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Health Reform Without Health Reform

By Michael D. Miller MD
March 1st, 2010

With a few weeks to go before the President’s March 26th deadline for agreement on a comprehensive health reform bill, the likelihood of that occurring is diminishingly small. However, even without a comprehensive bill, or even several incremental Federal laws passed this year, health reform will be happening in the States and the private sector, while the Federal government may also pull a few of the strings it has available to shift the operation of our healthcare system:

State Level Health Reform
“State-Level Health Care Reform” is the title of an article in the Feb. 20th issue of the National Journal.  This article discusses various initiatives states are considering and how their national organizations, (such as the NGA and the NAIC), are supporting these efforts.  Of course, States face significant challenges for making investments in health reform because of their legislative calendars and budgetary pressures.  To help states’ fiscal problems, the Department of Health and Human Services announced on February 18th that they were providing states’ Medicaid programs with $4.3 Billion in relief over 2 years.

In assessing how states might try to create health reform based upon Medicaid, it is also important to remember that Medicaid is not one program - and not even 50 separate uniform state programs - but that states have hundreds of waivers for the operation of different parts of their Medicaid programs.  For example, Massachusetts has 6 waivers - one of which is the basis for the state’s health insurance expansion program - and Arizona has 2 waivers, the first one approved in 1982 as the basis for the state’s entire Medicaid program.

Private Sector Initiatives
Private companies are continuing to try and reform healthcare from the both the cost and quality perspectives as both purchasers and sellers.  A friend who works for a large company with a significant footprint in healthcare, and a very large and diverse workforce, told me that they are addressing healthcare cost and quality on both ends.  First they are shifting their entire health benefits system to high-deductible type options, and they are also developing products and services to improve the efficiency and quality of healthcare delivery.  Other companies are doing similar things and working through coalitions such as the Leapfrog Group, the National Business Group on Health and the Pacific Group on Health to work collaboratively, (and perhaps corrosively), with health plans and large providers to control costs and improve quality.

Federal Initiatives
Without new sweeping laws, the Federal Government has significant administrative tools for changing how healthcare is paid for and delivered.  Beyond rule-making in programs such as Medicare and Medicaid, the government can use its purchasing power to change how private companies operate.  This lever was the focus of a February 26th New York Times article, the first two sentences of which may be heavy foreshadowing: “The Obama administration is planning to use the government’s enormous buying power to prod private companies to improve wages and benefits for millions of workers, according to White House officials and several interest groups briefed on the plan. By altering how it awards $500 billion in contracts each year, the government would disqualify more companies with labor, environmental or other violations and give an edge to companies that offer better levels of pay, health coverage, pensions and other benefits, the officials said.” [emphasis added]

Conclusion - Pluralism, Federalism, & Individualism
The individualistic nature of US society has long shaped government and social programs, and the role of individual decision making - going back to the Constitution - has been reflected in preferences for local control and charitable-community actions rather than government programs. The challenge for government officials and lawmakers at all levels is to create health reform in a manner consistent with this fundamental societal philosophy. This conundrum may have been summed up by Vice President Biden at last week’s health summit, which CNN reported: “Vice President Joe Biden says the philosophical debate over whether health care should be mandated is similar to debate in the 1930s regarding Social Security. He also says after being in Washington for 37 years, he’s ‘reluctant … to tell people what the American people think. I think it requires a little bit of humility to be able to know what the American people think, and I don’t. I can’t swear I do. I know what I think. I think I know what they think, but I’m not sure what they think,‘ he says.”

I’m not sure I’ve heard a clearer explanation of the quandary policy makers have in deciphering the desires of the American people for comprehensive local solutions that provide uniform individualized options that are simple and efficient while eliminating waste, fraud, and abuse without excess government intrusion, spending, or taxes so that costs are reduced and quality improved while maintaining personal choices of doctors, hospitals, and therapies and incentives for creating better treatments and cures.

Posted in Health System Reform, Politics | No Comments »

Missing Pieces of Health Reform

By Michael D. Miller MD
February 23rd, 2010

At a briefing in Washington DC this morning, two very well respected and reasonable economists talked about how the increasing prevalence of chronic diseases and care delivery in outpatient settings are driving up costs in Medicare.  They also asserted that a greater focus on real cost containment - and possibly cost reduction - should be the focus of health reform, and that this could be achieved by increasing team based care coordination and increasing personal responsibility for care and costs, among other focused initiatives that might require political courage…..which one of them noted appears to be currently in short supply.

Their conclusions and analyses are all well reasoned and reasonable, but having listened to these types of analyses and briefings for more than 20 years I was stuck by two things.  First, what they were saying wasn’t significantly different from what people had been saying for, well, more than 20 years.  And second, like most presentations about health reform, they focused on what needs to be changed but didn’t talk about how to create that change - except to focus on altering economic incentives.  (It is worth noting that one of the panelists recommended that government programs such as Medicare should consider not just creating incentives for people and providers to do certain things, (like use electronic medical records),  but rather should say, “if you want to get paid by us, you will do things this way.” Clearly this type of ‘my way or the highway’ approach can be effective, but it also faces much higher political barriers because it could result in a number of doctors and other care providers being excluded from Medicare.)

Motivators Other Than Economic Incentives
What also struck me about their focusing on economic incentive as the driver of change is that this can work for some people and organizations, but in healthcare, there are other factors driving people’s behavior - particularly the behavior of patients and community practicing physicians.  For patients, if they were to act the way economic models would predict, (i.e., always in their best economic interests), everyone would brush their teeth and floss more often, exercise regularly and rarely eat anything that came out of a frozen box or a deep fryer.  But such economic modeling assuming that people act based upon full knowledge AND that their economic interests are the overriding force behind their decisions.  And in the real world, neither of those assumptions are true.

So what’s missing from the health reform prescriptions based upon changing economic incentives for physicians, patients and others?  First,  increasing relevant and useful information can help increase the impact of whatever economic incentives are created.  For example, showing physicians that their practice patterns are different that their local peers can help motivate them to change how they care for certain conditions in ways that economic incentives may not.

And second, non-economic motivators for behavior change can be created that are aligned with  financial incentives (and disincentives) to change actions and attitudes.  These types of motivators are particularly important for individuals - whether they be patients or individual physicians.  In addition, initiatives to change individual behaviors and actions need to recognize the 80-20 rule, where 80% of people go one way and 20% don’t.  In promoting care delivery changes it might be more accurate to call it the 10-70-20 rule, where 10% of clinicians are early adopters, followed by another 70%, with 20% resisting the adoption.  Thus, the key to changing clinical practices at the individual level, (i.e. getting real world clinicians to adopt the care practices of “evidence based medicine” that health reformers talk about), is to get the early adopters to rapidly adopt the better care practices, and for them to become active  teachers and proselytizers for these changes with the receptive 70% of their peers.  (Note: the early adopting 10% are sometimes called change agents or agents of change.)

The remaining 20% who resist change should slowly be convinced by their peers resulting in longer term improvements. And in the shorter term, getting 80% adoption of changed care practices that improve quality and reduce costs would equate to some tremendous improvements for patients and society.

Returning to the Book
How to develop and implement initiatives involving such non-economic motivators and pair them with economic incentives to transform healthcare delivery - resulting in increased quality and reduced costs - is a core part of the book I’ve been writing.  Unfortunately, I’ve been trying to figure out how to make the book relevant within the rapidly evolving health reform environment over the last 2+ years.  Now that the dynamic has shifted back to fiscal responsibility and cost containment, and health policy is all about health politics, it may be time to finish the book so that it will be available for policy makers and stakeholders when health reform initiatives return in 2011 and beyond. If you have any thoughts or suggestions about these issues or the book, please feel free to comment here or contact me at the physical or email addresses on my contact page.

Posted in Delivery of Healthcare, Economics & Financing, Health System Reform | No Comments »

The Path Forward for National Health Reform

By Michael D. Miller MD
January 31st, 2010

The path forward for health reform is becoming clearer now that the dust from the Democrats losing their 60th vote in the Senate is settling.  While a freestanding, comprehensive law now seems very unlikely, achieving the core goals of health reform are possible via the regular order of a Reconciliation bill, demonstrations and pilot programs, waivers, existing authorities, and the appropriations process.

It’s the Stupid Economy
First, the President has appropriately reraised jobs and the economy to be his highest priority.  This shift may both help defuse the hyperpartisaness that has enveloped health reform, and increase action to improve the economy and create jobs since they are the source of the public’s ongoing angst and frustration.  However, the Administration and Congress should continue to pay attention to health reform since people’s concern over the economy and job-lock are partially driven by worries about the affordability of health insurance and healthcare.  In addition, location-lock for small businesses and entrepreneurs because of different state health insurance laws may be supressing job growth in those sectors… something I recently investigated in moving from Massachusetts to DC.

Reconciliation - Part 1
Second, any action related to health reform will need to embrace fiscal responsibility and deficit reduction.  This clearly points towards a Reconciliation bill that reduces the growth in Medicare spending, (and extends its solvency), along with some Medicaid changes to accommodate increasing enrollment while limiting States’ fiscal exposure in a down economy.  This type of Reconciliation bill would be similar to those that both Democratic and Republican controlled Congresses have passed in the last 20 years.  (In the current political alignment, Democrats will have to counter Republicans’ accusations that they are cutting Medicare rather than just slowing spending growth. Both characterizations are “true” depending on your political objectives.)

Strategic Demonstrations, Pilot Programs and Waivers
Just nipping and tucking at Medicare spending and increasing Medicaid’s enrollment and financial support to the States won’t meet anyone’s definition of health reform.  Therefore, to move the US health system along the path of reform to expand coverage, improve quality and control costs, there are targeted initiatives that the Administration and Congress can pursue to push forward with reforming health delivery and financing:

First the Administration can get much more aggressive with its use of Medicare demonstrations and pilots. These can build upon the HIT and CER programs included in last year’s stimulus bill as stepping stones for health reform.  The Administration already started in this direction with their “Demonstration Grants for the Development, Implementation, and Evaluation of Alternatives to the Current Medical Liability System” announced last September.  Granted this program was designed to provide some cover for Congressional moderates and to probably curry favor with some clinician groups, but the Administration also has the ability - and in some cases the legislative authority - for many other types of demonstrations and pilots.  For example, they could:

  • Proceed rapidly with the Advanced Primary Care (APC) model type of Medical Home demonstration they announced last September - and which I wrote about previously.
  • Resurrect the straightforward Medicare Medical Home demonstration that Congress authorized in 2006 for eight locations. (In 2008 authorization was expanded to as many locations as HHS wants.)  This demonstration was scuttled last fall because the evolving health reform legislation had language replacing it with two new ones.  Since the draft regulations for this program were completed in December 2008, they would just need to be updated and finalized for the program to start later this year or January 2011.  There is also no reason that this Demonstration couldn’t run in parallel with the APC Medical Home demonstration - perhaps in different geographic locations.

For these and other demonstrations and pilot programs, the key for success will be structuring them somewhat like clinical trials so that people and organizations are assessing very similar, if not identical things.  This would not be “cookbook medicine” since these demonstrations should focus on the organization of care delivery and not on individual care decisions. For example, the Medical Home demonstrations mentioned above are about the organization of services provided by primary care practices, not the specific decisions made by clinicians for individual patients.  Similarly, the use of surgical checklists is an operational process that has been shown to reduce errors, increase the quality of care, and reduce costs.  However, it does not specific what procedures the surgeon performs or how the anesthesiologist delivers medicines, etc.

One of the failings of past demonstration programs has been that they have been structured to analyze what people are already doing rather than ways of delivering care that might improve outcomes. For example, the Medicare care coordination demonstration that reported its “conclusions” last year failed to demonstrate very much since it was an evaluation of 15 different types of programs.  In addition, demonstrations are sometimes caught up in significant political and parochial interests.  This was the case for a demonstration program involving “Centers of Excellence” for cardiac care at hospitals.  This demonstration program was scuttled the first time around - and hobbled thereafter - because the hospitals in the demonstration’s geographic locations not deemed “Centers of Excellence” complained quite strongly - particularly to their Members of Congress.

Thus, evaluating what people and organizations are already doing is easy, but may not provide much useful information since care organizations tend to vary greatly in how they operate, even within local areas, so drawing specific conclusions from these types of semi-focused studies is difficult.  Conversely, evaluating specific care practices is harder because it requires changing day to day activities for clinicians and providers, but this type of more controlled experiment can actually demonstrate the value of a change.  And lastly, any of these demonstrations can be undermined by political or parochial forces so that the demonstration is stopped, delayed, or its requirements so diluted that the conclusions are of little value. Thus, to make these demonstrations valuable, career and political officials need to be diligent and have fortitude when they are developing, approving, and overseeing the creation and implementation of such demonstrations and pilots.

Expanded Use of Existing Authority
Once research projects have demonstrated and validated improved ways of delivering care, Medicare, (and possibly Medicaid and other Federal programs), could use their existing authority to pay more for the adoption of these changes - or pay less or not at all when they are not adopted.  For example, Medicare and private payers have stopped paying for so-called “never events,” i.e. clinical events that are completely avoidable and thus should never happen.  Similarly, it is probably within Medicare’s existing authority to not pay - or pay less - for surgeries or the insertion of central intravenous lines when a validated checklist is not used.  These checklists are process steps that have been proven to work and yet have not been universally adopted, which raises the question as to why Medicare is paying for clinical situations where these improvements are not used.

Medicare and Medicaid Waivers
Beyond demonstrations and pilots, and the use of existing authorities, Medicare and Medicaid waivers are other tools that can be used to implement significant changes. Waivers for Medicaid are much more common, and the entire Medicaid program could be viewed as a 50+ bags with 1,000+ waivers.  Technically these waivers are intended to “demonstrate” better ways of running Medicaid programs that would provide information for changing all Medicaid programs across the country.  In practice, these waivers have proliferated like Tribbles in a storage bin of triticale grain, with most States using many waivers for different aspects of their Medicaid programs.  (For example, Arizona didn’t have a Medicaid program until 1982 when it created its program under a statewide waiver. And Massachusetts’ health reform expansion law was only possible because of a revised/renewed Medicaid waiver.)

Medicare waivers are less common than Medicaid waivers, but can be more powerful.  For example,  Maryland’s Medicare waiver has enabled the state to run an all-payer rate setting system for hospitals for many years. And in the near future Massachusetts may be seeking a Medicare waiver to implement an all-payer bundled payment system that their Special Commission recommended last July.  Such a state-wide payment reform system would be an even more dramatic health reform step than the state’s insurance coverage expansion and coverage mandates. But it remains to be seen if the Massachusetts legislature will proceed with this important cost containment and quality improvement step - and if they can get a Medicare waiver when they are ready to ask for it since the Federal Government’s attitude toward such waivers may be different in 2012 or 2014 than it might be today, or was last summer.

Reconciliation - Part 2
It is clear that cost containment for Medicare, expansion of Medicaid, a flurry of demonstrations, pilots, waivers and the use of existing authorities would not constitute significantly health reform since even all together those initiatives would not significantly advance progress towards universal insurance coverage - a fundamental goal of health reform. And one of the criticisms of using the Reconciliation process in the Senate has been that the insurance expansion provisions and coverage mandates in the House and Senate bills would be stripped out under the Reconciliation rules.

However, having successfully included provisions in a Reconciliation bill when I was told that they would definitely be stripped out, I know that under the peculiar rules of Reconciliation all numbers that are the same are are not equal, and there are ways to configure provisions and their implementation to effectively achieve the following:

  • Implement significant and strong regulations/requirements/standards to prevent insurance and coverage denials, and pricing problems that are currently permitted under various loose state laws;
  • Create strong incentives for insurance coverage for most, if not all Americans;
  • Provide subsidies for low income people and small businesses to make health insurance affordable; and
  • Reduce the so-called “donut hole” in the Medicare drug benefit.

The first three of these are really the fundamental parts of health reform, and improving Medicare’s Part D benefit is a widely agreed upon goal. The other aspects of the legislation that was moving through Congress are important, but not really essential - and the public plan option has always been redundant and politically explosive pair of suspenders alongside the belt of strong insurance regulations.  In addition, these provisions are also supported by two of the major industries that could have opposed health reform - insurers and biopharmaceutical companies.

There may be some who would criticize the first three of these changes as causing prices to go up, etc. as they transform the health insurance marketplace in most states, but the reality is that this would replicate what has happened in Massachusetts - first with their insurance reforms in the early 1990s, and more recently with their coverage mandates and expanded low-income subsidies.  And despite some public rhetoric, it is working very well, people like it, and it provides stability and security for insurance coverage.  What it hasn’t done is address costs - which is why the state is looking at an all-payer bundled payment system which would give clinicians, provider organizations, and others  incentives to control spending without being intrusive into their care practices.

Paying for these legislative changes will of course be a challenge, but with a renewed focus on fiscal and social responsibility for the Federal Government and financial institutions, there are innovative ways to have all these health reform changes not result in an increase in the Federal deficit.

Conclusions:

  • The Administration and Congress should be making the economy and jobs their #1 priority, but should continue to work on health reform since health costs and the vagaries of the health insurance system continue to fuel people’s angst about job security and the overall economy.
  • Significant health reform can be done without massive restructuring in one sweeping bill.  Rather coverage can be expanded and costs controlled by constantly pushing and shoving, and massaging and tweaking. Many successful government programs have been built and improved over many decades using such an “incremental” approach - so it is a valid avenue for improving such a complex, multipronged, pervasive, and sinewy “industry” as healthcare.
  • Important and significant provisions were included in last year’s stimulus law, and additional government actions should be viewed as building on those initial steps.
  • Change is hard, but explaining the immediate and long-term benefits for individuals and society will be important for deflecting politically driven mischaracterizations.  In addition, pointing to Massachusetts’ success with insurance regulation and coverage expansion should demonstrate that such changes work in the real world.  And while many other parts of the country point to Massachusetts as a liberal, “Taxachusetts,” socialist enclave, the state’s recent election of Republican Scott Brown to serve the remainder of Ted Kennedy’s Senate seat should fully refute that mischaracterization.  If a state can elect Scott Brown, then they can’t be all that knee-jerk, socialist-liberal.

Next Steps
The next steps in the annual Federal legislative dance will be the release of the President’s budget proposal tomorrow, followed by the start of the Congressional budget process. The two things to remember about the President’s budget proposal are that it was written and locked up before the Massachusetts Senate election, and this document is generally as much about making political points and sending specific messages as it is about the numbers for specific programs and initiatives. That is, within the Administration’s overall 3 year freeze on non-security discretionary spending there will certainly be proposals for program increases and decreases, but it is Congress that actually makes these determinations. Thus many of the numbers and programmatic initiatives in the President’s budget proposal may be designed to score points with specific groups and to force Congress to make the hard decisions about where to get additional funding for its favorite programs that the President’s budget proposes cutting. For those who thought that President Obama would somehow transform or transcend the Washington political process this may come as a bit of a shock, but the reality is that the framework of the Constitution and the evolving nature of the US government and society promote the separation of powers and a balancing act among them, which at times can look something like an uncivil war.

Posted in Delivery of Healthcare, Health System Reform, Medicaid, Medicare, Politics | No Comments »

Health Reform’s Rock & Roll

By Michael D. Miller MD
January 21st, 2010

With the Democrats losing their 60th vote in the Senate in Tuesday’s special election, the political and health policy worlds are astir with angst about the fate of health reform legislation.  Everyone in those arenas has at least one perspective about what would be the best course of action… including MoveOn, which stated in an email today, “Tuesday’s election was a shock. But the aftermath was even worse:  President Obama and some Democrats in Congress are now considering scaling back health care reform. That would be a huge mistake.”

However, given that MoveOn was one of the leading organizations declaring that the public option was the most important part of health reform, I’m not too inclined to put much stock in their understanding of the fundamental policy or political forces in the US right now.

Despite MoveOn’s proclamations, it seems clear that health legislation in 2010 will be smaller than either the House or Senate bills.  Whether that occurs in a bipartisan way (unlikely), via reconciliation (more likely, but limiting the scope of the bill), or through some other mechanism, remains to be determined by the political officials looking toward the 2010 elections - with perhaps some input from policy people. In addition, it is likely that HHS (and possibly some states) will get much more active with demonstrations and pilot programs, and the Federal government may look to the investments in Health IT and Comparative Effectiveness Research made in last year’s stimulus law as more fundamental cornerstones to build from.

Regardless of what comes next, some rock and roll lyrics seem very prescient for what has happened with the health reform legislation:

Sometimes the lights all shinin on me;
Other times I can barely see.
Lately it occurs to me what a long, strange trip it’s been.

 

But still they lead me back
To the long winding road.

 

You can’t always get what you want
But if you try sometimes you might find
You get what you need.

These images may also be illuminating for the path ahead, and are consistent with some of my predictions:  A year ago I wrote about the long and convoluted path health reform legislation would likely travel. And in a post last June I stated that many factors could change the course of the legislative process.

“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.”

So, as always, keep your seat belt fastened and the tray tables in their upright and locked position.


Posted in Federal Healthcare Reform, Health System Reform | 1 Comment »

Healthcare as Part of the Social Safety Net - Policy Implications for Health Reform

By Michael D. Miller MD
January 6th, 2010

Researchers at the Urban Institute have recently released a book about the forces and values that shape the social safety net in the United States. (Repairing the U.S. Social Safety Net.)

Yesterday, they held a briefing to discuss their book and solicit comments from other experts. Demetra Smith Nightingale, one of the authors, described how different parts of the social safety net interact, and how societal values and assumptions shape the creation and evolution of individual safety net programs. One of their fundamental conclusions is that society’s trust in government is reflected in how safety net programs are structured.  When there is more trust in government the programs can be national in scope and administered by the Federal Government, such as with Medicare or Social Security.  But when there is less trust in government, then programs are created which may be funded or supported with government dollars, but the programs are administered by state or local governments or even by private entities.

It is clear that today’s society is in a trust the government less mode, and this is reflected in the movement of the health reform legislation towards state and private entity implementation. Why this is important is that the Urban Institute researchers also looked at how well various types of social safety net programs work, and they noted that those with more local implementation also have much greater variability of effectiveness and penetration.

Two other conclusions from the discussion may be important for the implementation of a new health reform law.  First, food stamps are really the most fundamental part of  the social safety net in the US since they are the most easily obtained and food is the most basic of human needs.  And second, the social safety “net” is probably more like a series of lines that may or may not productively insect.  This situation might be like two fishing boats:  One using a net can very efficiently and productively catch lots of fish, while another using a number of individual lines may be able to use a variety of baits, but will surely miss catching many fish.

Below are two of the charts from the book which were distributed at the briefing.  These are very informative because they summarize how the different parts of the social safety net interact and the policy framework which connects societal values, goals, program structure and implementation.

Urban Institute - Deciphering the Conflicting Values Shaping the U.S. Social Safety Net Figure 1

Urban Institute - Deciphering the Conflicting Values Shaping the U.S. Social Safety Net Figure 1.2

Posted in Federal Healthcare Reform, Health System Reform, State-Level Healthcare Reform | No Comments »

New Year, New Decade, New City, New Health Reform

By Michael D. Miller MD
January 4th, 2010

For the new year and new decade I’ve relocated back to Washington DC to be more directly engaged with the implementation of health reform and related initiatives.

Packing, moving and unpacking took longer than expected - sort of like passing health reform legislation - and I apologize for my infrequent postings. Being back in more direct contact with policy makers, national advocates and others here in DC, I’ll be writing more frequently and in greater detail about the implications and expectations of health reform legislation, law(s), and implementation.

On the horizon is the development and passage of legislation combining the House and Senate health reform bills.  The Conferees and Congressional staff certainly have some policy and political challenges in melding the two bills into one.  Like most complex legislative initiatives, it is likely that action will be precipitated by Congressional recesses - the first one in 2010 is in mid-February.  Since fast action wasn’t the guiding principle for getting health reform legislation this far, it is unlikely it will be brought to the President’s desk very soon.  However, with both chambers having passed legislation it is very unlikely that they won’t bring it across the finish line - at which point the work will shift to the ginormous tasks of writing regulations and implementation.  As always, make sure to wear your seat belts and keep your eyes on the road, but be on the lookout for erratic drivers.

Posted in Health System Reform, HealthPolCom Blog | No Comments »

Playing Poker with Health Reform

By Michael D. Miller MD
December 16th, 2009

The National Journal’s December 5th issue has a very interesting article comparing President Obama’s approach to key issues to his poker playing style.  (The issue cover states, “Obama as Poker Player.”)

Having played poker for over 45 years, I find the article’s discussion of his cautious approach and preference for standard games very enlightening. For many people today, poker is about Texas Hold’em, a game that is great for TV but rather simplistic in some ways because each player only has 2 cards and shares 5 others.  The National Journal discusses the intellectual, strategic, and personality difference between this game, and more sophisticated games such as five-card draw and seven card stud - as well as more “wild” games such as baseball, although it doesn’t mention my crazed favorite, midnight baseball.

What the National Journal doesn’t discuss is the difference between playing poker on-line versus in-person, and the difference between playing with a bunch of strangers and playing with people you know and might interact with professionally.  These differences are very significant, since playing on-line is all about the odds, and “reading” people can only be done via their betting behaviors.  However, playing in-person enables a player to physically read the opponents, (i.e. see their “tells”), and playing good poker is primarily about playing the other people, and secondarily about playing the cards in your hand and on the table.  And reading the other people becomes even more important - as well as possible - when playing with people you know and have interacted with in other settings, such as negotiating legislation.

So for the President, applying lessons and strategies from poker to health reform, Iran, and other key issues may work well, but I also hope that he remembers that great players don’t win every tournament, and the key to long-term success is knowing when to fold, when and how to bet, and perhaps most importantly how to see around the table to what is likely coming up in future deals so one can be in the game and optimally positioned for future hands.

Healthcare Reform’s House of Cards
For the current health reform efforts, it seems that the cards are being reshuffled and new hands dealt at a time when the legislative house of cards should be getting its final touches and glued together.  Instead, the house of cards seems to keep collapsing - although Senator Reid, (and the President), are doing their best quick-handed action to keep rebuilding it for another try before minor or major political quakes send the cards scattering again. From a fundamental process level, the pulling in and pushing out of new ideas - such as a allowing some younger people to join or buy-into Medicare - is what might have been expected in April, May or June, but not December, and this is not a good sign for enactment of a law anytime soon.

The Substance of Health (Insurance) Reform Without a Public Optio
At this point, it seems that a public option is out of the equation, and some House Members are signaling that they could pass such a bill, but some on the left are arguing that no bill is better than a new law without a public option.  Despite these loud protests, not having a public option isn’t the end of the world, (sorry HD), and I’ll soon write why insurance reforms and coverage expansion are much more important, (sorry MoveOn.org), based upon my past experience with health reform legislation, my time in Massachusetts, and my very recent and ongoing ground-level experience in getting new health insurance in the District of Columbia as I prepare to move there from Cambridge, MA. (Preview - Community rating and guarantee issue by non-profit insurers v. medical underwriting by for-profit minded insurers.)

Posted in Federal Healthcare Reform, Health System Reform, HealthPolCom Blog, Politics, State-Level Healthcare Reform | 3 Comments »

Historical Perspectives on Health Policy: Part 3

By Michael D. Miller MD
December 4th, 2009

I just found my copy of the book “Improving Health Policy and Management” edited by Stephen Shortell and Uwe Reinhardt.  The book’s eleven chapters address many of the hot-button issues in today’s health reform debate:

  1. Creating and Executing Health Policy
  2. Minimum Health Insurance Benefits
  3. Caring for the Disabled Elderly
  4. An Overview of Rural Health Care
  5. Effectiveness Research and the Impact of Financial Incentives and Outcomes
  6. Changing Provider Behavior: Applying Research on Outcomes and Effectiveness in Health Care
  7. Health Care Cost Containment
  8. Redesign of Delivery Systems to Enhance Productivity
  9. Medical Malpractice
  10. Prolongation of Life: The Issues and the Questions
  11. Challenges for Health Services Research

The observant ready will notice one critical issue from today’s debate missing from this list… Information technology.  That is because this book was published in 1992… and actually the titles of the first and last chapters also included “in the 1990s.”

What this points out is that the fundamental issues of controlling costs, defining benefits, and improving efficiency in care delivery and through financial incentives are not new to the health care debate.  Reinforcing this historical reality, I recently ran into Professor Stuart Altman from Brandeis - who is one of the most insightful and clear thinking non-ideological health policy expert I’ve ever had the pleasure of talking to and hearing testify before Congress. And he told me on a rainy NYC sidewalk that he has been talking to people across the country about how the current debate is both similar to and different than the early 1990s, the 1980s, the 1970s….. and back to even the 1930s…and despite the ongoing delays he is hopeful that legislation will be enacted this time.

So while the issues haven’t changed, and likely won’t change no matter what legislation is enacted in the coming months, (and years), the hope is that this time around progress will be made so that health care becomes less of a national obsession, (and drag on the economy), and people and politicians can focus on life, liberty, and the pursuit of happiness, rather than illness, accessing needed treatments, and financial uncertainty.

Posted in Comparative Effectiveness, Federal Healthcare Reform, Health System Reform, HealthPolCom Blog, Miscellaneous | 1 Comment »

End of the Beginning for Health Reform

By Michael D. Miller MD
November 29th, 2009

This week’s Economist has an article titled “The beginning of the end” about the coming Senate debate.  But I think they have it exactly wrong.  The passage of legislation through the Senate - and then ultimately through a Conference Committee and by both houses so it can be signed by the President - would be the end of the beginning for health reform.

In contrast to the many, many hours of work by Members of Congress, many more by their staff, and probably even more by interest groups and activists across the country, the implementation of a new set of laws will be the real beginning.  Implementing a new law reforming the insurance industry - and myriad other parts of the healthcare delivery and financing systems - will require drafting of many rules and regulation, reviewing and commenting on the drafts, digesting those comments, issuing final rules and regulations,  drafting RFPs for contracts to run various new entities, (such as insurance exchanges), awarding those contracts, and possibly hiring employees for new functions such as a Medicare Advisory Board. Whew.

It now seems that the likelihood of a new health reform law being enacted during this Congress (probably sometime in February or March) has tipped into the greater than 50% category - but just barely. (National Journal has 2 great articles about the current precarious situation - one about the process and politics in the Senate, and the other about eight key stakeholder groups and their issues and concerns.) However,  even if the political and substantive issues can be tweaked into good-enough alignment that would enable enactment today, many different events and scenarios that are too complex and numerous to list here could still derail the process.

If the legislation fails to pass at this 715th minute, then there will still be followed by a vast outpouring of activity.  But instead of being focused on a specific law, it will be about how to address access and cost at the state level, in the private sector, and via more pilots, demonstrations and other variations within the existing authority of Medicare and other government programs. However, without a new law these activities will be much less focus and contained - and much of the effort will be discussion and analysis about what should be done and where limited resources should go, rather than focused on implementing new initiatives.

These two options remind me of a question someone asked me at Thanksgiving dinner, “Don’t they [Congress] have to do something since we can’t continue the way things are?” The presumption that if no legislation passes, then nothing will change is a false assumption.  With no major health reform laws for the last 20-30 years, the healthcare system has changed dramatically - both through private sector and government actions.  Clearly those actions have been imperfect and temporizing rather than addressing fundamental problems, but they have resulted in change.

Which scenario will be “better” depends upon who you are and how the current situation is benefiting or hurting you and your family.  Certainly, for the majority of Americans, having a new law would be better because it would improve their security for having insurance that they can depend on and know is stable - a theme that has persisted since the early 1990s and was reemphasized this summer by David Kendall and his colleagues at Third Way.

Posted in Federal Healthcare Reform, Health System Reform, Politics, State-Level Healthcare Reform | No Comments »

Cost and Coverage c. 1989-91: Part 2 of Historical Perspectives on Health Reform

By Michael D. Miller MD
November 17th, 2009

As I mentioned in my last post, in going through old files I found many memos and articles about health reform.  Some of them from 1989-91 illustrate the long history of the challenge of controlling costs and providing care for more people - and eerie similarities to the current debate:

For example, below are some pieces of text from articles and commentaries published in the New England Journal of Medicine from January 1989 - October 1990:

  • “A Consumer-Choice Health Plan for the 1990.  America’s health care economy is a paradox of excess and deprivation.  We spend more than 11 percent of the gross national product on health care, yet roughly 35 million Americans have no financial protection from medical expenses. To an increasing degree, the present financing system is inflationary, unfair, and wasteful. In its place we need a strategy that addresses the whole system, offers financial protection from health care expenses to all, and promotes the development of economically financing and delivery arrangements. Such a strategy must be designed to be broadly acceptable in our society. To remedy this deprivation, we propose that everyone not covered by Medicare, Medicaid, or some other public program be enabled to buy affordable coverage, either through their employers of through a ‘public sponsor.’ … The U.S. health care economy is inflationary. It is still dominated by fee-for-service payment of doctors and hospitals by third party intermediaries with open-ended sources of finances. There is no total budget set in advance within which providers must manage the care of their patients. For the most part, there is no incentives to find and use medical practices that produce the same health outcome at less cost.” (1/5/89 -  Enthoven and Kronick)
  • “A National Health Program for the United States: A Physicians’ Proposal. Our health care system is failing.  Tens of millions of people are uninsured, costs are skyrocketing, and the bureaucracy is expanding. We propose a national health program that would (1) fully cover everyone under a single, comprehensive public insurance program; (2) pay hospitals and nursing homes a total (global) annual amount to cover all operating expenses; (3) fund capital costs through separate appropriations; (4) pay for physicians’ services and ambulatory services in any of three ways: through fee-for-service payments with a simplified fee schedule and mandatory acceptance of the national health program payment as the total payment for a service or procedure (assignment), through global budgets for hospitals and clinics employing salaried physicians, or on a per capita basis (capitation).” (1/12/89 - Himmelstein and Woolhandler)
  • “Sounding Board: It Is Time for Universal Access, Not Universal Insurance. … Universal health insurance is not a good idea.  To control goods and services through a single agency - especially when the driving force is economic - would fly in the face of the American way of doing things. … Rather than support such unworkable, soulless programs, I propose universal access through a pluralistic funding mechanism. … So, we ought not to be talking about a universal health insurance scheme, but rather about universal access - access to needed care, on a timely basis, with controls on quality and use that have been accepted by everyone involved.  The key principle of effective access and limited cost is the rationalization of care.  In this age of high-technology medicine and miracle drugs, we must realize that we can no longer do everything for everybody just because it is possible. Rather, we should develop a system in which decisions about what we do, when, where, and to whom are based on reasonable expectations of the benefits involved and on sound medical principles communicated clearly to patients and their families.” (7/6/89 - James Todd, MD - American Medical Association)
  • “Special Report: The Pepper Commission Report on Comprehensive Health Care. A look at the outcome of the commission’s deliberations give a good indication of what, in fact, it takes to build political consensus. The commission basically face two separate tasks - reform of the nation’s existing system for insurance medical or health care, and creation of a system for insuring assistance in the task of daily living we call long-term care. The commission voted overwhelmingly (11 to 4) in favor of a major government initiative in long-term care. … By contrast, the commission’s vote on health care reforms - universal coverage for people under the age of 65 (at a cost of $24 billion) and measures to promote the efficient delivery of health care - passed by the slim margin of eight to seven. … The difference between the commission’s votes on long-term care and health care, then reflects the many and pointed political pressures that will work against consensus on health care reform, not for it. … First, and most obvious, the vast majority of commission members face reelection campaigns this fall… … Second, and related, in the wake of the traumatic repeal of Medicare catastrophic coverage, members will remain acutely sensitive to potential voter reaction to any particular reform package. Third, in health care there are entrenched political interests. … Fourth, with a complex issue such as this, consensus on the whole requires many, many concessions on individual provisions. … Finally, outright partisan politics will undermine consensus on health care reform, as the commission found in the days preceding the vote, when the White House placed intense pressure on some members to resist any consensus before the November elections. … If we do not act promptly, I believe our health care system may well implode by the end of the century.   The need for action is starkly clear.” (10/4/90 - Senator John D. Rockefeller IV, Chairman of the Pepper Commission)

And other articles from 1991 show similar perspectives on health reform and the urgency for action:

Washington Post, February 17, 1991 “Devising a Cure for High Costs of Health Care: Support Grows for Concept of National Medical Insurance. … The idea [of government-imposed universal health care that would provide quality coverage for everyone], in various forms, is gaining the support of groups ranging on the political spectrum from the AFL-CIO and the American Association of Retired Persons to the National Association of Manufacturers and the American Medical Association.  For the first time since the mid-1970s, supporters of national health insurance believe they have a legitimate chance of winning congressional approval for a universal health care bill, if not this Congress, then the next. ‘This is the best shot we’ve had in 15 years,’ said a key congressional aide. With health care costs climbing more than 20 percent a year for major corporations and even more for many small businesses, disparate political groups are beginning to form a coalition for reform.

USA Today, March 11, 1991 - “Health care costs more, serves fewer.  No other part of the US economy seems less understood than health care.  Few realize why health care costs are so stubbornly high ($2,700 per American per year) or why health care seems to defy free-market economics. … What a growing number of people are coming to know is dissatisfaction with a health care system that absorbs ever-soaring sums of money while letting more and more people fall through the cracks. …  Of all the cold showers of reality falling on the USA as the ’90s dawn, none is as chilling as this: The healthcare system in this country is in deep, deep trouble.”  (Graphic shows that of the 37 million people in the USA without health insurance 49% are working adults.)

Bottom Line - The more things don’t change the more they sound the same.

Next Up: Part 3 - Perspectives from a 1992 Medical School Class “The Crisis in the American Health Care System”

Posted in Access to Healthcare, Delivery of Healthcare, Economics & Financing, Health System Reform | 2 Comments »

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