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From a very good article regarding Obama’s legacy in Politico found here:

  1. First, through the use of the stimulus money, his administration  created the infrastructure necessary for change:

A $25 billion incentive program in the stimulus for health information technology has helped drag a pen-and-paper medical system into the digital age, with adoption soaring from about 10 percent of hospitals and 20 percent of doctors in 2008 to about 80 percent of hospitals and 80 percent of doctors today. E-prescriptions are ubiquitous, and digitization is already reducing fatal errors and unnecessary tests caused by sloppy handwriting and inaccessible files. There have been problems getting electronic systems to talk to each other, sparking a backlash of sorts from irritated doctors, but Farzad Mostashari, Obama’s former health IT czar, is confident online medicine will inevitably produce the efficiencies common in online banking and dating.

2. Then, with the ACA,  a plan to improve access was implemented to address the game of uninsured “hot potato”:

It has already extended medical coverage to some 18 million uninsured Americans. It also closed loopholes that insurers used to deny coverage to insured Americans when they got sick. And it eliminated co-payments for quit-smoking programs, birth control pills, certain cancer screenings and other preventive care. As Obama has suggested, it’s what he was talking about when he talked about change.

3. Despite the reality that the right had no stomach for system change and the left had no stomach for cost controls, the majority of the ACA was about those two things. Improving the care delivery system was attempted by putting every idea, good or bad, tried or not, into the law and incenting folks to “don’t just stand there, do something.” Amazingly, it is working. First, the cost side:

Less than one-fourth of the bill was devoted to access. The rest was stuffed with almost every cost-control idea in circulation, from new competitive bidding rules for wheelchairs to a government Innovation Center to test new payment models to a “Cadillac tax” on pricey employer-sponsored plans. “We did a smorgasbord of just about everything people thought could conceivably help,” says Peter Orszag, Obama’s former budget director.

And so far, the cost curve is bending even faster than White House officials had dreamed. Health care is still getting more expensive, but since 2010, the growth rate has slowed so drastically that the Congressional Budget Office has slashed its projection for government health spending in 2020 by $175 billion. That’s enough to fund the Navy for a year, or the EPA for two decades. “We wanted to throw a whole bunch of stuff against the wall to see if any of it would stick, which probably sounded bogus,” Orszag says. “But if these results continue, they’ll fundamentally change the fiscal trajectory of the country.”

And on the quality side:

One recent report found that infections and other “hospital-acquired conditions” have declined 17 percent since 2010, when Obamacare created financial incentives for hospitals to avoid them. That reduction saved an estimated 87,000 lives and $20 billion. A similar effort to incentivize better management of discharged patients has coincided with a decline in hospital readmission rates that’s keeping 150,000 more Medicare patients at home every day, according to Meena Seshamani, director of the administration’s Office of Health Reform.

When put together, it is leading to a much more rational system. Maryland, for example, is experimenting with an “all payers” system:

A recent New England Journal of Medicine article found the state’s hospital costs increased at less than half the expected rate in the program’s first year, saving Medicare $116 million.

And everywhere there are changes to change the payment from one of paying for volume to paying for value:

There are signs that Obama’s convoluted jumble of changes may be starting to rationalize an irrational system. Patrick Conway, the director of the new innovation center, told me about a new Independence at Home experiment that coordinates nurse and doctor visits for frail and disabled patients—and saved Medicare $3,000 per beneficiary in its first year. One elderly diabetic who had 19 hospitalizations the previous year had only one after enrolling in the program.

When Medicare was signed into law, I guess they could have called it LBJCare. Today, no matter what it is called, no one is calling for us to put Grandma back in the attic and let her die. Medicare is here to stay. I suspect that 20 years from now, no one will even think about going back to volume based care delivery with rationing based on income and willingness to pay. Wonder what we will call our care delivery sustem?

The market has not worked to attract people to rural America to care for our rural citizens (a topic for another day). After doing some research for a talk, it turns out that health care professionals are actually responding appropriately to the market:

Rural residents seeking health care are (as a rule)

  • older than urban residents
  • in poorer health than urban residents
  • more likely to be disabled
  • more likely to be uninsured
  • more likely to face financial barriers in obtaining healthcare
  • more likely to incur travel burdens while seeking care
  • much less likely to receive services than are their urban counterparts if they suffer from serious mental illness. There are specific barriers to mental health access. These include
    • Service fragmentation
    • Lack of transportation
    • Lack of cultural and linguistic competency
    • Poor rates of Medicaid enrollment among people with mental illness
    • Stigma associated with mental illness
    • More poor immigrants

 The south offers more complex set of problems that make the market even less likely to be effective

  • Population is in decline and poverty is increasing in rural areas
  • Rural poverty tends to be persistent, historically complex, self-perpetuating, and psychologically and culturally oppressive
  • One third of the poor in the United States live in rural areas, and the rate of poverty in rural counties is increasing at a faster rate than it is in urban areas
  • Residents of rural counties in the south are more likely to be unemployed, less likely to be Medicaid eligible

All in all, President Obama’s vision, as articulated in his speech on Wednesday, said very well why we need to work to care for our fellow citizens despite there being no profit:

But there’s always been another thread running through our history – a belief that we’re all connected, and that there are some things we can only do together, as a nation.  We believe, in the words of our first Republican President, Abraham Lincoln, that through government, we should do together what we cannot do as well for ourselves. 

And specifically about healthcare:

We recognize that no matter how responsibly we live our lives, hard times or bad luck, a crippling illness or a layoff, may strike any one of us. “There but for the grace of God go I,” we say to ourselves, and so we contribute to programs like Medicare and Social Security, which guarantee us health care and a measure of basic income after a lifetime of hard work; unemployment insurance, which protects us against unexpected job loss; and Medicaid, which provides care for millions of seniors in nursing homes, poor children, and those with disabilities.

As you might be able to determine from reading my entries regarding the new health reform law,  I am excited about the possibilities and am looking forward to seeing how the regulations are written that implement the law. There are many agencies who will have a hand in regulation, but none more important than CMS. This agency sets the tempo and tone for the entire health care enterprise in this country. They dictate payment rules for Medicare. They dictate eligibility requirements for Medicaid. They set rules regarding the training of resident physicians. In short, although we may have believed we have a “market-based” health care system, in reality I worked in a system whose rules were dictated by some faceless bureaucrat that ran the Center for Medicare and Medicaid Services. This has been brought home to me at intervals when I am told that I have to turn my training program upside down to satisfy “CMS.”

This is why I am very excited about the news that Don Berwick will be named to head up CMS. I have been a huge fan of his organization, the Institute for Health Care Improvement, for the last 10 years. I first became aware of this organization when I decided that there must be a better way to see patients in a primary care setting than the way we were doing it. I began looking for others who believed in primary care and ran across IHI and their “Idealized design of Clinical Office Practice” project. Although we were unable to participate in these programs, I eagerly read about their efforts to incorporate:

  • Access: Care is available when patients want and need it. 
  • Interaction: Every patient is the only patient.
  • Reliability: “All and only” effective and helpful care is given.
  • Vitality: The practice is sustainable and continually innovating.

into clinical practice and we have been striving to make our changes in our clinical practice leading to enhanced care as a consequence. Much of the work of the Patient Centered Primary Care Collaborative is built on IDCOP principles.

Don Berwick’s organization has as its goals:

 No needless deaths
 No needless pain or suffering
 No helplessness in those served or serving
 No unwanted waiting
 No waste
 No one left out

and the strategy to accomplish this is to build will and optimism for change, drive broad scale adoption of sound changes, invent new solutions, build the future healthcare workforce, and to stay vital for the long haul by achieving excellence in loyalty, financial stability, and worklife for IHI.
Although I doubt he knows who I am, my interactions with Don have been rewarding and we practice better medicine because of my interactions with him and his organization. I look forward to watching him (should he be confirmed) change the culture at CMS. These are interesting times…

The latest discussion in the ongoing saga about how Americans are going to provide for the health care needs of our fellow citizens directs our attention to the Bible and what it says about the health care debate. Apparently the hand of Our Lord has been spotted in the events surrounding the election in Massachusetts, and several in Congress have asked for folks to continue to pray to disrupt the transformation of the health insurance reform movement. The ultimate victory was described further by Jon Stewart.

Apparently the thought that Jesus is taking sides in America has a long history. In fact, up until 100 years ago he was on the side of the socialists. He must have moved to a Red State.

President Obama has outlined his distillation of the bills passed by the House and (mostly) the Senate and has put a proposal on a web site for all to see. The President has outlined what he feels his proposal will do below:

  • It makes insurance more affordable by providing the largest middle class tax cut for health care in history, reducing premium costs for tens of millions of families and small business owners who are priced out of coverage today.  This helps over 31 million Americans afford health care who do not get it today – and makes coverage more affordable for many more. 
  • It sets up a new competitive health insurance market giving tens of millions of Americans the exact same insurance choices that members of Congress will have.  
  • It brings greater accountability to health care by laying out commonsense rules of the road to keep premiums down and prevent insurance industry abuses and denial of care.  
  • It will end discrimination against Americans with pre-existing conditions.
  • It puts our budget and economy on a more stable path by reducing the deficit by $100 billion over the next ten years – and about $1 trillion over the second decade – by cutting government overspending and reining in waste, fraud and abuse.

In a brief review of the details, the proposal does include enhanced provisions for training a primary care workforce and paying us appropriately for the care we will provide. Let the debate continue.

Dr Jeff Terry has written another letter to the editor of the Mobile paper regarding the lack of attention that alternatives to the Democrats proposed health care reform (such as HR 3400) have received. Aside from the obvious (the Republicans had 6 years to do something and what they managed to accomplish was to give a $2,000,000,000 gift to Pharma) there’s the question of whether the alternative proposal has any merit.

As mentioned before, Kaiser Family Foundation has put together a nifty comparison of all of the Health Reform proposals. Dr Terry asks what the Democrats want to accomplish. I would say that President Obama lays it out quite specifically:

The President has indicated that comprehensive health reform should:
• Reduce long-term growth of health care costs for businesses and government.
• Protect families from bankruptcy or debt because of health care costs.
• Guarantee choice of doctors and health plans.
• Invest in prevention and wellness.
• Improve patient safety and quality care.
• Assure affordable, quality health coverage for all Americans.
• Maintain coverage when you change or lose your job.
• End barriers to coverage for people with pre-existing medical conditions.
• The plan must put the country on a clear path to cover all Americans.

HR 3400 Overview

Allow people who purchase coverage in the individual market to deduct the cost of premiums from their income taxes. Provide refundable tax credits to individuals and families with incomes below 300% FPL to purchase insurance in the individual market. Establish Association Health Plans and Individual Membership Associations through which employers and individuals can purchase coverage. Implement state high risk pools or reinsurance programs to provide coverage for people with pre-existing health conditions. Require states to provide coverage to 90% of children with family incomes below 200% FPL as a condition for expanding child eligibility to 300% FPL, and require states to provide vouchers to children eligible for Medicaid and CHIP, to be used to purchase private insurance.

Or, Kaiser has a tool that will generate a side-by-side comparison. By doing that, you can see that HR 3400 has no requirement for individuals to have coverage. Permit employers to automatically enroll individuals in the lowest cost group health plan as long as they can opt out of coverage (which will lead to high deductibles for low wage employess and lessen coverage). Barriers to pre-existing illnesses and injury are not reduced. Medicare fraud is the only example of wasteful healthcare spending covered and it prohibits comparative effectiveness research from being used to deny coverage of a health care service under a Federal health care program and require the Federal Coordinating Council for Comparative Effectiveness Research to present research findings to relevant specialty organizations before publicly releasing them (this will almost certainly increase costs).

Dr Terry feels that Representative Price has a proposal “which offers real reform measures that put patients back in control of their health care and their lives”. I would argue that what it offers is more subsidies for the wealthy, less accountability for physicians, and less coverage for Americans. I hope Dr Terry will take a look at the Kaiser website.

As an academic physician, I only spend about 10 hours a week in direct patient care without residents to teach. I have been in Mobile since 1991and so have a number of folks who I have been treating for almost 20 years. On Friday, I saw 13 patients ranging in age from 10 (a person who when I delivered her weighed 500 grams and is now an honors student) to 89 (whom I did not deliver but who still drives herself to her appointments). In the time the patients were in the office we prevented the flu and pertussis (through vaccination), worked towards early detection of breast and colon cancer (through facilitating screening) and treated a number of acute and chronic ailments. What I did not do is have a discussion about end-of-life care. I was glad the subject never came up.

It’s not that I’m averse to having the discussion. In fact, on your porch over a glass of wine or  professionally if I’m caring for you in the hospital I’ll be happy to delve into the intricacies of whether a feeding tube is a heroic measure required by the Catholic faith. But in an office visit, given that I’m spending 15 minutes with a patient and my staff is busy arranging all of the other aspects of his or her care, that discussion is a time killer.

This is why I am following the “death panel” discussion with such bemusement. When Betsy McCaughey and Jon Stewart are having an esoteric discussion about what is in HR3200, I am wondering just how much they are going to pay me to have this discussion and how they expect me to document it. Ms McCaughey was ticking off the required elements and I’m thinking to myself that if I miss one of these, will I be accused of fraud if I try to bill for the discussion. I am all for the discussion and all for being paid a fair rate for having the discussion. In fact, it has been my experience that most people are 1) aware they will eventually die (teenagers and Boomers excluded)and 2) would like to be assured a modicum of dignity as that time approaches. It is my job as a Family Physician to help them with that.

My problem is with the approach. My conversations with patients about this topic do not tend to happen in a rational 90 minute sit down in an exam room. Rather, they tend to be in 15 minute blocks over a number of visits. As patients become more aware of the limitations of modern medicine, the conversations tend to become more focused.

What I would like to see is not an effort to better pay me for piece work (If I give a flu test I get an extra 10 bucks, I wonder what I’ll get if I talk someone out of a ventilator for their COPD?). Instead, what I would like to see is additional reimbursement (and a lot of it) for always or almost always doing the right thing. That would certification of the practice, similar to hospital certification. The Patient Centered Primary Care Collaborative is pushing for this with NCQA as the potential certifying agency. Then I would have to have a policy in place about, say, Advanced Directives requiring that I document elements of the discussion for certain patients and proof when an inspector came that I was actually doing what I said I was doing.  No more tick boxes, no accusations of fraud, nobody like Betsy McCaughey coming between me and my patient. A guy can dream, can’t he?