Wednesday, December 30, 2009

"We have met the enemy, and he is us!", Pogo

The US House and the Senate have both passed health care reform bills, and it is now up to the Conference Committee to craft a compromise bill that must then be passed by each legislative body. If a bill is ultimately signed into law by President Obama, we are likely to hear years of arguments as to whether or not this bill is a good or bad thing for our nation.

What likely will not be debated, however, is our corrupt and sclerotic political system that has produced these bills. Instead of honest debate, and collaboration about how to solve a problem, we have been treated to our representatives cynically selling their votes for this bill in order to to "buy votes back home" from local voters who continue to fall for this kind of nonsense. Want examples? Here are just a few:

Senator Ben Nelson, D-Neb., has insisted that the federal government promise to pick up the full cost of Medicaid expansion in his state, costing about $100 million over 10 years, paid for by the residents of other states. In addition, he insisted that a private, physician-owned hospital being built in Bellevue, Neb., be able to get referrals from doctors who own it, which according to new regulations will be illegal throughout the rest of the country.

Senator Christoper Dodd, D-Conn., procured $100 million dollars for construction of a hospital at a public university in his state.

Senator Patrick Leahy, D-Vt., negotiated $600 million in additional Medicaid benefits for his state over 10 years. Massachusetts is getting $500 million in Medicaid help for similar reasons, all paid for by those of us in other states.

Senator Mary Landrieu, D-La., extracted an extra $300 million in special funds for a new "Louisiana Purchase."

Senator Joe Lieberman, I-Conn.,along with most Republicans, has just taken the insurance money and tried to stop everything those lobbyists do not want.

Longshoremen union supporters of Democrats were exempted from most of a new tax on high-value health insurance plans, as were electrical linemen, police officers, firefighters, emergency first responders and workers in construction, mining, forestry, fishing and certain agriculture jobs.

As citizens can vote these people out of office any time we want, and yet we do not. We can insist on ethical behavior, but we do not. Yes, these bills are a complicated mess in many ways, although probably the best that we can do for now.

The problem is us. When we continue to re-elect corrupt, cynical politicians, who buy our votes with our own money, we get exactly what we deserve. So far, they have not been able to underestimate us.

Sunday, November 22, 2009

The Cost of Dying, 60 Minutes, November 22, 2009

60 Minutes presented an outstanding program that tells the story in human terms about how our country manages to waste so much money while not properly caring for those we love at the end of life. If you missed the program, take 14 minutes of your time to watch this outstanding piece of excellent TV journalism.

Monday, November 9, 2009

Two News Stories that Help to Make It Clear Why We Need Comprehensive Health Care Reform

Big insurers spend much less on medical care than previously reported

Dow Jones Newswire reports that a US Senate Commerce Committee investigation found that the six largest US health insurers spent less on medical care than what industry officials estimated. Of the total amount received in premiums by the companies in the individual insurance market, 74 cents of every dollar were spent on medical care, according to a review of publicly available of data on industry earnings. Meanwhile, America's Health Insurance Plans estimated that the industry spent an average of 87 cents of every premium dollar on medical care. Click Here for Complete Story

HMOs planning large 2010 premium increases despite strong 3Q earnings.

Forbes Magazine notes that although "most of the major managed-care companies" have announced strong 3Q results, the message "during this earnings season is that HMOs are focused on rebuilding margins, even if it makes insurance even less affordable." Goldman Sachs analyst Matthew Borsch "calls it 'the highest pricing trend in years.' The premium increases he's seeing are in the neighborhood of 13 to 15 percent for next year." Analysts say HMOs are concentrating on making up for operating profit margins, which "reached zero last year for the industry as whole." Moreover, the companies not only want recompense for the "higher costs" they incurred this year from COBRA, they must "cover rising ordinary medical costs that show no signs of slowing down." Barclays analyst Joshua Raskin predicts overall health spending in 2010 will "climb 9 percent."

Click here for the complete story

Tuesday, November 3, 2009

The bill is HR 3962, the Affordable Health Care for America Act

The Whatcom Alliance for Health Care Access is a long time community health care study group that I participate in, which is dedicated to improving access and quality of care in Whatcom County, Washington. It is composed of citizens from all walks of life and segments of society. On November 2, 2009, they reviewed HR 3962 and released their findings. What follows is my edited version of their conclusions.

General Comments
on the Bill

• This is a very comprehensive reform package that lays the ground work for providing changes and incentives to the delivery system that will reduce waste and improve outcomes overtime.
• Strong, thoughtful approach to Medicare payment reform that will result in implementation of recommendations over time
• Recognition and inclusion of reform initiatives. Specifics include a focus on wellness and prevention, expanding support for primary care training, creating opportunities for state and community level pilot projects and innovations and recognition of the importance of consumer engagement in reducing costs and improving outcomes.

Specific Comments Relative to Principles of Reform

1. Need to provide coverage and care for all people at all times regardless of age, employment status, economic circumstances and preexisting conditions
• Bill effectively addresses underwriting issues relative to age, health status and pre-existing conditions and creates level playing field for public and private market
• Bill provides options for all individuals (including low income) and most businesses to access affordable and in some cases subsidized health coverage through the exchange or through Medicare or Medicaid

2. Need to improve patient outcomes and reduce waste through improved care coordination, and a focus on primary care and preventive care.
• Emphasis on reduction of waste and fraud throughout bill including provisions in Medicare and Medicaid changes are seen as addressing this issue
• Reform elements throughout bill to increase primary care training including expanding residency options seen as positive
• Medical home recognition and including support of medical home pilot programs and shared decision making seen as effective
• Elimination of co-payments and deductibles for preventive services in Medicare and Medicare supports access to preventive care
• Grant program to help small employers to strengthen workplace wellness programs and support of community preventive services grants seen as important steps.

3. Need to assure consumer choice of providers and public and private plans
• Addressed through establishment of exchange and creation of a self sustaining public option.

4. Need to simplify the system (insurance administration, etc.) so that it is user friendly (understandable and transparent to consumers.)
• Creating level playing field in terms of underwriting and enactment of administrative simplification to reduce paperwork, standardize transactions and improve transparency seen as important step forward

5. Need to control costs and improve quality of care by reforming the payment system so that it rewards results and not activity and holds providers accountable for outcomes not procedures.
• Increased payments for primary care under Medicaid important step
• Addressing of Medicare payment rates based on geography and geographic variations in health spending through IOM studies with provisions for adopting recommendations is needed for cost control and quality improvement in Medicare
• Provisions for Center for Medicare and Medicaid Innovation creation and empowerment, creation of Accountable Care Organization program and Comparative Effectiveness Research Agency all needed to identify quality measures, provide the science to implement evidence based care and provide the incentives for the delivery system to implement those changes
• Changes to Medicare Advantage plans seen as supporting this principle

Some Persisting Questions and Issues

1. Affordability will be an ongoing challenge that needs to be monitored and addressed. How will that be handled?
2. What role will the public options play in health reform proposals to drive innovation?
3. Is financing adequate and sustainable?

Thursday, October 22, 2009

A Sad Irony

Senate Democrats lost a key vote October 21st on a $247 billion dollar measure to avoid decreased Medicare reimbursement payments to doctors over the next 10 years. This would not have been an increase, but would have simply kept them at the same level they are now. The proposal was blocked in a 47-to-53 vote and thirteen Democrats broke with their party's leadership to join a unanimous Republican opposition.

Why is this a big deal? Well, the irony of this vote is that is that we may be passing health care reform to expand care availability to the general public, while decreasing access for Medicare patients to needed primary care if this vote stands.

This measure had been separated from broader proposals to overhaul the nation's health care system, because it is a separate problem that predates health care reform proposals. Under the current formula, Congress balances the Medicare budget by decreasing doctors payments to compensate for increased utilization by the public. Primary care is hit particularly hard, since those doctors have high office overhead costs that must be paid. A 21% cut is planned for January 1st, and 10% cuts are foreseen every year thereafter. Since doctors are already limiting access for Medicare patients due to existing low payments, it does not take a genius to understand that this payment decrease will be a catastrophe for Medicare patients. How sad that 53 members of the United States Senate either do not to understand that, or cynically do not care.

Monday, September 28, 2009

What doctors think about health care reform

What do doctors think about proposed health care reform? The voices of physicians in the current debate have been almost exclusively from national physicians’ groups and societies, and little has been known about "the doctor in the trenches" and how they view things. A recent study the The New England Journal of Medicine sheds new light on this issue.

Turns out that a majority of physicians (62.9%) support reform that includes both a public and private plan options. 27.3% support reform offering only private options.

Wednesday, September 23, 2009

One reason medical care is so expensive: We All pay a Hidden Tax

Those of us who currently have private health insurance pay a "hidden tax", included in our premiums, to pay for costs incurred by those without coverage. A new study now calculates that cost to be $1,017.00 per family in 2008, which is in addition to the actual taxes paid to support Medicaid and other government programs.

In 2008, the uninsured received $116 billion worth of care from hospitals, doctors, and other providers, which was usually provided for emergencies that could no longer be ignored. Those costs had to be paid for somehow, and they were covered in the following ways:
  • On average, the uninsured themselves paid for more 37 percent of the total costs of the care they received.
  • Government programs and charities, paid for another 26 percent of that care.
  • The rest, approximately $42.7 billion in 2008, was unpaid (So called "uncompensated care").
To cover the rest of this "uncompensated care", the cost was shifted to private insurers by charging more for health services. These charges then result in the higher premiums we all pay. In 2008 the extra charge for family health care coverage was $1,017.00 and for a single person was $368.00.

The next time you here someone bemoan "increased taxes" to pay for health care reform, remember the truth. We need to get rid of the tax we already bear, and substitute a planned system that actually gets people in for needed care before things fall apart, thereby saving us all money.

Sunday, September 13, 2009

Do we wish to be the only rich nation in the world that lets a 32-year-old woman die because she can’t get health insurance? Is that really us?

"Nikki was a slim and athletic college graduate who had health insurance, had worked in health care and knew the system. But she had systemic lupus erythematosus, a chronic inflammatory disease that was diagnosed when she was 21 and gradually left her too sick to work. And once she lost her job, she lost her health insurance." Nicholas Kristof tells the true story of Nikki White in an Op-Ed column in the New York Times on September 13, 2009.

The story of Nikki White graphically explains what is wrong with our current system, and why health care reform is so desperately needed. After she lost her job and health insurance, Nikki tried everything to get medical care, but no insurance company would accept her. As Kristof explains, "She spent months painfully writing letters to anyone she thought might be able to help. She fought tenaciously for her life.

Finally, Nikki collapsed at her home in Tennessee and was rushed to a hospital emergency room, which was then required to treat her without payment until her condition stabilized. Since money was no longer an issue, the hospital performed 25 emergency surgeries on Nikki, and she spent six months in critical care."

Here is the irony - “When Nikki showed up at the emergency room, she received the best of care, and the hospital spent hundreds of thousands of dollars on her,” said her step-father, “But that’s not when she needed the care.”

By then it was too late. In 2006, Nikki White died at age 32. Her doctor, Amylyn Crawford, said, “Nikki didn’t die from lupus, Nikki died from complications of the failing American health care system.”

Access to early, appropriate health care is something that any of us can loose without warning. We need reform. I do not want to live in the only rich nation in the world that lets anybody die because they can’t get health insurance.

Sunday, September 6, 2009

How American Health Care Killed My Father

That is the provocative title of an article by David Goldhill in the September, 2009 issue of The Atlantic monthly magazine. After the needless death of his father, Goldhill began a personal exploration of the health-care industry. He found that for years it has delivered poor service and irregular quality with an astonishingly high cost. It is a system, he argues, that is not worth preserving in anything like its current form, and he believes that the timid health-care reform now being contemplated will not fix it. His insights as a non-health care professional business executive, who looks at things from a business point of view, are profound, and I encourage everyone to read the article. You understanding of the compelling need for change will be enhanced.

So, if change is needed, what is the experts prescription for change, in a nutshell? In a September 6, 2009 article from the The Brookings Institution a group of 10 health care policy experts detail a set of concrete, feasible steps to revamp the system to control cost and improve saftey and quality. The plan, “Bending the Curve: Effective Steps to Address Long-Term Health Care Spending Growth,” focuses on reducing the growth of health care spending, while also improving quality.

Their strategy consists of four interrelated pillars:
  • First, we all need better information and tools to be more effective in getting the right care.
  • Second, payments to health care providers should reward improvement in quality and reductions in cost growth, while emphasizing disease prevention and coordination of care.
  • Third, health insurance markets must be reformed and government subsidies restructured to create competition and improve incentives around value improvement rather than risk selection. This will require all to be covered in some way.
  • Fourth, people need support for improving their health and lowering overall health care costs, including incentives for achieving measurable health goals.
The report is well worth a read, in order to understand each of the pillars. Only by being informed on the issues so we know what is really being suggested can we cut through the claims of those trying to derail needed change. You can get a copy of this report by clicking on this text.

Thursday, August 20, 2009

The emotion you are feeling is “Frustration”

Are you frustrated with our current health care system? Does health care reform address your frustration?

Let's get real! Here is a run down on what people are frustrated about, and what the facts are about proposed reform!

  • Frustration: I can lose my insurance if I am out of work or my company cannot afford the benefit.
  • Frustration: I may not be covered due to a pre-existing condition, even though I have insurance. They can decide not to pay after I get sick!
  • Reform includes health coverage for all US citizens regardless of age, employment, wealth or pre-existing conditions.
  • Frustration: I can't find a primary care doctor to be my partner to focus on prevention, health and coordination.
  • Reform includes support for primary care, in order to train more specialists in this area to meet this need.
  • Frustration: I do not have a choice of who I see with my current insurance.
  • Reform includes assurance that you will have a choice of plans, providers and hospital, both public or private plan.
  • Frustration: The system is so complicated, I do not understand my insurance, and there is so much paper work.
  • Reform includes simplified regulations and uniform rules for you and your doctor, so that it is user friendly and understandable.
  • Frustration: Costs keep going up too fast! I struggle to meet my share of the bills.
  • Reform includes a change in the rules of the game, in order to help you get the best care the first time with the best quality results. This can lead to better care and lower costs for all of us.
  • Frustration: We are losing jobs because of the high cost of American products due to expensive insurance, and this makes me worry I may lose my job.
  • Reform will take away the extra costs that insurers must pay for those who are not covered. America will become more competitive.
All of us will benefit from reform. Even those of us who have good coverage right now. We need to get real. We need to do this.

Monday, August 17, 2009

Thanks to David Horsey at the Seattle Post Intelligencer for today's commentary in the form of this cartoon.

Originally published on Sunday, August 16, 2009 in the Seattle PI.

Saturday, August 15, 2009

Ugly Spectacle Endangers Reform

During the 2008 presidential campaign, Nobel Prize winning journalist and economist Paul Krugman warned that upon assuming office, President Obama would face “an unending procession of wild charges and fake scandals, dutifully given credence by major media organizations that somehow can’t bring themselves to declare the accusations unequivocally false.” In his column in the New York Times, Krugman now asks, "So, how’s it going?"

Sad to say, Krugman has hit the nail on the head, and the scurrilous attacks on the president over health care have no relationship to anything he is actually doing or proposing.

Take for example the claim that health care reform will create “death panels” (according to Sarah Palin) that will send the elderly off to an early grave. It’s a complete fabrication. Grossly and maliciously untrue. The provision actually provides that Medicare will pay for end-of-life counseling requested by the patient was initially introduced by Senator Isakson, a Republican from Georgia. No one screamed at him about this, and he continues to say that it’s “nuts” to claim that it has anything to do with euthanasia. Before this current campaign, some of the current peddlers of the euthanasia smear, (for example, Mr. Gingrich and Mrs. Palin) were both on the record as being supporters of “advance directives” for medical care in the event that you are incapacitated or comatose. Not only that, but legislation to establish the Part D Medicare drug program during the Bush Presidency also established counseling for advance directives. No false outrage was seen at that time.

The smear continues to spread, and I am saddened to see that so-called moderate Republicans, such as Senator Grassley, (R) Iowa, have endorsed the lie. As Krugman notes, "his role in the health care debate has been flat-out despicable". Senator Grassley claims that Senator Ted Kennedy’s brain tumor would not have been treated properly in other countries because they prefer to “spend money on people who can contribute more to the economy.” This week, Grassley told an audience that “you have every right to fear,” that we “should not have a government-run plan to decide when to pull the plug on grandma.”

Right now the politics of opposition are an ugly spectacle. When the distorted paranoia of some worried citizens is cynically manipulated by Republicans and special interest groups to fuel the mistrust with out right lies, is a very worrisome trend.

Those of us who support reform also need to tap into our sense of passion and outrage. Passion to achieve a family doctor for every family, lower cost, freedom to choose and coverage for all Americans, and outrage at the lies and fear-mongering that are being used to block that goal.

Now is not the time to shrink from the debate.

Thursday, August 13, 2009 is A Place to Find out the Truth! is a project of the St. Petersburg Times, the same newspaper that won the Pulitzer Prize for outstanding coverage of the 2008 presidential election.

This web site is the place for you to check the truth about claims made in the US health care debate. Reporters and editors from the Times fact-check statements by members of Congress, the White House, lobbyists and interest groups and then rate them on the "Truth-O-Meter". Amazing! Someone in the press doing actual journalism. The ratings range from "Pants on Fire" (recent winner Sarah Palin) all the way to "True". Check out these recent "Pants on Fire" rulings and enjoy yourself.

Sunday, August 9, 2009

Report from a Town Hall Meeting, Mt. Vernon, Washington

The news had been full of reports of angry crowds with rude and obnoxious behavior, harassing members of Congress who were attempting to discuss health care reform with constituents, so it was with a little trepidation that I set out for the 2nd of 3 meetings hosted by Congressman Rick Larsen for Washington's 2nd Congressional District. Could the normally respectful and open minded people I live and work with behave this way? Turns out, I need not have worried!

So many people came to the meeting that the large auditorium was completely filled, and a crowd of thousands spilled over into the outside lawn. Speakers were set up so that all could hear, and Larsen made a point of coming out on to the lawn area to take questions. Congressman Larsen treated everyone with patience and respect. Oh, to be sure, there were some who seemed bent on stoking ill will, such as the guy who had a picture of the President defaced to look like Hitler. These folks were far outnumbered by those who came to listen and have true dialog, and when the Congressman singled out the picture of President Obama as Hitler, to say it was not reflective of true and honest criticism and debate, there was a loud and prolonged applause from 90% of those in attendance. To those who complained that the house bill was rushed through by people who did not understand it, he made it clear that he had read the entire bill, and had a copy with him to refer to if there were specific questions. And the questions did come!

One of the most interesting things I learned at this meeting is how confused and misinformed some worried people are about the truth contained in the recent bill passed by the House of Representatives. For example, one woman thought that payment for care would be limited to $5,000. The Congressman explained that no, this figure was a cap on expenses for her to be responsible for, and not a limit on benefits. Another thought that illegal aliens would be covered, and was told that they are explicitly not covered by this bill. There were many other examples.

Larsen made it clear that he is not approaching reform as an ideolog, but rather, he wants to accomplish practical change by keeping the following principles in mind:
  • Ban discrimination for pre-existing conditions, age and gender;
  • Don't try to fix what isn't broken. If people have insurance and doctors they like, they should be able to keep them;
  • Eliminate fraud, waste and abuse in government health programs;
  • Invest in prevention and pay for quality of care, not quantity of tests;
  • And get reform that works for Washington State.
He particularly took pains to explain that Washington state currently is penalized for providing higher-quality, lower-cost care by Medicare because reimbursement rates are so low that many local doctors do not accept Medicare patients. Under the original health care reform bill introduced in the House, this problem was not fixed, and was expanded, so that the same unfair, wasteful reimbursement policies would have been expanded from Medicare to the public insurance option. As he said, "What good is an insurance card if you can't find a doctor who will treat you?" That was his reason for opposing the "public plan" option as presented. To improve this situation, Larsen has worked with colleagues from Washington and other states with the same problem to secure an agreement with House leadership to agree to reform Medicare payments, reward high-quality, cost-efficient care and remedy geographic disparities that hurt access to care for local patients.

All in all, I was very impressed. Congressman Larsen should be commended for working hard on our behalf, with clear principles of reform. He is obviously very knowledgeable and energized about this issue. Residents of our area should be commended for their attention and respectfulness of the town hall process. I was glad that I went.

One disappointment I do have is with our local newspaper, The Bellingham Herald. I could not find a report of our local meeting, but there were 2 articles with old news about how meetings are being disrupted. What a missed opportunity by our media to set the record straight!

Thursday, August 6, 2009

$ The cost of Health Care reform

You've probably heard it said by critics that health reform will cost taxpayers at least a trillion dollars. This sounds scary, which is the intent of the critics, but it turns out not to be true!

The quoted figure is not a trillion dollars a year, but rather a trillion dollars over 10 years. On a yearly basis, the cost equals approximately $140 billion dollars. To put this in perspective, the Part D Medicare Drug plan passed during the Bush presidency is about 600 billion dollars for drugs alone.

$140 billion dollars a year still overstates the cost, however. That is because other parts of the reform plan result in savings for Medicare, such as the reduction of subsidies to private insurers, reform of payment rates for doctors and a decrease in payments to hospitals for providing "free care" to the uninsured. When all of this is taken into account, the net increase in government spending for health care will likely be about $100 billion a year, which is a one-time increase equal to less than 1 percent of US national income, which has historically grown at an average annual rate of 2.5 percent every year.

While criticizing, right wing critics have stood against ideas to improve care and lower costs. For example, a plan to fund research which gives doctors, patients and health plans better information on what works and what doesn't, Republican critics have claimed a sinister plot to have the government decide what treatments you will get. Using this kind of perverted logic, a proposal that Medicare pay for counseling on end-of-life care is transformed into a secret plan for mass euthanasia of the elderly. There are many other examples.

Please, don't take hysterical criticism at face value. The truth is more complicated, but also reassuring.

Sunday, August 2, 2009

What's In It for Me? What are our obligations to each other?

As what passes for a health care debate rages all around us, I have come to realize that between the polarized extremes there exists a very important group of people who are the key to what will happen this fall, and that is the large group of Americans who have health insurance and who are worried they may lose advantages in any reform. All of the noise in our media is an attempt to reach this group, who are likely asking, "What's in it for me"?

I believe that those who currently have health insurance and good access to medical care would be well advised to support proposed health care reform for the following reasons:
  • They may lose their insurance coverage! Right now, 14,000 insured people lose their coverage every day when they lose their job or the employer cannot continue to afford benefits, and that number is expected to increase greatly with current trends.
  • Business can't afford the increasing costs! Under the current system, costs are expected to double during the next 10 years.
  • Young people are priced out of the system! Those looking for work at the beginning of their careers are most likely to get jobs without benefits, leaving them uncovered and raising the cost for all others.
  • Insurance often does not work when you need it, even if you have it! The for profit system is full of people who work hard to "ration your care" by figuring out how not to pay for things.
  • The payment system must be reformed! Our current mess of a non system is caused by the payment incentive and lack of incentives we now have.
  • Quality is often lacking! A sad and poorly understood fact is that even people with good insurance get the recommended care they should have only about 1/4 of the time. The care is not organized in a way that allows most doctors to manage their patients the best way possible.
  • They may lose their doctor! Very few medical students are going in to the primary care disciplines, due primarily to the fact that they cannot afford to. Retiring family doctors are not being replaced. Reform which supports primary care is crucial to attracting the best and brightest into primary care.

When all is said and done, however, thinking just about ourselves misses one of the most important reasons for reform. Perhaps the most important thing to consider is, what are our obligations to each other? Our entire American society is engaged in global competition with all the countries on earth for the innovations, jobs, products and benefits of the world to come. We must have a society with well educated, healthy and productive citizens to secure the benefits of the future. Our companies need a level playing field that does not saddle them with the unequal and exorbitant costs of a failed system.

If the the future is scary to you, it is really not because of the risk of changing, but because we might not change. Don't be fooled.

Saturday, July 18, 2009

The Party's Over

Up until now, we have seen some superficial co-operation among disparate interests over needed healthcare reform, but now the wheels seem to be coming of the bus. Republicans, conservative groups and some business organizations have begun accelerating efforts to derail legislation, by calling the Democratic proposals costly and dangerous experiments in "government-run" health care. Their main goal is to slow down the pace of the legislation in Congress in the hope of fomenting wider opposition. Sen. Jim DeMint (R-S.C.) has been quoted in the Washington Post as saying, "If we're able to stop Obama on this, it will be his Waterloo." "It will break him."

What we are talking about, of course, is regulation of the market, and figuring out how to cover all of our citizens. That is not "government-run" health care. In the many countries of Europe, for example, very few of them "run" the health care system, Great Britain being the notable exception. By trotting out their tired old stereotypes, I think that conservative activists are discrediting their cause, and depriving us of a real debate on substance.

The fact is that we already do have one "government-run" health care program", and that is Medicare. I will be the first to tell you that it does have faults, but it is highly rated by those it serves, and it is quite efficient in it's management, far more so that private plans are. So much for the evil, clumsy government.

We already have a dysfunctional healthcare mess for which we spend more than anyone else on the planet. The money we waste may not be a government tax, but we are paying it every time we buy a product made by a US firm or pay your insurance premium.

Tuesday, July 14, 2009

New US Surgeon General Choice Says a Lot!

President Obama has finally announced his choice for surgeon general, and it is Dr. Regina Benjamin, a 52-year-old family physician who has spent most of her career practicing in a Gulf Coast clinic in Alabama. She graduated from Xavier University of Louisiana in 1979, attended Morehouse School of Medicine from 1980 to 1982, and received a doctor of medicine degree from the University of Alabama at Birmingham in 1984. She completed residency training in family Medicine at the Medical Center of Central Georgia in 1987, where her medical training was paid for by the National Health Service Corps, under which medical students promise to work in areas with few doctors in exchange for free tuition. She has also earned a master's in business administration in 1991 from Tulane University.

I am hopeful that President Obama's choice of Dr. Benjamin is a clear indication of the direction he wants to take in health care reform. The fact that he chose a family physician, and not a corporate bureaucrat or medical school academician seems to say a lot about what he values!

Sunday, July 12, 2009

Mayo Clinic Principles of Health Care reform

I had an interesting experience this week when my friend, retired pathologist Dr. Bob Gibb, asked me to sit in with him on a group telephone call among alumni physicians trained at the Mayo Clinic. It seems that Mayo has decided to try and play a "convener role" in our national discussion of health policy, and this phone conference was part of an effort to spread their message and get the word out about what they believe is central to true health care reform. They have also developed a web site for the Mayo Health Policy Center.

On the call I learned that Mayo has 4 cornerstone principles that they believe must be included for meanigful reform:
  • Creating Value - do we actually improve health in a measurable way?
  • Coordinated Care - Mayo is an example of working together and not in silos
  • Payment Reform - provide incentives to coordinate care, improve outcomes and enhance patient decision making
  • Health Insurance for All- essential in order to share risk, and improve the health of entire populations.
Although they have nailed 4 needed elements, I would add two more principles that I believe are also essential for us here in the United States:
  • Choice - people want a choice of doctors, plans and hospitals when possible
  • Access -the Massachusetts experience makes it clear that "insurance for all" is a hollow accomplishment without enough primary care doctors to provide access to care!
During the call, there was a discussion of the thought behind the Mayo cornerstones which noted that they support the personal medical home as a way of achieving the principles, they do not believe that simply expanding Medicare is rational, since it does not address value, coordination and payment reform, and they do support some pilot projects to sort out the various ideas of how to manage the needed change.

Steven Pearlstein noted in a recent Washington Post article, "If we really want to fix America's overpriced and under-performing health-care system, what really matters is changing the ways doctors practice medicine, individually and collectively. Everything else -- mandate or no mandate, the tax treatment of health benefits, whether there's a "public plan" to compete against private health insurers -- is just tinkering at the margin." I could not agree more. In order to get there, however, we will need to pay physicians differently to coordinate care, and measure results. For this reason, payment reform is the most critical first step. Indeed, the results we are seeing today are just what our payment system is designed to produce! The American College of Physicians (ACP) 2006 report actually predicts the imminent collapse of primary care in the United States, due to the inadequate and dysfunctional payment policies of the government and other third party payers.

We have an historic opportunity to change course. Thanks to the Mayo Clinic for weighing in!

Friday, June 26, 2009

How Does The Patient-Centered Medical Home Transform Health Care Delivery?

Can Patient-Centered Medical Homes Transform Health Care Delivery? The answer is clearly yes, and that is a point I have tried to emphasize, but I often get asked by those less familiar with the subject, how does this really make a difference?

The basic idea in a nutshell is that in order to be effective and add value, health reform must deliver a new delivery system built on a solid foundation of primary care. There are two barriers to this happening:
The medical home is an approach to primary care organized around the relationship between the patient and their personal physician. It is is primary care that is "accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” It has now been endorsed by important, independent health care think tanks, such as the Commonwealth Fund.

In 2007, four primary care specialty societies, representing more than 300,000 primary care specialists, issued a joint description of the Principles of the Patient-Centered Medical Home:

  • A personal physician;
  • A whole-person orientation;
  • Safe and high-quality care (e.g., evidence-based medicine, appropriate use of health information technology);
  • Enhanced access to care; (e.g., phone visits, secure web visits, group visits with appropriate use of health information technology);
  • payment that recognizes the added value provided to patients and insurers who have a patient-centered medical home.
Today, few Americans say they have a source of care with these features, but I am proud to say that my medical group, Family Care Network, has made wonderful progress to become a full fledged Patient-Centered Medical Home for our patients. We now know what works. There is no excuse to delay. If we do not move forward in this effort, we will continue to reap the whirlwind of spiraling costs and plummeting value. Primary Care will disappear. Now is the time.

Thursday, June 4, 2009

We are witnessing a Battle for the Soul of American Medicine

The title of this column is a direct quote from an insightful article in the New Yorker magazine, June 1, 2009, page 36, written by Dr. Atul Gwande, entitled "The Cost Conundrum, What a Texas town can teach us about health care". Read this article!

"Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems."


Sunday, May 31, 2009

So Who Opposses Health Care Refrom These Days?

The news has recently contained several stories which note that many prior opponents of health care reform are now "working together" in common purpose to help bring needed change. At the same time, we are now starting to see anti-reform television advertisements that warn against "any form of government-run health care". The most widely available ads come from an organization that is calling itself "Conservatives for Patients' Rights ". If you believe in Santa and the Tooth Fairy, you might also think that a group of citizens spontaneously got together to educate the the reat of us, but the reality turns out to be far different! Conservatives for Patient's Rights is bankrolled and founded by a guy with a past named Rick Scott, best known for heading a company that paid the the largest health care fraud settlement in US history. Scott was a healthcare executive who grew Columbia Hospital Corp. from two El Paso hospitals in 1988 into the nation's largest investor-owned hospital chain and the world's largest healthcare company.

Columbia later merged with HCA, and Scott was forced out in 1997. Subsequently, a government investigation into HCA resulted in HCA paying $1.7 billion dollars in civil and criminal charges to settle the largest health care fraud settlement in US history, but Scott was not charged individually. He now owns a controlling interest in Discovery Health, and is the Chair of a chain of an urgent care center chain in Florida known as Solantic Corp.

As you watch the adds bankrolled by Scott and his Conservatives for Patient's Rights, you will notice broad statements that really have nothing to say about what is being proposed now for the US. Instead, he strives to create fear of change and rails against the "nanny state" "taking choice out of health care" and other vague notions, while quoting folks from Canada or the UK about problems they perceive in their countries' systems. You would never know to watch these ads that the proposals by the current administration adhere to the 4 pillars of reform that Mr. Scott advocates, which include choice, competition, accountability and responsibility . He forgot to mention equity, effectiveness, affordability and universality, however.

Take care as you watch these ads! Ask who paid for them, where they come from and what the sponsors have to gain by blocking meaningful reform. As President G.W. Bush once tried to say, "Fool me once, shame on you, fool me twice, shame on me!"

Monday, May 25, 2009

A Practical Approach to Health Insurance reform

When it comes to change on a national level, new ideas and needed reform proposals often come from the states. Maybe that will now happen with health care insurance reform.

On May 18, the Whatcom County Medical Society hosted a presentation by Washington State Insurance Commissioner Mike Kreidler, who accepted our invitation to speak to us about his innovative and practical plan for health insurance reform in Washington State, known as the Guaranteed Health Benefit Plan. As insurance commissioner, Kreidler has developed a wealth of knowledge, that includes experience running a health insurance company when KPS Health Plans were put into receivership. He has clearly put his experience to good use in the design of this plan.

Commissioner Kreidler’s Guaranteed Health Benefit Plan
would provide health care coverage for all Washington residents up to age 65, by virtue of residency in the state for one year, while it also preserves the individual's freedom of choice to pick the plan they want. Keidler described how it would work:
  • All residents get catastrophic coverage for health care costs exceeding $10,000 a year.
  • Limited preventive care is covered, which includes an annual checkup, immunizations and age-appropriate cancer screenings.
  • Funding comes from a payroll tax, shared by the worker and employer.
  • Consumers and employers can choose additional coverage for other care from any insurance plan serving the state, and costs will be much less, since the roulette wheel of catastrophic cost has been removed.
  • All insurance "customer service" – both catastrophic and routine, is provided by the private insurers.
  • For expenses in excess of $10,000, the insurance company pays at their contracted rates, and deals with the state for the payment to them
  • Individuals with no coverage of any kind are at leas covered for some preventive care, and all "catastrphic" care that exceeds $10,0000.
Commissioner Kreidler's approach is refreshing and very interesting. He builds on the structure we have now, while the plan causes minimal disruption to the existing system, extends coverage to all without mandates, and yet still respects choice in the system. It is a way to get moving on this important issue now. As he noted in his talk, all advanced countries have migrated to their own health care systems by building conservatively on the unique features of their pre-existing systems, and it is unlikely that we will have reform as a "big bang" event.

After his talk, Commissioner Kreidler left to fly to Washington, DC for talks with key legislators there. As the health care debate continues, I think that his is a welcome voice for common sense. and a practical choice to help people quickly!

You can get details about the plan by clicking here.

Wednesday, May 13, 2009

PM Bellingham Discussion on KGMI

I had a very stimulating conversation about health care and our need for reform on the PM Bellingham radio program, hosted on KGMI radio by Jacqueline Cartier and Ken Mann. They asked great questions, and gave refreshing insight from a younger person's perspective

Monday, April 6, 2009

Healthcare US Cost-to-Value Ratio Punishes Business

Each year, the CEOs of major US companies gather for the Business Roundtable, where they discuss serious issues affecting business. So what are they talking about during the worst economic crisis in generations? Health care! And their consensus is that our "dismal state of health care" affects our global competitiveness and the national economy. Their conclusion is based on the cost-to-value ratio that compares the dollar amount spent on health care in the US with the value received for that care. When comparing the dollar amount spent to the health of the citizenry, the roundtable findings show:
  • $2.4 trillion a year is spent on health care in the US
  • On a per-capita basis, that’s $1,928 per person for 2006
  • $1,928 per capita is 250% more than any other nation spends
  • On a cost-to-value basis, the US is 23 points behind its five top economic competitors (Canada, France, Germany, Japan, and the United Kingdom)
  • The governments of these five nations play a bigger role in their healthcare systems than the US does, although each nation operates on a different healthcare system
  • The US is 46 points behind its closest emerging competitors (Brazil, China, and India).
I may sound like a broken record, but our health care problems are not just about cost. We are definitely not getting value received!

Thursday, March 19, 2009

What does the Nation Think about Health Care Reform?

In December, the Presidential Transition Team invited Americans to host and participate in health care community discussions, and the employees and staff of Family Care Network were a part of that process. The idea was to for small, local gatherings to discuss health care, identify what's broken, suggest ideas to fix it and submit responses to the Transition Team for analysis of the nations feedback.

On March 5, Health and Human Services issued a special report of the community discussion outcomes. Over 9,000 Americans in 50 states and Washington, DC signed up to host a forum and 3,276 group reports were submitted to the Transition Teams special website (

The report shows that America’s concerns and views are very similar to the discussion that we had here at Family Care Network. Concerns focused on access to health insurance, rising premiums and high drug costs, and the “broken” health system, with poor access to primary care, and lack of affordability. Also of concern was being “under insurable,” medical mistakes and the system not being “for them.” Of the groups reporting cost of health care concerns, 28% focused on health insurance premiums and another 28% focused on the overall cost of the system.

The solutions suggested by the reporting groups highlighted the need for a system that is fair (36%), patient centered and choice oriented (19%), simple and efficient (17%), and comprehensive (15%). Fairness was a very common theme, and our current "system" was perceived to be quite "unfair". Some respondent groups said that health care should be considered a basic right, not a privilege and many felt the system should insure all Americans.

The analysis of responses found there were no significant differences in opinion based on rural or city location, region of the country, average income or employment status. The only exception noted was that those who represented the health care field expressed more concerns with provider shortages, the lack of a “system,” inadequate research, payment rates, medical malpractice, inefficiency of the system, and inadequate treatment of mental health.

If you are interested in reviewing the detailed report visit:

Thursday, February 12, 2009

The need has never been greater

My grandfather was a physician in general practice at the beginning of the last century, before the Flexner Report revolutionized medical training and brought medical education into the scientific age. His office was in the bottom of the family home. My grandmother would open the door, folks would come in, and the agenda was whatever was on the mind of the person who came. There was no phone interuption (there were no phones!), record keeping was easy (20 years on one 3 by 5 card), and most modern therapies had not yet been invented.

Today, many physicians in primary care continue to practice in the same basic style as my grandfather. They wait in their office to see what comes, and are only paid for this visit "piece work". It is as if the telephone was never invented, much less the Internet! They do not manage their patient panel in such a way as to improve their overall care, because they do not have the tools to know how the group is doing, and indeed, they may not even have thought about it.

Recently, Dr. Kevin Grumbach, professor and chair of the Department of Family and Community Medicine at the University of California, San Francisco, has renewed the call for a thorough "Revitalization of Primary Care". He correctly notes that the traditional model of primary care has not been very well supported by payers, purchasers or government agencies, and that people are turning away from it. In a recent article, he is quoted as saying, "This model of 19th-century practice -- of the doctor in the office and patients coming in -- is not going to work in the 21st century. We have come to the proverbial fork in the road." He identifies physician payment reform as one of the first steps we must take in revitalizing primary care, to provide the personal medical home. This is the work that we have been engaged in at Family Care Network.

Dr. Grumbach notes that the worsening shortage of primary care physicians is fueling "medical homelessness," which leaves patients without adequate access to primary care services and patient-centered medical homes. This is particularly tragic, since the ratio of primary care doctors to the population is the only statistic that has ever been shown to correlate with both improved health care quality and decreased cost of care. We must change now. The need has never been greater.

Wednesday, January 7, 2009

Flight of the Doctors

Jason Hwang has noted the recent, dreary evidence that primary care doctors are disappearing from the scene, and he correctly writes about the need "to encourage business models that reduce paperwork and red tape, while rewarding lifelong wellness care – the core tenet of primary care medicine."

I have written a comment on his blog, however, since I believe that he misses the importance of having independent primary care as a needed protection for patients.

Read more here: Flight of the Doctors by Jason Hwang