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!

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.

Surprise! People favor passage of health reform

A telephone survey of 1,005 adults was conducted by the Gallup organization on March 22, the day after Congress enacted health reform legislation. The margin error is 4 percentage points. The results show that "More Americans call Congress' passage of a healthcare reform bill "a good thing" (49%) than call it "a bad thing" (40%). Reaction is predictably partisan, with independents evenly divided.

In my opinion, when folks really get to understand how this bill will interrupt our endless cycle of cost increase and non coverage, that support will continue to increase!

Gallup concludes, "Passage of healthcare reform was a clear political victory for President Obama and his allies in Congress. While it also pleases most of his Democratic base nationwide, it is met with greater ambivalence among independents and with considerable antipathy among Republicans. Whether these groups' views on the issue harden or soften in the coming months could be crucial to how healthcare reform factors into this year's midterm elections. Given that initial public reaction to Sunday's vote is more positive than recent public opinion about passing a healthcare reform bill, it appears some softening has already occurred."

We can do this

The US Center for Medicare and Medicaid Services has just reported that U.S. health spending reached $2.5 trillion in 2009, and that health care's share of the economy grew 1.1 percentage points to 17.3 percent. This is the largest one-year increase in health care spending since the federal government began keeping track in 1960. Where I work, our insurance asked for a 35% rate increase to maintain our employee coverage for one more year. The same thing happened to my wife's family business this year. This experience has been repeated all over the country.

These findings underscore the fact that we are all experiencing an unprecedented "Tax" on the cost of our health care, except instead of coming from the government, it is being imposed by the insurance industry, who simply pass along their cost of paying for our dysfunctional system, while they also charge us for lobbying our Congressional representatives to stop needed reform. This is sick.

It is time to become outraged! The need for comprehensive health care reform to rein in unsustainable spending growth has never been more clear. The increasing burden on American families, businesses, and our state and local governments cannot be sustained.

What can we do now? Is there anything that might attract bipartisan support? Assuming that the minority party is willing to also work on this, I think that implementing a few modest steps now would help tremendously:

• Require that all be covered, with subsidy for the poor, and real penalties for those who opt out.
• Eliminate pre-existing conditions and have true community rating.
• Establish an online health plan marketplace in each state where plans can compete on benefits, service and price. Allow national plans to compete, but do not eliminate local plans.
• Monitor quality results by plan, and publish the results for all to consider when purchasing.
• Allow everyone to have an income tax deduction for their plan costs (not just employer plans) up to a certain annual cost.
• Enact reasonable tort reform legislation that actually directs most of the money to those who are injured.
• Require payment reform for care delivery, that incentivises provision of primary care, and encourages doctors and hospitals to provide the best care (not the most expensive), and are aware of and held accountable for their quality of care results.

We can do this, but only if our law makers work together and stop playing gotcha like middle school students. Actually, I apologize to the middle school students. They would do a better job.

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.

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.

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!"