Will the Lobbyists Make Meaningful Health Care Reform Impossible? A Response

In a post originally published on The Health Care Blog  and reprinted on Bob Laszewski’s Health Care Policy and Marketplace Review, health care analyst Brian Klepper asks: “Is Meaningful Health Care (Or Any Other Kind Of) Reform Possible?”

His answer: “I’d be surprised. Delighted! But surprised.”

I decided to answer him.

Klepper believes that the lobbyists are just too strong. Always incisive, he pulls no punches: “In a policy-making environment that is so clearly and openly influenced by money,” it’s just not likely that “Congress will be able to achieve health care reforms that are in the public interest.”

I disagree. I believe economic pressures are pushing us toward a political turning point. (If you want to understand what is happening in history or in politics, follow the money.) The Bush administration has been thoroughly discredited. Americans are ready for change. Healthcare reform will not happen tomorrow; it will require a bare-knuckled political fight. But it will happen, and this is why: Although lobbyists are powerful, so are voters. And they realize that we are approaching a flashpoint.

You’ll find the rest of the post here.

To comment, come back here.

Creepy Crawling Things in the OR: Medicare Bill Could Lead to Tougher Hospital Inspections

Reel back to 1965, the year Medicare and Medicaid legislation was passed. That year Congress gave the “Joint Commission,” a professional accreditation organization established in 1951, the unique authority to inspect hospitals and determine whether they meet the patient health and safety standards required to treat Medicare patients.

And who do you suppose pays the Joint Commission?

The hospitals that are being inspected. “Today, the Joint Commission collects $113 million in annual revenue, mainly from the fees it charges hospitals for telling them whether they comply with federal regulations,” observes Lisa Venn, J.D. M.A., writing on Advocate Alliance. 

Venn, who is the Manager of Compliance at a large teaching hospital, explains that “Deeming authority means that if Joint Commission gives its seal of approval to a hospital, CMS is satisfied that the hospital is following federal regulations. In other words, hospitals enrolling in the accreditation program only have to please one master. And that master is really nice, accrediting 99% of all hospitals it surveys.”

Health Care in Singapore: What's the Secret?

It’s always worth exploring how health care works in other countries, if for no other reason than that models in other countries give us the chance to see how some of the approaches discussed by American reformers might pan out. What do the experiences of Germany and Netherlands tell us about the possibility of a better mixed public-private system in the United States? How is China’s health care system a cautionary tale of market forces gone wild? The answer to these questions can add to—or detract from—the appeal of certain health care strategies in the U.S.

It’s hard to imagine a country that could provide a more valuable example than Singapore. The Southeast Asian city-state is widely regarded as a health care superstar, especially when compared to the United States. Life expectancy at birth in the U.S. is 78 years; in Singapore, it’s 82 years. The Singaporean infant mortality rate is a mere 2.3 deaths per 1,000 live births, versus 6.4 in the U.S. As some have noted, these trends persist despite the fact that the U.S. has far more caregivers: 2.6 physicians per 1,000 people, compared with 1.4 physicians in Singapore. The United States has 9.4 nurses per 1,000 people; Singapore, just 4.2. Last—but certainly not least—is the issue of spending: the U.S. spends almost 16 percent of its GDP on health care, while Singapore spends a mere 3.7 percent. 

For reformers eager to cite examples proving that their health care ideals are a formula for success, Singapore offers a powerful case study. Its population is healthy, its system isn’t overloaded by medical professionals, and health care spending doesn’t gobble up a huge chunk of its economy. 

So how does Singapore do it?

Finding the Money to Provide Home Care to the Elderly

Did you know that Japan has found an ingenious way to “create” money that can be used to care for the elderly?  Bernard Lietaer, author of Access to Human Wealth: Money beyond Greed and Scarcity (Access Books, 2003) describes the system in this interview with Ravi Dykema, publisher and editor of Nexus, a leading Holistic journal.

Lietaer begins with the basics, by explaining what money is: “I define money, or currency, as an agreement within a community to use something as a medium of exchange. It's therefore not a thing, it's only an agreement – like a marriage, like a business deal...And most of the time, it's done unconsciously. Nobody's polled about whether you want to use dollars. We're living in this money world like fish in water, taking it completely for granted.”

Lietaer, who co-designed and implemented the convergence mechanism to the single European currency system (the Euro), and served as president of the Electronic Payment System in his native Belgium, doesn’t take currencies for granted. He knows that a dollar is simply a piece of paper (which is no longer backed by gold).  It has value because we have agreed that it has value.

Medical Marijuana in Focus

In the July 28th issue of The New Yorker you’ll find an entertaining story by David Samuels that explores the economy of pot in California, where medical marijuana has been legal since 1996. Focusing on the supply and distribution chains that help to get pot in the hands of patients, Samuels weaves a colorful yarn, but one that focuses heavily—and somewhat derisively—on the personalities involved. Given the author’s emphasis on the stereotypical stonerdom surrounding legalization, the casual reader may come away thinking that medical marijuana is just another hippie cause, a 60s-style cultural crusade rather than a question of health care. But that’s not the case. 

Aging Hippies

Samuels’ account of the medical marijuana industry boasts quite a cast. There’s “Captain Blue,” a middle-aged grower with “black and greasy hair” and ill-fitting tee-shirts that “expose his round belly.” He sells weed to dispensaries that supply medicinal marijuana. Then there’s “Lily,” who transports ganja “from Northern California to Blue’s apartment” in the trunk of her car, and a woman named “Cindy 99” who runs a dispensary and who looks like an “adolescent boy’s fantasy of his best friend’s hot older sister.” Finally let’s not forget “Dr. Dean,” the free-wheeling M.D. who regularly prescribes marijuana thanks to a watershed night at his friends’ where he was introduced to marijuana via spiked lollipops and brownies. “It was like Amsterdam,” he dreamily tells Samuels.

If these sound like the characters from a teen stoner movie, that's certainly the way that they're represented by Samuels. With such an emphasis on the weed enthusiasts, it’s perhaps unsurprising that the author’s big conclusion about medical marijuana is that it’s just another way to keep the pseudo-subversive indulgences of the 1960s alive. “The legalization of medical marijuana has allowed for the illusion that farming pot can provide opportunities for travel and cool art projects and personal growth,” says Samuels. He then concludes that for aging hippies, “growing ganja lets you feel that you’re still living on the edge,” particularly if you’re a washed-up, wannabe political radical.   

The Century Foundation Medicare Reform Working Group

I am delighted to announce that The Century Foundation has created a working group to look at Medicare Reform.  I’ll be directing it. We’re going to do the work online, communicating with each other on a closed list-serve. In this way, we’ll be able to get a lot done without wasting time traveling to meetings. In the end, we’ll issue a report, and then we’ll get together and host a conference with keynote speakers and panels. (See our Press Release below for more information). 

We’ll be looking at many of the issues I have been discussing on this blog: how physicians are paid; the secretive panel, dominated by specialists, that sets fees; the need to reward providers for quality, not volume; over-paying for Medicare Advantage; overpaying for drugs; unwarranted regional variations in how much Medicare spends in different parts of the country; the need to squeeze the hazardous waste out of the system; the need for a comparative effectiveness institute that is truly insulated from Congress and lobbyists; the need to co-ordinate care; and the need for health IT.

Getting Health Care Polling Right

In my recent post on the issue of quality in health care, I spoke a little about how public opinion can be a poor guide when it comes to understanding the full scope of our health care problems. I noted that, according to Gallup polls, 85 percent of Americans report being satisfied with the quality of care they receive—despite the fact that patients get, on average, just 55 percent of the care that experts recommend for most major medical conditions. The lesson here is clear: if you really want to improve health care in the U.S., you need to look beyond superficial preferences and into the nitty-gritty of how health care is delivered in our system.

This holds true for the issue that Americans care about the most when it comes to health care: making their own care more affordable. But it’s not the public that’s at fault here; when it comes to questions of cost and affordability, people just aren't being asked the right questions. 

Consider the Gallup poll mentioned above, which asked how people felt about the cost and quality of health care. 45 percent of those polled said they were dissatisfied with our health care system’s performance in terms of quality; just 15 percent said the same of their personal experience. In contrast, a whopping 80 percent of respondents said they were dissatisfied with the system’s performance in terms of cost, and 40 percent said the same of their personal experience. Simple enough, right?

Why Congress Should Make Medicare Reform a Demonstration Project for Health Care Reform

Thanks the unbridled rise in healthcare prices, Medicare is going broke. As I mentioned in a recent post, four years ago the Medicare trust fund that pays for hospital stays started to run out of money.  In 2004 the fund began paying out more than it takes in through payroll taxes.

Since then, the balance in the fund, combined with interest income on that balance, has kept the fund solvent. But in just 11 years, it will be exhausted,” the Medicare Payment Commission reported in its March. “Revenues from payroll taxes collected in that year will cover only 79 percent of projected benefit expenditures.” And each year after 2019, the shortfall will grow larger.

Make no mistake: this is not an example of an inefficient government program spending hand-over-fist without caring whether it is getting a bang for the taxpayer’s buck.  As I discussed in that earlier post, health care prices have been climbing—without a concomitant improvement in patient outcomes or patient satisfaction—in the private sector as well.

Medicare Reform Could Pave the Way for National Reform

Before trying to roll out national health insurance, the next administration needs to address the structural problems that undermine the laissez-faire chaos that we euphemistically refer to as our health care “system.” Otherwise, we run the risk of winding up with a larger version of the dysfunctional, unsustainable system that we have today. Ideally, the administration should make Medicare reform a demonstration project for high quality, affordable universal coverage.

Let me be clear: Medicare reform does not preclude national health reform. To the contrary, by starting with Medicare, and showing what can be done, reformers enhance their chances of winning the larger war.

Speaking of Quality...

The ever-insightful Commonwealth Fund has just released its 2008 National Scorecard on Health System Performance, and reports that “the U.S. health system continues to fall far short of what is attainable, especially given the resources invested. Across 37 core indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with U.S. and international performance benchmarks.” According to Commonwealth’s metrics, overall performance has not improved since 2006.

As we mentioned recently, measuring performance in health care is a tough proposition, so it's worth discussing Commonwealth's rating system. The Scorecard looks at five components of what we might call "high-performance health care": healthy lives (preventable mortality & disability), quality (whether care is effective, coordinated, safe, and timely), access, efficiency (waste, appropriateness of care, administrative costs), and equity (disparities of care).

Doctors Dropping Medicare Patients

Over at the” Blog That Ate Manhattan “a NYC physician discusses “Doctors Dropping Medicare: TheDomino Effect” ( http://theblogthatatemanhattan.blogspot.com/)

“When the docs in my area began dropping Medicare, their patients had no where to go but to the docs like me who still participate in the plan.

“And so, over the past year or so, I began seeing more and more new older patients in my practice. The shift in my practice demographic was almost palpable as these new Medicare patients began filling my appointment book months in advance for routine annual visits. Add in a few retiring docs, and the influx of older women became too much to ignore.

“On the day I saw seven new Medicare patients, all coming from the practices that had stopped taking Medicare, I knew that I had to do something.

The Quality Question

It’s safe to say that Americans realize our health care system is in trouble. In polls, people cite paying for health care costs as one of their three most serious economic problems and consistently rank it as a top national priority behind the general economy, gas prices, and Iraq.  Earlier this month a Harris Interactive Survey found that a full one-third of Americans want to rebuild their health care system from scratch, a greater proportion than any European country. Finally, it seems that the American people have disabused themselves of the notion that the U.S. has the best health care in the world.

Or have they? While people may agree that too many Americans are uninsured and that health care costs too much, they still tend to think that the quality of care people receive—regardless how many people actually get it --is top-notch. This is a misconception that goes more or less unaddressed in the mainstream health care debate. That’s a sad omission: if we don’t talk about quality as a separate variable—and understand the reality of our system’s poor performance—we’re going to miss out on a big piece of the health care puzzle.

In May, the New England Journal of Medicine (NEJM) printed a graphical representation of two Gallup polls from November 2006 and 2007. The poll results show a deep “split between public dissatisfaction with the overall system's performance and patients' satisfaction with personal health care. (See below).

More on the Hospital Building Boom

Over at  Our Own System, Drew reports:

“The last month has brought news of plans for new hospitals including this one, this one, this one, this one, this one, and this one.  There are more to be sure.

“Aging hospitals, demographic shifts, increasing use of technology, and the evolution of patient care have spawned the need for new buildings.

“Another story of new hospital construction is particularly intriguing: 'An expansion at the University of Iowa Hospitals and Clinics will result in an increase in patient costs, but officials said they don’t yet know how much.'"

The Managed Care Roller Coaster

This post was written by Niko Karvounis and Maggie Mahar

At a health care forum held last year in Las Vegas, then-presidential candidate Hillary Clinton declared that she was intent on "taking money away from people who make out really well right now” in order to fund health care reform. When asked exactly which fat cats she was referring to, Clinton responded: “well, let’s start with the insurance companies.”

Clinton’s sentiment—that private insurers are making out like bandits while our health care system crumbles—is part of the received wisdom these days, especially amongst progressives who believe that for-profit health insurance doesn’t add much value to our health care system. But the reality is that in recent years, private insurers haven’t been doing so well financially.

Consider United Health Care (UHC), the nation’s biggest private insurer. Joe Paduda of Managed Care Matters reports that UHC will be cutting 4,000 jobs as part of a restructuring plan that includes eliminating Uniprise, one of its major brands. Since last fall, UHC stock has plummeted from $53 to $22 a share. WellPoint, another huge private insurer, has watched its stock drop from $82 a share in 2007 to $49 a share in June.

As Robert Laszewski wrote on the Health Care Policy and Marketplace Review in April,  “Wall Street finally seems to be figuring out that the health insurance business is, and has been for years, on a long walk off a short pier. What's sustainable about a business whose costs have continually exploded at 2-3 times the growth rate of the rest of the economy or the wage rate? Just where did Wall Street think this business was headed all those years the sector has been the darling of Wall Street?”

When a Friend is in the Hospital...

When friend or relative is in an accident and lands in the hospital…what do you do?

Your first impulse may be to buy flowers, visit the patient, call friends and let them know what has happened –so that they can visit too.

“Block that impulse!” says Lisa Lindell, a reader and author of 108 Days, the harrowing story of what happened to her husband, Curtis, after he suffered second and third degree burns over 35 percent of his body in a work-related accident.

Curtis would spend 108 days in the hospital, and Lisa details the predictable but completely unacceptable chaos that followed: a lack of communication among doctors, dangerous errors, Mean Nurses, infections, battles with hospital administrators—all at one of the finest burn units West of the Mississippi. Unfortunately, this won’t come as a surprise to many readers. In too many cases, hospitals don’t have enough nurses. Doctors who are called in to “consult” don’t consult with each other. The lack of electronic medical records leads to mistakes.

The Trouble with Medicare Advantage

Everyone understands why Congress was so reluctant to cut physicians’ fees. Reimbursements for primary care physicians are very low—so low that 30 percent of Medicare recipients who are looking for a new medical home can’t find one. Cut fees, and fewer doctors will take Medicare patients. The AMA, seniors and the AARP are all up-in-arms. Few politicians like to disappoint this trio.

But why are so many Congressmen willing to cut Medicare Advantage? After all, one out of five seniors is in the program: Won’t they be upset?

The truth is that, as many seniors have discovered, Medicare Advantage fee-for-service (the plan Congress has now voted to phase out by 2011) is not turning out to be an advantage for them.

Here is what David Fillman, an International Vice President of the American Federation of State, County and Municipal Employees (AFSCME), which represents some 1.4 million workers, had to say about MA’s fee-for-service insurance when he testified before Congress in January:

“Insurance companies have targeted our employers for the hard sell, including offers to pass through some of the federal subsidies to state and local governments.” 

Fillman rightly calls the subsidies a “windfall” –Medicare pays fee-for-service Medicare Advantage 17 percent more than Medicare would spend if it delivered the services itself.

Physicians 69; Insurers 30 – Ted Kennedy Shows Up For the Vote

When Ted Kennedy came onto the Senate floor, his colleagues cheered.

He was there to vote on the bill that would prevent a 10.6 percent cut to physicians who treat Medicare patients.

Just before Congress broke for the July 4 holiday, the bill missed the 60 votes needed to pass by just
one vote.

Today, Kennedy, who is battling a brain tumor, brought that vote to the Senate floor. “Aye,” the 76-year-old Kennedy said, grinning and making a thumbs-up gesture as he registered his vote.

Meanwhile, it appeared that Republican members of the Senate had been released to vote as they wished after it became apparent that the 60-vote threshold would be met. Pressure from seniors,  the AARP ,  and the AMA  had been mounting on members who voted against the bill June 26.

The Realities of Rural Medicine

Back in April, the Journal of Rural Medicine published an article that spelled out some of the ways in which rural medicine is a tough gig: Rural primary care physicians “tend to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients” than urban physicians. Worse still, “[a]fter adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practice in rural settings made $9,585 (5%) less than their urban counterparts."

So being a doctor in a rural region means less pay, longer hours (anywhere from 4 to 10 percent longer per week than urban doctors), and more Medicaid patients—none of which is particularly appealing to doctors.  (As I noted last year, reimbursement rates for Medicaid are abysmally low across the nation). At this point you may be thinking that this sounds like a warning to anyone even thinking about becoming a rural doctor.

Income

Not so fast. According to the Center for Studying Health System Change, the notion that the average rural doctor earns less is, well, what you might call an urban myth. While the Journal of Rural Medicine (JRM) looked only at primary care physicians and concluded that they make 5 percent less than their urban counterparts, CSHSC’s study of all physicians in rural practice tells a slightly different story.

Doctors Who Don’t Take Insurance: What Does It Mean for Patients?

More and more doctors are fed up with private insurers.  It’s not just a question of how stingy they are, but how difficult it is to get reimbursed. Paperwork, phone calls, insurers who play games by deliberately making reimbursement forms difficult to interpret…

Some physicians have just said “no” to insurers.

What does this mean for patients? Business models vary. Some doctors charge by the minute. I recently read about a physician who punches a time-clock when the appointment begins. She has calculated that her time is worth $2 per minute. Fifty-nine minutes = $118.  Will you be paying cash, or by charge today?
Somehow, I think the meter would make me nervous. I suspect I might begin talking very quickly. But this is only one model.

Rather than charging by the minute, some doctors charge fee-for-service. In those cases, many physicians mark up their fees well beyond what an insurer would pay. But, they point out, they also spend more time with their patients. No one feels rushed.

A story in a New Jersey newspaper describes how physicians in Northern Jersey have begun following in the footsteps of “elite Manhattan doctors and are withdrawing from all insurance plans.” The article compares fees with and without insurance.  On the right, the fees that insurers typically pay for these services; on the left, the fees that Jersey doctors who don’t take insurance charge:

Will Congress Cut Physicians’ Fees? Will Physicians Stop Taking Medicare Patients? Part 1

This week, conservatives and liberals will face off on a question that has divided the Senate—and united the House:

• Should Medicare slash the fees that it pays physicians, across the board, by more than 10 percent?
• Or should it try to save money by trimming the subsidy that it now shells out to private insurers who offer Medicare Advantage?  (Medicare pays private insurers 13 to 17 percent more than it would lay out if the government program cared for seniors directly. In theory, patients receive extra benefits that equal the bonus, though skeptics say insurers are simply pocketing extra profits. )

The battle began, in earnest, on Tuesday, June 24, when the House voted 355-59 to block a 10.6 percent pay cut for physicians which was scheduled to kick in on July 1.

Maybe Congress Should Hand the Job Over to Someone Else?

By Maggie Mahar

Today, I posted something on TPM Cafe that readers may find of interest.

I reprised some of what I said about events in the Senate last week, but then went on to consider what this means for Medicare reform. Perhaps reform requires a degree of “bi-partisan statesmanship” that a highly polarized Congress doesn’t have.

 What that in mind, HHS Secretary Mike Leavitt has made a startling proposal. I think it’s worth talking about it. If you’d like to comment, post on TPM, or come back here.