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| Commentary from Dave Durenberger November 6, 2008 |
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| NATIONAL NEWS | |||
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ALL THINGS ARE POSSIBLE
The Obama story about the 106-year old woman
from Atlanta and what it meant to her to cast a vote that really
counted this year is another reason we hoped he'd win. Whether
the touchstone was Republican President Abraham Lincoln or the
many women and people with disabilities or the civil rights
leader Rev. Martin Luther King, yesterday was one of those "This
vote's for you" days.
HILLARY CLINTON AND JOHN MCCAIN |
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| HEALTH POLICY | |||
| HEALTH POLICY REFORM Here is what they are saying in Washington D.C. about the president-elect’s approach. He and his team appear to be approaching health policy program and policy change as they approached the election. What’s the goal, what’s my role in achieving it, and who is willing to be helpful? The stated goal in the campaign was making health care more accessible and affordable by improving system performance and care quality. Success is reducing average family costs by $2,500. If a lot of spending and decades of supply, behavior, and financing regulation aren’t working, then let’s try something else. The “let’s try something else” approach is restoring confidence in the U.S. economy, financial markets, and income security policy. The first two problems seem simpler to diagnose and therapies abound. It’s a matter of choosing the right combination of confidence building, spending, rules and regulation, and tax policy. Restoring confidence in job, income and retirement security is another story entirely. Using tax spending stimuli simply erodes the tax base necessary to enable us to reduce the marginal rate of taxation on earnings, savings and investment. By the same token increasing tax-spending over public spending to privatize public protection programs like Medicare and Medicaid without changing the rules by which they have to compete won’t get us there either. HEALTH POLICY REFORM 2009 In preparation for the presidential campaign of 2008, every health care trade association and professional society and almost all health care purchaser associations lined up with a plan for reform. In the next 77 days each will send someone to a previously scheduled "insider forum" on what's going to happen in 2009. Anyone associated in any way with the president-elect will be much in demand as a speaker at these events. Assuming they have any time after checking e-mails asking for a little "face time". Health staffers for Democratic members of Congress will be similarly deluged with requests for information to make someone in the industry paid twice as much to sound like "an insider" to their group. Members themselves face a different challenge. Knowing the importance of the larger task facing the new President and the Congressional majority, they are looking for the role they can carve out for themselves in the committees on which they serve. Committee chairs and caucus leadership are scheduling meetings now to design and deliver on the challenge they face now as the electorates' choice for leadership. ALL HEALTH CARE IS LOCAL At the top of almost everyone’s list of policy changes is payment reform. Physicians and surgeons generate 78% of the medical costs in this country. 50% of the care costs are generated to serve the needs of 5% of us, mainly the chronically ill. Especially those in the last 24 months of life. Because we already know the degree to which physician decisions vary from one local health system to another across the country, it behooves us to look locally for examples of how best and how quickly we can improve care quality and accessibility by reducing the costs of unnecessary medical services. We are beyond the need to do five-year demonstrations. The Medicare program can start with differential payments to communities and to groups and systems within communities whose performance accountability is already substantially above the national average. We know that many physicians who are not part of large practice groups resist comparison. Especially with evidence based, or cook-book, or guideline, or pay for performance practice. That’s why so many physician groups in Wisconsin decided 6 years ago to take their own measure of quality and to seize the opportunity to benefit from comparison. John Toussaint who helped engineer this process has stepped out to form a ThedaCare Quality Institute. Much earlier in time the Institute for Clinical Systems Improvement was started in Minnesota to facilitate practice improvement. As retiring HHS Secretary Mike Leavitt can show you, there are local systems and communities already half-way to the goal the new President has set for quality improvement and cost reduction. Why would we waste a minute on one-size-fits-all payment policy when we already know where to look to see the future from which every professional will benefit? A TALE OF THREE CITIES To make the point that we can’t understand the systems of change unless we understand the local systems of delivery and financing, the National Health Policy Forum will host Chicago, Cincinnati, and St. Louis in a discussion over the best course to health care reform. Friday, November 14, 2008, 11:30 am to 2 pm at the ROA Building in DC. INVESTMENT NOT EXPANSION The health policy focus is on building a bipartisan foundation under Medicare payment reform, especially Part B, and on investments in the data gathering, research and analysis needed to accelerate efforts started by both Clinton and Bush administrations to improve health care delivery quality and performance. No one can argue with years of data showing the magnitude of waste in the system due to variation in the intensity of medical services between hospitals within geographic health systems and among geographic areas across this country. Like Dr. John Wennberg and colleagues at Dartmouth, whose Dartmouth Atlas has become the bible of the variation disciples, many of us believe in the reality of supply-sensitive unnecessary medicine. If you build a hospital, docs will fill it. If you buy the latest diagnostic equipment, patients must pay for it. Prescribe the newest drug and buy the latest device. Preference-sensitive care is a bit less intuitive. Unless you're a patient who has had the opportunity to be informed by your doctor that a deadly-sounding diagnosis has alternatives to surgery. Alternatives which are less costly, less painful, less time-consuming, and more healthful to you than the surgical alternative. Others acknowledge the reality of practice variation, but attribute it to uncertainty on the part of doctors. Experience tells them patients react differently to the same diagnosed illness. Medical training, not evidence and clinical guidelines, informs most decisions. Depending on where you trained and the "practice" in your area, you are led to decisions which others in a different practice area choose not to make. 80% of physicians in this country practice in groups of 4 or fewer. In many cases they won't benefit from the evidence and the guideline development routine in much larger practices. There are plenty of exceptions to this, but they are exceptions to the rule. If a consensus can be arrived at that reducing practice variation is the best way to lower the costs of care, then it is necessary to acknowledge that the areas of high intensity are also practice areas of lower than achievable quality. It follows from this conclusion that third party financing must reward the higher quality, lower cost practices differently and better. As a means of informing others how to improve their own practice styles and as a means of helping patients and payments. Much of the variation is in hospitalization. Meaning that reducing unnecessary hospitalization realizes savings to patient and payer, but losses to hospitals. So a way must be found to have hospitals and physicians participate in the benefit to the financing system of quality improving, cost-reducing practice. MN SENATOR AMY KLOBUCHAR AND SENATOR JUDD GREGG (R-NH) Will be two important leaders of bi-partisan efforts at health policy reform. Both recognize the message inherent in physician practice variation. Amy Klobuchar has a very important leadership event already scheduled for the Mayo Auditorium in the UMN Medical School for 11 am – 2:45 pm on November 25, 2008. Dr. John Wennberg and I will set the stage with background on the evolution of Medicare policy and of practice variation followed by a panel of national health care quality leaders from Geisinger Clinic in Hershey, PA, the Intermountain Healthcare in Salt Lake City, UT, and Mary Brainerd, the CEO of Health Partners in MSP. Mayo Clinic CEO Denis Cortese, M.D. will be the summary speaker with a glimpse of the potential for reducing costs by improving health system performance. INVESTMENTS IN HEALTH CARE IMPROVEMENT Health care is a premier knowledge industry. Physicians and health professionals are trained to diagnose and prescribe cures for unhealthy behavior or conditions and to provide them. They utilize specialty medicine and hospitals to provide medical remedies when necessary. Over the last 50 years the growth in medical knowledge and remedies has grown so fast that it is impossible for any one professional to know everything. Or is it? Parallel with the growth in medical technology is the growth in information technology. Has the information-dependent health care industry adapted info tech to med tech? Nope. Why not? Because "organized" medicine is wedded to as little organization as possible. "Organized" medicine exists to ensure as little competition and as little choice and as little information as possible. Insurance and benefit mandates exist to insure payment of services fees and to protect the judgment of the doctor from patient lawsuits. "Organized medicine" or integrated medical systems, coordinated care systems or physician group practices, HMOs, and the like exist. Over the decades they have adapted information to medical applications and are developing a body of medical knowledge what has proven capacity to maintain health and reduce the cost of illness. These are the heart of the medical "knowledge industry". Health policy reform must focus its "value for money" payment reform on these professionals. They made the investments in health tech evaluation, data analysis, and performance enhancement. Without waiting for a big government program to send them the cash to do it. They are poised to take the next step - to assume financial risk for their decisions and their patients' satisfaction. Rather than leaving that to big time managed care companies. With all due respect to our many friends in solo practice clinics, they are just that. Clinics - as in community health clinics. They do the best they can. But this is not the medical organizational model of the future. Unless Medicare, Medicaid and private insurance plans recognize this and encourage it over the objections of the privacy and cook-book medicine crowd, we will live longer than we should with unaffordable, harmful, inaccessible variations in our health care "system." ORGANIZED MEDICINE Anyone who has studied the history of American medicine can tell you that doctors have traditionally delegated to an American Medical Association the obligation to influence national health policy. So to preserve the autonomy and the economic protection of the individual practitioner. The same is sometimes true of 50 state associations of organized medicine to influence state policy regarding care quality and insurance benefit mandates. Two interesting consequences relative to health policy reform. First, the lowest common denominator of professionalism wins the day. It is just the way any “national” or “state” association works to keep members. Second, there is a growing consensus in this country that if we want to reduce the cost of unnecessary illness, unnecessary medicine, and unnecessary hospitalization we need to coordinate our care. Using vehicles like “the medical home” for example. Or other, what MedPAC calls, Accountable Care Organizations. “organized medicine” of this kind has been tried in many parts of the country and found to consistently produce better, less costly, and more accessible and reliable care. OPEN SEASON ON SENIORS Despite beautiful fall weather right through Nov. 4th, this is the dreaded month when millions of us face the health insurance choices we don't know how to make. Should I stick with my health insurance or choose another? As long as I can remember, people older than I have asked my advice, especially regarding Medicare choices. Why? Because so few of us are able or willing to make choices among products we so poorly understand, that vary by language and contract terms, that change from year to year, that specialize in fine print, that resent third party comparisons, and that depend increasingly on marketing that helps little. The result, we humans deal with health insurance just like doctors. If you find one you can understand and have no bad experience, you stick with it/her. The Medicare Modernization Act of 2003 changed none of this. Actually made it more difficult. Five years after enactment and four after implementation, the market has changed little. There are more choices. Many more - like MA private fee for service or Special Needs Plans which are marketer’s dreams as money-makers. But the money put into marketing overall is down from 2004 because insurance companies know we aren't going to switch. Maybe 5% of us at most. Their plans have less value than four years ago. Despite that Medicare drug insurance premiums will rise 31% on average with Humana jumping 51% and United's AARP deal just 18% - unless you're on a brand name drug etc. etc. etc. Co-payments go up a lot, more hit the donut hole with no life preserver and on it goes. "BACK TO THE FUTURE" HEALTH REFORM The editors of the Wall Street Journal, Republicans in Congress and state office, physicians who practice solo or in 2-4 person offices plus their AMA, and the individual indemnity insurance industry do not want to see any change in the healthcare system. The current system is essentially private, high quality, error-free, potentially affordable, and available to anyone who simply "shops around" like those of us who shop for groceries, dry goods, and vets for our pets. They blame all the costly problems in the system on government run health programs like Medicare and Medicaid and on an employer-paid health care system for workers. The high costs are blamed on those who shift responsibility for their bad health to others. 45 million uninsured are blamed on the choices made by healthy young Americans to trade pleasure for protection. The solution to cost control is simple they say. Turn the government programs over to the health insurance industry even if you have to use taxes to pay them more money. Taxpayers must also provide Health Savings Accounts and $5,000 to $10,000 a year tax credits to every American who buys catastrophic insurance plans from companies that refuse to play by any market rules. Encourage retail medicine, specialty surgical and diagnostic businesses pay medical schools more money to produce more doctors, stop the efforts to curb drug, device and diagnostic companies from buying the purchasing decisions of physicians and surgeons with lavish gifts and compensation for "education, research, and consultation." Stop any effort to "pay for performance" or to limit physicians from billing patients directly for their services. Doctors should be able to publish prices, but prohibit publication of clinical guidelines, comparative effectiveness of procedures or technology, or community-wide measurement of doctors' compliance with standard measures of quality care for chronic illnesses. On behalf of these ideologues The Journal last week joined them in condemning the Governor of Arizona, the Arizona business community, major hospitals and lots of others who oppose their Proposition 101 to prohibit any limits on any person's freedom of choice of private health plans or private health care systems. THE MORNING AFTER This was a most unusual election • Neither of the presidential candidates was the likely party candidate a year ago. • Both are from the U.S. Senate for the first time in decades. • The generational shift in the Democratic party raises questions about whether its possible to govern from the left • The Republican candidate thought so little of his party he wanted a Democrat colleague for vice-president • An eight-year incumbent President was nowhere to be seen Times are tough, but we’ve been here before • In 1978 and 1980 voters used Republicans to vent on Democrats • A second energy crisis caused by cartel producers withholding supply • Price inflation as high as 14.3% and interest rates at 22% • Unemployment in MN at 11% Nov. 1982 • Centrist GOP Senators came within an inch of their electoral lives across the north • U.S. Embassy in Iran in hostage, Soviets invade Afghanistan, and U.S. boycotts “80 Olympics The world has changed but we haven’t • The world is flat and green and the 2nd world is overtaking the 1st and buying our national debt • The 3rd world can use IT to leapfrog the 2nd if only we were interested • Boots on the ground wars are obsolete • Until 9-11-01 American Presidents thought it took a crisis to mobilize us…the failures of our banks and the election of an inexperienced African American proved them wrong National security is job no. 1 • When the Berlin Wall cam down and the Soviet Union collapsed, American President’s talked of a “New World Order” • This President must lead an effort to define our national security and our capacity to build the inter- national relationships to achieve it. • A bi-partisan energy policy with its concomitant impacts on environment and food policy is a good way for getting started Domestic security depends on economic security • The bursting of the price inflation bubble in the early 1980’s has now been followed by the bursting of the equity inflation bubble • A new President must call for a new national tax policy which fosters savings, investment, individual economic security and a role for the States • A New Federalism calls out the best in Republicans, Democrats and Libertarians and brings out the leaders in elected officials at all levels • If anything is obvious in the failures of the securitized credit markets, it is the failure of U.S. housing policy. Abandon HUD and regressive ownership subsidies in favor of a new savings policy which values shelter as much as ownership • Infrastructure and education policy should be made at the state level, not in Washington |
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| QUOTABLES | |||
“I believe that banking institutions are more dangerous to our
liberties than standing armies. If the American people ever allow
private banks to control the issue of their currency, first by
inflation, then by deflation, the banks and corporations that will
grow up around the banks will deprive the people of all property
until their children wake-up homeless on the continent their fathers
conquered.”….Thomas Jefferson 1802 |
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| UPCOMING EVENTS | |||
| UST Executive Conference on the Future of Health
Care November 7, 2008 University of St. Thomas Minneapolis, MN For more information and registration, visit Future of Healthcare The Price Of Medical Technology: Are We Getting What We Pay For? November 10, 2008 National Press Club (Metro Center) Washington, DC Discussion of whether the increase in diagnostic imaging scans has improved outcomes and whether other types of benefits might justify the increased costs associated with imaging technologies. For more information, visit Health Affairs Briefing Health Care Under the New Administration: What to Expect in 2009 and How to Promote Free Markets November 13, 2008 Citizen’s Council on Health Care Minneapolis, MN Speakers: Roy Ramthun (“Mr. HSA”), HSA Consulting Services, Dr. Thomas R. Saving, Medicare Trustee, 2000-2007, Cal Ludeman, Minnesota Commissioner of Human Services. For more information and registration, visit Citizen’s Council on Health Care William E. Petersen Symposium on Physician Leadership November 20, 2008 Opus College of Business, University of St. Thomas Minneapolis, MN This year’s symposium - The Strength to Change: Health Care Providers as Reform Leaders features Lois Quam, managing director of strategic investments, green economy and health care, for Piper Jaffray. For more information and registration, visit Petersen Lectureship ICSI’S James Reinertsen Lecture November 20, 2008 Hilton Minneapolis St. Paul Airport Bloomington, MN Bridging the Gap Between Consumers and Healthcare Providers: Old and New Tools for the 21st Century. For more information and registration, visit Reinertsen Lecture November Medicare Forum |
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| © 2008 National Institute of Health Policy |
