The Users' Guide to the Health Reform Galaxy

On health, and health care, everywhere

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

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

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

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

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

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

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

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

Health reform could hurt minority groups if not done right

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 that equity should be an important component of health reform.

Health care reform could actually hurt minority groups unless Congress makes some fixes. Without an explicit focus on equity, reform could leave millions of these Americans behind.

The goal of the reform bills in the House and Senate is to dramatically expand access to coverage, including for minority groups, which are traditionally under-insured. But the bills also envision measuring doctors’ and hospitals’ results and paying them based on how well they perform. And while that is a laudable goal, it could also hurt minority groups if not done right. If, for instance, we start measuring and penalizing hospitals depending on how many patients need to be admitted again, hospitals could have incentives to turn away the poorest and sickest patients; who tend to also be people of color. And safety net hospitals that underperform, already overburdened and underfunded, would be further deprived of resources.

The issue looms large given that racial and ethnic minority groups will be in the majority in the U.S by 2050. They already account for half the uninsured, are poorer in health, suffer more disease and are more likely to get inferior care. There are also equity implications in the transformation taking place in provider reimbursement as the notion gains ground that we need to systematically and rigorously examine how well our doctors and hospitals perform and pay them accordingly.  Especially important, in the interest of attaining quality care for all patients, is measuring how well the system treats minority groups.

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

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

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

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

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

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

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

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

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

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

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

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

What Massachusetts teaches us about emergency departments and reform

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

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

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

Close the revolving door at our hospitals

Bruce Siegel, director of RWJF's Aligning Forces for Quality, a national effort to improve health care quality in targeted communities, writes about reducing readmission rates.

Many of our hospitals, we were reminded last week, aren’t very good at following up in order to make sure that heart attack and heart failure patients won’t have to be admitted again shortly after being discharged.

The reminder came from a new study based on data from the Centers for Medicare and Medicaid Services that found that one in four heart attack patients and one in five heart failure patients are back in the hospital within 30 days of their discharge. The study confirms what people in medicine know: avoidable hospital readmissions are a serious and widespread problem. And as the health reform debate continues to unfold in Washington, it is a powerful reminder of how poor quality health care robs the system of precious resources that could be used to expand access to care. As a study reported earlier this year in the New England Journal of Medicine found, unplanned rehospitalizations cost Medicare alone more than $17 billion in 2004 – one reason why Congress and the Obama administration are weighing incentives to induce hospitals to lower readmission rates.