Commentary from Dave Durenberger

November 20 , 2007

IF MEDICARE WERE A BUSINESS
In fiscal year 2006, CMS spent $440 million of beneficiary money on call centers to serve the needs of their customers. Medicare call centers are staffed with people trained to read one of a series of scripted replies to our various questions about Medicare products and services. They have no scripts for the various programs designed to serve only low income customers (LIS, QMBY, state-specific MSP etc). They have 43 million customers (Medicare beneficiaries) including me.

In 2006 we made 29 million calls to Medicare to get answers to our Medicare questions. 21% of us got frustrated and hung up before receiving an answer. Of the 79% of us who completed calls, the satisfaction decreased 13% from the previous years. Independent research also shows the call centers provided accurate information only 61% of the time (GAO). Individual prescription drug plan call centers provided accurate answers 33% of the time. If Medicare or CMS were a private business with a revenue stream near $441 billion a year, how long would it survive competition?

EVALUATION OF P4P: PERFECT OR GOOD ENOUGH?
This week the Minnesota Medical Association released a report on "Pay for Performance" in Minnesota. The report provides a critical review of current P4P efforts in Minnesota. In this report, the MMA evaluates a number of P4P programs against the MMA's own principles and provides a "score" for each payment program. The CMS PQRI program receives the highest score for aligning with the MMA (24 out of a possible 33). The Bridges to Excellence initiative receives the lowest score for alignment with the MMA at 14 points.

The MMA has 5 principles for Pay for Performance against which they evaluate these different Minnesota payment plans. On the surface these principles make sense and include concepts with which few would disagree. The principles ask that payments drive overall system performance, strengthen the physician patient relationship, facilitate broad participation, be transparent, valid, and reward measurable improvement. It is hard to disagree with these principles or to disagree that P4P systems should keep these characteristics in mind as they evolve.

The MMA spells out some laudable goals for P4P and then goes into considerable detail on what is required in order to comply with each principle. One would hope that we can still make progress on payment reform and the much needed alignment of financial rewards and health outcomes for patients without first needing to ensure that the payment program met every principle as envisioned by the MMA. If every payment system had to be perfect before change could be initiated we would need to put on hold a lot of innovation happening right here in Minnesota. That would be a classic case of letting the perfect be the enemy of the good.

On Monday, the Star Tribune ran a story about the MMA's report and an event held last week at United Hospital entitled "Ethical Issues in Pay for Performance". Here was my favorite line from the story referring to the event at United: "One doctor in the audience called the payments a 'thinly veiled effort to control physician behavior.'" Nope, not a veiled effort at all. P4P is a direct effort to control behavior and to get different results.

ZAGAT SURVEY COMES TO YOUR DOCTOR'S OFFICE
The entertainment lover's "burgundy bible" will start publishing consumer ratings of doctors on a 30-point scale. With the help of health insurance plan WellPoint, Zagat will rate trust, communications, availability, and office environment. I suspect this will rank right up there with the direct-to-consumer marketing folks who bring us the best that cosmetic or aesthetic surgery, dental orthodonture, and other"medical" proceduralists have to offer. It hardly seems to pass for the kind of medical outcomes information we deserve from and about our medical professionals, their clinics, and hospitals.

HEALTH CARE PRICING
The consistently best work in our upper Midwest on public affairs economics is done by the staff of the Ninth Federal Reserve District and published in its monthly Fedgazette. The November 2007 issue is superior work. Editor Ron Wirtz writes on the subject "Health Care Pricing" of the coming tsunami of"health information" and pricing"transparency" and what are we to make of it all. For some, money. For others, complexity. For the majority of us he says its a matter of recognizing that we "don't know what we don't know." He does a nice job of comparing prices for various health-related products across the region, of explaining the semantics of pricing and transparency and ends with a great little piece entitled,"Is there a consumer in the house."

WHAT EVER HAPPENED TO SALARIED PHYSICIANS?
My friend Tor Dahl, the productivity expert, asks: "The quality guru W. Edwards Deming advocated a fixed annual salary as the best way to ensure quality work. Salary is the opposite of piecework. Compensation is unaffected by volume. That's the way we pay airline pilots, soldiers, judges, bankers, teachers, journalists. A case could be made that the more important we think an economic sector in society is, the more likely we are to pay salaries to those who work there...The health sector will have little interest in preventing disease if disease care is the only way it will be paid."

Then he refers to our recent Minnesota Nobel Laureate, Leonid Hurwicz, who taught Dahl economics. "It was Hurwicz who pointed out the unintended consequences of rewarding the wrong thing in society. The best incentive systems are those that positively rewarded the outcomes each one of us would desire for our life on this earth."

AMERICAN CANCER SOCIETY TAKES HEAT for its decision to spend its entire $15 million advertising budget this year on the consequences to cancer families of inadequate health insurance coverage. The heat comes from those ACS chapters who prefer focusing on traditional efforts to reduce the incidence of cancer, like smoking, or on early detection like mammograms or PSAs. Besides, even the U.S. Senate has eliminated the last vestiges of nicotine on the hill with a January 1, 2008 ban on the sale of "chewing tobacco, cigarette packs and cartons, and cigars." The problem as ACS and other large health associations see it, is that lack of access to all the diagnostics and medical remedies for cancer, heart and other diseases is a growing and much greater problem than prevention.

WE'RE NO. 2
Not many Minnesotans cheered when the annual United Health Foundation survey of the healthiest states in America moved Vermont into the No. 1 spot, citing our high rates of obesity (which must be growing) for our slip from perennial No. 1. But at the other end of the Mississippi River, the folks in Louisiana were cheering for a state team that moved from perennial No. 50 to No. 49. Louisianans want to keep moving.

Out of the hurricane's destruction of Charity Hospital in New Orleans, came a chance to reform how the people of LA are for uninsured persons. One decision they made was to create the Louisiana Health Care Quality Forum with $1 million to finance their effort. Wennberg provided the Forum with"a wealth of information and data" they can use to study the degree to which medical care for Louisiana patients is determined not by need but by institutional factors such as the supply of equipment, hospital beds, and specialists.

SHANNON BROWNLEE
Last week the NIHP co-hosted journalist Shannon Brownlee, author of Overtreated: Why too much medicine is making us sicker and poorer, along with the Institute for Clinical Systems Improvement and Minnesota Community Measurement. This first time collaboration of NIHP, ICSI and MNCM attracted over 250 physicians, hospital administrators, policy makers and journalists. This event was also the ICSI 2007 Reinertsen Lecture.

Brownlee based much of her book and lecture on the work of Jack Wennberg at Dartmouth and pointed out the upside-down economics of health care, where the supply of medical resources-beds, specialists, intensive care units-determines what care we receive, rather than how sick we are and what we actually need.

Brownlee also offered ideas on how to improve the quality of American health care without the "rationing" Americans fear. Instead of treatment being addressed in terms of "what is good for business", Brownlee suggests better evidentiary standards and comparative research to evaluate care. Her other suggestions include improving the patient-physician relationship, promoting more and better primary care, and finding a way to measure, promote and pay for efficiency. Brownlee suggests using existing models of care integration, such as Kaiser and Mayo, as mentors for others.

Brownlee offered all who attended a new appreciation for the groundbreaking work of Dr. Wennberg and his colleagues, even suggesting that the folks at Dartmouth should receive a Noble Prize for this work.

PRAIRIE ST. JOHN'S
During my three terms in the Senate, I knew every hospital in Minnesota and the surrounding area. I watched four hospitals in the Fargo-Moorhead area become two physician led systems and one hospital - the only one in MN - St. Ansgar's go out of business until it became a psychiatric facility which became a for-profit organization called Prairie St. John's. Recently, billboards along I-94 connecting Minneapolis and St. Paul announced Prairie St. John's was coming to the metro. To be precise they are intending to build psychiatric clinics in two of the metro's more affluent areas in east metro Woodbury and west metro Minnetonka.

That has health care providers, hospitals and health plans worried. Hospital emergency rooms are bursting at the seams with psych patients. Both inpatient and outpatient facilities are lacking. This is especially true for public-pay like Medicaid as opposed to private pay. So what is the community to make of a for-profit company opening sites in affluent areas? No emergency facilities. Perhaps no Medicaid patients? More of the Medical Arms Race Syndrome?

LONG TERM CARE
Senator Ron Wyden (D-OK) is a serious student of health care issues. He works hard at understanding its complexities. He is unafraid to take a stand as he has on a comprehensive health policy reform proposal in The Senate which is slowly attracting co-sponsors, including Sen. Robert Bennett (R-UT) who, like Wyden, has been a serious student of health policy for three terms. In Congressional hearings on nursing home quality earlier this month, Wyden asked CMS Administrator Kerry Weems: "Something is out of whack in this country when it's a lot easier to find information about a washing machine than to find information about long-term care facilities." Wyden, Ways and Means Sub-committee chair, Pete Stark, and others are concerned about how the lack of transparency in ownership of nursing homes leads to failures in accountability for quality.

On December 3 this year, the National Commission on Quality Long-term Care will issue a report on quality in long-term care. Launched more than three years ago under the auspices of the National Quality Forum, the Commission is co-chaired by former Democratic Senator Bob Kerry, now President of the New School in New York and former Republican House Speaker Newt Gingrich, President of his own Health Transformation Center and a variety of other public policy enterprises. The other members of the original commission, including your commentator, have long been involved in the myriad of quality, accountability, and financing issues and national commissions involving long term care. Hopes were high that this commission might break the health care cost control and universal coverage sound barrier with an attention-getting proposal to make long term care part of every health reform plan in the presidential debates.

Even though the commission was moved from NQF to Kerry's New School and members of the House and Senate and Governors Haley Barbour (R-MS) and Phil Bredesen (D-TN) were added, the final report makes for good reading, but not a mandate for change. Those of us who have been at this chore for now three decades can be hopeful that Ron Wyden, or Bob Bennett, or a new Executive, searching for a universal coverage issue that can be bipartisan, affordable and can move millions of Americans with disabilities from a welfare system to an insured consumer choice of assisted living services and settings, will seize this and other proposals going back to the Pepper Commission and legislative proposals in the 1980s and 1990s and finally get the job done. Before I end up - with my mother - in one of those nursing homes.

One bit of information we do know more about is the out of pocket costs faced by families with loved ones in LTC facilities thanks to a survey conducted by the National Alliance for Caregiving. Released Monday, November 19, the survey shows that out-of-pocket cost of caring for an aging parent or spouse is more than double previous estimates. National Alliance for Caregiving is a research and policy division of UnitedHealth Group. The findings are based on a telephone survey of 1,000 adults caring for someone over the age of 50 who require help with everyday tasks. Participants admitted to spending 10-20% of their income on out-of-pocket expenses such as groceries, transportation, prescriptions, clothing and home maintenance.

An article about the survey is available in the November 19th edition of the New York Times.

HOSPITAL PROFITABILITY
Modern Healthcare recently informed us that seven of the top 25 most profitable critical-access hospitals in the nation are in MN or western Wisconsin. The River Falls, WI area hospital is basically a Minneapolis-St. Paul exurb with a 2005 Medicare cost report showing a 20% profit margin on $5 million revenue. Hospitals in Slayton and Pipestone in easy emergency driving distance to two large tertiary hospitals in Sioux Falls, SD had margins of 18.75% on $2.4 million and 17% on $.9 million. Up in my home in Stearns County, the Melrose Hospital did 16.39% on its $2.2 million contribution to its owner CentraCare in St. Cloud.

UNINTENDED CONSEQUENCES
For decades the physicians who serve a large part of west central Wisconsin have owned and operated one of the best-performing multi specialty medical groups in the nation, Marshfield Clinic. Now over 700 physician owners, the Clinic is about to acquire its first wholly-owned hospital, Lakeview Medical Center in Rice Lake, WI, and it has discovered that the new Stark III conflict of financial interest rules will require it to turn its governance over to a board of community appointed trustees, which Marshfield is going to do.

BOREN'S BIGGER THAN FOOTBALL IN OKLAHOMA
He wouldn't admit it, but David Boren's impact on the Oklahoma University campus since arriving there as its President the end of 1994 is enormous. My friend-and St. John's University buddy - Al Eisele asked me to OU a couple weeks ago to lecture to his journalism classes. Al is also a former Mondale aide and Editor Emeritus of The Hill newspaper covering the Congress. The Gaylord School of Journalism is a beautiful three-story facility with great views into the 85,000 seat OU football stadium (also named for Gaylord the founding publisher of the Oklahoman Newspaper). Every day before football practice security people walk through Gaylord Hall to make sure no "strangers" are at the windows facing the football practice field. Fortunately for me I was teaching on a bye weekend. Al and I walked the sunlit campus, admired the sense of history restored to each of the buildings and the beautiful floral arrangements on north and south malls.

Gaylord Hall, University of Oklahoma (C) Creative Commons

We spent an hour with President Dave Boren who came into the U.S. Senate as a Democrat the same year I did and left at the same I did to take the OU job. OU is a one and half billion dollar a year corporation with tens of thousands of shareholders and Boren has somehow managed to make every one of them a contributor of sorts to the success of the university. It has more Merit Scholars enrolled per capita than any other public university in America. His wife Molly takes responsibility for campus landscaping-among many other activities.

He won't tell you this, but he personally has raised north of a billion dollars in contributions since he arrived with lots more on the way. Relations with the State Legislature at both OU and Oklahoma State seem first rate and public investments wisely track private. Boren's biggest challenges are two. First was getting the faculty and staff to go along with some changes in the employee health plan for the coming year; and second a letter to America which he is writing. He put it simply in a question to me: "Are you supporting anyone for President next year?" Eisele can't write about it, but there followed a pretty frank discussion by former office holders from both parties about the state of the union and the people we elect to determine its future in the world and in our lives. Boren's 33 year old son Dan is in the Congress now.

IRAQ-IRAN WAR
More than Congressional Democrats and Iranians are in trouble today. We all are. The new, and still "trustworthy", Defense Secretary Bob Gates tells Congress to "pay up or we're leaving." He won't have to because Congressional Democrats can't afford the political consequences that threat alone will visit on them. The first mistake Democrats in Congress made was voting for war in Iraq as a war on global terrorism. The second was to change their minds, blame Bush for the war, and claim to be funding "the troops."

The Bush White House from the day after the 2006 election has been taunting the new majority into using the war financing tools to direct the future of the Iraq War. It can't be done. Moving scapegoat Rumsfeld out of office for the Baker-Hamilton Team's Gates made certain they could control the strategy and it's financing. Now they are adding Iran, some would say their original target, and simply daring the"codel quarterbacks" to take them on while they reduce the warrior body count on the ground.

AFGHANISTAN-PAKISTAN WAR
One good reason not to declare war on Iran right now is that we have major wars we can't win without allies going on in both west and east borders of Iran. It wasn't so long ago that we helped Iraq fight a war against Iran. More recently Iran helped us fight our war against the Taliban in Afghanistan. It all changed with the war on Iraq. Iran knows it became the target at that point. It knew we couldn't maintain our initial resolve in Afghanistan with only Pakistan, a most unreliable Islamic partner. So now we know why as we see the rapid chaos develop in a traditionally chaotic nation.

STRETCHING THE ARMY
U.S. Army Chief of Staff Gen. George W. Casey followed me to the Journalism School at the University of Oklahoma a week later. In two appearances the general who was commander of multinational forces in Iraq from June 2004 until March 2007, talked about the state of the U.S. Army."We weren't ready on Sept. 11, 2001. It's mostly about the leaders. Make no mistake about it, the Army is stretched. It may not be able to deal with conflicts outside Afghanistan and Iraq. I've been telling the President, if something else happens its going to take me about 90 days to change directions."

CLINTON V. GIULIANI
If the Presidential election were held today, and opinion polls are to be believed, it's a battle between each party's"best chance to win" not"best President." If you look at traits we are seeking in our President neither ranks high. There is a presumption however that Hillary has the savvy, the money, the political talents, and the husband to win the primaries so even though she may not be the strongest Democrat (high negatives) it's a Democratic year and she's it. Giuliani has basically replaced McCain as the candidate we'll swallow to beat Clinton. The theory is that he has leadership talents, an image of strength and he will bring moderates from the north and east to a general election campaign to more than overcome what he and/or closest opponent Romney would lose in the South.

DEFICIT SPENDING VS ABORTION
The biggest foe of abortion and abortion funding in the Congress may well be Senator Tom Coburn (R-OK). His election to the Senate - and his earlier election to the House - may well have been decided on the issue of abortion. But, in a recent The Hill interview, Coburn said unequivocally"The greatest moral issue of our time isn't abortion, it is robbing our next generation of opportunity." He asks:"You're going to save a child from being aborted so they can be born into a debtor's prison?" Speaking to a meeting at the National Press Club, Coburn says "Bush has not been the ideal President when it comes of federal spending...It's not a bad thing power changed last year."

CONNIE MACK is a name synonymous with the history of baseball in America. Cornelius MacGillicudy owned the Philadelphia Athletics, changed his name to Connie Mack, and built a team no one will forget. His Grandson Connie Mack became a member of Congress from the west coast of Florida and then a United States Senator who made his mark in economics and tax policy. Most recently the retired Senator Mack co-chaired President Bush's Tax Reform Commission with former colleague and retired Louisiana Democratic Senator John Breaux. Senator Mack's son Connie Mack was elected several years ago to his father's House seat. This month he will marry a member of Congress, Mary Bono of CA, elected after the accidental death of her husband Congressman Sonny Bono.

JOHN GRISHAM WRITES ON FOOTBALL
Vikings fans are being treated to a quarterback fiasco this season that cries out for Joe Kapp to come to the rescue as he did in 1969. Instead, it's Jeff George who, right after the Eagles loss, called coach Brad Childress to volunteer to come back from his 2001 retirement. My suggestion: pick up the phone and call author John Grisham and ask him where his fictional quarterback Rick Dockerty is playing football or golf today. For anyone needing a fun, light read for the season, as opposed to traditional Grisham, pick up a copy of Playing For Pizza. I 100% guarantee you'll have fun with Rick and his friends and may even be able to finish this smallish 258 pager on a flight from DC to MSP (with one short break to chat Finance Committee with its chair Max Baucus in the NWA bulkhead aisle seat which was once reserved only for ND Senator Mark Andrews).

JON HASSLER is one of Minnesota's most gifted authors whose fictitious stories about life in northwestern MN around Rookery State University are read and reread by everyone including his most famous admirer, Hillary Rodham Clinton. Jon, with much help from his wife Gretchen, has been battling PSP (Progressive Supranuclear Palsy) for quite a number of years. Despite that fact, he works 5 or 6 days a week at his only partly autobiographical novel, Jay O'Malley; was recently honored by his friends and former colleagues at St. John's University, and takes the chilly part of the Minnesota year on the east coast of Florida.

UPCOMING WORKSHOP ON EVIDENCE-BASED MEDICINE
The Institute of Medicine Roundtable on Evidence-Based Medicine presents a workshop: Redesigning the Clinical Effectiveness Research Paradigm: Innovation and Practice-Based Approaches. It will take place on December 12-13, 2007. See the IOM's website for more details.

"Maybe the way to get the President to support SCHIP would be to authorize a ‘Medicaid Advantage' program." - Jim Tallon

"Resurrection Medicine" is what Ron Anderson, CEO of Parkland in Dallas calls the extraordinary complex and costly medicine we provide the 15-18% of Americans who consume 82% of all health care costs.

“Rudy Giuliani. There's only three things he mentions in a sentence - a noun, a verb, and 9/11."
- Senator Joe Biden

"Bush is too much a part of the problem to solve it."
- Roger Cohen, New York Times

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