Commentary from Dave Durenberger

June 14, 2007

ALL HEALTH CARE IS LOCAL
Three national analyses of health care quality and performance this week reminded us of what we all know. That for all the money we spend on health and medical care services, we can’t seem to get it right in this country. Anywhere. The good news is some Americans get a lot better care than others by almost any measure. And you can measure it. And encourage it, if we wanted to do so. That’s the bad news. In a national insurance program like Medicare, we actually pay more for lower quality care.

Highlights taken from Stephanie Saul's story in the June 11th New York Times illustrate the point – with maps. On June 12 the Agency for Healthcare Research and Quality (AHRQ) used 129 measures to rank Wisconsin care providers (hospitals and doctors) the best in the country, with an achievement score of 65% of how well they should/could be doing. On June 13, the Commonwealth Fund Commission on a High Performance Health System released the first ever comprehensive comparison of health system performance in each of our 50 states. Hawaii ranked 1st, Iowa 2nd, Wisconsin 9th, and Minnesota 11th.

CHECK THESE OUT……and then ask yourself what it takes to move the performance of every health and medical system as close to 100% of what each knows it can do. The answer is not in knowing what to do. It is in overcoming the obstacles our traditional U.S. “system” places in the way of doing it. The first is leadership.

We reward health care “leaders” who move out of service delivery and into medical commodities with billions of dollars in stock, and options for stock, in for-profit medicine. And we reward “health policy experts” from government or academia for following right behind them. Hoping their influence will improve a system they know well, but knowing in any event it's better pay than their day jobs.

Sometime, check out the location of for-profit “systems” against the state-by-state quality/performance ratings above.

PRICE AND PERFORMANCE TRANSPARENCY
At a Minnesota Legislative Commission hearing yesterday, a legislative leader asked a doctor testifying on innovative programs to reduce use of hospitals and ERs, to define the hospital “charges” for him. She couldn’t of course. Here’s an answer for you though. Thanks to the Pennsylvania Health Care Cost Containment Council, and more Reed Abelson in today's New York Times, we have more evidence there is absolutely no relationship between the prices we pay for medical services and the value we receive in exchange for our money.

The example Reed used is CABG surgery (without a valve replacement) and the PA variation price of 4:1. On quality of performance, Philadelphia Main Line Health’s Lankenau center performs a high number of surgeries with high success rate for $33,549 to private insurers, compared with university hospitals like Hahnemann and Albert Einstein at $80,000.

Add in the Medicare payments to many of these high-priced facilities for the number of poor living in the area (DSH) and for resident teaching (IME), and you know how important good research, transparency, and the kinds of policy recommendations coming from the Medicare Payment Advisory Commission (MedPAC) are in forcing behavior change in the medical industry.

ALIGNING INCENTIVES
The New York Times reporters this week are doing an excellent job of reminding us of the desperate need to align financial and other incentives with the performance results we need from our country's various health systems. "Incentives Limit Any Savings in Treating Cancer.” The headline on Alex Berenson’s June 12 story about cancer doctors blaming “the system that doesn’t value the time we spend with patients” as an excuse for inserting more drugs in chemotherapy treatments illustrates a problem that can only be resolved through what MedPAC is calling “Accountable Care Organizations.” Groups of physicians and health professionals who will take responsibility and risk for providing appropriate and necessary diagnosis and treatment for a complete episode of illness such as the cancers described in Tuesday's article.

THE LINE BETWEEN CAPITALISM AND GREED
This line is hard to draw. The Berenson story reminds us that the oncology profession created a therapeutic system for cancer patients in the 1980s to provide both chemotherapy and supportive medications for side effects like anemia. Doctors over time made a lot of profit (more than a million dollars a year for some) on administering both kinds of drugs, and became dependent on an income which they now claim is inadequate to compensate for “time spent with patients.”

DO THE MATH…where greed becomes obvious is in the accompanying Berenson story detailing how pharmaceutical reps marketed their cancer drugs to the doctors on whom the rest of us depend totally when our loved one’s lives are endangered.

DAVID BRAILER, MD
Former federal health information technology czar, Dr. David Brailer, has recently established a new private equity firm, Health Evolution Partners, that will invest in and help commercialize new ways to finance, organize and deliver care. The company will provide capital and industry knowledge to a diverse set of health care companies - an approach developed to realize the full value in the health care industry.

THE REALIGNMENT OF AMERICA
If you are still with me, think ahead to the kind of America our “health systems” are being asked to care for. There is obesity, aging, disability, cultural diversity and failing inner city school systems. Plus, our communities are changing right before our eyes. Americans are moving south, and immigrants – legal and illegal – are moving in. Economics are changing, politics are changing. No one understands this better than Michael Barone, senior writer at U.S. News & World Report, whose recent analysis you can read in the May 8th Wall Street Journal. This is no “one size fits all” America anymore. The sooner health care policymakers realize this, and forget their “plans” to treat us all alike, the sooner we get to universal access.

SEXTUPLETS IN MINNESOTA
Early this week Minnesota’s first sextuplets were born to the Morrison family at Children's Hospital of Minnesota ranging from 11 ounces to 19 ounces in weight. The same day six children were born to the Masche family at Good Samaritan Hospital in Phoenix, part of the Banner Health System. All but one was less than three pounds and they were Arizona’s first sextuplets.

Unfortunately, experts suggest that babies born at 22 weeks are right on the cusp of viability, meaning there remains only a "small amount of room for hope that at least one of the babies might survive," according to Dr. Edward F. Bell, a professor of pediatrics at the University of Iowa and a specialist in premature newborns. "There's a handful of 22-week babies that have survived, but it's a pretty uncommon event."

WE DON’T HAVE THOSE IN NEW JERSEY
Dr. John G. Scott is assistant professor of family medicine at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School. When he moved from Arkansas to New Jersey and told a new friend he was “a family doctor,” he was informed that’s not what they do in the Garden State. This and other insights are available in Stephanie Saul’s New York Times story on practice variation. In a June 11, 2007 special “The Business of Health” section you can also read Steve Lohr, Milt Freudenheim, Barnaby Feder, Reed Abelson, Tim Race, Alex Berenson, Matt Richtel and Andrew Pollack.

UP AND OUT OF BANKRUPTCY
The price of an early out from bankruptcy for our captive hometown airline, Northwest, is smaller and fewer planes, and overbooked flights. A thunderstorm in Washington, DC yesterday afternoon forced NWA to cancel my flight to the Kaiser Commission on Medicaid and the Uninsured meeting, and the earliest replacement flight left MSP this morning at 6:30am for Detroit, arriving at DCA halfway through the Commission meeting. I reget not being there for the discussion of Medicaid, SCHIP, Long-Term Care, and a start of an analysis of presidential candidate proposals for health policy reform.

CONSUMER DRIVEN HEALTH PLANS NOT THE QUICK-FIX SOLUTION
Despite President Bush's big push for increased consumer responsibility through the use of Health Savings Accounts (HSAs) and high-deductible health plans, the movement is not catching on as quickly as initially anticipated.

In fact, policy experts indicate that the rise in enrollment for such plans could be the result of limited employee choice when it comes to health care coverage. In an attempt to lower overall healthcare costs, many employers now offer no other alternative to their consumer-driven health plan. Tuesday's Wall Street Journal highlighted consumers' confusion and dissatisfaction with how the accounts actually work.

WHY WASHINGTON CAN’T GET MUCH DONE

by Ben Sargent ©2007 The Austin American-Statesman

If you are like me you wonder why Senate majority leader Harry Reid is always filing cloture petitions accusing Republicans of filibustering by amendments to keep the most deliberative body in the world from doing the “public’s business.” Or you wonder why the Attorney General and the Republicans accuse Harry Reid and the Democratic censure resolution of keeping Alberto Gonzalez from “doing what the public wants him to do.”

The fact of the matter is that most of the tough public policy issues facing the nation which require Congressional action are just darned tough for a representative democracy to decide. A little like trying to get the “Iraqi government” (another oxymoron) from acting to prevent a U.S. troop pullout. The majority party can get almost anything through the House of Representatives because the rules allow the majority to decide what will be considered on the floor of the House and for how long. But this majority party can’t get anything past the President, so it falls to the Senate to act.

This Senate’s Republicans are solidly in the President and the Party’s corner (even on immigration), and Presidential election campaign stakes are so predominant as to deter any bi-partisan heroics.

THE LATEST PUBLIC OPINION POLLS
The polls show the impact of the Presidential debates and just how many of us are focusing our judgment on them. Hillary Clinton appears to be the biggest gainer at the expense of Obama and Edwards.

On the GOP side, it is getting close to the time for Newt Gingrich to get serious and “on stage.” Early front-runners Giuliani and McCain do not present as “presidential” enough. Mitt Romney is more so all the time. Fred Thompson’s popularity says Republicans need the benefit of candidates who can debate the future, not the past. The bad news for the GOP is that the Wall Street Journal/NBC News Poll shows the party in its worst shape in 20 years with voters on the issue of “which party shares my values.”

NOT POLLED
Does the public have an appetite for an American Idol format for the presidential debates? A public vote after each debate to determine which candidates need to “get lost,” so the precious CNN time can be devoted to the most likely/most qualified. If a candidate can’t get, say 25% “hang in there” votes for two straight debates, he/she is off the debate schedule. What do you think?

CANDIDATE JOE BIDEN
I admire Joe Biden. I served with him from a time shortly after his first wife was killed in a horrible car accident until I left the Senate in January 1995. Ten months later I saw Joe in the Senate barber shop and asked him if he was running for re-lection in 1996 and he said, "Yeah, but for all the wrong reasons." His goal, he said, was to try to keep some balance in a Senate whose base was moving farther from the bi-partisan middle with each election.

Today Joe Biden is in his 35th year in the Senate and once again chairs the Senate Foreign Relations Committee. He is running for his party's nomination for President. Again he will be the most articulate, the most precise, the best informed, the most experienced and the fairest of the candidates from either party. He is running this time for all the right reasons - leadership for America at a time when this country's political leaders, and its President, continue to promise more than they can deliver.

PRESIDENTIAL CANDIDATE RUDY GIULIANI
Try to get a handle on Rudy Giuliani. We know he's a serious scowler, but today he is all smiles. In a debate response either to the attacks on him by a Catholic Bishop for his abortion rights stand, or to a lightening strike near the debate forum between the question and his answer, Rudy says, "Look, for someone who went to parochial schools all his life, this is a very frightening thing that's happening right now." In response to Democratic presidential candidate health care proposals, "They're moving to socialized medicine so fast it makes your head swim." I thought it took a lot more than Democrats and lightening to scare you, Rudy.

JUNE 19TH IN MINNEAPOLIS
Speaking of the “business of health care,” this community will be treated to two high-powered opinion leaders on this subject. Leonard Schaeffer, retired founding CEO of WellPoint will speak at a National Institute of Health Policy (NIHP) event on the Medical Arms Race Syndrome (MARS) at noon June 19th at Opus Hall on the University of St. Thomas Minneapolis campus. You can still register online at www.nihp.org.

At 6:30pm, Harvard University’s Regina Herzlinger will meet with the Center for the American Experiment on her new work "Who Killed Health Care?"

The NIHP event is part of a series analyzing what to do with the medical arms race which will feature former Aetna CEO, Dr. Jack Rowe on September 20, and former CMS Administrator Dr. Mark McClellan on October 15.

"Americans were proud to claim that our health care system was the best in the world; that is, until we discovered that it wasn’t."
-- Dr. Jerry Kassirer, in "Diagnosing Medicine's Ills," British Medical Journal; May 26, 2007

"I think there was a concern that I wasn't happy in Congress. Very candidly, this isn't the greatest job I've had."
-- Rep. Tim Mahoney (D-FL), after his first six months in Congress

"I cannot change my opinions in the absence of new data or understanding, in large part because I am not for sale."
-- Dr. John B. Buse, medical researcher and one of the early critics of the diabetes drug, Avandia

"You can't become a one-trick pony."
--Rep. Rahm Emanuel (D-IL), chairman of the Democratic conference, when discussing how Democrats should not be drawn into focusing solely on Iraq.

This past weekend, NIHP's Rachelle Kotrba joined 3200 other riders on a trek from Duluth to Blaine in the MS 150 Ride, raising $2.2 million for the Minnesota MS Chapter. An unforgettable experience benefiting a very admirable cause.

WISCONSIN INCREASES TAXES TO PAY FOR MEDICAID AND OTHER HEALTH CARE SPENDING
In an effort to pay for increased Medicaid spending, the Wisconsin legislature and Governor Jim Doyle are set to approve a cigarette tax increase from .77 a pack to $2.02. The Governor also plans to fund Medicaid and other health expenses through a 0.8% tax on hospital revenues and a $175 million transfer from the patients' compensation fund, despite protests from the Wisconsin Medical Society.

SUMMER READING FOR POLICY WONKS
Who Killed Health Care…Regina Herzlinger
Medicare Matters…Christine Cassell
Better…Atul Gawande
How Doctors Think…Jerome Groopman
Best Care Anywhere: Why VA Health Care is Better Than Yours…Phillip Longman
The Omnivore’s Dilemma…Michael Pollan
Her Way: The Hopes and Ambitions of Hillary Rodham Clinton...Jeff Gerth and Don Van Natta, Jr.
Medicine and the Market: Equity v. Choice...Daniel Callahan and Angela A. Wasunna

Copyright 2007 National Institute of Health Policy ~ www.nihp.org