really like to see get solved in our lifetime. And, I think you can choose to either get really depressed about the fact that we haven't solved it yet, or, you can reflect on how long it really takes to change the thinking around a particular problem and to make that problem really matter to a broad swathe of people, but eventually, success starts to seem more possible.  The sun is shining today, so I choose the latter.

There's lots of chatter going on in the blogosphere about this year's CTUW, so I'll just point you to a few of those, beginning with one of the very first posts on this blog, from David Morse about last year's CTUW.  And then you can check out the Wall Street Journal blog and the New Health Dialogue about this year's CTUW, and our prospects for making the goal of covering all Americans a reality. 

Health Reformer’s Lexicon: Patient-Centered Medical Home

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Patient-centered medical home

The National Committee for Quality Assurance (NCQA) provides the following definition:

The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients and their personal physicians, and, when appropriate, the patient’s family.

It is a model of care that aims to provide structured, proactive and coordinated care for patients rather than episodic treatments for illnesses.

In a medical home, the primary-care doctor operates as a “home base” for patients, overseeing all aspects of patients’ health; scheduling regular tests and check-ups by tracking health records electronically; advocating for patients with specialists; and, with nurses and other personnel, helping patients navigate the medical system so they don’t fall through the cracks or neglect to care for a chronic condition such as heart disease.

Why it matters: The medical-home model promotes coordinated care—especially for patients with chronic conditions. This in turn cuts costs while improving the quality of care.

Roots: Pediatricians were first to coin the term “medical home.” Concerned that the care of children, especially kids with chronic conditions, was not being coordinated effectively between specialists and the child’s pediatrician, the American Academy of Pediatrics advanced the concept of coordinating care through one doctor in 1967.

Thirty years later, in 2007, leading primary-care doctors’ organizations—the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association—listed requirements for a medical home in a formal statement.

Among these requirements is the idea that insurers recognize doctors’ additional work and the added value to patients for “work that falls outside of the face-to-face visit” and reward it with more compensation.

In the last few years, the American Medical Association has backed the medical-home concept; and by last year, 10 states had bills promoting medical homes.

Where the term appears: The president’s health reform proposal, like the Senate bill, sees the medical home more as an answer to shortages of primary-care doctors, nurses and others. It would spend money on training medical personnel in more efficient ways to deliver primary medical care, such as medical homes.

NCQA has established a recognition program to evaluate whether practices are operating as medical homes. Select health plans are using recognition standards like these to reward qualifying practices for improving health care quality.

Previous Lexicon entries include:
- Sustainable Growth Rate
- Accountable Care Organization
- Meaningful Use

Creating a Positive Exchange

Enrique Martinez-Vidal, Director of the State Coverage Initiatives program, discusses the role of states in building and implementing health insurance exchanges:

I think we can all agree that watching the federal health reform efforts over the past couple of months has left us feeling like we are on a rollercoaster ride. Given our continued work with state officials, we know that despite the drama here in Washington, DC, the states must continue to focus on health care issues despite the historic recession that has caused dramatic deficits in almost every state. Over the past decade, we’ve documented the efforts of states to expand coverage to the uninsured, to reorganize and improve their insurance markets, and more recently, to undertake efforts to increase value in the health care system by redesigning the delivery system and exploring alternative payment incentives. Even this past year, despite fiscal constraints and uncertainty about potential federal reforms, a number of states made substantial strides in implementing reforms.

States have a wealth of experience with health reform efforts and, among the many lessons we’ve learned along the way, perhaps one of the most important is that the success of any reform is dependent on how well it is actually implemented.  As critical as good policy is to the inherent success of a reform, so too are the operational components. That’s where the reform rubber meets the road.

A perfect example and most relevant to us theses days is the concept of establishing state exchanges. We know that President Obama’s most recent proposal follows the Senate’s framework to have states play an important role in creating and overseeing health insurance exchanges. Moreover, whether or not federal reform occurs, we believe that states will be at the forefront of establishing exchanges. Some states are contemplating creating or already working towards implementing their own exchanges as a way to improve the functionality of the individual and small group markets. Likewise, individuals and employers are yearning for more comparative information about their insurance policy benefits and costs. While we already have the experience of Massachusetts’ and Utah’s initial work to look to, they took very different approaches. With more state experimentation in this arena, there will be various iterations along the policy continuum.

Because there still remain many questions regarding how to build an effective and sustainable exchange, we have begun the process of building an inventory of resources to support state work in this area. In late January, we hosted a meeting for state policymakers in partnership with officials from Massachusetts’ Commonwealth Health Insurance Connector Authority to learn from their experience thus far. Most recently, we released an issue brief Preparing for Health Reform: The Role of the Health Insurance Exchange, that raises many important issues that states must evaluate and consider before establishing an exchange. An exchange can do a lot – organize the insurance market, provide a central source of information, enable comparability of benefit designs, administer public subsidies, facilitate the purchase of insurance through standardized enrollment processes, and improve competition among carriers. And, at its very core, an exchange can seek to alter competition in the health insurance market from one based on avoiding risk to one based on price and quality. That is, if you build it correctly.

States policymakers need to develop a thorough understanding of both their uninsured and insured populations, the existing sources of public and private coverage, and the current structure of the commercial insurance market in their state. The roles and responsibilities of an exchange must be defined to determine the appropriate administrative and governance structure it should have. States may need to determine how premium subsidies (if there are subsidies) will be targeted and processed, how to be strategic with effective outreach and enrollment, as well as how to mitigate the potential for adverse selection where one participating carrier ends up with a disproportionate share of high-cost enrollees. In the final analysis, it is critical for a state to clearly understand the goals it is trying to achieve as it takes on the restructuring of its insurance markets.

So, if states build exchanges, will the people come?  While this question may only be answered over time, we believe that, for states, much will depend on assuring they are well-prepared by having laid the necessary groundwork for the development and implementation of these mechanisms that hold the promise of improving insurance markets.

Health Reformer’s Lexicon: Meaningful Use

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit. 

The term: Meaningful use – assuring that health information technology (HIT) is used in a meaningful way to provide better patient care.

Congress earmarked billions of dollars to spur investment in “health information technology” (HIT) and electronic health records technology by health care providers, but money came with a string attached known as “meaningful use.” To qualify for these subsidies, doctors and hospitals must put the HIT they purchase to “meaningful use,” to improve the quality, efficiency, safety and coordination of care, and reduce disparities and engage patients and families in their care.

Why it matters: There is a lot of money at stake. Estimates are that between $14.1 billion and $27.3 billion in subsidies could flow to qualifying providers. These funds will help providers invest in HIT infrastructure. As results from the 21st  annual Healthcare Information and Management Systems Society leadership survey indicate,

Asked to identify their single IT priority during the next two years, 42 percent of respondents identified meeting meaningful use criteria.

But as we’ve noted previously on this blog, HIT in and of itself will not improve health care, it is how we implement and use it to engage with providers and patients that truly matters.

Roots: The Health-e Information Technology Act of 2008 was introduced as a bill “to promote the adoption and meaningful use of health information technology.” But the term “meaningful use” was put on the map by the American Recovery and Reinvestment Act of 2009, aka the “stimulus bill” under the bill’s Health Information Technology for Economic and Clinical Health Act provisions.

Where the term appears:  The usage that has mattered most of late came just two days before the end of 2009 when the Centers for Medicare & Medicare Services and the Office of the National Coordinator for Health Information Technology issued proposed rules that can be read here and here to define “meaningful use.” At 700 pages, at least one wag at Modern Healthcare deemed them "meaningful obtuse.“

CMS expects to finalize its meaningful use rule later this year.

New County Health Rankings Highlight Opportunities for Quality Improvement

Lisa Letourneau, executive director of Quality Counts, considers the implications of a new series of reports on county-by-county health variations.

No matter how healthy a community is, there is always room for improvement. For proof, just look at the County Health Rankings released recently by the Robert Wood Johnson Foundation and the University of Wisconsin’s Population Health Institute.

At first glance, the report on my home state of Maine in many ways confirms what health reformers have long understood: health follows wealth. With a few exceptions, the more affluent counties on the comparatively urbanized, southern coast of our state have better overall health profiles than the less-affluent counties in the densely wooded, rural parts of the state. For example, in Lincoln County, a coastal community in the mid-coast area, 9% of the population reports itself to be in “poor” or “fair” health. By comparison, that is a relatively low level and puts the county in the 90th percentile of results overall. But in Aroostook County, all the way at the rural north end of the state, the figure is 18%, twice the target level.

Health Reformer's Lexicon: Accountable Care Organization

The Health Reformer’s Lexicon is supposed to be a weekly feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.  But what can I say?  Snowstorms, and other developments, all can get in the way. 

The term: Accountable care organization (ACOs)

In a recent policy brief that examines the ACO concept, Urban Institute researchers Robert Berenson, M.D., and Kelly Devers, Ph.D., provide the following definition:

 A local health care organization and a related set of providers (at a minimum, primary care physicians, specialists, and hospitals) that can be held accountable for the cost and quality of care delivered to a defined population.

Why it matters: As Berenson and Devers note,
 
Proposing a new entity with the word “accountable” in its title begs the question of who is becoming more responsible for what, when it comes to delivering high-quality and efficient health care.

Policy makers are looking at ACOs as they search for ways to deliver well-coordinated care that produces positive outcomes while also slowing the rise in health care costs.

Roots: The term ACOs emerged publicly in a 2006 Health Affairs article where a footnote traces its etymology as follows:

The idea of using the term ‘accountable care organizations’ … grew out of an exchange between Elliott Fisher and Glenn Hackbarth at a Medicare Payment Advisory Commission meeting in November 2006.” (Fisher leads the Dartmouth Atlas Project, Hackbarth is the chair of MedPAC.)

Usage: The more fully refined ACO concept appeared nearly three years later, and a similar concept –“accountable care systems”– was explored in JAMA. 

But the references that may matter most at this point are the ones found in health reform legislation.

The Senate Finance Committee’s bill would:

Allow providers organized as accountable care organizations that voluntarily meet quality thresholds to share in the cost-savings they achieve for the Medicare program. To qualify as an ACO, organizations must agree to be accountable for the overall care of their Medicare beneficiaries, have adequate participation of primary care physicians and specialists, define processes to promote evidence-based medicine, report on quality and costs measure, and coordinate care.

 

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.

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.

'Bending the Cost Curve' by Tackling Overuse of Diagnostic Imaging

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, examines how some communities are using evidence-based  guidelines to rein in a conspicuous source of health care overspending. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

If you look closely in Aligning Forces for Quality communities, you can see how local laboratories are grappling with some of the most vexing delivery issues in health care. And there is probably no more vexing issue than overuse of health services—an issue that has figured prominently in the health care debate as Congress and the president wrestled with the question of how best to control costs.

Dartmouth researchers have estimated that as much as 30 percent of health care spending is for care that doesn’t improve people’s health—and don’t just take their word for it. Thompson Reuters came out with a new study last October attesting to the reasonableness of this estimate.

Diagnostic imaging, especially when it involves lower-back pain, is one case drawing the attention of overuse detectives. Lower-back pain is the fifth-most-common reason Americans see a doctor, and the common use of expensive imaging technology to diagnose it has become controversial. For more than a decade, guidelines for treating lower-back pain have recommend delaying imaging use for most patients because their backs typically get better, and their pain often subsides, within a month. A recent study published in Health Affairs took a look at the relationship between the supply of MRI machines, and their use for lower-back pain. Surprise, surprise: The researchers found “a clear relationship between MRI availability and MRI use for low back pain patients.”

The Wisdom of Crowds?

David Colby, vice president of research and evaluation, writes about what you, our readers, selected as the most influential articles funded by the Robert Wood Johnson Foundation last year.

In December, we asked the public to vote on the most influential articles funded by the Robert Wood Foundation in 2009.  It was our second effort to draw outside feedback into our Year in Research process. What do you think about the wisdom of the crowd?  Did the crowd miss important articles or themes?  Did the Foundation miss funding some important articles?  Please join the discussions by posting your thoughts and comments below.

The articles receiving the most votes in 2009 are:

• Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems;
• What Newly Licensed Registered Nurses Have to Say About Their First Experiences;
• A Closer Look at the Economic Argument for Disease Prevention;
• Association Between School Food Environment and Practices and Body Mass Index of U.S. Public School Children;
• Geographic Variation in Public Health Spending.

The wisdom of which crowds?  Last year, my picks and the picks of our readers were different. Last year, the picks of the nation and those from inside the Beltway were different. This year, the picks of single article voters and those who voted for more than three articles were different. Those who voted for more than three articles chose:

• A Closer Look at the Economic Argument for Disease Prevention;
• Association Between School Food Environment and Practices and Body Mass Index of U.S. Public School Children;
• Geographic Variation in Public Health Spending;
• Slowing the Growth of Health Care Costs - Lessons from Regional Variation;
• What Does It Cost Physician Practices To Interact With Health Insurance Plans?

Now you’ve seen the full results of the poll, I would love to hear from you about the crowd’s choices and our process. 

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.

Call to Action: Tapping Nurses' Leadership and Expertise

Susan Hassmiller, senior adviser for nursing at the Robert Wood Johnson Foundation, writes about the need for nurses to be full partners in reforming the health care system and improving patient care.

There’s image and there’s reality, and the two are not the same where nurses are concerned.  Nurses are seen as trusted, caring, compassionate, skilled health care providers. But that image doesn’t fully capture the reality of the roles nurses play in our health care system, which are much more extensive, substantive, pivotal and robust. 

Today, the Robert Wood Johnson Foundation and Gallup are releasing an unprecedented survey of 1,500 opinion leaders that provides insight into what we need to do to ensure nurses’ place at the decision-making table—and to give health reform every chance to succeed. In many ways, the  two objectives are inextricably connected.

For years, nurses have come out on top of Gallup’s annual poll of most trusted professionals. It’s a truism that the public trusts nurses. But this survey goes deeper. It finds that diverse opinion leaders—including those in insurance, health services, government, industry and academia—say that nurses should have more influence on health systems and services. 

Addressing the primary care workforce shortage to come

Deanna Okrent, senior health policy associate with the Alliance for Health Reform, writes here about a predicted shortage of primary care providers to treat a larger pool of insured Americans.

With the prospect that an additional 31 million Americans may gain insurance coverage under national health reform, many warn there may be too few primary care providers to treat them. 

Following enactment of reform in Massachusetts -- a state often studied to help inform the current debate -- increased demand for primary care led to longer waits for medical appointments and unmet needs for some types of care.  This may have been the result of pent-up demand from previously uninsured individuals. In a May 2009 paper on health reform in Massachusetts, Sharon Long notes that this demand is expected to stabilize as people have coverage for a full year and longer.

Many predict a similar phenomenon after national reform is implemented.  A contributing factor is the declining interest in primary care as a professional goal. Far fewer medical graduates entered residencies in family medicine and internal medicine in 2009 than they did in 1999. Among the reasons graduating physicians choose specialties and subspecialties over general practice are: 1) their large educational debts and  2) the relatively low compensation of primary care physicians, which means it takes longer to pay back that debt. 

Robert Otto Valdez makes Christmas appeal to the U.S. Senate

Robert Otto Valdez, PhD, executive director of the Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico, channels FDR and Jimmy Stewart to make the case for expanding Medicare to achieve universal health coverage.

I was reminded the other day watching “Mr. Smith Goes To Washington” that
sometimes you just need to say what needs to be said until the Senate hears what is
right. This is right: We all have a right to life and liberty. These are founding principles
of our nation; they define our social contract to one another. And one cannot have life
and liberty without good health. ALL those living and working in the USA must have
access to quality health care and healthy communities, lest we break the social
contract itself. The Senate’s debates on health insurance reform must restore our
nation’s social contract in accord with these principles.

President Franklin Delano Roosevelt commented that “the test of our progress is not
whether we add more to the abundance of those who have much; it is whether we
provide enough for those who have too little.” The Senate would be wise to heed
these words as they debate health insurance options for our nation. History shows
that private enterprise and the profit motive do not ensure the well-being of every
individual - public commitment is essential to achieve our ideals as a society.

We would do well to recognize our own history with the Social Security program,
the cornerstone of our nation’s economic security. At first, coverage was
limited to only a few. Only gradually, over several decades, was the program
expanded to its present nearly universal form. Today, it is recognized as our nation’s
most important anti-poverty program, the major or only source of income for many
seniors.

I'm dreaming of a white paper ...

David C. Colby, vice president of research and evaluation at the Robert Wood Johnson Foundation, shares his favorite health reform policy papers in the spirit of regifting.

While many of you might already have visions of sugar plums dancing through your heads, I (not surprisingly) have health reform on my mind.  That doesn’t mean I am not in the holiday spirit. In fact, I propose a “white elephant” holiday gift exchange here at the foundation. ‘Tis the season of regifting.  The best part of the gift exchange is how it highlights that value is truly in the eye of the beholder.  Many recycled gifts are still perfect gifts.

In that spirit, I want to regift to you some of this year’s health reform policy papers that are as good as stocking stuffers today as when they were released last February, April, June or October. I started with 12 gifts of policy analysis, but with Hanukkah wrapping up tomorrow, feel free to pick your favorite eight…

America’s Uninsured Crisis
Released in February by the Institute of Medicine (IOM), this report addresses three key questions: (1) What are the dynamics driving downward trends in health insurance coverage? (2) Is being uninsured harmful to the health of children and adults? (3) Are insured people affected by high rates of uninsurance in their communities?

Crossing Our Lines: Working Together to Reform the U.S. Health System
In June, three wise men, former Senate Majority Leaders Howard Baker, Tom Daschle and Bob Dole completed The Leaders’ Project on the State of American Health Care, a two-year consensus-building process resulting in a plan for reforming America’s health care system.  This report outlines their key recommendations.

How Do We Pay For Health Reform?
Conducted by Urban Institute researchers and released in July, this analysis reports that savings from many popular health reform ideas would finance the lion’s share of the cost of comprehensive health care reform. The authors also conclude that a combination of revenue options would provide more than enough money to fill the gap between the cost of reform and the savings resulting from it.

How Does the Quality of U.S. Health Care Compare Internationally?
This analysis from the Urban Institute, which we released in August, looks at the evidence on how quality of care in the United States compares to that in other countries and highlights the implications for health reform.

How Will the Uninsured Be Affected by Health Reform?
In this four-part series, released in August by RWJF and the Kaiser Commission on Medicaid and the Uninsured, the Urban Institute’s Lisa Dubay and Allison Cook calculate how many uninsured people could gain coverage through a health reform scenario that draws on proposals being discussed on Capitol Hill.

Bending the Curve
Released in September, this report is not about making candy canes. Compiled by the Engelberg Center for Health Care Reform at the Brookings Institution, the paper proposes that health care reform should include comprehensive efforts to achieve higher-value care. The report was co-signed by a distinguished group of scholars and policymakers: Joseph Antos, Ph.D., (American Enterprise Institute for Public Policy Research); John Bertko (Brookings Institution); Michael Chernew, Ph.D., (Harvard Medical School); David Cutler, Ph.D., (Harvard University); Dana Goldman, Ph.D., (RAND Corporation); Mark McClellan, M.D., Ph.D., (The Brookings Institution); Elizabeth McGlynn, Ph.D., (RAND Corporation); Mark Pauly, Ph.D., ( University of Pennsylvania); Leonard Schaeffer (University of Southern California); and Stephen Shortell, Ph.D., (University of California, Berkeley).

Is Massachusetts Reform Working for Doctors?
This study, published in the Oct. 21 issue of the New England Journal of Medicine, finds that 70% of practicing physicians in Massachusetts support health reform three years after its passage in 2006. We partnered with Blue Cross Blue Shield of Massachusetts Foundation to fund the research, which was designed and conducted by researchers at the Harvard School of Public Health.

Trust for America’s Health Prevention Poll
The poll, conducted for RWJF and Trust for America’s Health by Greenberg Quinlan Rosner Research and Public Opinion Strategies, indicates the majority of Americans support disease prevention investments as a part of national health reform. Poll findings were released in November.

A State Policymaker's Guide to Federal Health Reform
These three documents released by the National Academy for State Health Policy (NASHP) last month identify the most challenging health policy issues that states are addressing; describe the tools they have at their disposal and how federal health reform may affect those tools. It also describes the support they would need to implement federal health reform legislation.

County and City Health Departments: The Need for Sustainable Funding and the Potential Effect of Health Care Reform on their Operations
This report, released earlier this month by Health Management Associates, analyzes the effects that substantial funding cutbacks from local, state, and federal sources have had on already-strapped local health departments.

Leveling the Field - Ensuring Equity Through National Health Care Reform
Bruce Siegel, M.D., and Lea Nolan, M.A., from the Center for Health Care Quality, The George Washington University School of Public Health and Health Services, published this piece in the Dec 3 edition of the New England Journal of Medicine. The paper discusses how health reform legislation would reduce racial and ethnic disparities by extending coverage to disadvantaged groups.

The Cost of Failure to Enact Health Reform: Implications for States
Released at the end of September, researchers from the Urban Institute used their Health Insurance Policy Simulation Model to estimate how coverage and cost trends would change in every state between now and 2019 if the health system is not reformed.

Wishing you a happy and healthy holiday season. May all your policy papers be white!