Encouraging Communications About Patients’ Goals

Posted on September 18, 2009 by Michael D. Miller MD

I attended a great event yesterday where experts discussed how to improve healthcare quality and safety by increasing patients’ involvement in making healthcare decisions.

This seminar, “Patient-Centeredness and Patient Safety: How Are They Interconnected,” was organized by the Kenneth B. Schwartz Center and sponsored by the Massachusetts Medical Society and CRICO/RMF. Don Berwick (President & CEO of the Institute for Healthcare Improvement) was the main speaker followed by a panel consisting of two patient safety leaders from local hospitals and a patient involved with promoting patient engagement in quality improvement.

To start the event, Dr. Berwick discussed how his thinking about healthcare quality had evolved over several decades, and his increasing belief in the importance of patient involvement. He discussed his Health Affairs article on Patient-Centered care, and summarized his current thinking about how to design patient-centered care in 8 bullets:

Place the patient at the center
Individualize
Welcome family and loved ones
Maximize health influences within care
Maximize health influences outside of care
Rely on sophisticated, disciplined evidence
Use all relevant capabilities – waste nothing
Connect helping influences with each other

Communications Is Crucial for Achieving Patient-Centerdness and Goal Sharing
The essence of the panel’s discussion was about how to improve communications among patients and their clinicians so that each others’ goals were shared and understood. One example raised by a panelist was initiatives to prevent patients from falling in the hospital. Patients may see nurses being in bathrooms with them as intrusive or uncomfortable, but discussing their shared goal of not having patients fall and hurt themselves shifts the context of the nurse’s action and enables it to be embraced by the patient rather than resisted.

From the patient’s perspective too often clinicians may have their own ideas about what the goals of the treatment should be, but without understanding the patient’s life interests and goals the two may be disconnected. For example, clinicians often ask patients what they do for work to understand if the treatment or the outcomes will be compatible with their jobs, but often patient’s happiness or life fulfillment is related to something outside of work, such as playing the piano, playing with grandchildren, rollerblading, hiking with their dogs in the mountains, or hang-gliding. Treating a patient’s injury or illness so they can do (or be able to try to do) those activities may be very different than what would be indicated if the goal was to enable them to work in an office.

Creating Policies to Promote Communications and Goal Sharing
Dr. Berwick’s presentation also included a brief discussion of how evidence based medicine (EBM) can improve patient safety by avoiding unnecessary care and setting realistic expectations about the outcomes for chosen treatments. This is captured in his 6th bullet above. One of the challenges in the current push towards more EBM – and comparative effectiveness research (CER) – is what to actually measure in this research. Combining the health system’s desire for optimal outcomes with patient-centeredness, (i.e., his 2nd bullet – “Individualize”), could be achieved by including the patient’s goals for their treatment as one of the outcomes measured in EBM and CER programs.

Benefits of Measuring Achievement of Patients’ Goals as an “Outcome”
Process measures, (such as percentage of patients who’ve received a recommended treatment), are usually easier to evaluate, but are really proxies for clinical outcomes. Actual outcomes like mortality or hospitalization can be harder to evaluate, in part because of individual patient differences and thus the raw data needs to be risk adjusted. However, measuring achievement of the patient’s goals could be very important and valuable to add to these evaluations – and could be a rough way to inherently risk adjust the data, i.e. the “goals” of treating a broken hip may be different for a 50 year old person than someone who is 70. The actual measurement of such goal achievement could be done based upon answering the question of “how well were the patient’s goals met?” Clearly this would have to be quantified in some way – and perhaps that could be done by the patients themselves on an 11 point scale from 0-100%.

Not only would measuring this “patient goal achievement” outcome add a useful dimension to some research, but it would also put the question of “what are the patient’s goals?” right at the front of the patient-clinician conversation. And in the context of health reform and system improvement, by using the dictum of, “we manage what we measure,” measuring how well delivery systems and clinicians are achieving patients’ goals could be an important force for transforming care delivery.

Bottom Line for Patients and Clinicians
The next time you’re a patient talking to a clinician, be sure to talk about your goals for treating whatever ailment caused you to see that clinician. And clinicians need to tell their patients what goals they expect to achieve from the treatment they’re recommending. This is the start of a conversation since the patient’s expectations may not be realistic – such as for a patient with a severe fracture who wants to run a marathon in three weeks. But by understanding each others goals and expectations they can agree on what should be done and how to proceed.

Need for Continuity of Care and Primary Care Clinicians
Of course some patients may seek to “doctor shop” looking for a clinician who will promise to achieve their goals. This can be good if the first clinician isn’t attuned to the patient’s wishes, but it can also be bad if the patient’s expectations are unrealistic. That is why having a trusted relationship with a primary care clinician can be so important, since their PCC can help them evaluate and digest other clinicians’ recommendations. Again, it comes down to ongoing and two-way communications to understand goals and jointly develop treatment plans and decisions.

Biotechs Biting the Dust

Posted on July 22, 2009 by Michael D. Miller MD

On Tuesday, Epix Pharmaceuticals announced that they were dissolving. And unlike many innovative life sciences companies, they’re not being acquired by another company to take advantage of their research, nor are they evaporating because their one line of research failed in clinical development. Rather, they’ve just run out of money, can’t raise any more, and their assets are worth less than their debt. So they’re selling off what they can, and locking the door behind them.

While the company’s announcement isn’t too reveling about their history, looking at their information on Yahoo! Finance shows that while they have consistently lost money, (as do virtually all biotech companies without products to sell), year-over-year, revenue was increasing and the losses were shrinking. And the company’s profile described various areas of clinical development:

“EPIX Pharmaceuticals, Inc., a biopharmaceutical company, engages in the discovery and development of therapeutics through the use of its proprietary silico drug discovery technology to treat diseases of the central nervous system and lung conditions. Its therapeutic product candidates in development include PRX-03140, which completed Phase II clinical trials for the treatment of Alzheimer’s disease; PRX-08066, a small-molecule inhibitor that completed Phase II clinical trials for the treatment of pulmonary arterial hypertension and pulmonary hypertension associated with chronic obstructive pulmonary disease; and PRX-07034, which completed Phase I studies for the treatment of cognitive impairment associated with schizophrenia. The company also offers Vasovist, an injectable intravascular contrast agent to provide enhanced imaging of the vascular system using magnetic resonance angiography. It has collaborations with SmithKline Beecham Corporation, Amgen Inc., and Cystic Fibrosis Foundation Therapeutics, Incorporated. The company was formerly known as EPIX Medical, Inc. and changed its name to EPIX Pharmaceuticals, Inc. in 2004. EPIX Pharmaceuticals, Inc. was founded in 1988 and is based in Lexington, Massachusetts.”

The Boston Globe also had an article about Epix’s demise, which also noted that Biopure, another Massachusetts life sciences company announced it was going under last week – however Biopure, which had been working on a blood substitute, was much more of a “one trick pony” than Epix.

Last fall I’d written about how biotech companies were treading water because of problems raising new money, and while several other smaller companies have been acquired, I don’t recall hearing about such a previous high profile company completely dissolving. The ongoing challenge in the current economic quagmire will be for start-ups to find their initial funding, and to see if larger biotech and pharma companies can be enticed by science and economics to buy any of the remnant companies – although with the Merck/Schering-Plough and Pfizer/Wyeth pending combinations, those major players most likely won’t be in the market for new acquisitions anytime soon.

Diabetes Updates – New Diagnostics, Increasing Rates, and Implications for Health Reform, CER, etc.

Posted on June 17, 2009 by Michael D. Miller MD

Changes in the diagnosis and treatment of diabetes is a great example for understanding how healthcare delivery constantly evolves based upon new discoveries. And the history of these changes may help illuminate some thinking about health reform and the development and use of comparative effectiveness research (CER).

First, a little background on diabetes.

Diabetes Background
Diabetes mellitus (or “sugar diabetes”) occurs when the body has problems regulating the level of sugar (specifically glucose) in the blood. This can be because the body’s pancreas doesn’t produce enough insulin, or for some reason the person’s organs become resistant to the actions of the insulin that is present – or sometimes both occur simultaneously. Impaired control of glucose means that the levels get too high, which produces problems in the eyes, (leading to blindness), in the kidney, (leading to kidney failure), and in the small blood vessels elsewhere in the body, which can lead to nerve damage and low oxygen delivery to the extremities – particularly the legs and feet, (leading to amputations).

In olden times, diabetes could be diagnosed by sugar in the urine. (Medical lore says this was done by taste….) However, until insulin was discovered in 1921 there were no therapies for severe insulin deficiency. And even once insulin became available, sugar in the urine was still the way diabetes was diagnosed and monitored – usually with a dipstick that changed color depending on the sugar concentration.

It wasn’t until the 1960s that measuring blood glucose levels became possible – and only then in the doctors’ offices because the machines were large and expensive. In the 1980s machines small and cheap enough for patients to monitor their blood sugar levels at home became available. This enabled patients to start adjusting their own insulin dosages based upon their blood sugar levels. (Before this it was too dangerous for patients to significantly alter their insulin dosages because while too little insulin leads to too high sugar levels causing long-term damage, too much insulin can drop sugar levels too low and lead to confusion, coma and death.)

In more recent years it was discovered that keeping diabetics’ sugar levels near normal could prevent essentially all the adverse consequences of diabetes, i.e. blindness, renal failure and amputations. But doing this based upon finger-stick blood sugar levels even 3 and 4 times a day was tricky – and those were just single data points. So in the mid 1970s it was proposed that monitoring the amount of hemoglobin in the blood that had combined with glucose would give a measure of the average blood sugar level for the 2-3 month life of the red blood cells. (It was known that glucose irreversibly connects to the hemoglobin in red blood cells in a way that directly correlates to the blood sugar level.) This test, known as “glycosylated hemoglobin, (or HbA1C, or simply A1C), has been increasingly used over the past few decades to monitor diabetics and adjust their treatments, with the goal to keep A1C levels below 7%, since the level in people without diabetes is 4-6%.

Care Lags Discovery and Development of Innovations
Despite improved ability to monitor diabetes, it is still under diagnosed, and poorly managed. It is estimated that there are about 6 million people in the US who have diabetes, but don’t know it – which is about 25% of all people with diabetes. And in 2003-2004, only about 57% of people with diabetes had A1C levels <7%. (The medical and lost productivity costs for all people with diabetes may be approaching $200 Billion.)

And the prevalence of diabetes is increasing – and with it so are the costs of treating people with diabetes. Last year I wrote about this, and now the CDC has updated information showing the continuing growth in the number of people in the US diagnosed with diabetes:

Source: http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm

The treatment of diabetes has also changed. After insulin was discovered, different forms and modifications where developed to change how quickly it acted, and beef and pork sources have been replaced with biotech “human” insulins grown in bacterial cultures. Many different types of non-insulin treatments for diabetes have also been developed – these act primarily by increasing insulin production from the pancreas or the action of the insulin in the body.

Which brings us back to the A1C test. An International Expert Committee from the American Diabetes Association is now recommending that the A1C test be used to diagnose diabetes. This would replace (or supplement) the traditional fasting blood glucose diagnostic test, and the A1C test would still be used for twice yearly monitoring of the adequacy of treatment for people with diabetes.

These developments in diagnosis and treatment have progressed in tandem – each leveraging off the knowledge gained from the other – with the A1C test being part of the continuing evolution of tests for diagnosing diabetes. For example, the fasting blood glucose level for diagnosing diabetes has changed over the years. It was originally set at 140mg/dl in 1979, and then lowered to126 in 1997, when it was also decided that a level between 110-126 should be considered pre-diabetic, or “impaired fasting glucose.” And in 2003 the lower bound for “prediabetes” was lowered to 100.

Why A1C Now?
While A1C testing has been used for years, there have been problems in standardizing the measurement. (This is discussed in the ADA paper linked to above.) But now A1C measurement inconsistencies, (which occur for all lab tests), have been narrowed sufficiently so that the ADA committee is recommending that an A1C level of >6.5% be used to diagnose diabetes, (for patients who are not pregnant and do not have hemoglobin abnormalities – these can change HbA1C levels significantly), and that people with A1C levels >6.0% and <6.5% be considered to have “subdiabetic hyperglycemia” because they have a significant risk of progressing to diabetes.

So Back to Health Reform and CER – The Challenges Ahead
The challenges ahead are to make sure that we continue to utilize future discoveries in a timely and intelligent way. Which finally brings us to health reform and CER. Health reform that expands insurance coverage should dramatically improve the diagnosis and treatment of people with diabetes – which should also help control other healthcare and societal costs because poorly controlled diabetes leads to many other costly problems. However, immediate cost pressures present barriers to using the best diagnostic and therapeutic interventions.

Comparative effectiveness research is supposed to provide information about the best interventions, but as has been seen with advancements in diabetes, what is best often changes in progressive leaps based upon new discoveries. And one of the limitations of CER, (and all research for that matter), is that it takes time to do the work and analyze the results. Therefore, research really provides information about what was the best when the research started – which could have been several years before the results are known and disseminated. And this time lag effect can be even longer when the research is based upon previously published studies or analyses of clinical records.

The lesson here is that while CER and similar research can provide very important and useful information, it must be put into the proper historical and clinical contexts. What was state-of-the-art when the research protocols were developed may be 2, 3, 4 or more years out of date when the data is analyzed. This reality needs to be considered when such information is used for coverage and reimbursement, and decisions about health delivery and financing system redesign.

I am confident that most insurers are not paying for A1C tests to screen people for diabetes – and that it will likely take a year or more for even the most progressive insurers to do so…. but they eventually will. Which raises the question, what did they gain by waiting? And what did they, (and the patients), lose?

Addendum: The hospital lab my doctor uses charges $59 for a HbA1C test. So assuming that price doesn’t come down if more people are getting the test, the calculation needs to be made as to what is the ROI for using HbA1C as a screening test? And the CER questions are how to identify people who would most likely benefit from HbA1C screening, and how to determine how frequently the screening should be done?

Be Prepared for the Outcomes of Health Reform

Posted on June 8, 2009 by Michael D. Miller MD

Predicting the future is easy. Accurately predicting the future is hard. While some people make a living by predicting the future, most will not admit to this truism. But the difficulty of accurately predicting the future of legislation and politically driven processes is what makes it important for policy makers to be prepared with contingency plans.

“Be Prepared” is the Boy Scout motto. As a boy scout many years ago, I learned that this was more than just a saying, it was really used to guide planning and decision making for all sorts of activities: camping, cooking, first aid, sporting events, community service projects, etc., because by preparing for all contingencies, when something unplanned happened it wasn’t a “crisis,” it was just a detour that wasn’t part of the “original plan.”

Being prepared is important for the success of health reform as the debate intensifies this month, because there are many, many things that could influence the outcomes. Some of these factors are intrinsic to healthcare and the legislation – such as how to pay for health reform – while others are extrinsic to healthcare and the specific legislation. (I’ve made a list of the extrinsic derailing possibilities, but it is too long to include here.)

What contingency planning means for health reform is that not only does there need to be a multi-year implementation plan for the specific provisions of any new health reform law, but there also needs to be preparation for the unexpected – but inevitable – hurdles that will get thrown into the path of the development and passage of any legislation.

59 Days Until Reconciliation
While the legislative process is complex enough – and has been characterized as herding blind and deaf seagulls – such contingency planning is crucial because as of Monday, June 8th, there are 59 scheduled legislative days, (including Mondays and Fridays), before October 15th, which is the deadline Congress has set to pass health reform without the Senate resorting to using the Reconciliation process.

Passing health reform legislation via Reconciliation has some significant implications for the content of health reform – which is why it should concern stakeholders of all types. While the Reconciliation rules are somewhat complex, the gist is that provisions which don’t influence Federal spending can be excluded from Reconciliation bills. Therefore, if the bill developed this summer includes provisions to reshape the healthcare delivery system or improve quality, but which don’t change Federal spending within a ten-year period, then they can be dropped from the legislation. (This budgetary analysis is conducted by the Congressional Budget Office, which is another reason why their “scoring” of legislation is so crucial.)

Focusing on Immediate Symptoms v. Actual Problems
This could mean that substantive provisions for transforming healthcare delivery to improve long-term quality and cost control may be dropped from health reform legislation, resulting in a bill focusing on more immediate cost cutting and not addressing some of the fundamental forces driving increasing costs.

I have characterized the difference between issues such as increasing costs, and the forces driving the increasing costs as being similar to the difference between medical problems and the symptoms they produce. In this case, the symptom is increasing costs, while the actual problems are misaligned incentives and the resulting warped structures of the healthcare delivery system.

Legislative “fixes” have for many years focused on the symptoms – particularly short term cost reduction measures that some have characterized as rearranging the deck chairs on the Titanic. This year presents the opportunity for some real reforms to the underlying problems that have become embedded in the healthcare delivery and financing systems. Whether that can be accomplished in the next 59 days remains to be seen.

Theory v. Practice in Health Reform

Posted on June 1, 2009 by Michael D. Miller MD

Two great articles came out last week about the role of physicians in health reform – both as the source of problems and the need for them to lead in implementing solutions. (These articles also made me think back about some of my own positions on physicians engaging in health policy – see the bottom of this post.)

The first article was by Atul Gawande in the New Yorker, where he explores how physicians contribute to some communities having higher healthcare costs than others. The second article is in the New England Journal of Medicine, and is written by three distinguished health policy thought leaders, (Elliott Fisher, Don Berwick and Karen Davis), who discuss how physicians can help implement positive reforms.

While Drs. Gawande, Fisher, Berwick and Davis all know the same data and studies about the US healthcare system, the NEJM article discusses possible solutions at a theoretical level and advocates macro solutions that each of them have been associated with, e.g. Accountable Care Organziations (Fisher) and Triple Aim (Berwick). In contrast, Dr. Gawande goes to the practical ground level and explores why one town in Texas has such high healthcare costs. His conclusions are illuminating, scary, and not surprising to most health policy experts: The high healthcare costs are due to the overuse of medical services, (particularly some high cost tests and services), and this overuse is driven by profit incentives for physicians who have essentially shifted from practicing medicine in the interest of patients to running a business for the benefit of their bank accounts. (What is surprising is that while many of the local physicians understood this, the hospital administrators apparently didn’t recognize this situation.)

The importance of this ground level view for achieving the high performing health system envisioned by Karen Davis and others, should not be underestimated. With hundreds of thousands of physicians in the US – and most of them still working in small practices – changing clinical behaviors faces high hurdles. In theory, changing financial incentives to reward quality rather than just quantity of care provided should make significant improvements in cost growth and quality of care. However, achieving this without very damaging negative consequences will requires two major leaps. First, clinicians who are currently running profit maximizing medical businesses have incentives to oppose any changes. And second, if incentives are changed to reward quality, then there will need to for extensive information gathering and monitoring to ensure that the same profit maximizing behaviors that currently predominate in certain communities don’t result in patients being denied appropriate or needed care under what would likely be bundled payment systems. (This is why information gathering and monitoring needs to include both process and actual outcome measures which can be used to evaluate clinical and economic aspects of the healthcare system’s operations for both individuals and entire communities.)

My own belief is that successfully remaking the US healthcare system to perform higher and achieve the Triple Aim – whether it be through Accountable Care Organizations, other forms of integrated delivery systems, or Patient Centered Medical Homes – will require greater input and buy-in from physicians. And this will require significant local leadership – from both physicians and other community champions for change. I stated my belief in this last fall when being interviewed for the Massachusetts Medical Law Report’s Rx for Excellence Leader in Quality award. (see below)

My belief that leadership and communications by key individuals are needed for health reform to be successful hasn’t changed since the early 1990s. For example, I recently came across an EBRI report that quoted me discussing this in a 1992 meeting: “Mike Miller of Rep. Sander Levin’s office swung back to the need for leadership. ‘People want change but there is no agreement beyond this,’ he said. ‘Leadership has to put together the policy and sell it to the people, communicating the benefits and down sides, showing how it is better than what we have now.’”

The bottom line is that because physicians’ decisions determine about 70% of healthcare spending, physicians can and should both play a role as leaders in developing what changes make up “health reform,” and in communicating the value of these changes to both their peers and their local communities. The alternative is more of the same. And it is becoming increasingly unclear how sustainable our current system is, so that at some point the money eating system we have built may collapse like General Motors.

Savings from Comparative Effectiveness Research

Posted on May 28, 2009 by Michael D. Miller MD

The May 23rd issue of National Journal has two very interesting pieces about Comparative Effectiveness Research.

Scoring Savings from CER:
The first is in an interview with CBO Director Doug Elmendorf which includes this Q&A about scoring savings from CER:
“NJ: In the first five years after studying comparative effectiveness, are the savings that CBO can find relatively small?
Elmendorf: The estimates that we’ve done in the past suggest that by the 10th year, you are saving about as much as the cost of the research itself. By the fifth year, you are not. We would expect there to be savings in the private sector. The federal government captures only a piece of that through the tax effect. What I haven’t told you about is the net effect of comparative effectiveness research on national health expenditures. That will tend to be a net saver for the country sooner.”

CER in Health Reform:
The next article in the NJ issue, (“The Risk of Comparing Treatments”), is about the possible inclusion of a new agency or independent institute to conduct or oversee CER. The legislative fate of such organization may hinge upon how CBO scores increased or continued funding for CER, and as seen above, it seem unlikely that CBO will attribute large savings to CER.

While scored savings from CER may be small, the fight about how CER should be used is getting hot. The NJ article also discusses two new organizations that sound somewhat similar, but are actually on opposite sides of this issue: The Partnership to Improve Patient Care, and the Alliance for Better Health Care. The former includes innovative companies and groups from industries such as biotech, pharmaceuticals and medical devices. While the latter includes health insurance plans, physicians and others.

Interestingly, patient organizations are divided between the two, with more disease specific groups who place a high value on the discovery of new treatments are aligning with PIPC, while broader “consumer” organizations that prioritize better information about existing therapies have signed on with ABHC. Similarly, biomedical researchers could be viewed as split about CER, with academic researchers viewing the $1.1Billion in new CER money in the stimulus bill as a great opportunity for more funding, while industry researchers understand that the use of CER to make reimbursement and coverage decisions could reduce the incentives for investors to fund innovative private sector R&D.

So stay tuned. The next event in the CER skirmishes will likely be around what the Finance Committee includes in their legislation about a new agency or institute for CER in the bill they are expected to unveil in a week or two. Look for this issue, and other aspects of CER, to fuel one of the more interesting controversies within the health reform debate this summer.

Healthcare Policy and Healthcare Politics – Summer 2009

Posted on May 26, 2009 by Michael D. Miller MD

As Congressional Committees appear to be steadily walking towards the starting line for considering health care reform legislation next week, I’ve been thinking about various healthcare policy and political events and activities that will influence the substance and process for these efforts over the coming months – and perhaps years.

Because a complete examination of all the important events and documents from the last several months and years would be too long for a single post, summarized below are some of my observations and thoughts about the meaning of 5 touchstones that people will likely reference in the coming months as part of the health reform dialogue:

Massachusetts’ health coverage and reform initiative
The Senate Finance Committee’s 3 Policy Option Papers
Frank Luntz’s health care talking point paper for Republicans
The May 11th letter from 6 national groups to President Obama
The Democratic Party’s development of Organizing for America

As discussed below, each of these activities and documents has dual (or dueling) policy and political goals, (i.e. changing policy to improve the healthcare system, or designed to win political points), that may be aligned or in conflict.

1. Massachusetts Health Coverage and Reform Initiative

The original legislation was a political compromise that included:
- The use of private insurance to expand coverage
- An individual mandate
- An employer penalty for not having all their workers insured (a.k.a. play or pay)
Single payer is discussed and supported in Massachusetts, but wasn’t part of the state’s health reform initiative
The state’s Commonwealth Connector insurance exchange doesn’t include a public plan choice/option
Despite not being a single payer system, nor including a public insurance plan option, the state’s initiative expanded insurance coverage to more than 97%
With the success of increased insurance coverage has come expanded demand for primary care services and subsequently longer waiting times for those services
The state is looking at various processes for controlling costs as a second outcome to be achieved
The state’s ability to control health care spending will likely require Federal regulatory and/or legislative cooperation from programs such as Medicare, Medicaid, and ERISA

2. Senate Finance Committee’s Policy Option Papers

Between April 29 and May 20th the Senate Finance Committee released 3 papers describing options for health delivery system transformation, expanding coverage, and cost savings and revenue raising. (The Committee also held hearings on these papers.)
The overarching theme in these papers is transparency and accountability
Several issues are notable for their absence from the papers:
- Discussion of a single payer option for overall reform
- Cost savings estimates for a public plan option
- Changing or repealling Medicare Part D’s “Non-Interference” provisions as a source of revenue
The only mention of ERISA is in the savings and revenues paper – It is not discussed in the context of health delivery transformation or expanding coverage
Medicare’s physician payment formula problem is discussed, and the cost of a 10 year freeze is cited as $285 billion
Accountable care organizations (ACOs) and care coordination are frequently mentioned goals, but the papers generally only propose demonstrations or pilot projects rather than definitive programmatic changes

3. Frank Luntz’s “The Language of Healthcare 2009″ Paper

This paper advises Republicans how to talk about healthcare in a purely political context. It doesn’t substantially address policy aspects of health reform issues, and it is all about winning as many Republican and moderate hearts without considering their minds
The goal of Luntz’s talking points are to paint Democrats’ health reform plans as leading to government bureaucrats making health care decisions, rationing of care, and denying access to necessary care
The paper builds upon the premise that patient-doctor relationships are good and that government bureaucrats are bad. It specifically states that the Democrat’s “government takeover” of the healthcare system will result in a bureaucrat putting “himself between you and your doctor, denying you what you need”
Luntz’s paper leverages people’s fear about loss of control and autonomy, but it doesn’t address people’s immediate and real concerns that high costs are denying people access to the insurance or care they need – in effect rationing based upon the ability to pay for the ~49 million people in the US without health insurance and the millions more who are underinsured because they can’t afford their co-payments or deductibles

4. May 11th Letter to the President from 6 National Groups

The 2 page letter from AdvaMed, AHA, AHIP, AMA, PhRMA, and SEIU is mostly political posturing
The letter uses all the right phrases:
- “access to affordable high quality health care”
- “transform the health care system”
- “transparency that supports effective markets”
- “aligning quality and efficiency incentives”
- “encouraging coordination of care”
- “adherence to evidence-based best practices”
Karen Ignagni deserves big kudos for pulling together the other 5 groups and getting agreement for the letter, but herding their collective seagull-like members into agreement for specific reform proposals – other than an individual mandate to have insurance – will be a much bigger challenge, as Paul Krugman recently discussed in his recent column
Getting all these groups to the same side of the same table is a success of process, but not a successful outcome. A collective meeting of minds of similar groups was necessary for the enactment and implementation of Massachusetts’ coverage expansion law, and it is also being used in the state’s efforts to control the growth of healthcare spending

5. Organizing for America (OFA)

The Democratic National Committee (DNC) is working to develop OFA as a program to capture the grassroots energy and organization of the Obama campaign, with the goal of using OFA to support the Administration’s policy initiatives – the first of which is healthcare, to be followed by energy and education
On May 16th I attended an OFA-MA organizing meeting – along with about 500 other people from around the state. The open Q&A and my discussions with individuals made it clear that single payer has strong and wide support in this group, despite candidate and President Obama’s consistent message that if we were designing a system from scratch, single payer would be an attractive option, but given our immediate needs and problems, other significant targeted changes are needed to improve people’s lives by increasing coverage and controlling costs quickly and effectively. (Not too mention that such targeted changes face much lower political hurdles than a single payer reform option.)
OFA is gearing up for Congress’ consideration of heatlhcare legislation by organizing house parties across the country on June 6th to gather individual stories and prepare the OFA grassroots rooters to engage their elected representatives, the media, and whoever else they can reach on healthcare reform

Conclusions

How to pay for health reform still hasn’t been determined, and this summer Congress will also have to “fix” Medicare physician fee schedule – which will cost about $20 billion/year
The most difficult aspects of health reform, (outside of paying for it), are how to do risk/severity adjustments for payments and quality analyses, how to measure the success of initiatives using a blend of process and outcome measures, and how to estimate, (or “score”), costs or savings from many of these initiatives – particularly for those that involve behavior change, disease prevention or health promotion, or are expected to act synergistically with other initiatives, such as patient-centered medical homes or other care coordination intensive models
Agreement on principles is easy, but agreeing to specific proposals is difficult because one person’s waste is another person’s income
ERISA is the 500 pound gorilla-issue sleeping in the corner
Massachusetts is different than most other parts of the country – both in terms of policy and politics – but its experience presents valuable lessons about the process for bringing stakeholders to the same table and for creating a health insurance exchange with low-income subsidies
Politics will be required to enact national health reform legislation, but the specific policies put into new laws will be important for determining their success or failure upon implementation, because a disconnect between politics and policy can result in legislation that produces outcomes different from what are intended. For example, the Balanced Budget Act of 1997 changed the Medicare managed care program, (and renamed it Medicare+Choice), with the goal of expanding managed care options for people enrolled in Medicare. However, following BBA ’97 Medicare+Choice options decreased rather than increased. In addition, success or failure of one initiative sets the environment for the next, e.g. the failure of BA’97 to expand Medicare+Choice enrollment created the context for the development of the Medicare Part D prescription drug program in 2003. Similarly, the success of Massachusetts’ expansion coverage law has enabled the state to explore options for controlling overall health spending as a next step – something that would not have been possible if the expansion law had failed or been derailed…… as it had been twice before.

Footsteps

Humana on Health Reform

Posted on April 19, 2009 by Michael D. Miller MD

Humana has added another “educational” to its YouTube series – this one is about “why do we need health reform.”

It’s a good question, and since I’ve been somewhat critical of other Human videos, I feel obligated to say that this one is OK – mostly because it doesn’t contain too much substance, i.e. it’s a mile wide and an inch deep. And I do want to give the writers credit because the video starts by answering the question about what is health reform and why do we need it by stating, “The simple answer is…. Well there is no simple answer.”

But beyond that insight, they gloss over many of the important facets of the problems and possible solutions. For example, in talking about the uninsured, they state that those without insurance have two options: Pay cash or go without care. That is the simple answer, but the reality is that there are many sources of free care (including free medicines) for low income people without insurance. And many of the people without insurance are eligible for free or low cost insurance that they may not be aware of. So in reality, the choices for the uninsured go beyond Humana’s perspective of pay cash or go without care.

US Life Expectancy and Spending
Second, the video notes that the US spends more per person that other countries, but don’t live longer – and they illustrate that point with a figure of a man using a walker. While life expectancy at birth makes the US look much worse than other countries, the data for life expectancy at age 65 is very different. (See chart from Commonwealth Fund below.)

This difference is because, in part, the US has much higher mortality at younger ages due to accidents and violence – including suicides. Also, as the Humana video does depict, our diet and other lifestyle factors lead to poorer health. So it might be that while we are living as long as other countries, we use more intensive healthcare services to treat/manage our greater burden of chronic illnesses brought about by obesity and lack of exercise, etc.

One reform option that Humana mentions is ensuring that people with pre-existing conditions can get insurance coverage. The insurance industry has rallied around that change – as long as it is coupled with changes that ensure everyone has insurance so that people don’t wait until they get sick before buying insurance. This makes sense both for the insurance industry and the country as a whole.

What Insurance Does
The Humana video also presents the concept that insurance is a mechanism for spreading out the costs from a few ill people over a much larger healthy population. This “social insurance” model is what Medicare is based upon and is really the model for most insurance. Another theory of insurance – and one that some insurance products follow – is that insurance is a way to prepay for expected future costs. Some consumer directed health plans with health savings accounts combine these two theories of insurance into one type of policy, i.e. the high deductible insurance policy spreads high costs across a larger group, while the savings accounts enable individuals to put money away for expected future needs.

Competition with a Public Plan
The Humana video glosses over perhaps the biggest reform issue in today’s debate: Creating a public plan to compete with private insurance. The video describes the public plan as “like the one government employees have today.” While the Federal Employees Health Benefit Plan is cited as some as a “government plan,” it is really a lot more like an employer plan, since it provides Federal employees with multiple private insurance plan options. I don’t think this is what most people consider to be a government plan. Rather they are thinking more of something like Medicare or Medicaid, where the government sets the coverage and reimbursement rules and contracts with private organizations to pay physicians, hospitals, etc. for actual healthcare services. And of course the VA is another model for a government health plan, where the government actually owns and runs the hospitals, and the clinicians and staff are government employees, etc. While exactly what the political and policy leaders in Washington are thinking about for a public plan option remains to be seen – there are certainly many options for what this label could become.

Cutting Costs
The Humana video’s final section is about how to reduce costs. Here they present several current hot-topic options like technology and electronic medical records, giving people more information to compare prices and performance “like they do for everything from new cars to groceries so they might use their money more efficiently,” paying physicians for performance rather than volume, and helping people eat right, exercise more and take better care of themselves. All these are reasonable ideas, but will require considerable investments up from to achieve costs savings in later years.

Conclusions
The Humana video on health reform presents a number of superficial observations about the problems in the US healthcare system and some of the global options for change, but doesn’t delve into how to actually make any changes, and more importantly, the trade-offs that many of these changes would require. So while it might make some people feel they understand the issues better, it really won’t move the debate forward to improve the US healthcare system.

The video also notes that no clear consensus has emerged about what options to pursue, and it suggests that “if you have an idea, call your Member of Congress.” My experience having worked for a Member of Congress makes me wonder if that will really help move the debate forward. It also reminded me of the idea submitted to a newspaper by a reader to answer the question, “How Would You Fix the Economy?”

Patriotic Retirement
Pay the 40 million people over 50 in the work force $1 million each in severance with three stipulations:

They leave their jobs. Forty million job openings – Unemployment fixed.

They buy NEW American cars. Forty million cars ordered – Auto Industry fixed.

They either buy a house or pay off their mortgage – Housing Crisis fixed.

All National financial problems fixed!!!

Sounds good, except it would cost $40 Trillion, the Federal budget is about $3 Trillion, and the US GDP is a bit more than $14 Trillion. So I’m not sure the numbers for this “idea” really add up. But it sounds good as long as you don’t care about the facts – which is probably why the newspaper printed it.

Culture of Health Reform

Posted on April 13, 2009 by Michael D. Miller MD

One of the challenges for health reform legislation is the culture of the policy and political community.

Massachusetts’ insurance and coverage initiatives have been cited as lessons for health reform at the Federal level and other states. However, while observing a meeting of the state’s Special Commission on the Health Care Payment System last Friday, I was struck by how the culture of this group was very different than what I have often seen in Federal processes or within other states.

The Commission had agreed at their previous meeting that global payments should replace fee-for-service as the main payment route for medical services and products. At Friday’s meeting their discussion about what that system of global payments should eventually look like – and how to get there – was not confrontational, even though the Commission’s representation includes a wide range of stakeholders, including doctors, hospitals, two insurers, the state employees’ insurance plan and two elected representatives.

The collegiality and non-confrontational atmosphere of this Commission compared to national discussions of similarly broad groups – such as the Health Reform Dialogue – may provide important insights for other health reform efforts. The reasons why health reform in Massachusetts has this type of culture is probably a long list, but some of them might be:

The stakeholders realize that payment reform is part of longer-term cost containment efforts that will be necessary for the overall success of the state’s insurance expansion program
Despite the overall economic downturn, the state and its healthcare system are generally better off than other states and healthcare operations
The state has a generally progressive bent, and is somewhat culturally aligned, e.g. almost everyone is a Member of Red Sox Nation

Whatever the reasons for the agreeablity within the Commission and the state, progress thus far has been a significant achievement, and could lead the way for significant reforms at the Federal level or within other states – particularly if they can replicate a similar culture of cooperation and agreement.

Next Challenging Steps
Of course, the Special Commission won’t be making all the detailed decisions necessary for actually reforming payments, such as:

How quickly the new system will be initiated
How much the global payments will be
Who will get the global payments, e.g. hospitals, integrated delivery systems, physician groups, or some combination of providers
What types of quality information those receiving the payments will have to provide
What levels of cost containment will the new global payment system be expected to meet – and what measurements will be used to determine if costs are being constrained appropriately

Those types of decisions will be made by the state legislature and a government agency – or para-governmental entity created for these purposes. These upcoming decisions and their implementations will be where the even harder challenges await. However, given the Special Commission’s progress so far – and the state’s ability to implement and sustain the insurance expansion program – the likelihood that these harder steps will at least be partially successful seems good. So while critics have been predicting the downfall of the Massachusetts insurance coverage expansion experiment because of rising costs, that’s not the future I see.

The political and policy leadership in Massachusetts seem to have a sustainable group-think and desire to keep on the path they’ve started on rather than veering off into another direction to achieve immediate cost savings or politically expedient gains. The ability of the state to do this will be aided by some of the factors postulated above, as well as the political clout the state has in Congress, and the Governor’s relationship with the President. But those factors may change with time, so the ultimate ability of the state to sustain ongoing reforms and improvements to the healthcare system within the state may very well depend upon its momentum of success. They’ve had great success in reducing the number of people without health insurance. Now cost containment via payment system reform is the next success that must be achieved.

Health Reform With a Public Plan or Not?

Posted on April 9, 2009 by Michael D. Miller MD

National Journal’s cover story last week (“The Deal Busters“) was about the 4 issues that could kill health reform. And first on the list was creating a public health insurance plan option to compete with private insurers in the push for increasing coverage.

The National Journal does a great job of describing the stakeholder groups’ political pros and cons around a public plan, but it doesn’t delve too deeply into the policy implications of expanding health insurance coverage with or without a new public plan option. That issue was recently discussed in Charlie Baker’s blog – which included several key points about public versus private insurance plans:

Public plans often set the standard that private plans follow, and thus are not neutral actors in the market – Medicare is often ascribed such a market tilting role
Public and private plans face different financial pressures, i.e. private plans need to at least break even, while public plans can get financial infusions from their larger government entities
Public plans “can set provider prices at pretty much any level they like, while private organizations need to reach a mutually agreeable number,”[quoted from Charlie Baker's posting], which can lead to cost shifting from public plans to private payers – as happens today with Medicaid (and probably Medicare)
Public plans are required to go through administrative processes, (such as publishing rules for public comment, etc.), which makes changing their benefits structure or operations an extremely time consuming process

The discussion also included a number of factors that would be necessary for a public plan to actually compete on a level playing field with a private plan, including:

Premiums reflecting all administrative costs, including those performed by other government agencies
Medical claims and administrative costs being covered by premium revenues
Provider reimbursement rates being negotiated rather than unilaterally set
Providers being able to refuse to accept the public option for the under 65 population, while continuing to be able to accept Medicare patients
The regulating/marketing operations and the purchasing/selling roles for the public plan need to be separated and not done by the same entity
Payments need to be risk adjusted – this is necessary in any restructuring of insurance markets whether there is a public plan or not

Adding to the analytical information mix about the effects of a public plan option in health reform, the Lewin group just published a paper on this subject – “The Cost and Coverage Impacts of a Public Plan: Alternative Design Options.” This paper looks at several options for how a public plan could be structured, e.g. open to everyone or just individuals and small employers, and using Medicare or private sector payment levels.

Not surprising, the study found that using Medicare’s lower payment amounts to hospitals and physicians, and making the public plan available to everyone results in the lowest premiums for the public plan option and the greatest shifting of individuals from private insurance to the public plan. HOWEVER, the Lewin plans analyses are based upon several assumptions that other coverage expanding reforms proposed by President Obama in the 2008 campaign are also created:

Mandate for children to have coverage
Medicaid is expanded for all adults below 150% of the Federal Poverty Level
Tax credits are provided to people with incomes between 150-400% of the FPL who buy private insurance
Tax credits are provided to small employers with low-wage workers to offset some of the cost of health insurance
Large employers are required to offer insurance or pay a payroll tax
Medical underwriting and health status rating is eliminated, but rating by age is permitted

These changes are designed to increase insurance coverage, and are certainly individually and collectively important for fundamentally reshaping the health insurance market – particularly the last bullet. Therefore, the operations and influence of any public plan would be very different with those changes than in today’s insurance environment, and that needs to be considered in discussing the political and practical pros and cons of a public plan option.

Conclusions:
The conclusion I draw from all this – and which I’m paraphrasing from my comment on Charlie Baker’s blog – is that government programs serve a valuable social role, but the differences between public and private operations need to be recognized as they each carry specific benefits and limitations. Therefore, the real conundrum about whether a public plan in health reform is part of the right answer depends upon how the question is asked and whether it’s put into a policy or political context. Unfortunately, those two contexts are not separable in the real world, so the challenge in this debate is to connect the two in the legislative process, and see if a compromise can be reached to realistically increase insurance coverage and contain costs, but that won’t cause any stakeholder group to fall on their sword.

Health Policy and Communications

Health Policy Consulting and Writing to Improve Quality, Reduce Costs, and Increase Value in US Healthcare

Category Archives: Economics & Financing