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.

Our working group is comprised of professionals who understand these problems in depth, and we’ll be recommending how to address these issues. Many of the participants are very politically savvy, and I am hopeful that the people in this working group will be able to draw broad support from other physicians and public health experts. I believe that Congress is ready to act on Medicare Reform.

I am also writing a white paper on Medicare Reform that the Foundation will be publishing, both online and in print, soon. When it’s done, you’ll find a link on this blog.

More information on the working group follows below.

Group Featuring Nationally  Prominent Physicians and Public Health Experts Will Explore Ways to Improve Care While Reducing Waste

July 22, 2008, New York, N.Y.—The Century Foundation (TCF) today announced the formation of a new Working Group on Medicare Reform. TCF, a nonpartisan public policy research foundation, has assembled a group of prominent physicians and health care experts from around the country to assess the current state of Medicare and make recommendations to reform and strengthen one of the nation’s most effective and enduring public programs.

The Working Group will be directed by Maggie Mahar, a fellow at the Century Foundation, author/editor of the highly respected blog Healthbeatblog.org (www.healthbeatblog.org),  and author of the widely acclaimed book Money Driven Medicine: The Real Reason  Health Care Cost So Much (Harper/Collins, 2006). She notes that a unique aspect of this panel is its composition. “This Working Group is composed primarily of physicians and public health officials, because they know better than anyone what’s wrong with the system and what’s needed to fix it,” she said. “They also were chosen for this panel because they each have a reputation for being professionals who put patients first.”

Working Group members include:

• Robert Berenson, MD
  Senior Fellow, The Urban Institute
  
  
• Lawrence Casalino, MD
  Associate Professor, University of Chicago
  
  
• Christine Cassel, MD
  President  and CEO of the American Board of Internal Medicine and ABIM Foundation

• Peter Eisenberg, MD
  Medical Director, California Cancer Care

• Ezekiel J. Emanuel, MD, PhD
  Chair, Department of Bioethics
  National Institutes of Health

• Elliott S. Fisher, MD, MPH
  Director, Center for Health Policy Research
  The Dartmouth Institute for Health Policy and Clinical Practice
  Professor of Medicine and Community and Family Medicine, Dartmouth Medical  School
  Senior Associate, VA Outcomes Group, White River  Junction

• Diane Meier, MD, FACP
  Director,  Hertzberg Palliative Care Institute
  Professor, Geriatrics and Internal Medicine, Mount Sinai School of Medicine, New York

• James E. Sabin, MD
  Director, Ethics Program, Harvard Pilgrim Health Care
  Clinical Professor, Departments of Ambulatory Care/Prevention and Psychiatry, Harvard Medical School
      
• Steve Shortell, PhD, MP
  Dean, School of Public Health,
  University   of California, Berkeley

• John E. Wennberg, MD, MPH
  Thomson Professor (Chair) in the Evaluative Clinical Sciences
  Founder and Director Emeritus, The Dartmouth Institute for Health Policy and Clinical Practice

• Robert M. Wachter, MD
  Professor and Chief of the Division  of Hospital Medicine
  University of California, San Francisco
  Chief of the Medical Service, UCSF Medical Center
  Editor, AHRQ WebM&M http://webmm.ahrq.gov)  and Patient Safety Network (http://psnet.ahrq.gov)

The Working Group will create a blueprint for reform based on recommendations in the Medicare Payment Advisory Commission’s 2007 and 2008 reports. They will analyze the recommendations with the goal of refining, explaining, revising, or adding to them in ways that would strengthen the system. Among the issues they will consider will be:

• revising Medicare’s physician fee schedule to pay more for primary care, palliative care, and co-ordination and management of chronic diseases;
• rethinking Medicare’s fee-for-service system to reward doctors for quality, not volume;
• creating an independent Comparative Effectiveness Institute that reviews head-to-head testing of drugs, devices, and procedures to ensure that they are effective; and
• identifying and rewarding hospitals that provide better outcomes and higher patient satisfaction at a lower cost while helping other hospitals meet benchmarks.

Mahar believes that strong successful Medicare reform could be used as a demonstration project for national health reform. “As I see it, the larger goal of Medicare reform would be to show that lower cost and higher quality do indeed go hand in hand,” she said.

The Working Group plans to report its recommendations later  this year.

For more information about the Working Group or for media  interviews with Maggie Mahar, contact Christy   Hicks at hicks@tcf.org or  212-452-7723. Read Mahar’s blog at www.healthbeatblog.org.  Learn more about Century Foundation work in Medicare and Healthcare reform at www.tcf.org or www.healthpolicywatch.org. 

Comments

[Geriatric Physical Therapy]

Very important that you work online.
Thanks!!

[maggiemahar]

Brita--

Thanks for your comment. I
think everyone in the working group realizes that we need more preventive care to keep people well.

As for altenative medicine, probably different people in the group have different opinions, but, speaking for myself, I believe that "alternative" therapies should undergo the same "comparative reserach" to figure which therapies work better for which patients.

I personally am a big fan of both acupuncture and physical therapy. Physical therapy seems to me greatly preferabl going through knee or hip surgery, though obviously some people need a replacement. Others, though, probably do what you have done. Congratulations!

[Brita]

Please make sure that preventative care be considered as important as emergency care.
And that alternative care recognized and used in other countries be part of accepted Medicare/Medicaid treatments. Medicare is more than willing to pay for hip joint replacements at $40,000 each plus rehab but not for deep tissue and other masssage treatments (paid for out of my own pockets and peanuts in terms of cost compared to surgery) that has kept me on my legs and walking. My doctors shake their heads at my X-rays which are awful but I'm still mobile!!

[Maggie Mahar]

jms--

Thanks for your comment.
You are right that patients are typically seen by more than one doctor--no one physician is responsible for the outcome. And in a small group practice, a few non-compliant patients can skew outcomes.

This is why MedPac does not believe in paying individual doctors (or small group practices) for outcomes.

Rather, it would pay huge
multi-specialty groups (that some call Accountable Care Groups) --like Kaiser, or the Cleveland Clinic, measuring their outcomes against benchmarks of high-quality, efficient care. (When a Medicare patient goes to Mayo Clinic, for example, it costs Medicare 50% less than when a very similar patient goes to UCLA Medical Center.

Mayo is more efficient and less wasteful. The patient sees fewer specialists, and spends fewer days in the hospital. Outcomes and patient satisfaction are higher.

But what about doctors who don't work at a place like Kaiser or the Cleveland Clinic?

MedPac recommends experimenting with "bundling" payment to doctors and hospital for a single episode of care.

This means Medicare would pay a lump sum to be divided up among the primary care physician who originally saw the patient, the specialist he referred him to, the hospitalist who co-ordinated his care in the hospital, the surgeon, the hospital itself, the doctor who took him through re-hab; the primary care doc who followed up after he was released.

Obviously, figuring out how to divvy up the money won't be easy. MedPac recognizes this. But "bundling" would encourage doctors and hospital to collaborate with each other--which means better care.

Doctors would not be forced to accept "bundling" payments from Medicare. If they preferred, they could be paid the traditional way--but they wouldn't get a bonus for outcomes.

Those that accept the bundling idea are eligible for the bonus. But they also risk being penalized for poor outcomes and being paid less than they would have under Medicare's traditional fee-for-service.

So if you accept bundling, you're gambling that you and your team (other docs and hospital) can provide better care. This means you'll be more eager to collaborate--and careful about which specialists and hospitals you send your patients to. . ..

Re nurse practitioners and lawsuits. When it comes to malpractice, the U.S. is no more litigious than the U.K. Canada and Australia.

They generally make better use of R.N.s There is no reason why we can't pass laws that protects the doctor from exposure to suit while also setting the bar pretty high for the type of nurse-practioner's he is allowed to hire to share in primary care. (in terms of experience, etc. We wouldn't want doctors hiring less well-educated or less experienced RNs at a lower price . . )

[jms]

Maggie,
1) Coming up with a reward system to reward doctors for quality outcomes among patients with chronic diseases will be particularly challenging. Some of these outcome metrics might be measured over a period of 10 years or so. Multiple physicians are typically involved in the care of a patient with a chronic disease. Care is delivered in a variety of facilities--physician's office, hospital, outpatient treatment facility. How does one assign a particular outcome to a particular physician at a particular point in time? What if a patient is non-compliant with the treatment regimen(s), and how can one assuredly ascertain compliance?
2) Regarding the greater use of nurse-practitioners in the delivery of health care--certainly this is practical and feasible, as long as patients are willing to accept this model. I wonder, though, if the supervising primary care physicians are concerned about liability. I would imagine that medical malpractice lawyers out there see this development as a growth opportunity for their practices. One missed breast lump, for example, could lead to a huge malpractice award against the supervising physician.

[maggiemahar]

Barry and C. Anne--

Thanks for your comments.

Barry--
End-of-life care is really not what drives our health care bill. It's chronic care that is so expensive--there are five or six chronic diseases that account for roughly 80% of health care spending: diabetes, congestive failure, depression are three of them. Off the top of my head, I can't remember the others.
But the point is that people can live with these diseases for many, many years. This is why they are so expensive. And if they are not properly managed, they can require extremely costly treatments and hospitalizations.
For instance, if diabetes is not controlled, the diabetic can wind up undergoing many amuptations--first toes, then a foot, then part of the leg, etc.
One major reason why health care spending is lower in other countries is that they have much better preventive care and primary care, and fewer specialists.
Preventive primary care is usually free (no co-pays) so their are no barriers to using it. (Here, even small co-pays lead women not to go for mammograms.)
They also make better use of nurse-practioners. In some Scandanavian countires, healthy children rarely see a pediatrician. After their born, a pediatrician checks them out, but after that children receive their regular care from a pedicatric nurse.

C. Anne--
Thanks for your interest in the working group and the recommendation.
We'll be reaching out to many people for advice, and I've put her name in my working group file. (Some members of the working group also have written about medical apartheid.)

[C. Ann]

I'd like to suggest the addition of Professor Nancy Krieger in the Dept. of Society, Human Development and Health of the Harvard School of Public Health to the Working Group on Medicare Reform. She has published extensively on race and racism in health care.

[C. Ann]

I'd like to suggest the addition of Professor Nancy Krieger in the Dept. of Society, Human Development and Health of the Harvard School of Public Health to the Working Group on Medicare Reform. She has published extensively on race and racism in health care.

[Barry Carol]

Maggie,

I agree with you about palliative care in end of life situations but I wonder about a couple of things. First, how much would it cost (range as opposed to specific dollar amount) for a typical patient if adequately compensated? Second, how is this issue typically dealt with in Canada, France, Germany, Scandinavia, Japan and Australia? My impression is that they have a very different consensus around what constitutes good, sound medical practice. I deliberately excluded the UK because I think that country has long since made a societal decision to spend less of their resources on healthcare than others. For example, suppose you are a mentally alert 80 something diagnosed with advanced bone or colon cancer. I’m told that doctors will often just tell the patient and the family that there is nothing that can be done other than providing comfort cancer. In other words, we’re not going to treat you. In the U.S., we would be more likely to try everything unless the patient and the family make it abundantly clear that they don’t want that.

I’m not trying to make a judgment as to which approach is better from a humane or an ethical standpoint. I would say, however, that if the U.S. consensus is to adopt a considerably more costly approach because that’s what the society wants, we should not be criticized for spending significantly more money on healthcare than other countries.

[maggiemahar]

Lisa, Jack and jms--

Thank you!

jms --
Palliative care teams (which include a doctor, nurse and, ideally, a psyhcologist all trained in palliative care) spend a great deal of time talking to both the patient and the patient's family.

Part of their job is to help the patient deal with his or her fear of death, and to lay out treatment options (palliative care doesn't mean that you're giving up)

But the palliative care team talks about the risks as well as the benefits of these treatments, clearly, and in a compassionate way.

Often the doctor who hopes that he might be able to save you with yet another round of chemo or another procedure is reluctant to talk about risks, side effects, and death. He hasn't been trained to talk about death. His training has always portrayed death as the great enemy to be overcome.

Palliative care specialists also are particularly helpful in counseling a family that wants to hold onto a loved one when the loved one is exhausted and has come to terms with the fact that he or she is dying.

[jms]

An excellent idea, and a very good group of thoughtful physicians. A few quick thoughts:
1) Any reduction in reimbursement to surgeons will be rejected by the surgeons themselves, and can't even be contemplated until legislation has been approved at the national level to protect surgeons & OB/GYNS from abusive malpractice lawyers and ill-equipped juries (the state of Indiana, by the way, seems to have a good solution vis-a-vis the malpractice problem);
2) Undoubtedly, hospice care can (should) be utilized to a greater degree--however it is often the patient and/or the patient's family that requests aggressive care which has even the slightest hint of extending life. Part of our health care financing crisis comes from unrestrained consumer demand in life-threatening situations. How does one come up with a legislative solution to that?

[Jack Lohman]

Maggie, I'll withhold accolades/criticisms until I see the results, but I strongly support and congratulate your effort to reach an unbiased solution to a very difficult problem.

[Lisa Lindell]

Maggie,
I have complete faith in what you're doing and we're all lucky to have you doing it, thank you.

[Maggie Mahar]

Barry--

Thanks for your comment.

You are right: everyone will have to give up something.

I invited these people for three reasons:

a) they are patient's advocates. All of them put patients first

b) they are outspoken reformers. Peter Eisenberg, the onoclogist (and until recently a member of the board of directors for the American Oncologists society) is happy to say that too many oncologists are making "a pile of money administering chemo that doesn't help the patient" (I'm paraphrasing slightly. I've quoted him more accurately in my book.)

Two people in the working group are authors of the Dartmouth reserach. They have made it clear that the less expensive, less agressive care that people receive in Iowa and Minnesota leads to better outcomes that the care we receive in Manhattan and New Jersey where patients see more doctors and undergo more procedures.

Your suggestion that everyone always protects their own interest group
doesn't hold here. These are people of great integrity. And they realize that waste hurts patients.

[Maggie Mahar]

Beverly--

I am offended by the notion that I didn't choose the members of the group.

I did. And no one looked over my shoulder or "edited" the list.

When I mentioned to an African-American women who works here with me that someone suggested that there should be an African-American woman in the group (preferably a surgeon) she just shook her head and laughed.

(Many African-Americans object to the notion that there should be a token African-American in every group as just another form of racism.)

She also asked: "Did he give you a name?"

Her point was this: there are, as we all know, relatively few African-American women in medicine.

Moreover, the black doctors I know all work with the poor and the uninsured. They don't tend to work with Medicare patients because Medicare patients are not uninsured and (at least until recently) don't have the same problems with access as Medicaid patients.

The problem, for Medicare patients is not usually undertreatment--it is overtreatment. That is what much of Medicare reform will be about--squeezing out the hazardous waste.

So I chose physicians who have written, in depth, about that issue while also experiencing it in their practice.

In addition, I chose physicians who are not "political" in the sense of advancing themselves or some particular interest group.

They have just one interest group--patients.

Finally, regarding race and racism, you end your post "Add at least one (alert) minority . . ."

[Maggie Mahar]

Barry--

Thanks for your comment.

You are right: everyone will have to give up something.

I invited these people for three reasons:

a) they are patient's advocates. All of them put patients first

b) they are outspoken reformers. Peter Eisenberg, the onoclogist (and until recently a member of the board of directors for the American Oncologists society) is happy to say that too many oncologists are making "a pile of money administering chemo that doesn't help the patient" (I'm paraphrasing slightly. I've quoted him more accurately in my book.)

Two people in the working group are authors of the Dartmouth reserach. They have made it clear that the less expensive, less agressive care that people receive in Iowa and Minnesota leads to better outcomes that the care we receive in Manhattan and New Jersey where patients see more doctors and undergo more procedures.

Your suggestion that everyone always protects their own interest group
doesn't hold here. These are people of great integrity. And they realize that waste hurts patients.

[DOC IN FAMILY]

Maggie,

The harshest word I will use in this note is “disappointed”.

The working group you are leading on Medicare reform at the Century Foundation is full of admirable specialists in their fields. These members are replete with thoughtful and creative innovations in health care delivery. As universally majority providers, however, their ability to visualize their mission in the context of a rapidly-spreading, culturally divided environment may be compromised, at best.

This group will do admirable work. I am struck, however, by the many thoughtful professionals who have not been included and who could aptly complement that work (thereby expanding the scope of discussion) by including the ‘cultural regard’ factor. This factor, when not discussed during reform, is often the main agenda item of the “additional meetings” which must be held to revise the conclusions that have been preliminarily finalized.

In reading the goals and objectives of the working group, one could predictably retort that there is absolutely no reason to interject any dimension of cultural regard into this particular mission. The ability to see why it is essential that it be included is the indicator of a leader who understands the essential parts of responsible strengthening and reformation. If this working group wants to complete serious, thoughtful work at the level of integrity and foresight with which I have become familiar in your writing, they must be able to incorporate the issues of those who are (as usual), left to react in protest after the conclusions are reached.

Consider this: on your working group you have an ethicist who could steer some of those thoughts your way…but not with the realities/actualities that must influence the directions of change. You have a member who is looking hard at the social determinants of health, however not addressing that issue through our emerging research of racism (not race) and its role in health care delivery. You have a specialist who is associated, (indirectly, through her writings), with a physician whose on-the-record statements about minority health inequities are disturbing, to say the least.

Maggie, you are too sharp not to place “voices from the well” on your working group. My theory? You did not choose the members of the group.

“I can’t include everyone and I think we have some very qualified people here”, I hear you say.

I agree. Now, the work of expanding and re-defining “qualified” must begin. In the present health care arena, “qualified” must include other professions and other races; in particular those who are subjected to confirmed health inequities in every level of every system, often based on the very subjects you are about to review! Believe it or not, just having palliative care specialists on your working group may mean that minorities will be the first to be placed under that level of care rather than in an environment of aggressive treatment. That must be warded against in the new guidelines! That, Maggie, is how base and how raw this is.

You should feel quite normal in the way your group members have been chosen. GOOGLE, MICROSOFT and others who are advising the health care administrations did exactly the same thing that the Century Foundation did, even with documentation that there is a major problem going on here that weighs 300 pounds and can be heard breathing at every meeting. The federal government says that 87,000 people annually who received health care in America would be alive today if they were white. Make that 500 pounds!

Here’s my suggestion. Add at least one (alert) minority and add a nurse to your group. Try to make your hard work pay off for all to whom our government has responsibility.

Good luck with your working group.

With hope for revisions,

Beverly

[Barry Carol]

Maggie,

I think it is abundantly clear that, in order to achieve substantive healthcare and health insurance reform, every interest group is going to have to give up something. That includes doctors and hospitals (and lawyers).

I think it’s great that you’ve assembled such a high quality team for your working group, but forgive me if I’m a little skeptical about their ability and willingness to tell their fellow doctors what they probably don’t want to hear. Will they be willing to embrace price and quality transparency? Will they be willing to implement and use electronic records, even if they’re heavily subsidized by taxpayers? Will they be willing to follow evidence based guidelines, at least most of the time? Will they be willing to adopt less aggressive practice patterns, especially at the end of life, if it means lower income for them and for hospitals? Will they be willing to combine into larger multi-specialty group practices in order to increase efficiency and effectiveness? After reading Paul Starr’s description in “The Social Transformation of American Medicine” of doctors’ decades long history of trying to stifle competition at every turn, I’m not optimistic. Their recent opposition to retail clinics and greater use of nurse practitioners is only the latest manifestation of that effort. I also note that after Lyndon Johnson won a landslide election victory in 1964, he had overwhelming Democratic majorities in both the House and the Senate during the 89th Congress. Specifically, Democrats had a 68-32 majority in the Senate (over two-thirds) and 295-140 in the House (also over two-thirds). Yet, in order to get Medicare through the legislative process, President Johnson and the Congress had to agree to pay doctors their usual and customary fees.

I’ve said many times that doctors’ decisions to admit patients to the hospital, order tests, prescribe drugs, refer to specialists, consult with patients and perform procedures themselves account for the bulk of healthcare costs. Insurance company administrative costs and even drug prices are relatively minor issues in this context. Comparative effectiveness research will be helpful, especially if it leads to a refusal to pay for new drugs, devices and procedures that are little or no better than what is already available. Bundled pricing for expensive surgical procedures will also be helpful. When I see doctors (especially the specialists) and hospitals admit that they have to take their share of hits to bend to medical cost growth curve and make reform work, then I’ll believe we’re getting somewhere. Doctors and hospitals are a big part of the problem and they need to be a significant part of the solution.

[Howard C. Berkowitz]

" Yes, MedPac is recommending that all physicians be required to make full disclosure if all financial connections--which speaks "too the referral problem."

Clearly, there are abuses in this area. I worry, however, that there is so much search for conflict that it interferes with care. The perception of conflict seems to differ.

Imaging is especially obvious. I have never seen an orthopedic practice that didn't have X-ray (I'm not saying MRI). It seems to be accepted that X-ray is often needed both for initial diagnosis, and looking inside a cast. Yet I still remember the time when I was in a group primary practice, broke my ankle just before a visit, but the insurer demanded I be sent to a different hospital-based imaging center. Driving with a broken ankle is not fun, but was the only practical way to get there.

Other kinds of imaging are appropriate to other specialties. Cardiologists and OB/GYNs clearly use them on many visits, although even in a large metropolitan area, I know ethical physicians who have equipment but know their limitations. For example, most OB/GYNs are perfectly competent to use ultrasound through the abdominal wall, but transvaginal ultrasonography not only requires special equipment, but a great deal of experience. While some ultrasound examinations can be done by technicians, I've doubt that's ever desirable when using an intrusive transducer--and no, I am not going to tell the story of one of my transesophageal echocardiograms, other than the physician must have trained under Frederico Fellini.

"At the very least, a patient has a right to know the doctor has an interest in the place he is referring the patient to."

We had a discussion recently about rural care. Common sense is not always used when an insurer, or anti-conflict zealot, demands a physician not self-refer, which means the nearest "conflict free" facility is hours away. That facility may well be for-profit.

"Sometimes these situations can generate greater co-ordination of care. But they are also
likely to encourage over-treatment. The situation has to be watched closely."

It's not just coordination of care, but sometimes the timely availability of diagnostic services. You are probably sensitive to it, but I hear too many sound bites about greedy doctors to be concerned that there is a real interference with quality.

Incidentally, I'd note that a number of imaging technologies are coming down in price. I know of ultrasound units that consist only of the probe and an electronic black box that connects to an ordinary PC. Modern X-ray tends to use digital imaging rather than film, doing away with the need for darkrooms, wet processing, silver recovery, etc. There are some serious discussions about having ultrasound, perhaps with telepresence, aboard selected paramedic ambulances. Defibrillators once were considered too expensive to have in the field. Sometimes, making a technology more, not less, available produces economies of scale.

[maggiemahar]

robert and jd
Thank you for your comments

Robert- No this isn't PR.

I --and everyone in the working group-- is commited to national health reform. But many share my view that Medicare
reform is more doable right now --in part because the financial crisis will force Congress to do something.

And some of the elements of Medicare reform (paying primary care physicians more, doing comparative effectiness research, finding ways to pay for quality, not volume, encouraing use of health IT) pave the way for national reform.

I think you are right; if young people understand that this is a major step toward national reform, they should be interested.

Also many people in their 30s--and even some in their 20s--have parents in their early sixties, and are worried about whether they are going to have good healthcare.

jd

I realize the lobbyists will be opposed to anything that cuts into the for-profit health care industry's revenue.
A corporation's goal is always growth: more sales, more profits.

But when it comes to healthcare, society's goal is to contain costs. We cannot afford healthcare that continues to grow 2% faster than GDP. Over time, fewer and fewer of us will be able to afford care.

For a number of years, the lobbyists have been shaping public policy.
(See, for example, the Medicare Modernization Act
that prohibits Medicare from negotiating for drug discounts and that proivdes a windfall to insurers who offer Medicare.)

But I think we are at a turning point. The public is fed up. The Bush administration has been discredited.

It's worth noting that McCain voted against the Medicare Modernization Act.

So whoever wins the White House, it is very likely that Congress will repeal the windfall bonus to the insurance industry (WAll Street expects this to happen) and that Congress will authorize Medicare to negotiate for discounts on drugs the way the VA does. (The VA pays 50 percent less for 10 of the 20 drugs most popular with Medicare beneficiaries.)

Why do I think Congress will stand up to the lobbyists?

The vote earlier this month showed Congress voting against the insurance industry. Many people thought it couldn't happen. The conservatives in the Senate were very surprised.

But first the House voted overwhelmingly against the insurers, and then the Senate followed the House's lead.

The lobbyists are powerful, yes, but so are voters. Politicians know that all of the campaign contributions in the world won't save them if the voters are against them.

And if voters suspect that legislators are putting corporate interests ahead of the interests of seniors, they will lose their seats.

So, earlier this month, when legislators saw seniors and the AARP lining up on one side, and the insurance industry's lobbyists on the otoher side, they knew who to be afraid of --the seniors.

And this is not exactly a reform-minded Congress. This fall, it's likely that more reformers will be elected, and fresh blood will help.

Make no mistake, this will be a bare-knuckled political fight. But the liberals in the Senate dug their heels in this month--and refused to allow amendements that would compromise the bill.

U.S. history is a history of pendulum swings. We saw the country swing to the right in 1980, with the election of Ronald Reagan.After 1980, corporate interests became more and more powerful.

Now, I think we've reached another inflection point; we're going to swing in the other direction. More and more people are calling for real reform.

[jd]

Maggie,

Congratulations for getting this underway and I wish you great success.

What I will be most interested to see is how well you are able to solve the problem of simultaneously coming up with a reform proposal that would generate a major improvement in the value provided by health care AND would be politically feasible.

From what I can tell, any reform with bite (say, cutting costs by at least 10% without greater cost sharing while making at least modest improvements in quality) will not be able to garner enough support from within the industry to be viable.

A reform could probably succeed if one of the major industry sectors opposes it (physician, hospital, pharma, insurance), but any deep reform will have to cut into the revenue and/or profit of all of them and dramatically change workflows and business models.

I hope that your final recommendations address how you think industry resistance can be overcome.

[robertdfeinman]

Your working group may be focusing on Medicare, but if you frame this as the first step in a longer process to reform all of US health care then I think you might involve younger people in online discussions.

The idea would be this is a model or "test case" for a more broad effort to follow. This isn't PR, I do think that is the ultimate aim, right?

[maggiemahar]

NG, Lori, Gillian, Selena

Thanks for your comments.

NG -- Yes, I also read the piece in Health Affairs.
We definitely will be looking at workforce issues.

The scarcity of primary care docs is a growing problem and this is why MedPac recommends raising their pay and paying doctors who provide "medical homes" (this could include speciaists who have many diabetic patients.)

Greater use of nurse-practioners will also be important. I suspect that RNs who are reluctant to work in some of our more c haotic hospitals would be willing to work full time in a primary care practice.

Clearly, we need to redistribute some of Medicare's dollars to attract the people we need to staff reformed Medicare (not to mention universal care).

Lori-
On transparency: MedPac
recommends looking at outcomes and cost and setting benchmarks for hospitals. (Mayo Clinic for instance has very good outcomes and patient satisfaction at a significantly lower cost than many hospitals--proving once again that higher quality and reduced spending go hand in hand.

For two years, Medicare would send confidential information to hospitals as to where they stoood vis a vis the benchmark.

After the first two years (giving the hopsitals a chance to put better systems in place) they would published the informatiion.

Eventually, if the hospitals remained outliers, Medicare would no longer pay them.

Gillian--
Welcome.
Yes, the Facebook idea is very interesting. But do you think younger people are really that interested in Medicare??

Selena--
Yes, MedPac is recommending that all physicians be required to make full disclosure if all financial connections--which speaks too the referral problem.

At the very least, a patient has a right to know the doctor has an interest in the place he is referring the patient to.

Sometimes these situations can generate greater co-ordination of care. But they are also
likely to encourage over-treatment. The situation has to be watched closely.

[maggiemahar]

NG, Lori, Gillian, Selena

Thanks for your comments.

NG -- Yes, I also read the piece in Health Affairs.
We definitely will be looking at workforce issues.

The scarcity of primary care docs is a growing problem and this is why MedPac recommends raising their pay and paying doctors who provide "medical homes" (this could include speciaists who have many diabetic patients.)

Greater use of nurse-practioners will also be important. I suspect that RNs who are reluctant to work in some of our more c haotic hospitals would be willing to work full time in a primary care practice.

Clearly, we need to redistribute some of Medicare's dollars to attract the people we need to staff reformed Medicare (not to mention universal care).

Lori-
On transparency: MedPac
recommends looking at outcomes and cost and setting benchmarks for hospitals. (Mayo Clinic for instance has very good outcomes and patient satisfaction at a significantly lower cost than many hospitals--proving once again that higher quality and reduced spending go hand in hand.

For two years, Medicare would send confidential information to hospitals as to where they stoood vis a vis the benchmark.

After the first two years (giving the hopsitals a chance to put better systems in place) they would published the informatiion.

Eventually, if the hospitals remained outliers, Medicare would no longer pay them.

Gillian--
Welcome.
Yes, the Facebook idea is very interesting. But do you think younger people are really that interested in Medicare??

Selena--
Yes, MedPac is recommending that all physicians be required to make full disclosure if all financial connections--which speaks too the referral problem.

At the very least, a patient has a right to know the doctor has an interest in the place he is referring the patient to.

Sometimes these situations can generate greater co-ordination of care. But they are also
likely to encourage over-treatment. The situation has to be watched closely.

[SelenaHorner]

James Glinn makes a reference to your blog, Maggie, over at an Evidence in Motion blog. http://blog.myphysicaltherapyspace.com/2008/07/medicare-reform.html

With some of the reports I have read, it amazes me how much money is spent by Medicare for care provided in referral for profit situations. Often the reports not only mention the dollar amounts and the high pecentage of growth of spending in this area, but also the questionable care provided in referral for profit situations. My interpretation of those reports is that referral for profit situations aren't in the best interest of Medicare and increase Medicare costs. If unneccessary imaging or services are provided due to a conflict of interest, the patient really isn't being put first. Is this an area the working group will address?