President's Proposal- Intro to Reconciliation

I had hoped to get away from the whole health care reform discussion for a little while. Quite frankly, I was growing tired of it. But, we have one more “event” to get through before we know which direction health care may be heading. Even after this so-called “summit meeting” on Thursday, we still may not know. I’ll make another post anyway.

I have to admit, when this process started out over a year ago, I was skeptical but still optimistic that we could come to a bi-partisan solution to the cost crisis we’re facing in this industry. When HR 3200 was introduced I became leery. When the Town Halls hit I became frustrated. When the Christmas Eve vote occurred in the Senate I was ticked-off. Like most Americans, I’m simply tired of the politics, and tired of the “protecting the turf of the self-interests” mentality that exists in health care. I’m not nearly as optimistic of the final outcome today.

After reading and summarizing the 1000+ pages of HR 3200 last July, reading the 11 page “President’s Proposal” was a snap; almost too much of a snap.

For a president who gives himself low marks for not explaining health care reform better to the average citizen- he didn’t raise his grade with this. (You can grab it by clicking here). It took me awhile to figure out what it even said.

Here’s my understanding.

In a nutshell, the President’s Proposal is reconciling some of the numbers between the Senate and House bills, pushing some dates around to accommodate some existing agreements, and adding some of the fraud and abuse initiatives requested by the Republicans to come up with a “bi-partisan” document.

The President’s Proposal eliminates the “Nebraska Absolution” and expands Medicaid Funding to all states and tries to address the need to reform the Medicare payment approach which contributes to the escalating costs. And, to continue with its grandstanding against the insurance industry (which is legitimate to a point), his proposal creates another government agency (the Health Insurance Rate Authority) to deal with health insurance pricing (in response to Anthem California’s recent request for a 30%+ rate increase for individual policyholders).

As I was reading it I was wondering what all of this is going to cost and the size of the bureaucracy that would be required to pull it off. I’ve said all along that the perfect free-market does not work in health care because of the way we’ve evolved. The government has to play a role no matter what we do. I understand that. But, there needs to be a balance. This is just too much government- and too much expense.

As the White House said when it introduced this thing, this is just the “starting point” for the discussion on Thursday. But, I have no idea how any real debate is going to occur since none of the major issues of disagreement were addressed.

A Kaiser Foundation Poll completed a couple of weeks ago found 38% of Americans would be “happy or relieved” if Congress ended up doing nothing on health care reform. About 58% would be “disappointed or angry”.

I still believe too much good work from both sides was accomplished over the past year to walk away and do nothing. All of the proposals (Republican and Democrat/free-market and organized-market) have components that could be put together to make a dramatic impact on the trajectory we find ourselves on today. Unfortunately, the legislative make-up we have in place doesn’t see it that way.

I see “reconciliation” on the horizon. And, I’ll be one of the 58% disappointed or angry citizens if that happens- even it means something was accomplished.

Medicare Advantage- A Free Market Example?

A lot of the debate that has been raging about health care reform can be boiled down to a basic principle: how much of our health care system should be guided by the principles of a free-market; and how much should be guided by a more organized and controlled method? Some call the “organized and controlled” socialized medicine, I wouldn’t go that far.

The evolution of our Medicare Advantage program for seniors may provide some insight into which approach may work the best.

Trying to address and manage the costs of our Medicare program has been on the table for quite awhile. In 1997 the Medicare Choice program was put in place as a mechanism to wrap “managed care” into the benefits received by Medicare beneficiaries. This was largely funded by the government and used individual health plan contracts to deliver the health care services to the population. So, this was a combination of a free-market/government approach.

As funding for services from the government deteriorated over the next five years, nearly half of the Medicare Choice programs cancelled their contracts leaving over 1.5 Medicare beneficiaries scrambling to find replacement coverage. The free-market delivery combined and government funding combination wasn’t working very well.

In 2003, Medicare Choice was changed to Medicare Advantage and included increased funding from the federal government and a slightly different structure to deliver services to the Medicare population. These programs increased participation significantly as health plans and private market players jumped at the opportunity to grab some of this new revenue. These private market players did very well. But, it came with a cost.

Some organizations utilized aggressive marketing and compensation arrangements to take advantage of Medicare beneficiaries to gain enrollment. The free-market crossed the line. In 2008, new marketing and compensation rules were put in place to protect the individual consumer.

Today, there are over 2,300 Medicare Advantage plans available to Medicare beneficiaries. More than 10 million people (1 in 4 on Medicare) are enrolled in a Medicare Advantage Plan. On average, individuals are able to select from 30 different plans in addition to Medicare- and some have an option of over 70 plans.

These programs all offer different benefits, out-of-pocket limits, copayments, deductibles, and premium costs creating a monumental task for the individual consumer to figure out which program is best for them. And the costs of these programs continued to increase (opposite of what should happen in a free-market). In 2010, enrollees of the Medicare Advantage Prescription Drug Program will face, on average, a 32% increase in their premiums.

So, while a true free-market is the desire of our country, we have already proven a true free-market simply does not exist in health care. There are too many external factors at play. And while a variety of options may look nice, too many options only confuse the consumer and disrupt the operation of the market.

University of California-Berkley Nobel Prize winning economist Daniel McFadden puts it this way, “If consumers are up to this task, then their choices will ensure that the plans, and insurers, that succeed in the market are the ones that meet their needs. However, if many are confused or confounded, the market will not get the signals it needs to work satisfactorily.”

Too many consumers are confused and confounded today. The market is getting the wrong signals.

Click Here to grab Kaiser Foundation’s Write-up on the Medicare Advantage benefits structure for 2010

So- Which Way Do We Want It?

The February 9, 2010 Wall Street Journal reported that United HealthGroup recently began sending doctors individualized assessments for their treatment of breast, lung, and colorectal cancer patients. The reports seemed to indicate that while breast cancer patients received care that met with most professional protocols, patients with lung and colorectal cancer did not.

Treating cancer patients is one of the largest cost-drivers in our health care system today. Employers will confirm that one or two cancer patient in their entire population can result in significant increases to the health insurance rates for everyone. That’s the problem with the system we have today.

The United HealthGroup initiative confirmed what many of us had already surmised- a lot of the prescriptions and processes used in cancer treatment may or may not be of benefit to the patient, and they cost a lot of money.

Health plans and health systems are spending a lot of time and resources to determine what works best for treating particular conditions. They’ve been doing it for years. Most health plans are including “pay-for-performance” components to try to incent the delivery system to follow protocols, engage in electronic technologies, and improve the care delivery of the patient. Comparative effectiveness is alive and well in the health plan system. Those that deliver the care don’t like it- but it’s the way they get paid today.

A few months ago the U.S. Preventive Service Task Force produced their own results concerning the use of mammograms for breast cancer detection in females. This body was established in 1984 of independent private sector experts in prevention and primary care delivery. When they produced their results indicating it is really statistically necessary for an annual mammogram beginning at the age of 50 instead of 40 a huge hue and cry was raised from the masses as an example of government’s intrusion into our health, our health care, and our way of life. This was the perfect example of “Death Panel Health Care” with the politicians.

In order to get a handle on the costs of this uncontrolled system we have today we need to know what works, what doesn’t work, and what works sometimes. We also need to know what it costs. Call it comparative effectiveness, protocols, evidence-based, or whatever you want there are simply too many options, technologies, and pharmaceuticals, to continue the path we’re on today. The system needs some guidance and direction.

The health plans are already providing most of the direction. The system as a whole needs to decide whether it needs some other options to consider as well. And we need to quit complaining when results are published that don’t necessarily agree with the way things have always been.

The way things have been is what got us into this mess in the first place

A Letter to President Obama and Congress

January 29, 2010

Dear President Obama and Congress,

I watched your State of the Union address last Wednesday evening. It may have been one of your best performances. As one of the many pundits commented afterward, it was a “smart speech”.

You are correct in your assumption that a “deficit of trust” exists with the American people. Your approval ratings should give you a pretty clear indication of what we think. The responses and continued partisanship we heard from both sides of the aisle after the speech are pretty good indications that while the message you delivered may have been appropriate, passionate, and delivered with eloquence, the way our legislative interaction occurs is going to remain the same. The deficit of trust is not going to go away any time soon. I was disappointed in that.

Over three years ago we became a military family. This wasn’t by our choice, but like so many others, by the decision of our son to serve our country in the United States Marines. We are preparing for our third deployment- this time to Afghanistan (after Iraq).

While this wasn’t our choice, we accepted the role we have to play as a family and as a country to support both him and all who are serving to protect our country and our freedoms. We are grateful and appreciative every time our citizens come together to show their appreciation for their service and sacrifice; and they do it a lot. America is a great country. It is a passionate country. And, it can come together to support and defend the ideas and the people it believes in.

We’ve learned a great deal over our three-plus years of deployments, sacrifice, and anxiousness. We’ve learned that while we are confronting a very dangerous enemy on the field of battle they are also working diligently behind-the-scenes to destroy the structure and spirit of the American way of life. The attempted bombing on Christmas Eve was another wake-up call for the American people; the enemy is still there. We need to remember that Al Qaeda never said that the way they will defeat us is through military efforts. They intend to do it by destroying the soul of the American spirit in whatever manner they can. And, they are very creative.

I certainly agree that your speech addressed the topics most concerning our citizens today; the economy and jobs. This was smart. While you may not agree on the approach to address them, I believe there is agreement on both sides that something must be done to put people back to work and get the economy moving again.

I would only also ask you to remember that all of the arguments, disagreements, and partisanship you continue to exhibit only contribute to the efforts of our common enemy. Terrorism doesn’t only exist on the battlefields of Iraq or Afghanistan. Terrorism doesn’t only exist with the bombings and spectacular events created by this enemy. Terrorism also exists by destroying the common vision and soul of our country. Jobs, health care reform, the economy, energy policies, and all the rest don’t mean a thing if our enemy succeeds in accomplishing its goal of destroying the unity of the American spirit.

Please work together. Don’t let them win.

Sincerely,

A Military Father

The Public Is Educated In Health Care 101

The Kaiser Family Foundation puts together some interesting work that can help keep a perspective of the reality of what is going on in this industry. The politics, the complexity, and the individual self-interests have made this all very confusing to the average citizen. Over the past 10 months they’ve been given a lesson in Health Care 101 whether they wanted to take the class or not.

Here’s Where We Stand Today:

Kaiser’s January Health Tracking Poll finds 54% of the American public feeling that addressing health care reform remains an important part of addressing the broader needs of our economy. The message is very clear that something needs to be done to correct the trajectory we are on today. On the other hand, 39% feel we need to address other things first. Everyone is concerned with the impact anything we do will have on the deficit. Overall we’re concerned about the up-front costs that will be required to make it work and we don’t have a clue of what the real costs will be.

While the need exists, there is no strong support for any of the current proposals being considered by Congress. Getting to where we are today has been ugly. I wouldn’t imagine there is any great sense of trust in the final product that has been produced as a result of this process. Interestingly, 42% of the public supports the current proposals being considered and 41% oppose them. But, it’s the intensity of the support or opposition that makes it interesting. Those that oppose it really oppose it, and those that support only “somewhat” support it. The strength of the support is still at risk and vulnerable to individual issues.

Most (42%) still feel the country will be better-off by pursuing the current alternatives but patience is wearing thin. A growing number (37%) feels our country will be worse off if we continue down this path. If the pattern continues it won’t be long before the percentage of people feeling our country will be worse off will pass the others. That will make for some interesting political discussions.

When you consider that between the House and Senate Bills you are dealing with over 3,000 pages of legal jargon it is no wonder that the average citizen does not have a good idea of what is included in the legislation. I wonder of our Congress really knows what is included in the 3,000 pages (sorry, that’s another post). While the public wants to be educated, it is still very vulnerable to the talking points of particular points of view and the public (fortunately or unfortunately) hears and somtimes believes those who yell the loudest.

The Kaiser study found that the most widely recognized provisions (those identified as included as a component of the legislation) were those that were “touted by both supporters and by opponents”. We have a signficant education opportunity as we move the public to Health Care 202 (the next level). Let’s just hope we don’t make it as ugly as Health Care 101.

It’s an interesting study and well worth the time spent reviewing it. After the elections in Massuchsetts last week we’re all still wondering the direction health care reform will take. But at least as of today the public still knows we need it, they just don’t necessarily like the proposals that are out there today. Hopefully, we’ll now take the time to regroup and listen to them a little more closely as we move forward.

I'm Just Ticked

Ok, I’ll tell you from the start this post is going to be biased. I’m ticked.

In Massachusetts, the special election to fill Senator Ted Kennedy’s seat is on the line. We’ll know the outcome later tonight (maybe- it’s going to be close) and it will be the start of a whole new ballgame. Ironically, the outcome of health reform (Senator Kennedy’s passion) as well as the broader Democratic agenda that has been laid-out in front of us is also on the line.

Democrats are scrambling and planning for the worse, Republicans are lining-up to prepare their own strategy to put a halt to the direction the Democrats have been taking. While I am not a Massachusetts resident- I would hope our goal would be to focus on putting the right person in this leadership role- regardless of the political ramifications (and I know I’m dreaming here).

We’ve been critical of both the approach and structure of the health reform direction since the House put out its version last August. We’ve been more critical with the strategy and direction of both the Obama Administration and the Senate as they focused more on a Christmas Time-Line than doing what is right. And, we’re even more skeptical of all of the side deals that are being cut to move this thing through.

We have said all along that our health care system is in dire need of reform. The Republican approach (if there is one) is too light, and the Democratic approach is too heavy. Neither side is addressing the fundamental structural problems that need to be addressed immediately to prevent us from moving into what Jim Collins calls “Stage 5 Decline”- capitulation and death. The system we have today simply hurts too many, is too expensive, and has been built by patch-working various ideas together over the years.

Our Congressional leaders need to be leaders and not followers of the special interests and lobbyists. That’s what got us into this problem in the first place. They need to be knowledgeable of the real issues- especially when lives are on the line. And, they need to remember health care is not the only thing on the minds of the voters across this country.

Massachusetts Democratic candidate Martha Coakley commented on Monday that we should be planning an exit strategy for Afghanistan because “there are no more terrorists there”. She said they all left Afghanistan and went elsewhere. As a citizen whose son is heading to Afghanistan to battle the terrorists and reads the casualty listing on the DOD site daily, I was simply appalled.

If this is an example of the base-line knowledge of the people we want to be leading the country we are in a sorry state. It’s time we put people in place that can connect with the American people- and not put people in Washington to simply fulfill someone else’s political agenda. As Mark Twain said, “Patriotism is supporting your country all the time, and your Government when it deserves it.” The Government doesn’t deserve it right now- for either party.

Republican, Scott Brown would get my vote on this one. And, Democrats have better start trying to figure it out how to deal with the fallout either way.

EMR/PHR/EHR- We're Good At Confusng People

As part of the American Recovery and Reinvestment Act of 2009 the government included a sizeable chunk-of-change to try to get the health care industry caught up in the world of technology. We all know that with the fragmented system we have today, tests are duplicated, many still rely on paper, and many times the communication and coordination between the patient and the multiple care teams they may access is hindered. Some organizations (Kaiser Permanente, Mayo, Allina Health Systems to name a few) have already made great progress simply due to the delivery structure they use. Most still have a long ways to go.

So, the Department of Health and Human Services produced another monstrosity of a document outlining the “meaningful use” criteria that will be considered to qualify for the billions of dollars eligible for payment if providers (hospitals/physicians/etc.) initiate information technology (IT) in their delivery. These criteria are open for comment with final rules due sometime early in 2010. Doctors and hospitals are already concerned with the “burden” these rules would place on their organizations. Technology companies are encouraged with finally having a roadmap they can follow (See our Blog of April 26, 2009). You can read the document by clicking here.

The goals outlined in the document are admirable; “to improve the quality of health care, such as by promoting the coordination of health care and improving continuity of health care amonth health care providers, by reducing medical errors, by improving population health, by reducing health disparities, by reducing chronic disease, and by advancing research and education.”

But, once again health care is confusing people with its definitions. We’ve also posted a 2006 white paper by HiMSS Analytics providing a pretty decent description of the difference between an Electronic Medical Record and an Electronic/Personal Health Record:
Electronic Medical Record- Clinical data depository, clinical decision support, controlled medical vocabulary, order entry, pharmacy and clinical documentation applications.

Electronic Health Record/Personal Health Record- A subset of the EMR. Owned by the patient- includes patient input and access that spans episodes of care across multiple delivery organizations.

While the DHHS meaningful use criteria reflects an EMR (by the definition above)- they are calling it an EHR. While consumers may have access to the EMR as it is described, they don’t control it. While we certainly need to improve the interface and technology in health care today- the consumer needs to be a part of it- not a victim of it.

Many consumers are already exploring other options to organize and track their health care information. Google Health, Microsoft HealthVault, Mayo, Revolution Health, and others are already providing consumers with software and technology to begin to interact more effectively with the system we have today.

As the delivery system moves forward in improving its communication and coordination by improving its technology- let’s not (once again) leave the consumer to be on the receiving-end of the experience. Let’s also get our definitions straight and make certain we all stay on the same page.

As we know, health care is good at confusing people- even amongst ourselves.