Health Reform Evolution

May 12, 2008 / Michael D. Miller MD / Economics & Financing, Health System Reform, Medicare, Politics, Private-Employer Based Health Insurance / No Comments

Placing health reform in an historical context shows how the debate has evolved. For example, the National Bipartisan Commission on the Future of Medicare was formed to address Medicare’s projected insolvency – at a time when the overall focus for health reform was on cost containment. However, while the Commission met and deliberated, the booming economy shifted the debate away from cost containment towards access and coverage expansion, and the Commission’s 1999 final report, proposed adding an expensive outpatient drug benefit to Medicare.

Comparing two more recent perspectives on the future of the US healthcare system also illustrates how thinking about health reform evolves.…

Health Care Cost Containment – Reality versus Rhetoric

May 2, 2008 / Michael D. Miller MD / Economics & Financing, Federal Healthcare Reform, Politics / No Comments

Cost Containment
Controlling Healthcare Costs
Reducing Health care Spending
Eliminating Waste, Fraud and Abuse
Creating More Value from Healthcare Spending
Increasing Cost Effectiveness for the Healthcare Dollar

These are the types of headlines and catch phrases that we are going to see over the next 6 months as the healthcare focus in the 2008 elections zeros in on spending and costs.

A couple of weeks ago I wrote about how the economy has become the #1 issues of concern for the 2008 elections. Because of this, costs and spending will be the major focus for the political debate about healthcare reform.…

A Perfect Stormy Mess for Health Reform

April 15, 2008 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, Federal Healthcare Reform, Health System Reform, Medicaid, Politics, State-Level Healthcare Reform / 4 Comments

A year ago the hype in healthcare was about state-based reform initiatives. Massachusetts was implementing its law, and several other states – including California – were considering their own proposals for increasing insurance coverage as a first step towards universal coverage and cost containment.

How things have changed in a year. Not only has California’s initiative crumbled under the expected costs to employers, but the economic downturn has undercut states’ healthcare expansion ideas, and may force them to cut back Medicaid enrollment and/or services. This week’s National Journal has an article titled “State’s Rapidly Shifting Gears,” that discusses these and other issues, including how a few years ago states cut their Medicaid payments to providers, so that on average Medicaid pays physicians 69% of Medicare levels, and how pending Federal Medicaid rules and proposals would reduce funding for State Medicaid programs making it difficult for states to reverse these payment reductions.…

Ensuring Enough Primary Care Clinicians

April 8, 2008 / Michael D. Miller MD / Access to Healthcare, Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Politics / 3 Comments

Like many complicated problems in the US healthcare system, setting a goal can be easy, but achieving it can be hard. In recent years there has been a number of proposals for increasing the use of primary care clinicians to help patients with chronic diseases (like diabetes) manage their care and avoid long-term complications – and to presumably lower long-term healthcare spending. For example, the “Patient Centered Medical Home” proposal supported by a dozen organizations, (including companies and family practice and pediatrics associations), doesn’t specifically use the term “primary care,” but it gets to the same result – heightened relationships and communications between patients and a particular clinician or clinic.…

Culture of Healthcare Organizations

March 17, 2008 / Michael D. Miller MD / Delivery of Healthcare, Economics & Financing, Health System Reform, Quality of Care & Safety / No Comments

Culture change is one of the core messages of a book I’m working on, so I was interested to see an article about “cultural transformation” in Modern Healthcare by John Mitchell, CEO of Harbor Community Hospital in WA. He notes that there is frequently a disconnect between a hospital leader’s stated goal of wanting to create a great culture and their actions: Retaining a central command and control structure does not empower people, and forcing solutions onto hospital staff who feel uninspired to excel will not produce sustainable improvements. Rather cultural changes leading to improved quality and reduced costs requires the leader to inspire the staff to perform while also empowering them to achieve shared goals.…

Principles for Health Reform & EBM

March 13, 2008 / Michael D. Miller MD / Comparative Effectiveness, Economics & Financing, Health System Reform, Politics, Private-Employer Based Health Insurance / No Comments

The National Federation of Independent Businesses (NFIB), just launched their health reform campaign called Solutions Start Here. Their 10 small business principles for healthcare reform includes:

Evidence-based:
The healthcare system must encourage consumers and providers to accumulate evidence and to use that evidence to improve health. Appropriate treatment choices and better wellness and preventive care should be key outcomes.

Current information and decision systems make it difficult to accumulate, interpret and use evidence affecting treatment decisions. One result is overspending on treatments and underspending on prevention. Decision-makers must understand the impact of their decisions on both costs and outcomes. Such an understanding must be based on solid clinical and economic evidence.

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Evidence Based Medicine – NICE or Nasty?

February 27, 2008 / Michael D. Miller MD / Access to Healthcare, Comparative Effectiveness, Economics & Financing, Federal Healthcare Reform, Politics, Therapeutic Substitution & Interchange, VA/DoD / 4 Comments

The US Medicare Payment Advisory Commission (MedPAC) recently released a report on “Creating a Center for Evidence-Based Medicine” that was prepared by an outside analysis group. Before dissecting the MedPAC report, let me just lay out some of the more controversial aspects of evidence-based medicine (EBM):

How are the results of EBM research used for coverage or payment?
Are the EBM conclusions based upon reviews of prior studies or on research done specifically for the EBM analyses?
Are the EBM conclusions relevant only for a clinical research situation, or do they reflect real-world practices?
All medical practices evolve and “best medical practices” are reflected last in textbooks…..

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E-Health – A Medical Information Miracle or Mess?

February 26, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Economics & Financing, Health System Reform, Information & Communications, Politics / 3 Comments

Information technology tools has been touted for years as a cornerstone for improving the quality of healthcare and reduce spending. While, clearly this has not been achieved, many e-health initiatives are being launched, and it is unclear how successful or efficient these will be. I am often concerned about the effect e-health systems have on the health care quality when my own physician spends so much time looking into and typing on his laptop. But to avoid discussing the challenges of e-health based upon my n of 1, below are 4 perspectives that are more expansive and analytical:

The Commonwealth Fund recently released a report about 27 state governments’ e-health activities in 2007.…

NPR Story on Presidential Candidates’ Health Plans

February 22, 2008 / Michael D. Miller MD / Access to Healthcare, Economics & Financing, Federal Healthcare Reform, Politics, State-Level Healthcare Reform / 2 Comments

I caught part of the report on NPR this morning about the Presidential candidates’ positions on healthcare. The gist of the story was that Clinton favors more extensive individual mandates than Obama (who only favors mandates to cover children), while McCain favors tax credits to make health insurance more affordable.

Whoever becomes the next President, something will clearly be different starting in 2009. Regardless of the candidates’ campaign/political statements, the next President’s actions on healthcare (unlike in foreign affairs), will largely depend on what they can negotiate with the next Congress – which seems like it will be more Democratic than it is currently, but probably not with 60 Senators to force votes on matters that the minority finds objectionable.…

Technology and Health Care Costs

February 12, 2008 / Michael D. Miller MD / Comparative Effectiveness, Economics & Financing, Health System Reform, Innovation, Politics / No Comments

Peter Orszag, the Director of the Congressional Budget Office (CBO), recently testified before the Senate Budget Committee about increasing health care costs. One of his conclusions was that “the most important factor driving the long-term growth of health care costs has been the emergence, adoption, and widespread diffusion of new medical technologies and services by the U.S. health care system.”

His testimony concludes that by using “comparative effectiveness” research to “generate more information about the relative effectiveness of medical treatments and changing the incentives for providers and consumers,” would create a situation where “savings are possible without a substantial loss of clinical value.”…

Costs & Access

February 3, 2008 / Michael D. Miller MD / Access to Healthcare, Economics & Financing, Health System Reform, Medicaid / No Comments

Today’s Boston Globe has a lead article about the higher than expected costs for Massachusetts’ healthcare program implemented to create near universal insurance coverage. The costs of this program have been greater than expected due primarily to more people joining the subsidized health insurance program. (This greater than expected number has been attributed to underestimates of the actual number of uninsured in Massachusetts prior to the start of the Commonwealth Care program.)

The higher costs are certainly a problem for the state’s budget – although almost 50% of these costs may be paid for by the Federal government under the state’s Medicaid waiver.…

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