Commentary from Dave Durenberger

October 3, 2007

The event will take place at the University of Minnesota on Monday October 15, from 2-3:30 pm. NIHP members are offered a discounted rate for this event. Online registration is now available. Space is limited so register soon.

The NIHP has teamed up with the Medical Technology Leadership Forum (MTLF) at the University of Minnesota's School of Public Health to host this event, in conjunction with MTLF's 2007 Fall Forum.

To follow the MARS conversation, or to find more information on past sessions, visit NIHP's website.

CHILDRENS HEALTH
The national debate over the SCHIP program demonstrates how difficult will be the quest for Universal Coverage. There is the concern about excessive spending. Republicans thought nothing of spending $700 plus billion on a new prescription drug program for elderly and disabled, but can't stomach $35 billion for children's health insurance coverage. There is the ideological problem. Because SCHIP is administered, along with Medicaid and similar programs, by state government, SCHIP is another effort at "socialized medicine." This despite the fact an increasing amount of Medicaid/SCHIP money is going to private managed care plans. There is the "tax and spend" problem. Since Republicans stopped Democratic efforts to pay for SCHIP improvement with money from the over-subsidized Medicare Advantage program for private health insurance plans (which Modern Healthcare editorially calls "a $150 billion swindle"), Congressional Democrat and GOP leaders decided to tax cigarettes another 61 cents a pack. No new taxes.

©2007 Washington Post Writer's Group

Remember Texas Governor George W. Bush's "Helping Hand?" Back in 1999-2000, he proposed the federal government use existing state Medicaid programs to help finance access to prescription drugs for the elderly and disabled who were most in need of the drugs and had the least economic capacity to meet their needs. Folks like the "dual eligibles," for example. Once elected, Karl Rove explained the opportunity the President had to move AARP and the elderly lobby from the electoral preference for Democrats to Republicans. Republicans in Congress then added consumer driven health care, HSA's, defined contribution, and the privatization of social insurance to the MMA. All the rest is history. History that the Bush veto supporters seem to ignore as they revert to helping only the poor and the needy, preserving health insurance privatization and defined contributions.

I voted against using tobacco taxes to fund health insurance expansion on at least one occasion, keeping it from being reported out of the Finance Committee. David Brooks in "The Entitlement People," from the September 28th New York Times, does a nice job on people like me and "other previously powerful folks...who are not in a position to set policy but are prominent enough to get noticed." The notion that it was good tax policy to tax the lower income, unhealthy population to provide coverage for others, or even to discourage bad habits, never seemed right. Nor does the current notion that it's good tax policy to use tax revenue to pay for medical services, and then tax the income of the hospitals and the docs. Seems bass ackwards somehow.

EVERYONE LOVES KIDS
The medical geniuses who run Walt Disney Parks and Resorts have promised Florida Children's Hospital in Orlando $10 million for naming rights and lobby design of a new $40 million 200 bed children's wing next to its 15 story cardio-vascular tower. Orlando Regional Healthcare's Children Hospital already features a Magic Kingdom Cinderella Castle and claims to attract ped patients nationally and internationally. Proving how "magic" this Orlando kingdom really is, the Nemours Foundation, with a $4 billion endowment, plans a third children's hospital on a site it owns in nearby Lake Nona. This despite the fact that Florida has a certificate of need law and Becky Cherney, the articulate head of the Florida Health Care Coalition representing the area's largest employers, including Disney.

©2007 Tribune Media Services

The Nemours CEO in Florida, Jeff Green, welcomes the Disney gift for a competitor and tells Floridians who are concerned about this mad arms race not to worry. "At least eight other U.S. cities have three or more Children's Hospitals that work successfully together." That's not the point, Jeff. They can "work together" all they want, but the investment they all make in both routine pediatric care and in specialty staffing for exceptional care is passed on to consumers of all other health and medical services in central Florida. And through national private and public payers to those of us in the rest of the country who may refuse to compete at this level when we know the presence of all this expensive service potential means it will have to be utilized.

REDUCING HEALTH CARE COSTS
Steven A. Schroeder, M.D. is a San Francisco doctor who served many years as President of the Robert Wood Johnson Foundation in New Jersey. He is now in the College of Medicine at the University of California, San Francisco. In his Shattuck Lecture published September 20, 2007 (New England Journal of Medicine), Steve argues America is much more likely to reduce the growth in health care costs by investing in health improvement than in healthcare improvement. Behavioral health problems cause 40% of all deaths in the U.S. Start with obesity, physical inactivity and smoking and go from there.

There are still 44.5 million smokers in this country and 435,000 of them die 15 years prematurely, passing an expensive moral hazard on to the rest of us. They are increasingly lower socio-economic status (only 2% of doctors and 8% of post-grads smoke) and many are chronically mentally ill with problems of substance abuse. These are the people the Congress would have us tax another 3 cents a cigarette so it can avoid taxing everyone to help access poor kids to preventive health and remedial medical care. 71% of smokers claim they'd like to quit and investing in cessation health would be worth it.

©2007 Tribune Media Services

Schroeder walks us through the similarities and dissimilarities between obesity and smoking, examines other causes of premature death, and then makes the case for concentrating public investments on those Americans less fortunate by reason of socio-economic status or genetic disability. "To the extent the U.S. has a health strategy," Schroeder says, "its focus is on the development of new medical technologies and support for biomedical research....these popular achievements are unlikely to improve our relative (to other developed countries) performance on health."

In the absence of political action in a population without a voice, the burden falls on the health professions, "especially physicians, to become champions for population health." He might well have taken note of the increasing voice of employer America in what is being call "health management" or "health promotion." In fact, there are now so many commodity players in the health risk assessment, health fitness and management "space" that the National Committee for Quality Assurance (NCQA) is developing a role for its nationally recognized accreditation and certification tools for those who claim health outcomes. The health management industry is also championing "health parity" benefits in insurance policies, tax deductions for fitness club memberships, and access to tax subsidies in cafeteria benefit plans.

NCQA STATE OF HEALTH QUALITY REPORT
On September 25th, the National Committee for Quality Assurance (NCQA) released the 11th annual State of Health Care Quality report at the National Press Club. The report highlights the progress that our nation is making in improving the quality of care for millions of Americans and points to the improvements that still need to be made.

The quality of care for more than 80 million Americans enrolled in 767 health plans improved in 2006, but the gains were smaller than they have been in past years, according to the report.

The State of Health Care Quality report is produced annually by NCQA to monitor and report on performance trends over time, track variations in patterns of care and provide recommendations for future quality improvement.

The report and more information about NCQA can be found at www.ncqa.org.

HIMSS 2007 DAVIES AWARD TO ALLINA
This is the health info systems equivalent of the Baldridge. Being the first in the country to receive it is very significant. It is truly a leadership accomplishment. So is the leadership in the Minnesota Clinical Information Exchange Program Allina is doing with Medica, BCBSMN, Health Partners. This is part and parcel of the evolution of what MedPAC is calling "accountable care organization." It is a systems approach to providing health and care management services in which consumers (patients) are encouraged to be more and more involved (61,000 area residents already involved in Allina's MyChart). In effective info systems, the importance of standardization cannot be overstressed.

I can see this leading into what Jack Wennberg is calling (in the next issue of Health Affairs) an "informed consumer choice" health system. Jack argues that the definition of "medical necessity" must be "informed patient choice," which legally requires the physician to be fully informed, to be sure her patient is equally well informed and has the opportunity to make choices of diagnostics, therapy, rehab etc.

From a delivery systems standpoint, Allina will provide for all patients with lots of information about a seamless set of health, medical and supportive services readily available from qualified professionals in easily understood format. At some point, well understood variety of financial incentives for making individually appropriate choices. The Aspen Group merger announced last week (along with Columbia Park Medical Group's merger with Fairview) is a clear indication that both economics and patient service accessibility are moving the Twin Cities from individual practices and small clinic practices to more integrated care systems in which info systems link people with service, satisfaction, accountable reporting and financing systems.

DR. JOHN ROWE ON THE MEDICAL ARMS RACE SYNDROME

Dr. Jack Rowe speaks to community healthcare leaders at the University of St. Thomas, September 20, 2007

Jack Rowe is well known for his work in medicine and academic medicine. And better known for taking old Aetna Insurance from a $279.6 million loser in 2001 to a $2.7 billion profit health insurance company by the time he chose to retire in 2006. Last week he came to the NIHP at St. Thomas with a message that wasn't all that encouraging. He focused his response to taming the MARS on paying only for high performance. He shared examples of the rather courageous efforts he made at Aetna to target the problems of system reform, improve health outcomes and lower costs. He provided a unique insight into the level at which today's health insurance plans actually compete. Innovative benefits and services to premium payers.

The problem, he says, is "we can't patent any of our really innovative plan changes. I can adapt a good idea in my Aetna office, head for the elevator and before I exit on the ground floor CIGNA has adapted my innovation." Or AHIP decides that everyone ought to adapt whatever Jack's new idea is.

What most of us took away from Jack's insightful presentation on "paying for performance" is how difficult it is to implement and how long it is going to take to be effective as cost containment policy. Part of the problem in achieving a value goal is the P4P mimics. In 2003, there were 39 P4P plans in the national market. Today there are about 150. If every plan and every clinic has its own P4P, nothing will change. Like expecting 50 HMOs in any market to change physician behavior. 3 or 4 will. 50 will not.

HOSPITAL CONSTRUCTION SPENDING
I know my friends in the hospital business don't like to discuss this topic. They have learned so very many ways to justify what they are doing that they believe them all. The Medicare Payment Advisory Commission (MedPAC), however, is obliged to make recommendations to Congress annually for increases in Part A payment to hospitals for both Inpatient and Outpatient services. Access to capital is always an indicator of payment adequacy. One measure is construction costs and the facts are that non-federal hospital construction averaged around $10 billion a year for 10 years through 2000.

But since 2000, construction has risen at a steady pace every year reaching over $30 billion in 2007. Modern Healthcare's annual survey shows as much as $60 billion in hospital construction design activity currently. According to the Center for Studying Health System Change, three of four hospital systems in Indianapolis were building three new full-service hospitals, expanding two general hospitals, and all four have specialty cardiac facilities. All of this is occurring while hospital inpatient admissions have been relatively flat. So this year MedPAC proposes to understand why this is happening and to advise Congress whether anything could/should be done about it.

How much is improving/replacing outdated facilities, or keeping up with growing populations and/or the need to deploy health information technology? Or, how much is an arms race competing with each other and with specialty facility owners for well insured patients desiring access to new technology and amenities? How much of this is response to incentives in the current payment system to increase utilization? Where are the incentives to increase efficiency, productivity and safety? Or to respond to reductions in hospitalization that should come from decreasing referrals for chronically ill, especially in the last 24 months of life?

PHARMA AND THE DOCTOR-PATIENT RELATIONSHIP
Should patients be concerned about the influence drug companies have on the prescribing behavior of their doctors? The chief medical leadership of most of the Minneapolis-St. Paul area health systems say the answer is yes. The 2 million people they serve should be concerned. These Minnesota medical leaders believe we should have the same concern about medical device companies and imaging and diagnostics companies. Why worry? In the home of LifeScience Alley and some of the world's largest device manufacturers? Because the doctor patient relationship is built on trust. As one of the leaders in this group, Dr. Brian Rank, Medical Director at HealthPartners Medical Group, said September 22 in a Pioneer Press op-ed, "tactics like these undermine the trust patients have in physicians to be unbiased advocates for their health."

These big system medical directors have been meeting together for nearly two years, sharing information about what each organization has been doing to gradually reduce the amount of "free gifts," which are the pattern of the industries' relationships with health professions of all kinds. I can't speak at any medical meeting without walking the gauntlet of the meeting sponsors. When I ask the docs why, they say most docs wouldn't come if they had to pay a proportionate share of the cost of these meetings. That's true for other professions as well. In a nation whose medical professionals already rank far above the OECD averages in income for their services.

The Minnesota medical directors want to restore public confidence in the professions by eliminating even the appearance of conflict of interest. The challenge for them is twofold. One is that greed among the surgical and imaging professions is endemic. They say this, not me. The other is that they don't want to "throw out the baby with the bathwater." How are technology innovators to learn about the safety, efficacy, appropriateness, and comparative effectiveness of their products without talking with physicians? And how much physician time can you expect if you don't pay for it? That‘s the challenge they face. That is the challenge you and I face. Companies suggest that ethics codes will suffice. Won't happen. Some form of transparency to the relation is essential.

CONSUMER DIRECTED HEALTH CARE
PHARMA enlisted the aid of the public relations, marketing and advertising industries nationally and locally to beat back efforts in Congress to add effective limitations on direct-to-consumer marketing of prescription drugs to the new FDA modernization bill Congress passed.

Our neighbors across the street in Minneapolis announced last week that pharmacy customers at Target stores can choose from 19 flavors to help make liquid medications more palatable for children. While not a novel idea, Target will be the first to offer the choice free of charge. Walgreen's charges $2.99.

CALIFORNIA HEALTH CARE COVERAGE
While Independent Republican Governor Arnold Schwarzenegger vows to take his proposal to raise taxes on health and medical services in order to expand insurance coverage, San Francisco Democratic Mayor Gavin Newsom is moving to fulfill his promise to provide all residents access to health care they need. He started with a couple clinics and an effort to make sure that those applying for care were enrolled in existing programs for which they were unknowingly eligible.

Now the plan is slowly expanding the Healthy San Francisco program to other clinics. People are eligible for primary care, dental exams, mental health and substance abuse services, hospitalization, radiology and prescription drugs. Newsom's secret is how he thinks about "universality." The Mayor said, "We asked a different question. How do we provide universal health care to all San Franciscans?" That's the right question. Because it's exactly what Minnesotans replied when we asked them four years ago if they wanted universal coverage. They said they'd much prefer universal access to health care. Cost in the city of 750,000 is estimated at $200,000 a year without new taxes.

WHY COME TO THE U.S. FOR MEDICAL CARE?
New York State is appealing the Bush administration decision to stop New York from spending Medicaid funds designated for emergency medical care only on chemotherapy for cancer patients. CMS says there is a policy prohibition against spending Medicaid money on illegal immigrants or non-resident aliens, except in genuine medical emergencies. Its part of the Republican effort to discourage public assistance for non-citizens, which also includes having my aged mother with a dementia prove she's a citizen. I'm guessing most aliens would find it easier to migrate to any one of 40 other nations with national health systems if they were doing it only for medical services.

©2007 Horsey, Seattle Post-Intelligencer

One reason I think that way is that increasing number of American citizens are finding ways to travel to one or more of these 40 other countries for medical services, which are on a performance and outcome par with American medicine at substantially lower prices. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in fact has an international accreditation effort underway with an advisory group, which includes former Allina Health System CEO Gordon Sprenger. Knowing that this "outsourcing" trend is just developing, JCAHO would like to get out ahead of it, but some national medical professional associations think they should not. The AMA, for example, has criticized the effort. Ostensibly on the theory that accreditation which Americans can rely on will just encourage Americans looking for relief from the high cost of health insurance or medicine here to find and use high value medicine elsewhere. That could be a problem for American physicians who have shown a traditional reluctance to embrace competition, even from docs just like them, but organized differently like into multi-specialty or coordinated care groups.

CMS CHIEF KERRY WEEMS may well be an "acting" Administrator at CMS for the next few months since the Finance Committee is concerned its work not bog down in partisan attacks on administration Medicare and Medicaid policy while it struggles to pass SCHIP, Medicare Part B physician payment changes, and tax reform legislation. But there will be no question who is in charge of the Medicare and Medicaid Center. Nor that setting priorities, getting work out the door, and not avoiding tough issues will be the order of the day along with "transparency" and other characteristics for which Weems is well known as a long-time HHS administrator.

REPRESENTATIVE JIM RAMSTAD - SENATOR PAUL WELLSTONE
Jim's announcement that he would not run for re-election to Congress from Minnesota's 3rd District made many of us happy - for Jim. He told us the passion and the joy was gone, not to be regained. At age 61, the timing was perfect and his district, as always, has a plethora of qualified Republican candidates. As the Republican base in his suburban Minneapolis district shifted right, the votes for Jim and for democratic candidates in the district increased. So he became "Republican In Name Only," or RINO on right radio.

Jim said his proudest achievement is The Paul Wellstone Mental Health and Addiction Equity Act, which President Bush should sign soon. If Jim Ramstad had a personality opposite, it was Paul Wellstone who, with his wife Sheila, died a tragic death during the campaign for his third term in the Senate. Jim likes elected office because it is an opportunity to develop relationships with good people. And no matter how they behave, he sees only good in them all.

Paul Wellstone came out of his 1990 win over incumbent Senator Rudy Boschwitz with both guns blazing. He didn't care who he hit and what people thought. Like Ramstad, he was a cause fighter. He came to office with a whole lot of causes and new ones kept finding him all the time. The ones he couldn't find time to handle, Sheila took on and together they found no hill too steep nor valley too deep. Taking on the Senate's unwillingness to allow any member to exert his right to delay legislation became a challenge he quickly learned to cope with. After so many times standing on the floor questioning deadlines set by leadership, he found the leaders would compromise if he simply threatened to delay final passage.

©2007 Tribune Media Services

So when Jim and Paul found common cause in equal access to health insurance benefits for persons with mental health problems they made the ideal team and victory was within their grasp when Paul died. Each came to the cause from personal experience and neither would ever give up. Jim found a Democratic champion in Patrick Kennedy, they used Patrick's father's position in the now Democratic Senate, and the bill is about to become law.

Is Minnesota a red state or blue state? I think Minnesota is Jim Ramstad AND Paul Wellstone. Two guys who would give you the shirts off their backs if you needed them, but wouldn't give you a vote unless they believed it was really better for people than for you or them.

POLITICS IN MINNESOTA
Given the fact incumbent Republican Senator Norm Coleman is up for re-election in a really blue state in a blue year, he seems to be doing much better than his likely DFL opponents. 70% of us recognize Democrat Al Franken, compared to only a third who know his DFL opponent, anti-tobacco lawyer Mike Ciresi. Unfortunately for Al, 34% of folks don't want him as their Senator, compared to 27% who do. 52% of us like Senator Coleman, but only 45% approve of the job he is doing as a Senator. That may explain why Coleman's bumper sticker is a nice simple "NORM 08".

WILLIE WONTIE?
Newt Gingrich is both in and out of the Republican Presidential race. Friday last he said it would take $30 million in contributions during October to get him in; Saturday an aide says Newt would rather remain head of a non-profit I hadn't even heard of called American Solutions For Winning the Future. The AP says ASFWF is the political arm of a "lucrative empire" Gingrich has created, most of which we see as by-lines for Newt's opinions. Will Newtie ever be a candidate for President? I am betting we haven't heard his last on the subject.

MORE ON BRIDGES THAT SHOULDN'T FALL DOWN
Minnesota DOT has decided to let a $393 million contract to the highest bidder with the longest completion date and the latest fad bonuses for early completion. Losing bidders are talking of lawsuit. Minneapolis City Council is debating whether to go along or not. Congress has decided to spend $250 million on the Minnesota bridge, $750 million on other bridges in similar repair, and $1.25 billion on a bunch of other stuff irrelevant to the problem. Minnesota's Governor has put off the prospect of raising highway taxes until the regular legislative session in January 2008. But he can't put off signing the contract for the new bridge, but is forced to because someone in Washington with check-writing authority isn't ready to sign.

Senator Barbara Boxer says, "If there is a way to fix infrastructure without money, I would like to know what that is." Secretary of U.S. DOT told the Senate that the I-35W Bridge that fell down 8-1-07 was fine according to her data. And Minnesota Senator Norm Coleman has called on the GAO to study the national bridge program. Again. So, tell me, what's the big deal other than it was nothing short of a miracle that only 13 lives were lost, everyone else got medical help in record time, nobody here is asking for $2 billion for a $200 million bridge - as in Louisiana. We in Minneapolis-St. Paul are all driving on eight lane interstates where only six lanes existed before. Some move as slowly as always at rush hour, others faster. There is little evidence that our metro highway system cannot handle the strain of one lost bridge nor that any businesses are approaching bankruptcy. So all's well in Lake Woebegone, where the children are all above average and responsible adult political authority behaves predictably.

CONGRESSIONAL SPENDING

©2007 The Washington Post

Senate Finance Committee chair, Max Baucus (D-MT), arrived in the Senate in 1979 when I did. One of the hardest votes we took that year was to raise the statutory limit on the national debt above $1 trillion for the first time in history. Last week Baucus lamented the fact that he helped raise the debt ceiling to $9.815 trillion so the nation can meet congressionally authorized spending through the end of the Bush presidency in 2009. When Republican Bush took office in 2001, the debt limit was $5.95 trillion - an amount which had not been raised since 1997. The estimated total spending for Iraq/Afghanistan from March 2003 through September 2008 is $1 trillion, plus another $1 trillion in interest paid on the wars' debt.

FREEDOMS WATCH.org vs. MOVE ON.org

©2007 Tribune Media Services

Rich guys doing the best they can to reduce political discourse in America to rubble. Their ability to raise money $1 million per donor and convert it into television, radio and print advertising during elections is bad enough. Now they are at it around votes in Congress and feeding frenzies generated by talk radio. Compared with most other money in politics, public accountability for these guys is nil. Congress can't find a constitutional way to deal with it given the Supreme Court's devotion to the "free speech" clause in election financing.

On October 24th, the Iowa Health Buyers Alliance will host a conference focused on "Getting Quality Up and Costs Down." Contact IHBA for more information.

The Health Improvement Institute will host a November 12 workshop on Quality of Health Information on the Internet. This workshop will provide a forum in which experts and stakeholders can discuss current issues regarding web-based health information. Visit HII online for more information.

On November 15th, NIHP will present Shannon Brownlee of the New America Foundation and her instantly popular new book "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer." How the over use of American medicine is killing thousands of us, who the villains are, and what we ought to be doing about it.

NIHP is hopeful of presenting Brownlee (whose book is currently available in most bookstores or on-line) jointly with our community's healthcare quality program sponsors. Continue checking NIHP's website as further information on this event becomes available.

"We are heading towards pharmageddon. The medicalising of society is convincing people they need a pill for everything. Drug companies recruit patients, particularly good-looking and articulate ones, to help promote new drugs in the media. Life and death decisions should not be taken by tabloids."
- Paul Flynn, a member of Parliament for the Labour Party

"We're No. 1 in something. That's good," said Dr. Ed Ehlinger about the University of Minnesota's selection by Trojan Condoms as the first among 139 colleges and universities for sexual health on campus. "About two-thirds of the students on our campus are sexually active." Go Gophers!!

"It's not unusual for wealthy men to decide they can dive into fatherhood and Social Security at the same time. This presidential field is awash with candidates of late middle-age whose kids can still qualify for Breakfast with Santa...Not that we're resentful of the fact than men's biological clocks never seem to ring. Or that they're not the ones who have to decide if they can handle both children and a career."
- Gail Collins, New York Times, September 13, 2007

"The issue is whether the war [in Iraq] is worth the risk of breaking our Army and being unable to deal with other risks to our nation."
- Congressman Ike Skelton (D-MO), September 11, 2007

©2007 Atlanta Journal-Constitution

"I never thought I would say this, but I long for the pragmatism of Ronald Reagan." -Congressman Rahm Emanuel (D-IL), referencing President Bush's threats to veto Democratic spending after refusing to veto any GOP spending.

"I don't think it's a case of just this bil...The President is playing catch-up, realizing that he made a mistake that he didn't veto a lot of bills when the Republicans were in control of Congress."
- Senator Charles Grassley (R-IA) on the White House's tough stance on CHIP.

"It was an exhilarating process. There were countless meetings with business leaders who were surprised to find themselves sitting next to me."
-Senator Hillary Rodham Clinton speaking of how it felt to make a new health reform plan seated between two business leaders.

"Check your idealism at the door. Congress is an organized appetite. The future cannot hire lobbyists, so the past is always overrepresented. Committees have a short term focus, like most of corporate America; a few good quarters get you job security and maybe a promotion."
- Congressman Jim Cooper (D-TN)

"Well, we talk too much of (morality) and practice too little of it."
-Congressman Jeff Flake (R-AZ)

"I think it's a mess."
- Former GOP Speaker Newt Gingrich

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