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Implementing Health Reform - The Long, Hard and Twisting Maze

By Michael D. Miller MD
April 13th, 2010

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….

MAZE-Man

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

Preparing for Health Reform Summit (and More Snow)

By Michael D. Miller MD
February 24th, 2010

Over the last week stakeholders and pundits have written and spoken exhaustively about tomorrow’s health reform summit and the President’s proposal released on Monday.  All together this has been a bit overwhelming.  What seems clear is that all sides and constituencies are trying to reiterate their goals and fundamental positions while still maintaining optimism that some significant reform can happen this year.

Today is like the lull before the storm - and Washington, DC is predicted to get another 5+ inches of snow starting late tonight - so rather than add to the cacophony of statements, opinions, and predictions, below is video about some favorite things that may help alleviate some angst and put people in a better mood for both the summit and the snow.

And if the aftermath of the summit and tonight’s snow leave people a bit disappointed or unsettled, then perhaps the video can help too.

Posted in HealthPolCom Blog | 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 »

More on Medicare Medical Home Demonstrations

By Michael D. Miller MD
October 28th, 2009

Last week, I wrote about the new “Advanced Primary Care” (APC) model demonstration announced by the Department of Health and Human Services, and how it might interact with the previously announced - but not yet implemented - Medicare Medical Home demonstrations.  In that post I noted that the healthreform.gov fact sheet stated the two demonstrations would move forward together in 2010, and the CMS webpage for the Medicare Medical Home demonstration hadn’t been updated since April.  Well, both of those situations have changed.  The CMS webpage was updated on Monday stating that the Medicare Medical Home Demonstrations will not be moving forward because the House version of health reform legislation would repeal the Medicare demonstration and replace it with two other medical home demonstrations - one independent practitioner-based and the other community-based.  (See bottom of post for text of CMS webpage update.)

Hurry Up and Wait
So while the APC demonstration linking Medicare, Medicaid and private payers for medical home projects is presumably moving forward, we’ll have to wait until health reform legislation gets wrapped up to see if it will have any Medicare specific companions.  Similarly, we’ll have to wait and see how much of the Federal legislation is devoted to delivery system reform via medical homes, accountable care organizations or other initiatives, how much is payment system reform, how much is cost containment, how much is coverage expansion, and overall, how much of it locks in some of the current system’s structure, i.e. in a new public plan option - for which a preferred form seems to changing almost daily.

Stay tuned, and keep your seat belts fastened and tray tables closed, it’s likely going to be a bumpy ride for the next several weeks.

The full update from the CMS webpage is below:

10/26/2009 - In Washington, the efforts to reform health care and health insurance include proposed legislative language that would have an impact on the Medicare Medical Home Demonstration as described in section 204 of the Tax Relief and Health Care Act of 2006 and amended by section 133 of the Medicare Improvements for Patients and Providers Act of 2008. Specifically, section 1302 of House Bill 3200 contains a provision to repeal this demonstration and replace it with an independent practitioner-based medical home pilot described further in the bill. In addition, the House bill includes a second medical home pilot to evaluate community-based medical home models.

At this time, CMS believes it would be impractical to pursue clearance of the Medicare Medical Home Demonstration, which has been under review at the Office of Management and Budget, given the pending legislation that would repeal it and replace it with a similar pilot. CMS is moving forward with an Administration-initiated demonstration announced by Secretary Sebelius on September 16, 2009, whereby Medicare would partner with existing multi-payer medical home pilots to improve the delivery of care. This demonstration, titled the Multi-Payer Advanced Primary Care Practice Demonstration, would be implemented in 2010.

Posted in HealthPolCom Blog | 1 Comment »

Wavering Health Reform

By Michael D. Miller MD
July 12th, 2009

As news of some disharmony in the efforts to reach consensus for health reform legislation sprayed out from Washington, I’ve been trying to find the words to explain what this means.   It’s always been clear that the “devil is in the details” and that when it came time to forge enough agreement to pass legislation, (as it did last week), there would be ups and downs as provisions are modified, dropped and added.

Beyond that simple description, it would take many, many words to explain how the process for achieving success in health reform legislation could work.  So instead, below are some pictures, that I hope will be worth thousands of words more than the brief comment below each one.

Roller Coaster

The process will continue to be have ups and downs - and unexpected loops - which may leave some people nauseated.

Roller Coast Again
Putting together successful legislation requires understanding the science of health, and the “physics” of how all the parts of the healthcare system and the political process interact. [Note how the pieces slow down and come closer together at the peaks, and then speed up and spread out in the valleys.]

Roller Coaster
And hopefully amidst all the ups and downs and loops, the final result of health reform will have a heart (and soul).

And lastly, not to forget the “Golden Rule,” below is a video that two other health bloggers (Matt Yglesias and Jonathan Cohn) linked to in their blogs to illustrate the importance of financing and the “golden rule” for making - or breaking - health reform.

And of course, in this case, the “Golden Rule” is….. “He (or She) who has the gold, rules.”

I’m going to be in DC this week to take the pulse of health reform. So stay tuned for the prognosis of success amidst all the twists and turns in the substance and process of health reform.

Posted in Health System Reform, HealthPolCom Blog, Politics | 1 Comment »

Making Health Reform Work

By Michael D. Miller MD
May 1st, 2009

With momentum for health reform continuing to build, events have overtaken the scope of the book I’ve been writing - which has had the working title “Fixing the US Healthcare System.”  Therefore, I’m reconstituting the draft text and outline to increase the focus on how to effectively implement changes in the healthcare system - while still discussing the substance of reform.  To highlight the need and importance of effective implementation, the new working title is “Making Health Reform Work.” (A one page summary of the book can be found here.)

“Making Health Reform Work” will be different from other health reform books by going beyond just describing the health system’s problems and recommending solutions, to also exploring processes for effectively implementing positive changes and reforms.

I’d be happy to hear any comments or suggestions about the concepts and ideas presented in the summary.

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

Butterfly Effect in Health Reform

By Michael D. Miller MD
April 16th, 2009

A short piece about Tom Daschle in last week’s National Journal made me think about the importance of the presence, actions, and attitudes of individuals for the direction, success and failure of health reform initiatives.  This is sort of like the “Butterfly Effect” of health policy. [Background:  The “Butterfly Effect” is a thought experiment related to chaos theory, and is based upon the theoretical concept that how a butterfly flaps its wings can dramatically change the weather thousands of miles away.]

Senator Daschle was very qualified to lead the Administration’s efforts on health reform, but several factors led to his removing himself from consideration to be Secretary of HHS.  Since that time, Governor Kathleen Sabelius has been nominated, but not confirmed for that position, and Nancy-Anne Deparles has started as the Director of the White House Office of Health Reform - a position Sen. Daschle was also supposed to hold.  These shifts have caused movement on health reform to be slower than it might have been otherwise.

So, as the “Butterfly Effect” theory indicates, these changes in “starting conditions” will likely lead to different end results. Whether these end results will be better or worse than what might have happened if Senator Daschle had quickly become Sec. of HHS and Director of the White House Office of Health Reform, is hard to know.  But in politics and policy, delays arising from non-substantive issues are generally not a good thing for reaching consensus and making progress.

Battle Over Health Reform
While I don’t think that Sen. Daschle’s tax issues were necessarily a bum rap, I do think he got a bum’s rush out of the jobs for other reasons.  Which is why I was glad to see the National Journal checking in to see what Senator Daschle was up to and what he thought about the progress on health reform.  He stated that he’s been, “very pleasantly surprised so far by most of the important health sectors and the degree to which they continue to be supportive of meaningful health reform.”  He then added, “As long as that environment persists, I think we can stay on the offensive.”

I’m not exactly certain who he means by “we” - it could be the Democrats, the Administration, those who support fundamental reform, etc.  But what caught my eye was  his phraseology “we can stay on the offensive,” which implies that this is a battle or contest of some sort.  That presumption of one side against another may be reason for concern because the Republicans seem to be counting on their ability to polarize as a way to block whatever changes they don’t like.  And if the Democrats adopt a similar stance, then the prospects for health reform legislation to be passed and implemented may be smaller than if both parties don’t engage in a polarizing dance.  [There is also a lesson here from Massachusetts, where comprehensive health reform legislation was twice passed and repealed before actually passing and being implemented into a significant coverage expansion program.  That is, passing legislation is only the first step.  Implementing it takes years, during which time political winds and control of the White House or Congress can change - resulting in dramatically different end results.]

So whether the weather will be favorable for health reform in the next 6-9 months - or just an ill wind blowing - remains to be seen.  But ongoing delays in putting people into substantive positions within the Administration will not diminish the theoretical swirling winds of chaos and the uncertainties about positive outcomes.

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

Avoiding Drug Interactions - Advice from the FDA

By Michael D. Miller MD
December 2nd, 2008

As new and better medicines are developed, people are taking more medicines on a regular basis.  (It is estimated that about 20% of people take 3 or more medicines for chronic conditions.) This is a good thing for improving health, but it also presents potential problems when medicines interact with each other, or they interact with foods, over-the-counter medicines, or dietary/nutritional supplements that people are also taking.  That is why it is always important to talk with your doctor and pharmacist about your medicines and any other things you are taking.

To provide people with updated information on this issue, the FDA recently released a new Consumer Information document titled, “Avoiding Drug Interactions.“  This educational material provides basic information to people, and also serve as a reminder for patients to discuss these issues with their physicians and pharmacist - which is one of the main messages from the FDA: “Keep all of your health care professionals informed about everything that you take.”

My only concern is that while these documents from the FDA are very good, they are still stretched thin and thus limited in their ability to disseminate this information.  While the FDA works directly with pharmaceutical companies to distribute information about prescription medicines to physicians, for more general information directed at patients - as in this type of document - they still face challenges in disseminating them so they are widely used.  Perhaps in the coming years, the FDA and outside groups will be able to develop better relationships for more organized ways to distribute this type of information.

Posted in HealthPolCom Blog | 1 Comment »

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