Monday, December 19, 2011

3 Principles that can bring us together for meaningful healthcare reform

The usual discussion about health care reform often resembles a food fight in middle school. Insults pass for argument, and facts get ignored or selectively presented only when they bolster one's opinion. What would it look like if we talked about what we all truly care about. Could we have a different discussion?

When I have discussed this issue with others in my community, there are 3 important principles that seem to ring true with most of us.

First, we need to invest  in "us" and the future we want to build. If we envision America as a successful land of opportunity, it means that we need a healthy workforce, able to compete and healthy students able to learn new skills. Our investment now in an equitable system that allows that to happen is simply a requirement needed to  make it so! This future will not happen by accident, and our failure to act now will doom our next generation to a future much different than we would like for them.

Secondly, we must end waste! It makes no sense to spend money on treatments that do not heal, or on complicated paper work that drives up costs. Fraud must be eliminated. Research on how to improve care must be supported, and the public should see the benefits!

Finally,  we need to end cost shifting, and share the burden fairly. Medical pricing today makes no sense. The cash paying person is charged the most. Hospitals overcharge for some things to pay for what is not covered. Some people get a tax break on insurance and some do not. A healthy society needs every one to be covered, and the cost must be affordable for all, or our society will remain broken and care will remain out of reach for many.

Friday, November 25, 2011

A Twitter Debate about Health Care reform

I had an interesting experience after  I used Twitter to note and lament the resignation of CMS Director Dr. Donald Berwick.  Craig Casey, an insurance agent in San Diego, sent several "tweets"disparaging Dr. Berwick and taking issue with"Obamacare". It is impossible for me to tweet an adequate reply to Craig, so I am using this column to reply point by point:
20+ million more on Medicaid equals Dr. shortage in / or rationing. you have elderly relatives Dave? 
This statement assumes that these folks were not receiving care before, and that suddenly they will now show up! The reality is, however, that they have been  seen for expensive and uncoordinated care in emergency rooms, and for complications due to no consistent primary care access. Obamacare will shift that to early primary care, and yes, we will need more folks to provide that care as things change.
Quoting his own comments about  , he committed political suicide, no assassination. Good bye Obamacareite. Actually, Dr. Berwick has been a tireless advocate of safety in health care as head of the Institute for Health Care Improvement, and he has always focused on the patient and how we need to work together to achieve better outcomes of care. This work takes study and organization, which has caused him to step on a few toes in the insurance industry and elsewhere. This has lead to pressure by republicans in Congress to make his confirmation impossible. He should be proud of who his enemies are. Organized medicine has supported him completely.
The cost curve was bent upwards, health  rates have jumped 20% since  was passed UNaffordable care act. This is just not true. Insurance rates have been going up at an astronomical rate for years. The Employer Health Benefits Survey by the Kaiser Family Foundation, which specializes in health care issues, found that health insurance premiums have jumped by 9 percent in 2011. Drew Altman, president and CEO of Kaiser, said that the premium increase was not because of Obamacare but that the Obamacare law accounted for 1 to 2 percentage points. He noted, “It reflects the costs of covering young adults up to 26 years of age under their parents’ policies" and also "the costs of providing prevention benefits without cost-sharing". We can actually expect cost savings later from these measures!
Not when their reimbursement rates are being cut by the false promises of coverage via . This makes no sense to me. There is a problem at present due to the fact that Medicare rates are due to decrease 27%, because of the flawed update formula from years past, but that has nothing to do with Obamacare.
Since you And Berwick brought it up, MedPAC, IPAB, & CER.  equals . disprove it then. This is nutty talk. The reality is that we ration care now, and always have, by ability to pay. Even people with insurance are now often having trouble affording care. If we don't start paying for health care based on quality instead of volume, and work together to organize and provide services that we all need for a healthy and productive society, more of us will be priced out of needed care ever year. That is not an outcome that we can afford.

Wednesday, November 23, 2011

Dr. Donald Berwick Resigns as Head of CMS

Donald Berwick, MD, a tireless advocate for patient safety in health care, has decided to resign his post as administrator of the Centers for Medicare and Medicaid Services (CMS), effective December 2. I am very sorry to see him go.

Dr. Berwick will have served only 17 months in the post. President Obama nominated Dr. Berwick, who was head of the Institute for Healthcare Improvement, for the CMS post in April 2010, a move that was hailed by diverse groups such as the American College of Physicians, the American Academy of Family Physicians, AARP, Walmart, and Consumers Union. Inspite ofthis broad based support, President Obama found that GOP opponents were blocking his Senate confirmation, as part of their all out strategy to stop health care reform. This caused the president to install Dr. Berwick as CMS administrator through a "pocket" appointment while the Senate was in recess, a special appointment that is set to expire by law at the end of 2011. Dr. Berwick was renominated in January 2011, but he still faced implacable opposition from Senate Republicans. His resignation, therefore, comes as no surprise.

According to news reports,  Dr. Berwick told the staff of the Department of Health and Human Services in an email, that he had "bittersweet emotions", and that although their work was challenging and incomplete, that "we are now well on our way to achieving a whole new level of security and quality for healthcare in America."

Amen. I hope so. Thank you, Dr. Berwick, for your leadership.

Monday, October 3, 2011

How to not save money while providing healthcare!

As of October 1st, the State of Washington has decided to "save money" on Medicaid (DSHS) medical care payments, by allowing maximum of three “non-emergency” visits to emergency departments each year.   They have drawn up a list of more than 700 diagnoses as “non-emergent” that include such surprising symptoms as chest pain, abdominal pain, miscarriage and breathing problems, and the decision affects all Medicaid patients, including children. 

Now all of us want to save money on rising health care costs, and if some is wasted in the emergency department, it makes good sense to try and reduce the waste, but this plan is ridiculous! People who go to the emergency department often do so because they have no regular physician or other alternative and they do not know where else to go. The "savings" the state thinks they will get will actually be a cost to the hospital who is not paid, and that will simply drive up costs for the rest of us. Limiting access to people in pain, having trouble breathing or having a miscarriage, without providing an alternative, is dangerous, unethical and wrong.

The Washington State state chapter of the American College of Emergency Physicians (WA-ACEP) has filed suit to void this action by our state Health Care Authority. Their action follows an unsatisfactory effort to work with the Health Care Authority before filing suit. 

Any effort to save money in medical care must also address patient safety, effectiveness, timeliness, efficiency, equity and the needs of the patient. This action by the State of Washington fails on all levels! 

Wednesday, August 31, 2011

We should be ashamed. We should be angry.

What kind of a country do we want to be?
For some time now, we have been learning about the steady decline in the welfare of children in the United States.  20% of children now live in poverty, schools are often failing them, health care has been difficult to access, immunizations are down, families are stressed,  and now we are informed in an extensive new study that the newborn death rate in the United States is now higher than in 40 other countries including Malaysia, Cuba and Poland. Our previous ranking was 29.

The great tragedy here is that many of these deaths can be prevented, with improved access to appropriate medical care, leadership for effective public health education, prenatal care and parental education and support.

Access to basic health care for all needs to begin first with our children. And it is the responsibility of all of us to step in, when parents are unable to. Yes, this is a moral issue, but also in our general self interest. The well being of today's children determines our future. 

Our society is pursuing a self destructive course by failing to provide all of our children with access to good health, education and a nurturing environment to grow up in, while at the same time we indebt them by failing to pay our bills. We should be ashamed. We should be angry. This is why we need health care for all in this country. This is not the rich against the poor. All of us in these United States of America must compete against the world. There is no valid reason why our children should be handicapped in their start in life compared to those in Malaysia, Cuba and Poland. There is no  good way to spin this.

WE'RE NUMBER 41! WE'RE NUMBER 41! Does that sound right to you? And we pay more than anywhere else.

These are the countries where a baby has a better chance of living in the first critical months of life:

San Marino
Czech Republic
New Zealand
Brunei Darussalam
Republic of Korea
United Kingdom

Friday, June 10, 2011

Bending the Cost Curve

In the continuing debate about the budget crisis and health care reform many partisans continue to miss the fact that the process of healthcare and how we pay for needs to change, if we are going to affect the actual cost of care. For example, the State of Massachusetts has now officially endorsed a complete move away from fee-for-service and towards an ACO-like delivery system and financial reform. Blue Cross Blue Shield is the dominant payer in that State and has developed the model in the link to pay ACO-like groups of providers.

This is complicated stuff that is not susceptible to opinionated sound bites, and that is why the talking heads and politicians do not often address this issue, but it is critical to understand! If you are interested, you can check out 1 year of research on this model’s effect on cost and quality here:

Blue Cross Blue Shield Massachusetts Report Click Here

The results are very promising! This is how we "bend the cost curve" and this is an example of the needed change that I have been talking about!

Monday, March 14, 2011

The Character Assasination of Dr. Don Berwick

Dr Don Berwick, one of the most highly qualified administrators ever nominated for public office, is about to be sacrificed on the altar of politics.  Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee, recently told reporters  that he has discussed Berwick's nomination with Republican senators and they plan to oppose Berwick under any circumstances. “Republicans won,” he said about the nomination.

Trouble is, I don't remember hearing about any fight.

Tom Curry, Executive Director and CEO of the Washington State Medical Association wrote in his March 14th Monday Memo to physician members that:

This is one of those instances where it would be better to fight and lose (while defending one’s view of the underlying reform legislation) than “duck and cover”.

I agree. This deserves to be a fight - a big fight - a loud fight. Dr Berwick is a world leader in understanding the problems of quality and inefficiency in US healthcare. It is an area of study and learning that he has dedicated his life to. His nomination is supported by all of organized medicine. Why? Because physicians know the quality of his work and the seriousness of our problems. The barrier to his confirmation is, interests that profit from our current mess are going all out to scare people and paint Don Berwick as a radical who wants to ration their health care. Consider the website This site is a project of The Heartland Institute, who according to sourcewatch is "a frequent ally of, and funded by, the tobacco industry" who "now refuses to publicly disclose who its corporate and foundation funders are". They are also known to have been funded in the past by the tobacco, oil and gas industry as well as the infamous Koch Brothers.

Do we want shadowy, secretly funded pressure groups paid for by big business to make our decisions for us, before debate occurs, or do we want a full discussion in the light of day? This is disgusting. Our legislators need to hear from us now.

Thursday, March 3, 2011

Healthcare and YOU

Sorry to say, but when it comes to understanding health care reform, our media have done a woeful job of keeping us informed and the general public remains very confused and unenlightened. For example, recent studies demonstrate that many Americans who believe they understand how the law works are actually thoroughly misinformed, and some are not even aware it is still in effect.A poll released by the Kaiser Family Foundation at the end of February found that about 20 percent of people wrongly believe that the law ended when Republicans in the House of Representatives voted to repeal it earlier this year, and 26 percent replied that they didn’t know if it was still the law or not! Well, it is.

What is a person to do if they would like to get a cogent, accurate understanding of the new law, without the partisan bias and media spin? Fortunately, there are now some good choices! A new site, called HealthCare and  avoids the heated politics behind the legislation and focuses instead on what the plan means for consumers. People who log on to the site can slect their state, age group, and circumstances to find a personal and customized explanation of the law’s provisions, with a timeline indications when portions of the law will take effect.The site has been developed by a coalition of groups t hat includes the American Academy of Family Physicians (AAFP), the AARP,  the American Medical Association, the American Nurses Association; the Catholic Health Association; the National Community Pharmacists Association; the American College of Physicians; and the American Cancer Society Cancer Action Network. Check it out!

 Want to find out what actual coverage options are available to you right now? Remember

Tuesday, February 22, 2011

The Best Care Anywhere

I recently had an interesting encounter with a long time friend and colleague who left his private practice of family medicine and started work for the Veterans Health Administration in one of their new community primary care centers. "How's it going", I asked. "Are you happy in your new position?" I believe that his answer to me is something that everyone needs to hear.

My friend explained that the uncompensated hours he used to spend in his private practice dealing with administrative issues, multiple insurance requests, and conflicting drug formularies are now a thing of the past. "Unlike my life in private practice, my time is now completely devoted to the care of my patients, and collaboration within the practice on how to make our care better. I have scheduled time throughout the day to catch up on needed paper work and administrative duties, and we also have planned collaboration sessions with other VA health care professionals to learn and plan our team work for patient care".

The VA, once maligned in previous generations, has been quietly at work, transforming itself into what many now believe is the the highest-quality healthcare provider in the United States. They have done this by emphasizing access to primary care, creating health care teams that learn how to coordinate their care, and paying attention to the scientific evidence of what does and does not work for patient benefit. As a result, our United States Veterans Health Administration has become the only fully functioning, evidence-based healthcare system in the entire country.

Unfortunately the transformative changes in the VA are impossible to duplicate in our current private system, because of the way our current system is set up. As a doctor who works on healthcare improvement issues everyday in the real world, I have learned that the biggest barriers I face are insurance companies and the lack of planning and coordination among those who work in healthcare.

So, what are the lessons for us who struggle outside of the VA system as we plan for healthcare reform? For me, the answer seems clear:

Personal medical home - use this full service , primary care model as the template to deliver and organize our care
Payment reform - value the doctor's time and reward quality instead of volume
Use information technology - in a systematic and intelligent way to track care, identify outcomes and interact with our patients
Plan intelligently - so that needed access to care is available
Allow doctors time - for the planning and care coordination that is so necessary to improve their care and so undervalued today.

A great book to learn more about the change in the United States Veterans Health Administration and how it compares to our overall health care system is Best Care Anywhere: Why VA Health Care is Better Than Yours, by Phillip Longman.

Sunday, January 2, 2011

How to Rate the New Health Care Changes

The Affordable Care Act contains a series of provisions that are phasing in, as scheduled, until the final period of complete implementation in 2014. Now, with the advent of 2011, several provisions take effect which start to change things for all of us. I give each change a "thumbs up" or "thumbs down" rating below.

New rule for tax-free savings accounts. If you have an HSA, like I do, so called non-prescription "over-the-counter drugs" that are not actually prescribed by a doctor are no longer eligible to be paid from that account. This is the kind of rule that might look good to a bureaucrat, but to me it is ridiculous. People now will be calling for prescriptions for their Tylenol, resulting in wasted time and money by all of us. Instead of saving money, this will be a fiasco.  Thumbs down!

Health-insurance companies “medical loss ratio”. Plans will now be required to spend at least 80 to 85 percent of the premium for actual medical care and quality improvements for patients, instead of administrative costs. Those that fail to do so will be required to issue a rebate to their customers beginning in 2012. The US Department of Health and Human Services says on that this will protect up to 74.8 million insured Americans from unreasonable rate increases. Last year, in 2010, we saw large increases from insurance companies who were attempting to pad their revenue before this provision took place. Thumbs up!

Closing the Medicare drug coverage “doughnut hole.” Drug companies are now required to provide a 50 percent discount on brand-name prescription drugs to Medicare recipients who fall into the coverage gap in the Part D drug plans. Also, federal subsidies will be phased in for generic prescriptions in the Part D coverage gap. This gap will be progressively be closed over the next 10 years. It would be better to require competitive bidding by these companies, but this is a step in the right direction. Thumbs up!

Medicare bonus for Primary-care physicians and general surgeons. These doctors will receive a 10 percent bonus payment for treating Medicare patients, which should help to encourage better access, although it is not enough, in my opinion to make much of a difference. Thumbs up!

Preventive care for Medicare recipients. In a big change of philosophy, seniors will now be able to get free preventive services that include annual checkups and personalized prevention plans. No more waivers! Thumbs up!

Medicare Advantage changes. Medicare recipients are eligible each year to choose private insurance companies for their care, a system called Medicare Advantage. We have all seen the adds! In the past, these plans were eligible for payments that were higher than ordinary Medicare, and these costs were born by increased premiums for all Medicare beneficiaries. Now, Medicare Advantage payments will be tapered down over the next few years to eliminate this subsidy. The new law has already resulted in higher premiums for many Medicare Advantage plans, but it prohibits these plans  from raising cost-sharing requirements higher than what is required under traditional Medicare. Thumbs up!
• Center for Medicare and Medicaid Innovation.
This center is already up and running and has launched multiple initiatives to test new ways of delivering care to patients that reduce costs and maintain or improve quality. One idea is an Accountable Care Organization (ACO), which is a new entity in which health-care providers can work together to contract for and manage care. Work is already under way here in Whatcom County to try and build such a system! Thumbs up!

Community Based Care Transitions Program. One of the most expensive problems in health care, that also is a sign of poor quality is the readmission of discharged patients to the hospital right after they are sent home. This program seeks to improve care for seniors after they leave the hospital, by coordinating care and connecting patients back to services in their communities. Thumbs up!

Medicaid incentives for prevention of chronic disease. The plan includes grants for states to help begin support services for Medicaid (low-income) recipients to cope with chronic problems, such as tobacco use, weight control, and various health conditions. Thumbs up!

All in all, things are slowly moving in the right direction. More details here: