Healthcare is changing in Whatcom County – be a part of it

Free Community Forum - Help guide our new direction.
Friday, June 24, 2011,12 -6 PM,  Christ the King Community Church, 4173 Meridian, Bellingham, WA

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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 www.HealthCare.gov 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:  http://www.healthcare.gov/law/timeline/index.html 

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.

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.

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!

$ 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.

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:

• We are losing primary care providers, and very few new doctors are in the pipeline to replace them
• The way primary care doctors are paid is inadequate and dysfunctional, so that they are not paid for the work that patients truly need and want them to do.

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.

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."

AMEN.

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!