Senator Obama proposes "The Quality Cure"

Potential voters in November are starting to pay more attention to what the leading presidential candidates have to say about how to reform our health care system. In a new article from the New York Times magazine, David Cutler responds to the principles underlying Senator Barack Obama's proposals. Cutler basically says that the US should focus on improving the quality of care rather than on reducing our consumption of it. Rather than pay less, they want to pay more wisely, and encourage health-care providers to do more of what they should and less of what is wasteful by building proper incentives into the system. Chief among these ideas is to support the personal medical home, which we have been writing about in this blog, and to continue the role of our private health care insurers, but with oversight and regulation that promotes these aims. In my opinion, this is the right direction, and voters have a clear choice in November.

2008 Health System Scorecard Shows No Improvement

Alas! The Commonwealth Fund Commission on a High Performance Health System released its first health system scorecard two years ago, and found that the United States fell far short of benchmarks for access, quality, efficiency, and other key measures of health system performance. Now, two years have gone by, and the 2008 edition of the scorecard paints an even bleaker picture. Instead of organizing around change for improvement, supporting the ability of primary care to provide a personal medical home and holding insurance companies accountable to help improve care, congress has gone through their annual dithering about how much to lower doctor rates, insurance plans have continued to cherry pick low risk subscribers, and the number of primary care doctors has continued to dwindle. It is no surprise that we have gone from bad to worse! Our system is perfectly designed to get these results.

The United States scored an average of 65 out of a possible 100 across 37 indicators— below the overall score in the 2006 report, which was already abysmal! The U.S. health system is on the road to a train wreck. Of greatest concern, access to health care has significantly declined. As of 2007, more than 75 million adults—42 percent of all adults ages 19 to 64—were either uninsured during the year or poorly insured, up from 35 percent in 2003. At the same time, the U.S. did not keep pace with gains in health outcomes achieved by the leading countries. The U.S. now ranks last out of 19 countries on a measure of mortality amenable to medical care, falling from 15th as other countries raised the bar on performance. Up to 101,000 fewer people would die prematurely if the U.S. could achieve leading, benchmark country rates.

The U.S. spends twice per person what other major industrialized countries spend on health care, and our costs continue to rise faster than income, while our quality results continue to plummet. We will soon have $1 of every $5 of national income going toward health care. We should expect a better return on this investment. We should be outraged.

Who really pays for health care?

The best article I have ever seen to explain this complicated subject!

By Ezekiel J. Emanuel and Victor R. Fuchs
March 27, 2008
For The Chicago Tribune

Who really pays for health care in the United States?

Americans believe employers pay the bulk of workers' premiums, government pays for Medicare, Medicaid and the State Children's Health Insurance Program and individuals pay some premiums as well as deductibles and co-pays. This is wrong. Business, government and individuals do not share the financial responsibility for health coverage. Individuals bear the full cost of health care through lower wages and taxes.

Employers like to say—and often believe—that they pay for health care. They complain that the huge increases in health-care costs are coming out of their bottom lines—as if costs come out of profits. Union leaders also like to have their members think that health benefits are a bonus on top of wages and that the leadership is negotiating hard to get them the free benefit.

Employers sponsor health insurance for the majority of Americans, but that is not the same as employers bearing the cost for workers' health insurance. Wages and fringe benefits, such as health insurance, are simply components of overall worker compensation. When employers provide health insurance to workers, they may define the benefits, select the health plan to manage the benefits and collect the funds to pay the health plan, but they do not bear the ultimate cost. What is labeled as employers' contribution to the health-insurance premium is really paid for by employees through lower wages and take-home pay.

Looking at the facts

This cost-wage trade-off is usually well hidden from employers and workers, but many studies show that it is a painful reality for average Americans. For instance, over the last 30 years, health-insurance premiums have increased by 300 percent after adjustment for inflation. During that time, after-tax corporate profits per employee have increased 200 percent, while workers' average hourly earnings, adjusted for inflation, decreased by 4 percent. Rather than coming out of corporate profits, the increasing cost of health care has resulted in relatively flat wages for 30 years.

To illustrate, consider Wal-Mart Stores Inc. and Safeway Inc. Wal-Mart, a non-unionized retail giant, is notorious for skimpy health benefits. From 2004 through 2006, its after-tax profits averaged 1.9 percent of sales. Safeway, a highly unionized supermarket chain, offers generous health benefits that cost more than 2 percent of sales. But in 2004 through 2006, its after-tax profits averaged 1.8 percent of sales, virtually the same as Wal-Mart. The difference between Wal-Mart and Safeway in the provision of health benefits is not found in the companies' profits.

Another way to see this is to compare the change in workers' wages with the change in health-care costs. Why were the mid-1990s such good economic times for average Americans? Between 1994 and 1999, the growth in health-care costs was low and therefore wages went up. But from 1988 to 1991 and 2001 to 2004, health-care costs went up rapidly, sending wages down.

What about Medicare, Medicaid and SCHIP? The government's funds for health care don't come from governors, senators, representatives or the president. When government pays for increases in health-care costs, it taxes current citizens, borrows—asking future taxpayers to foot the bill—or reduces other state services that benefit citizens. Health-care costs are now the single largest state expenditure, exceeding even education. Recently, as costs for Medicaid and other government health-care programs have increased faster than tax receipts, states have resorted to cutting the funds for education, forcing the substantial recent rise in tuition and fees for state colleges. Middle-class families, falling victim to rising health-care costs, are finding it harder to pay for their children's education.

Time to get serious

So, what does the trade-off mean?

First, Americans need to forget about the myth of a free lunch. Workers are not getting something from employers while paying nothing. They are paying for their health insurance, including the premiums supposedly contributed by their employers.

Second, to help the struggling middle class, we need to get health-care costs under control. There is no way to have a sustained rise in middle-class incomes without restraining the growth in health-care expenditures. Similarly, if we want government to invest in better primary education and more affordable colleges we need to find a way to hold down the cost of health care. We are robbing our children to pay for medicine.

We need to rewrite the social contract in America. We need to get employers out of providing health insurance. It is one of the most inefficient ways to get people covered, and it impedes efforts to keep costs down.

Instead, we need to provide all Americans with a standard benefits package regardless of their income, employment status, health status or age. This will provide Americans invaluable peace of mind, defuse labor-management conflict and get people to focus on value and determining whether more health care is worth the added costs.

Keeping costs sane

How do we get health-care costs under control? We need to eliminate the overuse of medical tests and treatments. For instance, studies have shown that doctors perform more than twice as many Caesarean sections in Miami and Fresno, Calif., as in Minneapolis, even after taking into account the differences among patients—with no improvement in the health of mothers or babies. Similarly, many studies show that more hospitalizations, use of specialists and frequent tests do not lead to improved survival rates or quality of life—just much higher costs. Further we need to use cost-effective medical care when there are options. This is obvious for prescribing generic drugs rather than similar brand-name drugs, but it is also true for tests and treatments. Most important, patients with chronic conditions such as diabetes, heart failure and emphysema account for 70 percent of health-care costs. We need more coordinated care with fewer specialists involved to keep these patients taking their medications, adhering to their diets and other treatments, and staying out of hospitals where costs are high.

Achieving these changes will not be easy, but three policy changes will set the necessary foundation. First, an Institute for Technology and Outcomes Assessment is critical to collecting information comparing the effectiveness and costs of different medical interventions. That data will allow doctors to choose the most effective treatments. Second, we need a crash program to institute electronic medical records. Today, only 15 percent of doctors and 25 percent of hospitals have computerized records. The government has to provide financial incentives and mandate that within five years all doctors and hospitals have interoperable electronic medical records.

Finally, we need to change how we pay doctors and hospitals. Most doctors are paid fee-for-services, that is they get money for doing more tests and procedures and not for coordinating care and ensuring high quality medical care. Doctors need to be paid on the basis of performance and patient outcomes.

Controlling health-care costs is not easy, but for average Americans it is the only way to sustainably increase wages. And if we do it right, it will actually improve the quality of health care.

Dr. Ezekiel J. Emanuel is chair of the department of bioethics at The Clinical Center of the National Institutes of Health. Victor R. Fuchs is a professor of economics (emeritus) at Stanford University.

Senate Hearing Links Physician Payment Rates to Primary Care Shortage

Several witnesses testified before a Senate committee on Feb. 12th that our nation's health care system continues to undervalue primary care services, and that this is leading to a skewed physician payment structure that is rapidly creating a shortage of primary care physicians throughout the nation.

Amazingly, although he agrees with and understands the data, the governments spokesman on this issue reaches an illogical conclusion, however. "When I say primary care services are undervalued, that does not mean that just increasing the prices paid to primary care is the solution," said Bruce Steinwald, director of health care for the United States Government Accountability Office, or GAO, during testimony before the Senate Health Education, Labor and Pensions Committee. "As you are well aware, we face unsustainable trends in the Medicare program and in the health care system as a whole. And, just as payment incentives are misaligned in primary care, they are misaligned in specialty medicine as well."

Yes, that is all true, I guess, but retaining primary care physicians will involve paying them more!

Medicare operates under a fee-for-service system, which rewards doctors based on the volume of services they provide. Medicare is the prime example of "how the system undervalues primary care services," and this discourages medical school students from pursuing a career in the primary care field, and causesthose in practice to restrict who they will see and retire early. These payment disparities have been exacerbated by technological improvements that allow subspecialists to provide more procedure type services in a shorter period of time, which leads them to an increase in payments and income, making these specialities more attractive career options for medical school students. In contrast, primary care physicians rely primarily on face to face time during office visits for their income. This means their ony option to be "more efficient" is to reduce time with their patients, which leads to rushed care and compromised quality.

I agree with the director, when he said, "This undervaluing of primary care services appears to be counter productive given the vast literature describing the relationship between health care costs and quality".

Medical Home Accredidation Process Now in Place

The Patient Centered Medical Home is a medical practice that facilitates a partnership between individual patients, their personal physicians, and when appropriate, the patient’s family. Care is facilitated by information technology, health information exchange and other means to assure that patients get the indicated care at the time and in the way that they need and want it, in a culturally appropriate manner.

The concept of the personal Medical Home reflects input from the American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA).

Now the National Committee for Quality Assurance (NCQA) has released standards for patient-centered medical homes. This means that health care providers and purchasers now have a means to recognize these practices and assess the add value added to patient care.

At present, few physician offices in primary care specialties, would likely qualify for recognition as a patient-centered medical home under the new NCQA standards. In spite of this fact, however, there is ample evidence that the availability of primary care is crucial to quality health care outcome, and more efficient care. The irony is that primary care is rapidly disappearing from the health care scene, since it not not nurtured and properly paid for.

There is widespread agreement that primary care is in crisis. Medical students often do not choose to practice primary care medicine. Existing doctors are often overwhelmed and patients aren't satisfied. Insurers say they are disappointed with its cost and quality.

The Patient Centered Medical home provides a way to change the status quo by enabling physicians to provide comprehensive primary care through stronger partnerships with their patients. Those that choose to integrate elements of this new model into their practices now have a mechanism to prove this distinction to patients and insurers. In order for these enhanced services to be sustainable, however, this designation must be recognized and rewarded by payers.

I ask all insurers to quickly develop products that support this effort. The time is now. We do not need another set of expectations for primary care physicians that are unfunded.

Why does an organized approach to health care matter ?

In a recently reported study in the journal Health Affairs, supported by The Commonwealth Fund, researchers at the London School of Hygiene and Tropical Medicine determined that the United States ranked last among 19 industrialized countries on a measure of preventable deaths.

The study, "Measuring the Health of Nations: Updating an Earlier Analysis," compared rates of "amenable mortality" before age 75. This means death from causes that are preventable with timely and effective health care. Other nations improved dramatically between the two study periods, 1997-98 and 2002-03, while the U.S. improved only slightly on the measure. Previously, the U.S. had ranked 15th among the 19 countries.

This measure of preventable deaths is a valuable indicator of health system performance, because it measures what we care about most, namely, is our health care effective? The measures include causes such as appendicitis and hypertension, as well as illnesses that can be detected early with effective screenings, such as cervical or colon cancer.

The authors state that if the U.S. had achieved the average rate of the three top-performing countries, there would have been 101,000 fewer deaths annually by the end of the study period. The top performing countries were France, Japan, and Australia, all of which have various forms of organized, universal coverage for their populations.

How do people in different countries view their health care ? How do their opinions compare to those in the US?

As we debate how to achieve an improved health care system for the United States, the opponents of change often raise the specter of "socialized medicine", and invoke stories about the horrible care and service in other countries. What has been lacking in this discussion is, how do the residents of the United States and other countries actually feel themselves about their experiences within their respective health care systems?

A new seven-nation survey has just been released by The Commonwealth Fund. It shows that U.S. adults were the most likely to say they experienced medical errors, more likely to report they went without care because of the cost, and more likely to feel the health care system needs to be rebuilt completely. The results, are published in the journal Health Affairs.

The article, Higher-Performance Health Systems: Adults' Health Care Experiences in Seven Countries, 2007, also shows that U.S. adults have the highest out-of-pocket costs and the greatest difficulty paying for needed medical care.

The survey was conducted among 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. One-third of U.S. adults surveyed called for rebuilding the system, and this was the highest rate of any country surveyed. In addition to cost concerns, the experiences of U.S. patients indicated more fragmented and inefficient care in the U.S., including medical record and test delays.

Commonwealth Fund Senior Vice President Cathy Schoen, the lead author of the study, said "Patients in the U.S. are frustrated by high costs and a complicated health care system,".

The survey also examined the experiences of adults who have a "medical home", which was defined in this study as a regular source of care that is accessible and helps coordinate their care. Across all seven countries, only about half to 60 percent of the adults reported having such a relationship with a health care provider. In each of the countries in the survey, those adults who did have a medical home reported a significantly more positive care experience.

Food for thought as we discuss how to improve our system!

Is there a Health Plan proposal that stands out in the Presidential Race? I think so!

On October 23, 2007 , Democratic Presidential Candidate Sen. Joseph R. Biden Jr. of Delaware unveiled a health care plan that would provide health insurance for all children, provide more coverage options for adults, and focus on disease prevention and modernizing the nation's health care system.

Biden's plan would permit uninsured Americans to buy into an insurance program similar to the one that provides health care benefits to federal employees and members of Congress. People would pay on a sliding scale based on income. Biden's proposal would continue the Medicare program, and inaddition, allow people between the ages of 55 and 64 to buy into the Medicare program, with the federal government providing a subsidy to low-income individuals.

The State Children's Health Insurance Program (SCHIP) would be expanded to children in families with incomes of 300 percent of the federal poverty level or below. This equates to $61,950 for a family of four, and coverage to children in the family would be extended to at least age 21. Biden's plan also would have the federal government "reinsure" 75 percent of the cost of catastrophic health costs for cases exceeding $50,000 per individual, in order to help keep the cost of the commercial plans low.

Senator Biden has said that if he is elected, he would convene a meeting, within the first 90 days of his administration, with all players involved in health care, in hopes of making coverage both universal and affordable. "Getting this done will require the kind of experience and leadership that comes from years of success corralling bipartisan support for numerous issues," he said. "I have that experience and it will prove invaluable when I am president."

Here are some other important elements of Biden's plan:

• Eliminate co-payments for physicals, vaccinations, vision and hearing screenings, and preventative dental checkups for children of all income levels.
• Prohibit employers and insurers from collecting or using genetic discrimination when making decisions about hiring or providing health care coverage, including the cost of a policy.
• Invest at least $1 billion yearly to help hospitals, physicians, and other health care providers move to electronic health records systems.
• Add 100,000 new nurses to the workforce in the next five years and establish scholarship and loan repayment programs to encourage people to join the public health workforce.

After reviewing all of the plan proposals from the Democratic and Republican candidates for president that have so far been released, this plan seems like the best to me! It combines the strengths of our private insurance system with intelligent government subsidy for those who need it. It also encourages access to needed types of primary care in order to improve quality and decrease cost. It addresses a growing problem of older adults not yet able to join Medicare, ensures treatment for children, and covers the large group of younger adults who are ignored by most other proposals. Most importantly, this plan avoids the "false choice" between pouring more money into our dysfunctional current system, or going to a government take over of health care. It is an intelligent middle way, that includes important reforms along with intelligent funding.

One of my adult daughters has given money to the Biden campaign based on her support of this proposal, and I hope this plan receives a great deal of attention and debate!

Click here to read more from the Biden Campaign

There is One Politician Telling the Truth about Health Care

Although our political landscape is littered with candidates who are ducking the issue, or speaking in platitudes, there is one courageous politician who is telling the truth about the need for health care reform in the United States, and I heard him speak on June 11, 2007.

Physician and former Oregon Governor John Kitzhaber is the founder of The Archimedes Movement, which is committed to creating opportunities for meaningful engagement about health care reform. He gave the keynote address here in Bellingham, Washington, at a community forum sponsored by the Whatcom Alliance for Health Care Access, which works locally to help obtain access to needed health care in our community.

His message was that fundamental change is needed to fix America’s “broken” health-care system, and he made the case forcefully, and then outlined what needs to be done.

Kitzhaber is promoting legislation introduced in the Oregon legislature that would restructure his state’s health-care system to provide universal care. “The responsibility to fix the health-care system does not belong to someone on the other side of the country,” Kitzhaber said. “It belongs to us.”

Kitzhaber, who is a physician, focused on the broader problems in American health care, including the pending financial crisis that will peak after millions of retiring members of the baby boom generation will seek benefits.

He also spoke of the “coverage gap” in the current system — the estimated 50 million Americans who do not receive health benefits through work and don’t qualify for Medicare or Medicaid. These uninsured individuals typically do not receive preventive care and then often end up later in emergency rooms, which adds huge unnecessary costs to the system that are shifted to those who do pay for health care, Kitzhaber noted. At the same time, many of these folks are working individuals who are taxed to pay for the health care provided to others by the federal government, who are on Medicaid or Medicare, in spite of the fact that they themselves cannot afford their own care.

“It’s a huge hidden tax that adds enormous costs,” Kitzhaber said. “It makes no sense as a business model and it makes no sense as social policy.”

Kitzhaber said there needs to be a serious discussion on the national level about fixing the system, and that time is running out. SB 27 introduced in Salem is a way to get the issue on the national stage, so that congress must address it. He pointed to Oregon’s 1989 attempt to gain authority over how it administers federal health-care funds as an example of a state forcing a national discussion on the issue. Information about the current bill is available at WeCanDoBetter.org.

Although much of the talk focused on the finances of health care, I was pleased that Dr. Kitzhaber pointed out that we will not solve the problem if we do not reform how health care is delivered. We must emphasize the parts of health care that we already know confer the most benefit, such as primary care, education, health screening and chronic disease management, while empowering people to make choices that fit with their own values. Currently, our "system" favors paying for the expensive and the technological care which is often at the end of life, while trying to save money by limiting peoples access to the most valuable benefits. “It makes no sense as a business model and it makes no sense as social policy.”

"The ability to fix the U.S. healthcare system does not belong to someone else. It belongs to us. If we're not willing to do it for ourselves we can do it for our children and grandchildren."

AMEN

You can learn more and sign up to help at WeCanDoBetter.org.

A CHANGE IN THE FACE OF MEDICINE

This article was written by family physician David H. Hopper MD, from Princeton, WV, upon the occaision of his premature withdrawal from Family Medicine practice. It is an eloguent testimonial to something that is happening all over the United States. The article appeared in the Bluefield Daily Telegraph.

A CHANGE IN THE FACE OF MEDICINE

Change is always difficult, yet as it says in the Bible, Ecclesiastes 3:1 “There is an appointed time for everything. And there is a time for every event under heaven.” After almost 30 years of serving the people of Princeton and the surrounding region, change took place in the lives of many in this community with my closing of Total Life Family Practice.

This decision was not an easy one, for my partner and I have enjoyed many good years caring for our patients through this practice. However, despite the governor’s logo, we are no longer “open for business.” With this closure over a dozen jobs have been lost and many thousands have lost their family doctors.

The demands of the practice of medicine are continuing to grow. Managing piles of paperwork, dealing with drug formulary and insurance issues, meeting rising overhead with inadequate reimbursement from Medicare, Medicaid and insurance companies, paying high WV malpractice insurance premiums and handling numerous other issues make private practice increasingly difficult. These problems are nationwide, but seem to be even worse here in WV.

Over the years 8 physicians came and left the practice, all of whom moved out of state. Recruiting and retaining doctors became increasingly hard. It became progressively harder to take time off to follow other callings such as my medical mission trips to Sudan or other misfortunate places. Finally I made the extremely tough decision to close my practice.

My decision was an individual one and certainly does not apply to all primary care doctors, but it is one that seems to be increasingly common. The private practice of family medicine has become less and less appealing. The joy of long term patient care relationships, the fulfillment of knowing that you had been able to manage multiple problems which would have required visits to numerous specialists, and the pleasure caring for the children of children you delivered is still available to the family doctor. However the stress of the system, which has persistently undervalued primary care services, has led shrinking percentage of new graduates to enter these fields.

In a recent issue of CA: A Cancer Journal for Clinicians, Dr. Richard Wender, President of the American Cancer Society said: “Adults with a primary care physician as their personal physician are 19% less likely to die prematurely than individuals who utilize a specialist as their personal physician.” And “Despite the striking evidence of the critical role played by primary care clinicians in the cancer fight, the future of primary care services in the United States is uncertain. Several high profile publications have questioned whether we are facing ‘the end of primary care.’ ”

Change will continue to take place in American healthcare, and it must. However it is sad to see the most personal aspect of the healthcare system die off. Be thankful for your family doctor, and support a system that allows whole person medicine to survive.