The Users' Guide to the Health Reform Galaxy

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.

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."

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.

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.

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. 

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. 

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!

Performance Measurement and Public Reporting Are Driving Tangible Quality Improvements in Minnesota

Jim Chase, president of MN Community Measurement, argues that results from six years of measurement and public reporting in Minnesota and other regions have boosted quality, with clear implications for national health care reform. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

Last year, doctors at the HealthEast Care System in St. Paul noticed something interesting: After starting to meet monthly to focus on the dozen health care quality measures that MN Community Measurement reports publicly each year, they found they were among only a handful of Minnesota medical groups to get above-average grades on at least half the measures.

The annual measurement report “demonstrated that we could achieve better outcomes for our patients -- because others were doing it,” said Linda Walling, medical director for clinical informatics at the 14 HealthEast clinics. “Our clinicians want the best for their patients and this appealed to their competitive nature.”

That first step, it's a doozy

It’s tough times for those of us in the blogosphere who are focused on health reform.  After all the frenzied activity this year so far, we’re now in the position of wondering what deals are being cut behind closed doors as the Senate debates its version of a bill.  Oh, you still hear the occasional hand-wringing about whether [INSERT PREFERRED VERSION OF BILL] will cover enough people, do enough to control health care spending, or, if you want to believe the extremists, end up funding amoral behaviors, but for the most part, we’re all waiting to see if a signed bill will be in our stockings, or not. 

I have two innate characteristics that tend to war with each other over things like health reform legislation—one, I’m a rules-driven person, and I believe in process to the extent that it allows for fairness and for a range of perspectives to inform the debate, but two, I’m also naturally impatient, and I hate process when it is subject to numerous wrangling and gaming attempts until it no longer looks like a process anymore, it just looks like...a bureaucracy.  So part of me wants to find value in this hurry-up-and-wait period that Congress and the Administration have been engaged in all year, with respect to health reform legislation, but part of me wants to say, let’s just get this part over with, already, and move on to the next part.

Some of my impatience, I think, comes from what I learned in law school (on top of learning that I didn’t, actually, want to practice law), and it’s this:  the law, or rather, the compilation of statutes and legislative acts and regulations that we understand to be the law, is a really blunt instrument for change.  No matter how many pages of legislation you pass, legislation alone will not change the behaviors and practices that have led us to our current health care woes.

Health reform: A holiday gift for every consumer?

Steven Findlay, senior health policy analyst with Consumers Union, explains why health reform would benefit everyone, even if it is initially disorienting.

The great health reform debate of 2009 has moved into a new phase this month with the full Senate now debating the legislation. I can’t imagine a more profound Christmas, Hanukkah, and Kwanzaa present for the nation than a Senate bill by December 24. The redeemed Scrooge himself would be proud.

Though initial Senate passage won’t seal the deal, it would create momentum that could be tough to stop.

Misinformation about how this legislation will affect consumers has abounded amid the hyper-partisan debate and the complexity of the bills. So let’s be very clear on this critical point: This legislation will benefit every American in the long run. Every single one of us. And we are not talking about some vague social good, or an indirect trickle-down effect. The legislation will directly impact our lives for the better by expanding health insurance coverage and making it more secure, by making the health system fairer and more consumer-friendly, by taking solid steps to improve the quality and safety of care, and, over time, by constraining health care costs and premiums.

To be sure, if it becomes law, the legislation will also create anxiety and confusion. Change always does. New choices and new rules would bring initial stresses. And, of course, the legislation creates a new and far-reaching demand — the requirement to have health insurance. There’s no way around it: That requirement will trigger some tough moments for millions of currently uninsured families. They will have to choose whether to adjust their budgets and obtain coverage or pay a tax penalty (and remain uninsured) because they decide they simply can’t afford the coverage even with the government subsidies that will be available.

Imagining the pain of such decisions already makes us sad. But we at Consumers Union believe that the “individual mandate” or “shared responsibility” requirement will provide people with something of significant value. First and foremost, it could spare your family from severe financial strain or even bankruptcy if serious illness strikes or an accident occurs. Health insurance also lowers the barrier to ongoing care with coverage of routine doctor visits and preventive health services.

Regulators need to step up enforcement to protect consumers

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

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

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

Rhetoric of consumer choice may be a double-edged sword

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

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

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

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

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

Preparing for health reform in the states

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

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

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

Where were you?

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

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

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

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

How important are individual mandates in achieving health reform?

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

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

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

Talking about health care quality on the Hill

Anne Weiss, Team Director for Quality/Equality at RWJF, writes about a recent series of visits that took place in DC.

Earlier this week, I found myself walking the marble hallways of Capitol Hill, right at ground zero for health reform as the House and Senate were preparing final bills for vote.  RWJF’s Aligning Forces for Quality (AF4Q) grantees were visiting with their Congressional delegations on Capitol Hill, and I got to come along for the ride.  (For those who just came in, AF4Q is the Foundation’s signature effort to improve health care quality in 15 communities around the country.  You can learn more about AF4Q here) 

I’m not talking here about a casual “hey, I was in the neighborhood, so I thought I’d drop in and say hi” kind of visit, either.  Just imagine what it might take to nail appointments for 15 grantee teams with two Senators and at least one Representative for EACH team during a typically frantic 48 hours on the Hill.  Then factor in that we were there during a week when the national debate over health care reform was positively deafening (and so were the demonstrators on every corner, especially the guy who threatened eternal damnation for supporters or opponents of the public option, I forget which).  This formidable undertaking took months to plan and prepare for, so we were lucky to have all the support we needed from RWJF’s Project Connect, a project that helps RWJF grantees build relationships with their members of Congress and other policy-makers.  The Connect support is invaluable for lots of reasons, but two especially:  one, they know how to help grantees make the most of a few precious moments with very busy legislators and two, they kept us all safely on the right side of legal rules that prohibit RWJF grantees from lobbying.  Thanks to Project Connect, all 15 grantee teams arrived in Washington on Monday morning having thought about what they wanted to get out of the meetings, how to tell their stories effectively, and prepared to make their pitch in a hallway or on an elevator if required.

Are accountable care organizations the answer to our problems?

Kelly Devers and Bob Berenson of the Urban Institute write about the latest policy brief by Urban and RWJF, which focuses on the concept of creating more accountable entities in health care.
 
In the often contentious health reform discussions, ideas that are good in theory often gain quick currency, but deserve closer examination as to whether they might actually work.  One such idea is the accountable care organization (ACOs).  Accountable care organization are entities—and we’ll clarify what we mean by “entities” in a second—that are intended to address one of the conundrums of our current health care system:  how to pay providers for high-quality, efficient care.  Under our current fee-for-service payment system, we end up paying for volume, not quality or value, that is better quality for the money we spend. In addition, many of the ways we deliver health care, especially for common chronic conditions like diabetes or heart disease, have become increasingly fragmented and cumbersome for both the provider and the patient.
 
To address these interrelated problems of provider payment and delivery, many health care leaders and experts have become increasingly interested in ACOs as a way to bend the cost curve, i.e., deliver higher-quality care to more people without contributing to our escalating health care tab.  ACOs are commonly understood to be local entities comprised of clinicians—primary care and specialty physicians, hospitals—that are responsible for delivering quality care and controlling health care costs in ways that current providers are not. 
 
However, the concept of what ACOs are and how they might work is still murky.  Therefore, in a new policy paper out today from the Urban Institute and the Robert Wood Johnson Foundation, we try to go to uncharted territory, and wrestle the ACO concept into the real world. 

The secrets of Massachusetts' success (including bigger carrots and smaller sticks)

Robert Restuccia, Executive Director of Community Catalyst, writes about the less-talked-about lessons from Massachusetts-style health reform.

Massachusetts as model – it’s a common claim in health policy circles. With the lowest rate of uninsured residents in the nation – just 2.7 percent – it’s clear to those watching that Massachusetts’s mix of Medicaid expansions, sliding scale subsidies, private insurance reforms and individual mandate are working to expand coverage and have served as the template for national reform. 

But there are other, less obvious lessons from the Massachusetts experience that have not really filtered into the political and policy discourse in Washington.  Here are a few of the most important.

There are good policy and political reasons for putting coverage expansions ahead of cost containment

Massachusetts made the strategic decision to tackle health coverage before cost containment – making it easier to keep all players at the table.  Despite bold words to the contrary at the start of the process, the Congressional leadership and the Obama Administration too are finding it hard to arrive at a consensus on significant cost containment while still keeping the industry backers of coverage expansion at the table.  But Massachusetts is using the pressure from the cost of its coverage expansion to jump-start a more serious debate about cost containment than ever before.

Faster is better

The current health reform is not the first time Massachusetts attempted to enact a near-universal coverage program.  In the late 1980s under Governor and soon-to-be Presidential candidate Michael Dukakis, Massachusetts enacted a major health reform proposal with an employer “pay or play” as its central element along with a number of other smaller programs.  Today those smaller programs, implemented almost immediately after reform passed, are still going strong, while the employer pay or play, which was not scheduled to go into effect for several years after passage, was first delayed and then repealed as the political and economic environment shifted.

What Massachusetts docs think about health reform

Gillian K. SteelFisher, a research scientist at the Harvard School of Public Health, writes about a recent poll she and her colleagues conducted with physicians on health reform in Massachusetts, highlighted today in the New England Journal of Medicine.

With the passage of the 2006 health insurance law, Massachusetts has made significant changes in health insurance coverage and now can claim the lowest uninsured rate in the country.  As the debate on health reform in Washington, D.C. unfolds, policymakers at the national level have turned their attention to the state’s health reform; in fact many of the Congressional proposals currently on the table include elements from the Massachusetts plan.  In this process, there have been some criticisms of the reform, with suggestions, for example, that the reform has made it more difficult for people to access care.

We already know from past research that the reforms hold majority support among the public, but what about physicians who are on the front lines of care and directly see the potential impacts of that reform?
To address that question, my colleagues and I polled more than 2,000 Massachusetts physicians.  Our goal was to assess their perceptions in three areas: their overall support for the legislation, their views of its impact on their own practice, and their views of its impact on health care across the state.

The long and winding road to reform

Peter V. Lee, co-chairman of the Consumer Purchaser Disclosure Project (CPDP) and executive director for national policy of the Pacific Business Group on Health, writes about provisions to improve the quality of health care in pending reform legislation.

We’re seeing important movement on health care reform front, as the Senate Finance Committee moves its version of a bill to now be part of the debate. Whether or not we manage to get one bill that everyone can agree on, there’s no doubt that some have found the long wrangle in Congress over health reform depressing. But call me an incurable optimist—after looking at all of the different versions of the bills floating around, I’ve taken heart in the fact that while none of the bills are perfect, they all contain good provisions that could help improve the quality of health care and make care more affordable.

For instance, there is very good language in each of the three proposals – in the Senate Health, Education, Labor and Pensions Committee, Senate Finance and House "Tri-Committee" – on measuring and reporting quality. They call for setting national priorities with processes that engage consumers, employers and other stakeholders; make sure the patient’s perspective is at the center of measurement efforts; and require more information on how patients fare. The proposals also focus on comparative-effectiveness research so patients, doctors and insurance-purchasers know which treatments really works.

CBO's scoring window: why it matters

Michael J. O’Grady, PhD, a senior fellow at the National Opinion Research Center at the University of Chicago, writes about the Congressional Budget Office and how it scores proposals.  The CBO recently issued a price tag for the Senate Finance bill on health reform that is being voted on right now.

The current debate our country is having about overhauling our health care has highlighted the sometimes challenging interaction between the worlds of budget policy and health policy.  One such interaction is the issue of scoring windows.  The Congressional Budget Office (CBO), the official scorekeeper of reform proposals, typically projects spending for a 10-year period.  However, on September 14, Senator Kent Conrad (D-ND), Chairman of the Senate Budget Committee, requested that CBO provide a twenty—year estimate of the Senate Finance Committee bill.  He was right to do so, and here’s why.

First, let’s talk about why CBO moved from the original 5-year window to the current 10-year window.  The shift occurred for a number of reasons.  The Budget Committees began looking at a longer time horizon.   In the FY 1994 Budget Resolution Congress established a 10-year budget “point of order” in the Senate.  Then in 1995, Speaker Gingrich introduced a seven year balanced budget plan, adding further momentum to estimate budget impacts beyond the five-year window.  By 1996, CBO released its first 10-year budget baseline.

Let's learn some health reform lessons at home

Lynn Blewett, director of the State Health Access Data Assistance Center (SHADAC), shares more lessons from the Massachusetts experience with health care reform. 

As the federal reform moves forward, we’ve heard many different ideas about how to improve access to health insurance coverage, bend the curve of growing health care costs, and improve the efficiency and quality of health care services.  Washington policy-makers are grappling with uncertainty about how these reform strategies will work and what the unintended consequences might be.  Wrestling with this type of ambiguity is inherent in most policy-making, but it’s particularly challenging when the stakes are as high as they are for health reform.  After all, Congress doesn’t often attempt to reform one-sixth of our economy in one legislative session.

One way to resolve the uncertainty about reform strategies is for policy-makers to look and see how other countries have designed their health care systems.  However, the US is so different from other countries culturally and historically, it’s often impossible to simply transplant reform ideas from outside the US and have the same impact.   We aren’t entirely out of luck, though.  We do have home-grown evidence based on what works.  This evidence is provided by the states, who have been implementing many innovative reforms with some very promising results.  States are demonstrating that reforms can lead to effective, efficient American health care with increased access to coverage. 

Following the money: doing health care better at less cost

Thomas Bodenheimer, a physician and professor at the UCSF School of Medicine, and Rachel Berry-Millett, a University of California medical student, preview an upcoming Synthesis report on care management.

As much as we all aspire to an ideal state of health, there are some people who are sicker than others in the United States.  Approximately 10% of patients consume 70% of health care expenditures.  In this group are the patients who have multiple chronic conditions, many medications, frequent hospitalizations, and limitations on their ability to perform basic daily functions. 

Health care spending for people with five or more chronic conditions is 17 times higher than for people with no chronic conditions. With the projected growth in the Medicare population in the next decade and the far higher prevalence of chronic conditions among this group, the cost of caring for this population threatens Medicare’s future viability. A real way to “bend the curve” is to improve the care and coordination of people with multiple chronic conditions.

Recent research that we conducted for the RWJF Synthesis Project showed us that this challenge may, indeed, be possible to address.  We preview the research in a new NEJM perspective, and our full Synthesis report will be available in a few months. 

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.

Lessons from Massachusetts about the impact of health reform

Sharon Long of the Urban Institute writes about how health reform might change--or not change--the health insurance many people have.

I suppose I was naïve, but I really thought we’d be making progress on health reform this fall. Instead, we’re still mired in contentious debate based as much on fear as facts. One concern is the possibility that health reform could undermine employer-sponsored health insurance coverage—the backbone of the US health care system. Massachusetts, which has mounted an ambitious initiative with many of the same features currently under consideration at the national level, offers a real-world case study of what health reform can mean for employer-sponsored insurance (ESI) coverage.

The bottom line? ESI was not weakened once health care reform took hold in Massachusetts, which now enjoys the country’s lowest rate of uninsurance. Indeed, ample evidence suggests that the 2006 health care reform law significantly boosted ESI coverage, countering the trend toward lower ESI coverage in the rest of country.

Bringing home the costs of doing nothing

Bowen Garrett, a senior research associate at the Urban Institute, writes about new research about the consequences of doing nothing on health reform.

The health reform proposals currently under heated debate, by the very nature of the problems they are tackling, are complex and contain many moving parts.  This complexity makes it difficult for people to envision what their health insurance and health care will look like under reform.  It is natural for those who have good coverage now to prefer their current situation, which they know, to an uncertain world under health care reform.  Being shielded from the full costs of the health care they receive, people who now have coverage from their employers can be comfortably numb to the sting of rapidly increasing health care costs that we all face.  The problem is, the status quo is not lying still.  It is moving—in a very bad direction.

Earlier this year, my colleagues and I at the Urban Institute put out a report about the economic implications for the nation if health reform legislation does not happen this year.  Based on economic trends and health care cost growth and other factors, we predicted that large numbers of people who have private health insurance coverage now would lose it over the next 10 years.  Middle-class families would be hit the hardest.  Health care costs paid by employers, and federal and state governments, would rise dramatically.  Individuals and families would be forced to pay more in taxes, face slower wage growth, and bear even higher out-of-pocket health care costs than they do now. 

Our findings for the nation as a whole were striking and sobering, but they become even more relevant to us when they get closer to home.  So today, with the Robert Wood Johnson Foundation, we’re releasing a report that estimates what would happen state-by-state, and in the District of Columbia, if health reform fails.   

Are we there yet?

Many years ago, I went to law school, passed the New York State bar, and then never practiced an hour of law subsequent to that time.  I wanted to promote social change using communications and policy advocacy as my tools of choice, not the law.  But even though I found law school to be, on the whole, a fairly miserable experience, I did learn some vital lessons there about what the law can and can’t do to change institutions and people in our society.

Our lives are fundamentally governed by our political/legislative system that in turn governs other systems, like the law.  The air we breathe, food we eat, the schools our children attend or don’t attend—all of this, influenced by law.  But most of the time, we’re not aware of the laws and legislation and regulations that are governing our existence—and even if we are, we may not care about them very much.  Because unless we’re actually breaking the laws, and are then caught and punished, we’re often living quite comfortably within the legal limits imposed on our existence.  E.g., I don’t consciously think about the speed limit when I’m driving to and from work every day, I’m just sort of automatically trying to not drive like a speed demon maniac. 

The possibilities of aligned interests on health care

Margaret Stanley, former executive director of the Puget Sound Health Alliance, writes about the value of bringing diverse stakeholders into local alliances to reform health care.

As national leaders have learned again and again, assembling a fractious group of doctors, hospitals, insurers, businesses, patients and public officials around something as complex and divisive as overhauling health care isn’t easy.

But nowadays, as reasonable, well-intentioned people try to reach agreement on health reform in the midst of the ranting and clouds of misinformation, reaching consensus is especially important, because everyone’s got a role to play in making our health care better. 

From what I can tell, it may be easier to achieve true consensus around health care reform at the local level.  That’s why much of my hope for a real health care overhaul rests on the power of local organizations, like the one I headed for three years, the Puget Sound Health Alliance.  In a few years, we were able to forge partnerships across stakeholder lines to improve the quality and efficiency of health care across the Greater Seattle region.