Update- Women's Preventive Health -Starting At The Wrong End

The health care system in this country is a reflection of our culture. The profit-motive is there, the amazing advances in medical science and technology is there, bloated costs are certainly there, inefficiency is there, and what the system decides to pay for and not pay for is decided by trying to weigh the costs and benefits of the marketplace with the needs of the society in general. It’s no wonder the system is so messed up. The pieces aren’t aligned.

The Obama Administration changed its tune on dealing with the preventive women’s health issue that was created by the Affordable Care Act; (specifically, requiring contraception services be provided at no cost to the individual). The original position and employer mandate was ludicrous (even to those not involved with politics) as the perception of infringing upon religious rights looked very real. The Administration should have known better on this one.

From a pure public health standpoint, the logic of the original mandate made some sense. Religious institutions provide a significant portion of health care in this country. Catholic hospitals make up twenty-percent of all hospital beds and in many geographic areas are the only hospitals around. To address the desire to reduce abortions and unwanted pregnancy, the Administration felt these institutions had to be included in the original mandate- women’s health is a large cost item in health care and whatever final rules were developed needed to include all major players.

The decision created an outcry and the Administration had no choice but to change their approach.

Now, instead of requiring employers to provide these services- the Administration shifted the responsibility to the health insurers. Nobody really knows how this is supposed to work but the “religious freedoms” argument for employers was theoretically resolved.

Instead, the new decision creates another administrative layer to add to an already confusing and complicated health care structure. And, don’t think anything is “free.” Somebody is going to be paying for it somewhere.

Our health care costs reflect our society. In many respects, the costs are a scorecard on how we live. A significant portion of our costs reflect our lifestyles and using contraception could be considered a lifestyle if you really want to get into it. Don’t get me wrong, reducing unwanted pregnancies and abortions is important. However, a large part of today’s unwanted pregnancies and abortions reflect lifestyle more than anything else. That's what really needs to change. Providing access to necessary health care services is one thing. Providing free access to health care services that encourage irresponsible lifestyles is another.

We need accountability in our health care system today- not encouragement to just continue what we’re doing because it’s free. Some may argue the Administration's decision was a "step in the right direction." Unfortunately, this was only a baby step if a step at all. As usual, we’re starting from the wrong end.

"Women's Preventive Health" We've Gone Too Far

Even though I didn’t agree with the overall concept from the beginning, I’ve tried to be a supporter of the Affordable Care Act. Since its passage in March, 2010 I’ve been a passive supporter- but an avid advocate for overall change in our health care relationships. I never did understand why the primary focus of the Affordable Care Act was to first get everyone insured (see previous blogs going back to 2009). I understand the theory of it- but getting more people into a broken system without focusing on what was broken made no sense. We should have learned a lesson from Massachusetts. However, the Affordable Care Act was the law we enacted, I was ready to get on-board to help make it work.

In the beginning, I respected Obama for using so much of his political capital to finally address a crisis that is coming (and is still coming) in health care. He’s certainly paying for it now.

I followed all of the legal challenges, watched as stakeholders grumbled, tolerated the huge government bureaucracy being created, and listened to the political rhetoric both for and against the legislation. All the while, I tried to continue to see the positives associated with what we had to do to address the crisis at hand.

And then the rules for “women’s preventive health” were released. Here again, I tried to look at the "bigger picture." I certainly understood the need for prevention and the use of our health care system to address broader social issues. I agree with the focus of the Affordable Care Act to address prevention as opposed to sickness.

But the legislation crossed the line for me with these new rules as it now infringes upon the fundamental religious beliefs and practices of others.

The idea of providing contraceptive resources to prevent unplanned or unwanted pregnancy certainly makes sense given the world we live in today. This is a huge cost to our society in many areas. However, to require religious organizations to now compromise their beliefs to comply with a government-mandated law is simply not who we are as a country.

The intent of the Affordable Care Act is to fix a major economic problem our country is facing. I had hoped, despite all of the complaints and criticisms, the Act could provide the framework from which to work. I tolerated all of the government rules and regulations as a necessary evil to incent stakeholders to finally begin work in different ways. I supported the cause because I know that change is necessary.

However, when the Act now is requiring individual citizens to compromise their religious beliefs for rules established by the government, it’s time for me to get off the bandwagon. The government has simply gone too far. I hope our legislative process is able to correct what I believe is a fundamental infringement on our personal rights. Until it does, the Affordable Care Act has one less supporter than it did before- and from the sounds of it, it can't afford to lose many more.

Atul Gawande- Remembering What We're Fighting About

When you are in the middle of a fight, very seldom to you ever stop, assess, and confirm that you remember why you are fighting in the first place. Most of the time we just keep on fighting.

That’s what we’re doing with health care. Even though legislation has been passed to change the way things work, we’re just continuing to fight because many adamantly disagree with the approach that is being used to make the changes and most don’t really understand what is going on. If you didn’t understand the health care system before- you really don’t understand it now. If we don’t change, it is very likely the end-result will cost a lot more and create more damage before we are through. The health care debate has become a part of a much deeper discussion our country is having with itself and still hasn’t quite figured out the right answer.

Atul Gawande’s June 1, 2009 New Yorker article had quite an influence on getting us where we are today. (It’s a good article- You can link to it Here) Sometimes it’s important to step back and reflect on why this fight started in the first place.

The health care system Gawande describes is influenced by many different incentives both internally created and externally driven. The influence of the incentives and the personal make-up of the health care stakeholders determine the type of health care system that is developed in a local community. The health care system then determines the economics (how much it costs and how it is delivered). Gawande believed the health and age of a population have little to do with significant variations in the cost of health care we are experiencing today; it’s the system used to deliver health care that really matters.

Yes, critics have challenged some of the facts but the challenges don’t erase the picture of health care the article constructs. The challenges don't negate the reality.

Even as we continue to fight about it, we should also take some time to step back and reflect on the health care system described by Gawande almost 3 years ago. We need to take a moment and remember what we’re fighting for- and hope we are making some progress to come to a solution as we fight.

At this point, the progress seems questionable.

Iowa Caucuses- Health Care IS an Economic and Debt Issue

The Iowa caucuses are over and it’s on to New Hampshire. To nobody’s surprise, it was a close contest, a lot of money was spent, and a lot of negative advertising was used in the strategies. Republicans still aren’t united behind any single contestant- but the field will narrow over the next few weeks.

Iowa gave us the first look at the results of the Citizens United decision made by the Supreme Court last year. There is going to be even more money spent, with candidates hiding behind the covers of the “super PACs” created on their behalf. Free speech? We’ll see.

Iowan’s are a rational bunch. They look at things from a different perspective than those in Washington D.C., New York, California or the other highly populated areas. They care about community, about agriculture, and about things that are relevant to themselves. They don’t usually like the negativity associated with politics- but the Iowa caucuses proved the negative ads work. We’ll see a lot more of them.

Interestingly, Iowa Republican’s participating in the caucuses listed the economy and the debt as their primary issues of concern. Health care and abortion listed in the distance.

The Iowa caucuses proved that we continue to keep health care as a separate and distinct political issue even though fixing our health care mess is directly related to both the economy and the debt. A Pew Research Foundation study in April, 2011 determined the unfunded liabilities associated with pensions and health care for state governments increased 26% (to $1.6 trillion) in one year alone. Health care IS an economic and debt issue.

Iowa has always been the starting point of the presidential election process and used to either gather momentum or begin the elimination of candidates. Iowa also provides lessons as to what works and what doesn’t work in the campaign process.

The Iowa caucuses taught us: The Republicans are still not sure who to get behind to run against Obama in 2012, Super PAC negativity works (unfortunately)- and we’ll see a lot more, "retail/door-to-door" politics is still effective, and we still don’t believe reforming health care has much to do with jobs, the economy, or our debt.

We’ll see what we learn in New Hamphshire.

2011 Government Financial Report- Unacceptable

Right before Christmas (December 23) the Government Accountability Office (GAO) released its “2011 Financial Report of the United States Government.” The GAO works for Congress and operates as a bi-partisan watchdog to monitor how taxpayer dollars are being spent.

The press release associated with the release of the report stated, “The U.S. Government Accountability Office (GAO) cannot render an opinion on the 2011 consolidated financial statements of the federal government, because of widespread material internal control weaknesses, significant uncertainties, and other limitations.

Specifically, the press release cited; 1. Serious financial management problems at the Department of Defense (DOD) that make its financial statements unauditable, 2. The federal government’s inability to adequately account for and reconcile intragovernmental activity and balances between federal agencies, and 3. The federal government’s ineffective process for preparing the consolidated financial statements.

The report identified a material weakness of $115.3 billion in improper payments, information security issues across government, and tax collection activities.

I’ve posted the study in the Library of our site. It discusses some of the basic numbers ($1.3 trillion deficit compared to $2.1` trillion in 2010; 1.9 million new jobs compared to 350,000 in 2010) and an overview of some of the actions taken to try to get the country on the right track. You can look at the numbers and decide how well they are working for yourself. The numbers indicate some progress was made- just not nearly enough.

From a health care perspective- the report makes two significant points- Medicare, Medicaid, and Social Security are big parts of the problem (representing 45% of all spending), and the Medicare Trust Fund will run out of funding in 2024- five years earlier than was projected in 2010.

While many are calling for “cuts” that usually impact the “boots on the ground” citizen, this report shows we would likely find huge opportunities to reduce spending simply by putting accountable accounting systems in place to track where money is going and how well it is being invested.

In a nutshell, the accounting controls and books used to measure how well we’re doing financially as a country are a mess. In all honesty, we probably don’t have a real clue how big our debt really is- and its inexcusable. The financial managers associated with such a report in the private market would likely be fired.

We should expect no less from those responsible for the allocation of our taxpayer dollars- including the Congress (both Republican and Democrat alike). They need to be held accountable for the results of their efforts. This effort is unacceptable.

Too Confused to Use?

A study by GfK Custom Research of 502 private-sector employers painted a picture of where employers stand today regarding the Affordable Care Act and offering health insurance benefits to employees. Not surprisingly, most still don’t believe the Affordable Care Act will have much impact on the future costs of health care, and many believe it will actually increase the costs in the future. However, the majority of employers still don’t understand what is in the law and how it is supposed to work- so, the comments are based more on perception than fact.

Over 55% of the employers indicated they would continue to offer health insurance to their employees even after the major components of the “insurance reforms” of the Affordable Care Act are put in place. However, the responses were dependent on the size of the company. Most large companies plan to continue to provide health insurance- while smaller companies aren’t so sure. Over 30% of the companies (both large and small) are unsure whether they will continue to offer health insurance as a benefit to the employees in the future. Not surprisingly, the majority not offering health insurance now base their decision on cost (not on the Affordable Care Act).

In 2004, about 68% of the employers offered health insurance to their employees. The number stands at 60% today. By 2014 (when the theoretical “health insurance exchanges” are supposed to be operational) the number will likely be somewhere between 50-60%.

If the numbers hold, consumers are going to need to purchase health insurance different than they have in the past. They are going to need more education, more guidance, and more “transparency” than ever before. Transparency has never been a core competency of Health Care.

So, while Health Care focuses on all of the other transactional details to establish exchanges, develop new delivery models (Accountable Care Organizations), collect data, and all the rest let’s hope it doesn’t forget about the needs of those who can really have an impact on changing the trajectory we are on today- the individual/the patient.

All the new ideas won’t make much of a difference if the individual doesn’t understand how they work- or are too confused to be engaged to use them.

Transparency- Getting People To Use Information Is The Real Key

The November, 2011 publication of the American Journal of Medical Quality found 80% of the “highly findable” health care rating sites (rating doctors and hospitals) draw on anecdotal patient reports (the patient opinion and experience) more than anything else. According to the article, the sites many are using to research care providers and show highly ranked in the search engines don’t use some of the measurements Health Care would like them to use to help make informed health care decision. Only half of the highly findable sites include quality information and a third feature cost data. Forty-four percent featured performance results based on claims data or board-certification information.

Despite the effort Health Care is making to increase the amount of data and information available to the general population, a large segment remains frustrated with their inability to find what they need when they need it. Their frustration lies in three key areas: A lack of awareness of what is available, not knowing what questions they need to ask, and then finding the information once they know what they need. Individuals will likely continue to rely on family, friends, and their social networks as a more reliable source until Health Care packages and markets the information in a way that is relevant to the individual.

As Health Care continues to improve the "transparency" of how with works with the general public it will need to continue to acknowledge the “trust barrier” that exists with many individuals. Individuals will gravitate to the sources they feel they trust and provides information that is relevant to them. Collecting information is the first step, analyzing the information is the second step, packaging and communicating the information is the third step. And, it seems as if “experiential rating sites” have done a better job packaging and communicating their relevance to the general population than those that use the metrics Health Care prefers.

Maybe Health Care can learn from them.