Health Reform Hiatus – or Not

I’ve been reading so much about health reform that the inside of my eyelids are burning with headlines about draft committee bills, CBO scoring, Republican responses, editorials for and against various amorphous proposals, and multiple organizations advocating about a public plan option, a public plan option, a public plan option…….

I was hoping that for the July 4th Congressional recess week the public’s and pundits’ attention would go elsewhere, but then I saw this week’s Economist cover picture of President Obama:

Economist Magazine - June 27, 2009 Obama and Health Reform
(If you look closely you can see that the syringe is graduated in Trillions of dollars from $0.25trn to $1.5trn – indicating that paying for health reform is likely to be the main cause for political pain.)

International Perspectives
International perspectives may be useful in assessing healthcare systems and reform options.  Usually people, (and pundits), in the US look to other countries for lessons about how to fix the US’s problems – despite Atul Gawande’s January 2009 New Yorker article that described how other countries’ health care systems have historical roots rather than being based on social contracts or grand political decisions.

Rather than looking outward from the US, the Economist provides the opportunity to see how other countries view the US health care system and out current reform efforts.  [Note: the British have no to observe the July 4th holiday hiatus – after all, for them the date doesn’t mark a holiday of independence, but rather the beginning of the unraveling of their global colonial empire.]

The June 26th issue has 2 one page columns about the politics of health reform, and a 3 page article that looks at the problems and possible solutions.  The article, “Heading for the emergency room,” is particularly interesting since it uses the terminology I adopted several years ago to describe the issues of high cost and limited insurance coverage as symptoms rather than as fundamental problems in the US healthcare system, and to highlight the fundamental problems as actually being  the incentives created by the US’s Fee-for-Service (FFS) reimbursement system.  As the article two sentence introductory summary clearly states: “America’s health care is the costliest in the world, yet quality is patchy and millions are uninsured.  Incentives for both patients and suppliers need urgent treatment.”  Although I’m sure that US physicians, (and other clinicians), and hospitals, (and other healthcare institutions), wouldn’t want to be called “suppliers,” the analysis is spot on.

The article also addresses issues of prevention, health IT, and increasing competition information, transparency and accountability, but eventually returns to the conclusion that incentives need to be realigned – “More competition and transparency would help, but the main goal of any reform plan must be to address the perverse incentives that encourage overconsumption [and overdelivery] and drive up costs.”

This is the same conclusion that’s been reached in Massachusetts.  The state’s Special Commission on the Health Care Payment System is expected to release their recommendations in July about how to take health care reimbursements in the state from being based upon a FFS system to one that pays physicians, hospitals, accountable care organizations, etc. using global payments – a term that has multiple possible meanings which will get more precisely defined during the legislative/regulatory process in the coming months.

Conclusions
Stat tuned.  Following the July 4th hiatus, Congress will be in session for 4 weeks and there will certainly be lots of action.

Congress’ ability to move health legislation towards consensus and closure in July will be very important since when they return in September there will only be 25 legislative days until the October 15th trigger date for using the Reconciliation rules in the Senate. Of course, there is no requirement that Reconciliation be used after October 15th to achieve the President’s goal of health reform this year, but if bipartisan agreement cannot be reached before then, the temptation to go the Reconciliation route requiring only 50 votes to pass legislation will be very hard to resist – despite the fact that it may limit the substance of what can be included in health reform.

At the state level, Massachusetts has been touted as a model for national health reform – having achieved >97% insurance coverage without the use of a public plan. Its actions in the coming months to realign incentives towards quality, value and team-based, patient-centered care rather than volume of services and clinician autonomy, may be even more significant for truly transforming healthcare in the United States – assuming that healthcare in the States are to become united rather than continuing to be segregated across state lines.

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