Healthcare Turkey Talk

Posted on November 21, 2011 by Michael D. Miller MD

Thanksgiving is a great occasion for learning what people think about the future of the US healthcare system.* This year, I’m going to find out what people are thinking about some of the coming health delivery system changes – particularly Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMH).

I’ve conducted this two-question informal survey with handfuls of people and found their level of knowledge and positive reactions equivalent to Congress’s approval rating, i.e. 9%. This is worrisome, since if transforming the US healthcare system to increase value and quality will be partially based on ACOs’ and PCMHs’ superior care coordinating abilities, it will be hard to improve cost, quality, and access at the local level if the average person/patient doesn’t know what these organization are, there is inherent aversion to their names, or there is resistant to unexplained “changes.” (For example, several people I’ve talked to have thought Accountable Care Organizations seem like HMOs, and Patient-Centered Medical Homes are home care, nursing homes or hospice.)

So fair readers of this blog, let me know what you hear at your Turkey dinners and associated holiday events – and I’ll post back next week what I heard from my disparate and decidedly unrestrained friends and relatives.

*Unlike most meals and gathering of family and friends, Thanksgiving dinner goes on for a long time, there are no ceremonial interludes, and it is generally a sit-down affair so you can’t move on to someone else – or out the door. This means “Aunt Sally” can pull your ear or kick your leg (either figuratively or literally) for upwards of 2 hours about what’s wrong with the US healthcare system and what how to fix it. My advice is to ask questions to find out root concerns and to gauge people’s understanding of the coming ACA changes in both healthcare delivery and insurance coverage. Also, if you find yourself referring to a recent study from Commonwealth or Kaiser Family Foundation, (or a similar organization or government group), STOP, put food in your mouth and nod encouragement for them to keep talking, because quoting the best studies to someone impassioned about their healthcare will be about as successful as convincing your 7-year-old cousin that 3.14159 is a great dessert.

Era of Accountable Care

Posted on October 24, 2011 by Michael D. Miller MD

For many months I’ve been talking about the array of health transformation initiatives the Department of Health and Human Services has been deploying as both demonstrations and programmatic changes. I’ve been characterizing this strategy to create more accountability as an evolving menu, buffet, or map – sort of like those magical Harry Potter maps where the lines keep appearing on the parchment to create a recognizable image.

As part of releasing the final rules for the Medicare Shared Savings Program, HHS also put forth a document subtitled “Menu of Options for Improving Care,” which is a list of some of the landmarks in the future map of an Era of Accountable Care. This document listed “options for healthcare providers of all sizes, types, all across the country” to work together to coordinate patient care, improve quality and lower costs. Besides the Medicare Shared Savings Program for Accountable Care Organizations (ACOs), these options include:

Partnership for Patients ($1B over 3 years)
Bundled Payments for Care Improvements (4 models proposed and 4 more planned)
Comprehensive Primary Care Initiative (Medicare partnering with Medicaid and private payers in 5-7 local markets to support primary care improvement)
FQHC Advanced Primary Care Practice Demonstration (with HRSA)
Advanced Payment Accountable Care Organization Model (pre-funding for physician groups wanting to form ACOs for the Shared Savings Program)
Pioneer Accountable Care Organization Model (demonstration program for advanced ACOs)
Financial Models to Support State Efforts to Integrate Care for Medicare-Medicaid Enrollees

The Menu document clearly indicates a coherent strategy for doing what the Medicare Payment Advisory Commission recently recommended: “Medicare payments should strongly encourage providers to move towards [ACOs, bundled payments, capitated models, shared savings programs] and make FFS less attractive.”

HSS’ Menu document is an initial description of the map HHS is drawing for providers about these more attractive options. In contrast, in all the debate about health reform and Medicare there has been very little discussion about the future of Fee-for-Service payments or how to make FFS more sustainable - except for the $300B budgetary hole and pending 30% fee reduction in Medicare’s physician payment system’s Sustainable Growth Rate formula. However, making “FFS less attractive” is certainly one of the transformational “sticks” Medicare has been wielding based upon provisions in the Accountable Care Act* and through other Medicare initiatives such as Value Based Purchasing, not paying for Never Events, and using Competitive Bidding for certain products and services. And the future will see more and expanded use of these types of initiatives to “make FFS less attractive.”

CMS Has Already Been Transformed

Another significant distinction between HHS’ current actions and what they have traditionally done is that HHS is not moving forward alone by modifying Medicare and Medicaid. Instead they are actively seeking to work in alignment – if not outright partnership – with private payers. This is clearly stated in the CPCI and the Multi-payer Advanced Primary Care Initiative, which has already started in 8 states.

I have previously written about Accountable Care, (and how it is fundamental for successful health reform), and with the unveiling of the menu from HHS I am encouraged that we are on the way to an Era of Accountable Care – because that is what people really want and society needs, i.e. Accountability for Clinical Outcomes and Accountability for Economic Results. It is only through those two avenues of accountability that we will achieve my version of the 3-Part Aim:

Saving Lives
Cutting Costs
Creating Jobs

Health Reform is Essential for Creating Jobs

“Creating Jobs” doesn’t usually appear in lists about the goals for health reform, but it is really a fundamental reason for fixing our fractured healthcare system: By reducing the financial bite healthcare is putting on families and companies – as well as creating security for access to health insurance for individuals – health reform will pour capital and confidence into the economy leading to the creation of jobs. That will be an era of healthcare that we can all count on.

——————————
* The given name for the health reform legislation is the “Patient Protection and Affordable Care Act,” and it is often referred to as the Affordable Care Act or the ACA. However, I believe the transformational components of the ACA are its features that will create accountability for the clinical and economic outcomes our healthcare system produces, and thus I call it the Accountable Care Act. In the context where others are referring to this law as Obamacare, or as a government take-over of the US healthcare system, or portrayed voluntary counseling as death panels, then I am very comfortable nick-naming the ACA the Accountable Care Act.

Health Reform’s Challenges – Some Things Don’t Change

Posted on October 6, 2011 by Michael D. Miller MD

A few years ago I was asked to write a Forward for a book about the transformation of healthcare in the US. I recently came across what I’d written about the rapidly changing US healthcare system and the challenges of controlling the growth in spending. I’m sharing it below (in the original Courier font) because what I’d written still is applicable for today’s situation, and particularly the summary sentence: “If today’s leaders — both health professionals and politicians — make wise decisions to support and foster integration of the delivery system and administrative standardization, while guaranteeing universal coverage, we will have a strong health system to support a strong nation.”

Forward

Health care in the United States is changing very rapidly. This seemingly obvious statement has taken many people by surprise despite the fact that the environment for health care has been evolving for decades. Both the actual delivery of health care and its financing are dramatically different today than when my father first started practicing medicine. I do not make this personal reference casually. Rather, I believe it is very important to remember that for everyone, illness, health, death and dying are among the most personal of issues within their lives and the lives of their family. I state this up-front because just as health is a very personal concern, health reform is an issue of people, personalities, and their relationships.

Just two decades ago, well after my father started practice, diagnostic testing was much more limited — MRIs were experimental, and fiberoptics were being introduced. Treatment options have similarly expanded with new procedures, (ambulatory surgery, fiberoptic surgery, and home IV), and new pharmaceuticals, (ACE inhibitors, antivirals, EPO, and new biologics), are standards of care. Similarly, reimbursement and financing of health care has also changed dramatically: Fee-for-service was predominant with payments made for submitted charges. Discounting and capitation were basically nonexistent for most physicians. Managed care was an unrecognized concept except in the form of care management by personal physicians prior to the explosion of specialists.

Clearly health care in 1993 is very different from health care in 1973 — for both patients and physicians. It is also very different for hospitals, insurance companies and businesses. To imagine in 1973 that General Motors would be spending more for health care than for steel in the 1990s would have been as inconceivable as imagining that AIDS would redirect the force of the 1960s sexual revolution into a social philosophy of safe sex. Situations such as these permeate American society, and have added many new moral and financial issues to the current round of reform debate.

Every time I talk with groups of professionals involved with providing or paying for health care — physicians, nurses, hospital administrators, business owners — I try to impart the perspective of rapid change and evolution to them. I have also tried to convey this to the policy makers with whom I have worked in Washington D.C., both in Congress and on President Clinton’s Health Reform Task Force. The key is to remember that dynamic change is always a constant process, and health reform — either market driven or legislatively directed — is definitely a continual process.

Some have argued that “health reform” will result in great losses for many Americans — losses of quality or choice or autonomy or benefits. Although guarantees are impossible to make in such a sweeping process, I strongly believe that in the end — perhaps after a rocky transition — the gains will greatly outweigh any downsides. This applies for everyone, not just for those who will gain the most, i.e. the uninsured or the underinsured. For example, increased organization and uniformity in our health care system will allow health care professionals to focus on delivering health care, maintain control of clinical decisions, and worry less about multitudes of benefit structures and paperwork mazes. Patients will benefit by having a rational system which provides guideposts to assure coordinated quality care rather than by default having to undertake their own care management because the disorganized system provides little or no assistance.

This evolution of health care delivery will be tightly linked to reforms of financing and risk assumption. Successful integrated health delivery systems will be able to accept the risk under a capitated payment system, but their ultimate success will depend upon providing their core “product,” i.e. health care services, and being able to document the quality of the care. The ability to coordinate these two functions will require a tight working relationship between the system’s administrative management and the systems “product” managers, i.e. physicians and other health care providers.

In thinking about how to achieve success in health reform, the relationships between individuals is extremely important to remember, and surprisingly easy to forget. It must be recognized and remembered that health reform is a people issue. Not only does it involve people’s basic needs, but it is a service provided by people for people. And at its most basic level, the process of reform is a people puzzle, not a technological one. This is clearly seen in the personal relationships and negotiations which encompass the politics of health reform.

Even more striking is the people-centered nature of health reform in the marketplace. Ultimately putting together a reformed health care delivery system requires the building of new relationships between organizations, i.e., hospitals, groups of physicians, and other providers. However, these relationships are ultimately personal ones, involving the individual physicians, other caregivers, and the managers of the larger entities. These relationships are not easy to build, but recognizing their necessity as a foundation for system development is the first step in the process.

Thus, reform initiatives — both local and national — in the coming years will likely be characterized by the saying “Market Driven & Medically Directed,” because the marketplace will force integration to proceed, but the shape and control of the resulting integrated systems will be directed by health care professionals — predominantly physicians.

The chapters of this book provide perspectives, information and guidance for health care reform leaders on how to think about health care delivery as a local and a regional phenomenon — an outlook often missing from national debates. The overriding conclusion is that through appropriate integration and alliance building, health care can be improved and costs contained.

This volume focuses on: 1) the market forces driving the current evolutionary process in health care, 2) the resulting niches which health organizations are being forced to fill, and 3) how they are responding in order to successfully fill these new niches. Overall, the volume describes how health care professionals can think and prepare for the coming decades as our health system evolves from one marked by disorganization and multiplicity to one of more integration and uniformity.

The issues discussed in this book are not the final word in health reform. In fact, if market driven health reforms are the only changes seen in this country, it will be a road to disaster. One of the major downsides of solely market driven reform is that through integration and the alliances formed by health providers, businesses and insurers are able to reduce cost shifting within the system which has been used to support uncompensated and charity care. This reduction of a hidden tax would benefit businesses, but carried to its extreme could also lead to a situation where the uninsured truly will be without access to any health care because those who can pay will no longer be subsidizing those who cannot. This will cost our businesses and the nation more in the long run both financially and morally.

In the end it will be the actions and decisions of front line health care decision makers which will determine the strength of the health care system the U.S. will carry into the 21st century. If today’s leaders — both health professionals and politicians — make wise decisions to support and foster integration of the delivery system and administrative standardization, while guaranteeing universal coverage, we will have a strong health system to support a strong nation. Less fortunate alternatives will leave us weakened both financially and morally. Although I do not believe in utopian scenarios, I do believe that progress will be made, and problems addressed in a positive and significant manner. It is clear that the marketplace participants — health professionals and their organizations, being driven by businesses — are following through on their end of this equation. It remains to be seen how well the political leaders of our country follow through on their end of this balance.

Michael D. Miller, M.D.
November, 1993
Washington, D.C.

18 years later it is clear that the issues and solutions haven’t changed significantly: Cost containment, quality improvement and expanding access were (and are) the goals, and the solutions involve creating “a rational system which provides guideposts to assure coordinated quality care rather than by default [patients] having to undertake their own care management because the disorganized system provides little or no assistance.”

2011 is clearly as different from 1993 as 1993 was from 1975. One of the biggest difference is that political leaders have finally followed through by passing significant legislation – which didn’t happen in 1994. Another significant change is the ability of information systems to acquire, analyze, and distribute data and comprehensible/actionable information to clinicians, payers, providers, and patients.

While we’re making progress, it won’t come unaided and unguided. The pieces necessary for making dramatic improvements are being put into place from a variety of sources, including legislation (e.g., HITECH and PPACA), other government actions (e.g. Medical Home and innovative payment demonstrations), non-profits (e.g., RWJ Foundation’s AF4Q and Care About Your Care), and initiatives from companies (e.g., Prometheus, Leapfrog, and redesigning health benefits). The challenge now is for businesses, providers, payers, clinicians, regulators, legislators, and patients (or at least their advocacy organizations) to follow through and turn those pieces into a coherent and integrated system – or really connected and coordinated systems – that provides greater value and more accountability for both clinical and economic outcomes.

Health Law Is Reforming System Via Market Forces

Posted on April 3, 2011 by Michael D. Miller MD

All the controversial rhetoric about the new health reform law is missing a huge reality: The law is driving dramatic changes in the real world. Almost every major health delivery system is preparing to reorganize how they provide care to hundreds of millions of Americans by becoming Accountable Care Organizations (ACOs).

Health Systems are Voting With Their Wallets
The magnitude and level of financial interest in ACOs – and proof that it is not just cautious planning – were dramatically illuminated by recent actions and a Washington Post article:

On Thursday, HHS released the long anticipated proposed rule for ACOs and Medicare “Shared Savings.” For the rest of the day the Federal Register’s website was nearly shut down by people trying to download the 429 page document.
Today’s Washington Post article, “Complicated health-care law leads to payday for consultants,” includes figures about the tens of thousands of dollars consultants are charging for strategy sessions about how to think about ACOs, and the millions of dollars in fees they are getting for actually helping health systems to become ACOs. Health systems were signing consultants up for these engagements before the draft regulations were released because of their expectations of how dramatically competition among ACOs will change their financial incentives and structures. And some of the phrases in the article highlight the level of importance being placed on ACOs: “ACO frenzy,” “Oversubscribed,” “Glittering high fees” and, “I have never seen anything quite like this in my 35 years in this business.”

Bottom Line
I could write more about the proposed ACO rule, my interactions with health systems looking to become ACOs (and the organizations helping them), and how ACOs will very likely produce significantly more savings for Medicare than the Congressional Budget Office has projected, but the bottom line looks like this:

ACOs are happening.
The Medicare ACO/Shared Savings rule will shape their form, but not their creation.
ACOs – and their quality/efficiency incentives payments – will fundamentally transform health care in the US.
This transformation will be like an avalanche as health systems compete locally to demonstrate how much more Accountable they are to patients and payers, i.e. how they provide higher quality at lower costs than their competitors down the street or across the river.
While the official title of the new health law is the “Affordable Care Act,” it very easily – and perhaps more accurately – should have been called the “Accountable Care Act” because it is that part of the law which will actually lead to more affordable care for more people.

As always, stay tuned and keep your seat belts tightly fastened for the upcoming wild ride. Like a roller-coaster, the fun is just beginning.

Accountable Care Now

Posted on March 7, 2011 by Michael D. Miller MD

If all arrows in Washington pointed to the same spot for solving the healthcare and Federal spending problems could the politicians, pundits and policy people agree? Or would it take some new and powerful force to shine a spotlight and focus the collective vision on this solution, and what would that force be?

These are the two questions I’ve been asking myself as the battle over Federal spending has become near white-hot, and as it has become increasingly clearer that long-term Federal solvency and deficit reduction will require addressing the growth in healthcare spending – particularly Medicare.

[Source: Kaiser Family Foundation "Medicare Spending and Financing," February 2011]

To summarize the highlights of this situation:

Cutting non-defense discretionary Federal spending can’t produce the reductions needed to significantly impact the deficit – contrary to the general misunderstanding about how the Federal budget is spent. (See this recent Washington Post article, and the bullet below from an associated poll.)
- “There are widespread misperceptions about the state of the federal budget. A majority of voters incorrectly believes the federal government spends more on defense/foreign aid than it does on Medicare and Social Security (63%). Also, a similar majority (60%) incorrectly believes problems with the federal budget can be fixed by just eliminating waste, fraud and abuse. Voters do not casually agree with these untruths- at least 40% strongly agree. Further, less than half (44%) believe Medicare and Social Security costs are a major source of problems for the federal budget (49% disagree).”
Medicaid spending is high but counter-cyclical, so improvements in the economy and employment will reduce those costs by cutting the number of people using the program
Social Security is a straight numbers issue – while the Baby Boomers are increasing the program’s numbers, the per person cost growth is close to CPI
Medicare is not counter-cyclical, its growth is a combination of the Baby Boomer influx and the per person growth rate, which is projected to be about 7%. The result is that since Medicare accounts for about 15% of total Federal spending, the Medicare program is the keystone to solving the Federal fiscal puzzle

Solving the Medicare Puzzle
Wouldn’t it be great if there were a way to reduce Medicare long-term spending, and one that most politicians and policy people agreed was the right solution? Fortunately there is. And it’s already in Federal law: It’s a concept that many Democrats and Republicans have repeatedly endorsed because it increases local control and decision-making, while shifting incentives from quantity of services to quality of care. This new model is called Accountable Care Organizations (ACOs), and it was included in the new health reform law, (a.k.a. Patient Protection and Affordable Care Act, or “Obamacare”). This short provision in the law adds ACOs as a fundamental change to Medicare, (i.e., not just a pilot or a demonstration), and it enables Medicare to pay ACOs in any way that both Medicare and the healthcare provider (or delivery system) agree to. Further, it encourages Medicare to work with private payers to enhance the motivations for creating successful ACOs. [See 1899(i)(3) and 1899(j) of Title XVIII of the Social Security Act (42 U.S.C. 1395) as added by Public Laws 111-148 & 111-152.]

So why isn’t there a collective multi-partisan and multi-stakeholder rally of support for ACOs?

Making healthcare delivery systems and providers into effective ACOs won’t happen quickly – it will require a stepwise transition. (However, many, many hospitals, health systems, group practices and others are gearing up for the transition – which will likely involve bundled payments and focused bonuses for achieving desired outcomes – but the roads to becoming a full ACO will be varied and lead to many different successful structures.)
The proposed rules for the ACO provisions of the health reform law haven’t been issued yet, so there is still significant uncertainty about how Medicare will implement their new authority.
Political philosophy against government programs – particularly on the national level – is now a very strong force focused on repealing “Obamacare” like college students during spring break fixated on a blinking “Free Beer” sign.
The ACO provisions lack the specific payment formulas or dollar amounts that fiscal forecasters desire for building models and developing multi-year estimates. As a result, the savings projections, (a.k.a. scoring), have estimated only very modest reductions in Medicare spending since there is significant uncertainty about how ACOs will develop and evolve.

Solutions
Here’s why those savings projections are too conservative, and what can be done to swing the political tide the other way:

Hospitals, healthcare systems, other providers, and other organizations are already preparing to become ACOs. That is, rapid movement towards ACOs is happening across the country, and it needs Medicare to be a positive – and maybe even aggressive – supporter. This private sector movement is similar to the reaction health providers and payers had to the potential national health reform legislation in 1993-95 – (see chart below) – but this time the reform is actually in law, and the private sector responses are much broader and intense…. From what I am seeing, this activity is about 10 times greater in terms of resources being committed, and plans being developed and implemented.

[National Health Expenditure Increases: Actual and Adjusted for CPI]

The other “solutions” to reducing Medicare spending are the typical “cuts” in payments to hospitals and doctors, or reducing benefits to seniors…. But for either of those to significantly reduce long-term spending would require politically and socially untenable changes to Medicare. In addition, these changes would involve much greater Federal government intrusion in actual care delivery decisions than would effectively implementing the ACO provisions of the ACA.
For Americans to be receiving UnAccountable Care as the norm is no longer acceptable – just as driving cars without seat belts or dumping raw sewage into rivers is also not acceptable today, even though it was the norm in the past. Just as the standards of care for medical practice change, so should the overall structure of care delivery. For example, high blood pressure in the elderly used to be accepted and not treated because the thinking was that the high pressure was a good thing and needed to push blood through hardened arteries. That idea is no longer accepted, and not treating hypertension today would be UnAcceptable care.
There needs to be a public groundswell for “Accountable Care Now.” This can be true grassroots support, grass-tops advocacy from opinion leaders, and even “astro-turf” campaigns from national advocacy organizations and companies. The end result needs to be getting public opinion and voices to be coherent and loud for change. What matters is that the chorus for “Accountable Care Now” sound something like:

What Do We Want?

Accountable Care!

When Do We Want It?

Now!

Bottom Line
If Medicare beneficiaries, organizations paying for healthcare, (including Medicare and Medicaid programs), and everyone else – including leading healthcare professionals – start a drum-beat for “Accountable Care Now,” it will become UnAcceptable to be delivering or paying for UnAccountable Care. And elected officials across the spectrum, pundits, and policy leaders will have to – and want to – start looking under the Accountable Care spotlight and put their efforts toward making Accountable Care a reality Now – or at least ASAP.

Fundamentals of Health Reform and Transformation

Posted on February 5, 2011 by Michael D. Miller MD

Trying to follow what’s being written about implementing health reform has been like trying to drink a waterfall. Having followed these issues for many years I’ve gleaned some fundamental aspects about many of the ideas and recommendations that simplifies how to approach this flood – including how to evaluate ideas and proposals like Patient-Centered Medical Homes (PCMH), Accountable Care Organizations (ACO), Shared Savings, Health Information Exchanges (HIE), Pay-4-Performance (P4P), etc…

Structure v. Reimbursement Systems/Arrangements
First, discussions and descriptions that don’t affirmatively recognize the distinction between Structures and Reimbursement Systems can create significant confusion. For example, the requirements for a PCMH to be recognized by the National Commission for Quality Assurance are structural, but how they are reimbursed will strongly influence how successful such practices are for improving quality of care and controlling costs.

Similarly, at one level ACOs are structures for organizing care – albeit to assume some level of financial risk. But their reimbursement systems and arrangements (both external and internal) will be tremendously important for their clinical and financial success. For example, the health reform law has a “Shared Saving Program” for Medicare and ACOs, but it specifically state that Medicare can reimburse ACOs under three different options:

A shared savings arrangement (essentially a one-sided risk situation where the ACO can get savings but isn’t at risk if costs are higher than projected)
Partial capitation (i.e., some two-sided risk)
And, any other type of arrangement that the Secretary of HHS thinks makes sense.

Until the proposed recommendations for this part of the health reform law come out, (and they are expected very soon), it is mostly speculation as to what each of those three options might look like – as well as what related options might be created as demonstrations by the new Center for Medicare and Medicaid Innovation.

Process v. Outcome Measures
Another confusing aspect of discussions about reformed or transformed healthcare is a blurring between measuring processes and outcomes – both clinical and economic. Part of this blurring occurs because process measures are often used as proxies for outcomes. While these type of proxy measurements are common in clinical medicine, (e.g., blood cholesterol levels are a proxy for risk of heart attacks and stokes), using them for broad transformations in healthcare is more challenging because there is generally a very strong desire to see the savings (or improved clinical outcomes) before investing time or money to expand the reforms.

Conclusion: Focus on the Fundamental Big Questions
So, to simplify thinking about how to create a better healthcare system in the US, I recommend coming back to these two sets of questions:

What is the structure? And what are the reimbursement systems/arrangements?
What process and outcome measures will be used to evaluate the new structures and reimbursement systems? And how do those process and outcome measure relate to each other, i.e. how do we think the process measures lead to better outcomes?

US Healthcare Spending – 2009

Posted on February 5, 2011 by Michael D. Miller MD

With all the focus on US health spending I thought it would be useful to update the pie chart I’d posted previously that showed 2007 and 2006 National Health Expenditures. So below is the chart showing US health spending for 2009.

What can be seen by comparing this chart with the previous ones is that the percentages haven’t changed very much. Which means that the foci for cost containment still needs to be on hospitals and physician services and how they influence other types of spending. For example, avoiding hospital admissions, and utilizing clinical services provided by non-physician professionals, etc…. More on this to come in future posts.

Implementing Health Reform – The Long, Hard and Twisting Maze

Posted on April 13, 2010 by Michael D. Miller MD

Health reform is now the “law of the land,” and “written in law.” However, as people are quickly realizing, after a year of campaigning and more than a year of legislative action, implementing the new law will require navigating a long, difficult, and twisting path – even before any amendments are considered in this or subsequent Congresses.

Navigating the fast and slippery route to successfully implementing all the provisions of the PPACA will be daunting. Three relatively recent laws are examples of the time and steps required for such implementation – and each of these was much simpler than the PPACA:

The Medicare Part D law was signed in December 2003 and the new benefit started in January 2006. This gave the Federal government about 2 years to develop the rules, sign up providing plans and facilitate enrollment by creating an exchange-like website and other resources, while the plans conducted the actual enrollment.
The Massachusetts health reform/insurance expansion law was enacted in April 2006. This was followed by a long series of staggered implementation steps. For example, insurance reforms, (on top of the state’s pre-existing significant insurance regulations), became effective in January 2007, and the new individual mandate started in July 2007.
The Federal stimulus law was signed in February 2009, and the HITECH Act part of the law included significant provisions and funding to boost the development and adoption of information technology by healthcare providers. At the end of December 2009 a key draft rule on “meaningful use” was released, and it is expected to be finalized soon. In the meantime, the Department of Health and Human Services has distributed funding to start the adoption of specific types of health IT. (The April 2010 Issue of Health Affairs has a series of articles focusing on the implementation of the HITECH provisions of the stimulus bill.)

Written in Law – Not Written in Stone
The implementation of these laws illustrates how it takes months and years after a law is signed to create the implementing rules and regulations, and to contract with organizations to actually carry out significant parts of the new law – and this is before any modifications are made by subsequent laws.

In the coming weeks and months, many entities will continue combing through the final law – which because of the circuitous path it took to Congressional passage is much more difficult to read and understand than most other new laws. Some of the most challenging aspects of implementation will be in the states, where government agencies will have many new responsibilities and/or will need to be created. Federal and state governments, and many private organizations, will also probably need to hire people to carry out this implementation – and hiring government employees can be a lengthy process.

In addition healthcare companies – particularly health plans and insurers – will be working to determine how their business operations will be affected by new state and Federal regulations, despite the fact that those regulations haven’t been written yet. And all but the smallest businesses will be seeking to understand how they will comply with – and possibly benefit from – the new insurance rules and financial incentives.

Overall, it is clear that the implementation will be the hardest part in taking health reform from a concept and a campaign position, to reality for individuals and society. I know that many people in Washington DC – particularly Congressional, HHS and related health reform staff – worked very hard for many, many months in an exhausting process to get the law passed. For Congressional staff at least, the implementation will be the responsibility of others, while Congress’ work will be to ensure that this implementation is consistent with their intent, and to work with HHS to adjust provisions according to the real-world bumps and detours in the road from here to there.

Conclusion
The cartoon below summarizes the expanding and complicated challenge of implementing health reform through the inevitably twisting and complicated path better than any combination of words could… I’ll have more about specific provisions and implementation in the coming days, weeks, and months….

Politics of Health Reform: Selling Anger or Catharsis

Posted on March 22, 2010 by Michael D. Miller MD

With the health reform legislation process winding up, it is clear that going forward politics are – and will be – front and center, with the divide between the Democrats and Republicans as wide as the orbit of Pluto…… the planetoid, not the Disney character. This divide is depicted in black, white, and red in the National Journal’s March 13th Insiders Poll question, “If Congress enacts something close to President Obama’s latest health care reform plan, how would that affect your party in the midterm elections?” 87% of Democrats thought it would “help a lot” or “help a little,” and 100% of Republicans thought it would help them.

They can’t both be right.

Each party is banking on their ability to sell health reform their way: Democrats will present it as a significant step towards fixing many of our healthcare system’s and country’s problems. Conversely, the Republicans will characterize it as fundamentally evil and something that will end individual freedom and civilized progress because of “government takeover of healthcare” being run by a “healthcare czar.”

These sentiments and strategies are clear in the quotes accompanying the National Journal’s poll:

Republicans:
“The tax increases, the wild spending, and the backroom deals and threats will shock voters of all parties, producing a GOP revolt.”

“Passing the bill will help the GOP by fueling voter (especially senior) anger at an arrogant majority that knowingly ignored popular opinion.”

Democrats:
“It will help a lot of people, show that Democrats can act, and get the ‘sausage making’ off the news.”

“If it passes, people [will] see it’s not the end of the world and learn more about its benefits. The more they know about it, the more supportive they are. Best of all, we can begin talking about something else.”

However, one Democrat in the 9% who thought enacting the law would “hurt a lot” said, “The Right hates it, the Left is not satisfied, and the middle is scared.”

Majority v. Minority – Catharsis v. Anger
Without dissecting the merits of their positions, these divergent perspectives are due to the parties’ different roles in our two-party democracy: The majority needs to present their actions in a way that fosters catharsis in people, (particularly in voters), by actually improving some problem. Their goal is to turn that catharsis into positive feelings about the majority party, leading to votes in future elections. Conversely, the minority party needs to create anger about what the majority party is doing or proposing, with the goal of turning that anger into….. (no surprise here)…… votes in future elections.

Thus the key for the party leadership, individual elected officials, and their communications and campaign staffs, is how to best create catharsis or anger – depending upon which side of the fence they are on.

An old friend, Dan Wasserman, the political cartoonist for the Boston Globe, in his March 2nd cartoon depicted this very nicely:

[This cartoon was also reprinted in the March, 6th issue of National Journal]

Challenges of Political and Policy Communications
How people, (i.e. voters), perceive the issues and problems – and potential solutions – is strongly influenced by how they are presented and described. It is this communications process that builds or derails political and policy initiatives and campaigns. No matter the long-term success or failure of the health reform law, the road from now until the November elections will be filled with messaging to instill voters with either catharsis or anger – particularly swing voters in key states and CDs. For the Democrats, creating cathartic feelings will be much, much easier as specific provisions of the law become effective.

For Republicans, creating anger will be possible from the outset. In the near term having a new law will give them a focal point for anger, with proposed regulations and rules being easy and rich targets. In the longer term, as the new law actually improves many people’s lives, it will be harder to accomplish that goal. However, by that time, if they can use the near term anger they’ve created to take control of one or both houses of Congress, or the White House, as the majority party they will be the ones trying to create catharsis – so some successes via implementation will be to their benefit. In addition, if that happens, for political reasons Republicans will not want to repeal or significantly unravel the new law since continued implementation of health reform – without dramatic alterations – will deny Democrats one of their main campaign issues that they have historically used to generate anger among their base and swing voters.

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Post Script: Turning Anger Into Productive or Destructive Action
[Omitted for space considerations.]

How Long is the New Health Law?

Posted on March 21, 2010 by Michael D. Miller MD

With the House of Representatives passing the Senate’s version of the health reform legislation tonight, it can now be signed by the President. An historic step by any measure. While one of the criticisms leveled against the bill has been its length – typically cited as 2,409 pages – I recently pointed out to someone that the 2,409 page length is because the bill is printed to make it easy to read by using a large font, leaving lots of space between the lines, and sequentially indenting subsections to make the overall structure clearer. (Below is one page from the printed version of the bill.) However, by changing the font and reformatting it, I was easily able to make the entire bill fit on 60 pages.

So how long is the bill? It all depends. But certainly the 2,409 page length “fact” – and similar figures – will be tossed around as pseudo-quantitative arguments that the new law is too complex, which will be another example of fun with facts in support of political positions.

Health Policy and Communications

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Category Archives: Federal Healthcare Reform