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 donberwick.com. 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.

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 You.org  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 HealthCare.gov

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.

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 

Act now to maintain access to your doctor if Medicare payment rates go down

For some time now, people covered by Medicare have been having an increasingly difficult time finding primary care physicians who will accept them into their practice. This has been a problem due to the fact that low Medicare rates of payment make it very difficult for primary care doctors to be financially successful. Now, there is a danger that this access problem might become a full fledged crisis around the nation.

On December 1, 2010  Medicare rates for physicians are scheduled to decrease by more than 23%, and then, on January 1, 2011, rates are scheduled to go down another 7%. This is not because of health care reform, but rather is due to Medicare's sustainable growth rate (SGR) formula, which automatically pays doctors less if the use of medical services paid for goes up, in order to "balance the budget". Congress has avoided fixing this problem, and now, with a likely Republican majority  in one or both houses of the new Congress pledging no new spending, it is very possible that nothing will be done to rectify the situation.

 Is there anything that you or a loved one on Medicare can do to maintain future primary care access if this happens? Fortunately, yes there is! Look into signing up with a Medicare Advantage plan that your doctor accepts which contracts directly with physicians to provide care for Medicare patients. These plans often work in creative ways with physicians to enhance primary care coverage, and save money by screening and treating early to reduce costs. In my medical group, Family Care Network, we contract with four MA plans, and we ask all new patients to sign up with one of those in order to become a patient with us. Open enrollment for choosing a new Medicare Advantage plan begins November 15, 2010. A good approach is to ask your doctor's office what plans they work with, and then visit an independent Medicare insurance agency to review your options and pick the plan that is right for you!

10 big health reform changes yet to come

Yesterday marked a major milestone in our progress to create a high-performing health care system for the United States. Provisions in the Affordable Care Act have now taken effect, such as the requirement for insurance plans to allow young adults to join or stay on their parents' plan until age 26, and a ban on insurance plans' practice of "rescinding" coverage after individuals get sick.

There are additional health care reforms are coming in the next months and years that I am looking forward to. These are designed to improve how our care is organized, delivered, and paid for. Here are 10 big changes yet to come:

1. Health Insurance Exchanges and New Market Rules
Health insurance exchanges will give us the ability to compare and choose among health plans, while setting the rules for fair competition.
2. New Nonprofit Plan Choices
Innovative, nonprofit cooperatives have transformed health care delivery into mission-driven, patient-centered, and value-enhancing systems that are accountable to patients and consumers.
3. Health Plans will be required to meet minimum medical loss ratios and requests for Insurance Premium Increases will be reviewed.

4. New changes to encourage primary Care and disease prevention
These include increased primary care payment rates under Medicare and Medicaid, preventive services without patient cost-sharing, and support of community and employer prevention and wellness programs. The act also increases funding for community health centers and the National Health Service Corps. These provisions start to focus our health system on primary care, encourages doctors o enter primary care specialties and get us ready for more fundamental payment reforms.
5. Stimulate Innovation
The Accountable Care Act establishes a Center for Medicare and Medicaid Innovation, which will allow us to test innovative payment methods for the personal medical home. Medicare reimbursement rates are decreased by 1 percent for hospitals that have high rates of readmission for certain conditions. Individual states will be allowed to test integrating Medicare and Medicaid-covered health services provided to the poor on Medicare.
6. Accountable Care Organizations
These are collections of health care providers that can formally assume responsibility for the cost and quality of health care given to a defined group of patients. Research has shown that ACOs have the potential to reduce growth in health care costs and improve patient outcomes by introducing incentives for efficient use of resources and encouraging greater coordination of care.
7. Independent Payment Advisory Board
This board has authority to identify areas of waste and opportunities for improving the quality of care for Medicare beneficiaries. The board’s recommendations will take effect in years when Medicare costs are projected to exceed predetermined rate-of-increase targets—unless Congress passes legislation to override those recommendations, in which case Congress would be responsible for achieving the same level of savings.
8. Quality Improvement and Public Reporting
The law requires public reporting of physician quality and patient experience through a "Physician Compare" Web site for Medicare beneficiaries. It also makes Medicare data available for pooling with data on provider performance from other payers—an important step toward creation of an all-payer provider performance database. (Privacy will be protected.) Reports by health plan will be available to the public.
9. Medicare Private Plan Competition
Plans must compete on value, quality and service, and will no longer receive extra funds.
10. A Tax on High-Premium Health Insurance Plans
The new law imposes a 40 percent excise tax on health plans with premiums in excess of $10,200 for individual policies and $27,500 for families, to take effect in 2018. This will be adjusted in case of unexpected increases in medical costs prior to 2018.

A Great Opportunity to Discuss Progress in Health Care

The origin of tour word for doctor comes from the Latin word doceō, which means "I teach". We have recently been living through an explosion in medical knowledge, and for this reason, the doctors of the Whatcom County Medical Society are proud to present an event every fall that seeks to communicate with our patients around these developments. The Mini-Medical School is presented by Medical Society members on current topics of interest or controversy in medicine.  Beyond physicians sharing information, these presentations offer an opportunity to talk with physicians about how they think about health and disease, how they analyze problems and how they apply science in their work. I hope that we have a great turnout. Here is this years schedule!

Wednesday, September 8 “Food Sensitivity: allergies, intolerances and strong convictions”

Dr. Kevin Dooms, Bellingham Asthma, Allergy and Immunology

Wednesday, September 15 “Health Care Reform: what’s in it for me?”

Dr. David Lynch, Family Care Network

Wednesday, September 22 “Whatcom CSI: fact and fiction of death investigation

Dr. Gary Goldfogel, Whatcom County Medical Examiner

Wednesday, September 29 “The Evidence is Clear: surgery is the most effective treatment for obesity and diabetes”

Dr. Walter Medlin, PeaceHealth Medical Group

Wednesday, October 6 “Cancer: the art and science of diagnosis and treatment”

Drs. Ian Thompson and William Hall, Northwest Radiation Oncology Associates

Wednesday, October 13 “Vaccine-preventable diseases and vaccines: how safe and how effective?”

Dr. Greg Stern, Whatcom County Health Department

All lectures are free to the public and will be held 7:00—8:30 p.m. at St. Luke’s Health Education Center, 3333 Squalicum Parkway, Bellingham, WA

Information: call (360) 676-7630 or email: wcms@hinet.org

The right man for the job has Bellingham and Whatcom County connections

The White House has announced that President Obama will bypass the nomination process of the United States Senate in order to make a recess appointment of Dr. Donald Berwick to be the head of the Centers for Medicare & Medicaid Services (CMS). This is due to the fact that the White House has been unable to even get a hearing scheduled by the Senate, much less go through the process.

I believe that this nomination is of great importance, and it signals that the administration is serious about moving forward on creative and needed health care reform. Dr. Berwick has been universally praised by a wide spectrum of health care leaders as the best man for this job. President Obama has chosen a strong advocate for a patient-centered health-care system to be in charge of much of health-care reform. This is a very good thing!

There are three aspects of health-care reform that must be considered simultaneously if we are to achieve real reform - cost, access and quality. Cost and access have both proven to be politically polarized topics. Quality, however, should be what unites us all, and that is the experience that Dr. Berwick brings to the table. Dr. Berwick has done more than anyone champion quality and his organization, the Institute for Healthcare Improvement (IHI), is famous among physicians for catalyzing health-care providers around how to improve their care and decrease error. This should not be an ideological issue. Unfortunately, the radical right has already pounced on this announcement, and referred to Berwick as a "radical". This is a tragedy. If Dr. Berwick is a radical, it is because he favors that health care reform must revolve around thechoices, preferences and desires of patients, and not insurance companies. That truly would be a radical change from what we have today. He elevates the needs of patients above insurance companies, government or medical providers.

It has been my privilege to work with Dr. Berwick right here in Bellingham and Whatcom County. The Pursuing Perfection project began in 2001, when Family Care Network and St. Joseph Hospital worked with other community partners to reorganize their work around the patients that we serve. We were one of13 locations in the US and Europe to focus on fundamental improvement in patient care throughout the health care system, and Dr. Berwick traveled to meet with us as a part of the involvement of IHI. He is the real deal.

If a man like Dr. Don Berwick cannot find a smooth confirmation because of political polarization, then no leaders can. That means that the best people will continue to ignore the call of public service, since an unimpeachable record of achievement will be less important than political ideology. What a shame. No, what a tragedy.

A Creative and Welcome Development

The State of Washington has just announced the creation of the Washington Health Program, which is a non-subsidized version of the Basic Health Program (BHP). Like the Basic Health Program, the new offering is administered by the Washington State Health Care Authority (HCA).

This is a creative and welcome development! Washington residents currently have few, if any, affordable options for health care coverage. Right now, there are more than 100,000 people on the BHP waiting list, who cannot enroll due to a lack of funding by the state. The Washington Health plan will provide folks with a more affordable option designed for basic, no frills medical care coverage. The new program provides essentially the same benefits as the BHP, but with no subsidy and no cost to the state. Enrollees pay the entire premium, plus a small amount for administrative costs.

The HCA is contracting with Community Health Plan (CHP) of Washington to provide the coverage. The plan lowers the purchase cost by including a cap on annual costs. Enrollees having the option of choosing a $75,000 or $100,000 expense cap in health care coverage per year. According to past experience, less than 2% of BHP enrollees accumulated $75,000 or more total cost in 2009.

Some details from the HCA:
· Premiums are to be as low as $100 per month.
· A 35 year-old could expect to pay between $125 and $183 depending on their location and the coverage options they select.
· Washington Health is available to any state resident who is not enrolled in the BHP, Medicaid, or eligible for Medicare.
· It is designed for low income people, but there are no income limitations. It is available statewide.
· Community Health Plan (CHP) is contracted mainly with federally qualified community clinics, and there are few private primary care physician in their network.
· Coverage is expected to begin July 1 and applications are being taken now through the Washington Health website at www.washingtonhealth.hca.wa.gov. Applications can also be requested toll-free at 1-800-660-9840.

The Dawn of a New Day - 5 BIG wins in the Health Care reform Act

1. Health insurance companies will not be able to discriminate against you because you have a pre-existing condition.

The problem has been that millions of adults and children have been denied insurance specifically because they have a medical condition. The Kaiser Family Foundation says that 21 percent of people who apply for health insurance on their own get turned down, or charged a higher price or offered a plan that does not cover their pre-existing condition. This will stop!

2. Young adults will be able to keep their parents' insurance until age 26.

The health care reform legislation requires insurance companies to allow dependent children to stay on their parents' insurance policies until age 26. The children can't have jobs that offer insurance, and they must be claimed as dependents on their parents' taxes.

Currently dependents get booted off Mom and Dad's health insurance much earlier than this, depending on the state they live in, sometimes as early as age 19. This will stop!

3. You will be eligible for a subsidy to buy insurance if you make less than $88,000 per year for a family of four.

Starting in 2014, the health care reform bill provides subsidies for people who don't get insurance from their employers and therefore have to buy it on their own. The amount of the subsidy will computed based on your income, whether you're single or have a family, your age, and where you live. For example:

• A 40-year old making $30,000 a year in a medium-cost area of the country will get an $850 subsidy toward buying a policy, which should cost about $3,500, according to a Kaiser Family Foundation subsidy calculator.

• A 40-year-old in the same city who has a family of four and is making $60,000 will get a $4,220 subsidy toward a policy that costs $9,435.

You can estimate your own subsidy by using this Kaiser subsidy calculator.

4. If your employer does not offer insurance, that might change!

Starting in 2014, if your company employs more than 50 people, it will be required to offer you a health plan that covers at least 60 percent of your overall health costs, or the company will be fined $750 per year per full-time worker. That fine could increase to $2,000 if the reconciliation act passes.

5. Health care reform has major benefits for senior citizens!

The AARP reports that health care legislation does important things for seniors:

• It gives people on Medicare new access to free preventive services such as screenings for cancer and diabetes.
  
• It will decrease and then, by 2020 it will close the "doughnut hole," Part-D drug payment gap where Medicare stops paying once a senior has spent more than $2,830 on prescription drugs and resumes when the individual's out-of-pocket spending has reached about $4,550.
• Spending for Medicare beneficiaries is budgeted to increase 2 percent each year.