Marginalization, the Demonization of the Other, and the Health Care Debate

Images should never be used to polarize, terrorize, and evoke hate. But often they are. Why? Because this is effective politics.

There is a very interesting post with some insight on this topic up at Mudflats (Tiptoeing Through the Muck of Alaskan Politics).

As always, there is a liberal slant, so caveat emptor.

Public vs. Private Insurance

I found this tidbit quite some time ago - apologies for not posting it sooner.

"Public and private insurance have distinct strengths and distinct weaknesses. Private insurance is generally more dynamic and flexible than public insurance, but at the same time less stable and more administratively complex and costly. Public insurance is better at spreading risks broadly—given the extreme concentration of medical costs, private plans inevitably have incentives to “cherry-pick” healthier patients—but this advantage carries with it the potential cost of a lesser capacity to adapt rapidly to changing technology or the distinctive personal circumstances of individuals. Thus, a public-private hybrid can provide an important check on both the public and private sectors, ensuring flexibility and stability, market accountability and democratic accountability, inclusive social protection and private innovation—in short, a broadened range of good, meaningful choices."

This comes by way of Jacob S. Hacker, Professor of Political Science at U.C. Berkeley (a title he holds among many others). The rest of his paper is excellent; a must read if you are in favor of (or simply curious about) the benefits that a Public Plan will afford.

Failth-based Health Reform Initiatives

Picked this one up from the Kaiser Daily Health Policy Report, and thought I'd pass along:

Faith-based groups Faithful America and Cover All Families have launched a campaign on Christian radio stations advocating for health care reform, the Wall Street Journal's "Washington Wire" reports. The ads, titled "Abundant Life," feature a voice saying, "All Americans should be able to get the care they need for their families, when they need it. God desires abundant life for all people. It's time we step up, ask our politicians to move the debate forward, so we can get the reform we desperately need." The campaign also urges listeners to contact their congressional representatives about health care reform. The ads are running in seven states -- Arkansas, Colorado, Florida, Indiana, Louisiana, Missouri and Nebraska -- which have "representatives and senators who may well determine the fate of health reform," according to CAF (Mundy, "Washington Wire," Wall Street Journal, 5/21).

Those of you reform-minded liberals may have some unlikely allies in your fight. Keep this in mind.

Do Your Eyes & Ears a Favor...

Today, I had the absolute pleasure of listening to the Senate Committee on Health, Education, Labor, and Pensions' Executive Hearing on Delivery Reform: The Roles of Primary and Specialty Care in Innovative New Delivery Models.

The recorded webcast is available here, and the entire 126 minutes is well worth the watch.

Proposals to Provide Affordable Coverage to All Americans: A Synopsis

I've finally managed to work my way through the Senate Finance Committee's paper on policy options to expand coverage. This is, as Ezra Klein notes, the guidebook that the Committee will use when building its bill. For our purposes, I've highlighted 20 of what I feel to be the key proposals on the table:

1. Merge the individual and small group markets, so as to better distribute risk
2. Grandfather current coverage plans available, so that citizens may keep their current coverage if they so choose
3. Create one or more national insurance exchange(s)
4. Mandate health insurers offer a bare minimum of four standard coverage options: high, medium, low, and lowest
5. Provide tax credits and assist with continuation of COBRA coverage for low income tax individuals and certain small employers
6. Establish a public plan (either Medicare-like, TPA, or state-run)
7. Expand Medicaid access and coverage (e.g. income eligibility up to 150% FPL, elimination of face-to-face interview entry requirements, include drug coverage as a mandatory benefit, expand Medicaid coverage in U.S. territories)
8. Increase CHIP income eligibility to 275% FPL
9. Change the Federal Medicaid Assistance Percentage (FMAP) formula to more efficiently distribute funds to needier states
10. Establish at CMS an Office of Coordination for Dually Eligible Beneficiaries, to more effectively manage the disproportionate use of care
11. Reduce or phase-out the Medicare Disability Waiting Period
12. Temporary Medicare Buy-In for individuals aged 55-64.
13. Establish an individual mandate, effective 1/1/2013 (at the latest)
14. Perhaps establish an employer mandate -- not yet definitive
15. Encourage development of a personalized prevention plan and routine wellness visit for all Medicare beneficiaries
16. Remove or limit Medicare & Medicaid beneficiary cost sharing for all preventive services (e.g. no copayment or deductible)
17. Establish additional grants to states for the prevention of chronic disease and encouragement of healthy lifestyles
18. Employer wellness credits
19. Bolster Medicaid HCBS (Home & Community Based Services) program and shift focus away from institutional LTC
20. Establish new requirements for data collection and public reporting

Those are the big ones.

Obama on Comparative Effectiveness

A few weeks ago, during his interview with David Leonhardt of the NY Times, President Obama provided perhaps the most eloquent words I've yet heard on the Comparative Effectiveness controversy. The full interview is available here , but I've provided an excerpt for our purposes:

You have suggested that health care is now the No. 1 legislative priority. It seems to me this is only a small generalization — to say that the way the medical system works now is, people go to the doctor; the doctor tells them what treatments they need; they get those treatments, regardless of cost or, frankly, regardless of whether they’re effective. I wonder if you could talk to people about how going to the doctor will be different in the future; how they will experience medical care differently on the other side of health care reform.

THE PRESIDENT: First of all, I do think consumers have gotten more active in their own treatments in a way that’s very useful. And I think that should continue to be encouraged, to the extent that we can provide consumers with more information about their own well-being — that, I think, can be helpful.

I have always said, though, that we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.

And so, in that sense, there’s always going to be an asymmetry of information between patient and provider. And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options. And certainly that’s true when it comes to Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.

And right now we’re footing the bill for a lot of things that don’t make people healthier.

THE PRESIDENT: That don’t make people healthier. So when Peter Orszag and I talk about the importance of using comparative-effectiveness studies (9) as a way of reining in costs, that’s not an attempt to micromanage the doctor-patient relationship. It is an attempt to say to patients, you know what, we’ve looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one. And if a provider is pushing the red one on you, then you should at least ask some important questions.

Won’t that be hard, because of the trust that people put in their doctors, just as you said? Won’t people say, Wait a second, my doctor is telling me to take the red pill, and the government is saving money by saying take the blue —

THE PRESIDENT: Let me put it this way: I actually think that most doctors want to do right by their patients. And if they’ve got good information, I think they will act on that good information.

Now, there are distortions in the system, everything from the drug salesmen and junkets to how reimbursements occur. Some of those things government has control over; some of those things are just more embedded in our medical culture. But the doctors I know — both ones who treat me as well as friends of mine — I think take their job very seriously and are thinking in terms of what’s best for the patient. They operate within particular incentive structures, like anybody else, and particular habits, like anybody else.

And so if it turns out that doctors in Florida are spending 25 percent more on treating their patients as doctors in Minnesota, and the doctors in Minnesota are getting outcomes that are just as good — then us going down to Florida and pointing out that this is how folks in Minnesota are doing it and they seem to be getting pretty good outcomes, and are there particular reasons why you’re doing what you’re doing? — I think that conversation will ultimately yield some significant savings and some significant benefits.

And there you have it.

Wyden vs. Baucus

Hat tip to Ezra Klein on this recently released Lewin Group working paper, which reviews the Baucus and Wyden proposals, identifies the similarities and differences, and presents ideas on how the differences could be resolved.

What I'm interested in are the similarities:

• Both bills require all Americans to have coverage;
• They both provide subsidies for the purchase of insurance for people living below 400 percent of the federal poverty level (FPL);
• Both bills would create a national network of exchanges to provide access to a range of affordable health plans;
• The bills would require employers to contribute to the cost of covering their workers;
• Employers would be able to continue providing health insurance;
• Both bills prohibit insurers from declining coverage due to health status;
• Both extend Medicaid benefits to 100 percent of the FPL; and
• Both have some form of a public plan option.

Will it be these items, and these items alone, on which a consensus is finally built?

And It Never Will Be...

On that dreaded comparative clinical effectiveness research clause that has surfaced in the most recent stimulus bill, I believe Steven Pearlstein of the Washington Post puts it best:

"This isn't Britain."

Freedom vs. Security

Brian Klepper of the Health Care Blog has posted a fine piece on a recent U.S. Appeals Court decision to overturn that made by a lower court, which would have forced public release of Medicare physician data.

There's lots of goods stuff in this post surrounding the privacy interests of physicians vs. the public benefit of increased cost and pricing transparency. Klepper concludes:

“My guess is that the Appeals Court’s decision for physician privacy at the expense of patient knowledge will be extremely short-lived, and end up being nothing but a minor negative footnote in the steady march toward better health care in America. Certainly, there is good evidence that some progressive health plans increasingly understand the value of using their data to drive better patient decisions, and to make physicians aware of their own performance.”

Although Klepper's conclusion is entirely what I would hope for, I'm much more skeptical. I'm inclined to believe that many more rulings of individual privacy over the public good will likely be made in the near term. And what will come of this? More of the same. But only time will tell…

Daschle & Reform

On the Daschle debacle, I think Ezra Klein puts it best:

Instant reaction: This is good for the cause of ethics in government. Senators and Congressmen who look forward to an executive branch appointment someday will now be much more wary of immense consulting gigs and highly paid speeches to industry stakeholders.

But this whole debacle has been very bad for health reform. Put aside Daschle's unique advantages -- his knowledge of the Senate, his relationships with legislators, his direct line to Obama. The administration will now spend time finding a new nominee, vetting him or her, waiting while they build trust and relationships in the administration and on the Hill, and so forth. I'd say the chances of health reform happening in 2009 -- and thus at all -- are lower now than a week ago. This also makes it more likely that the process is Congress-driven as opposed to White House driven.

The Seamless Adjustment

There is an excellent snippet up on BNET from an HBR article entitled The Last Act of a Great CEO. The article provides five tips on how newly-tapped CEOs can seamlessly adjust to their new role:

Five Ways to Capture Your Predecessor's Knowledge:

• Empathize with your predecessor. During the transition, you and your predecessor may be less than perfectly comfortable. If the outgoing executive is retiring, he may feel that he's plunging into an abyss of insignificance. You may have anxieties about your own readiness to step into the role. Understand that you're both uncomfortable, and behave generously toward your predecessor.
• Solicit input about your new team. Ask your predecessor to identify your team members' strengths and weaknesses, their developmental goals, and their potential. Ask on what basis they were promoted into their roles. Find out who's most likely to tell you bad news when it needs to be told. And map out the dynamics and major alliances among members.
• Extract lessons learned. Ask, "What problems did you encounter early on in this role? How might I head off similar ones as I transition into the role? What other problems could come up that I'm not seeing, and how can they be avoided?"
• Share the "first 90 days" plan. In the earliest days, you'll need to make moves that exert a positive impact and that signal the key themes of your agenda. This includes ways in which you'll depart from your predecessor's strategy. Get your short-term plan on the table as soon as possible. Ask the outgoing executive which initiatives and capabilities spelled out in the plan are foundational and how best to usher them in. Probe for advice on low-hanging fruit you haven't yet spotted. If your predecessor is tempted to engage in any undermining activity, this sharing may help to bring him inside the tent.
• Don't assume you have to reach agreement. Evaluate your predecessor's opinions and perspectives on how to excel in your new role based on your knowledge of him. In comments you're inclined to dismiss, look for the grain of truth. In insights you're rushing to embrace, look for the grain of salt.

If you ask me, these tips ring true for any employee assuming any new position, regardless of title, CEO and analyst alike.

Database Auditing

I'd like to take this opportunity to call attention to Dana Blankenhorn once more, as he provides some excellent insight into an emerging database auditing business.

He has situated his observation within the context of the recent Ingenix settlement esulting from a fraud case filed last year by New York attorney general Andrew Cuomo.

"But there is another issue here, a tech issue. That is the need to regularly audit key databases, and the increasing risks companies run for relying upon them. We’re talking here about more than security audits here, but audits of the accuracy of information a database contains. The problem is especially acute for databases that include value judgments, like quality of care. Doctors as well as patients are going to be heading to court far more often, challenging medical databases."

And the solution?

"Potentially a giant new industry in database content auditing is about to spring up. Law students might want to take a few database management courses if they want to make the big bucks."

Is Mr. Blankenhorn on to something? Have any of the larger research firms performed any market sizing or landscaping exercises on this niche?

The 15 Promises

I took some time recently to revisit the Health Care Agenda posted on the Office of the President-elect's website at change.gov. I began picking apart the promises set forth, and have arrived at a working list of what I deem to be The 15 Promises.

In four years time, I intend to revisit this list and provide commentary on:

1. What was attempted.
2. What was achieved.
3. What progress was made.
4. What was successful.
5. What failed, and why.

The 15 Promises

1. Ensure everyone who needs it will receive a tax credit for their premiums.
2. Create a new Small Business Health Tax Credit to help small businesses provide affordable health insurance to their employees.
3. Require large employers that do not offer coverage or make a meaningful contribution to the cost of quality health coverage for their employees.
4. Lower costs for businesses by covering a portion of the catastrophic health costs they pay in return for lower premiums for employees.
5. Require insurance companies to cover pre-existing conditions.
6. Minimum coverage requirements for preventive services, including cancer screenings.
7. Establish a National Health Insurance Exchange with a range of private insurance options as well as a new public plan.
8. Reform the insurance market to increase competition by taking on anti-competitive activity that drives up prices without improving quality of care.
9. Allow the importation of safe medicines from other developed countries.
10. Increase use of generic drugs in public programs.
11. Take on drug companies that block cheaper generic medicines from the market.
12. Require hospitals to collect and report health care cost and quality data.
13. Invest in proven strategies to reduce preventable medical errors.
14. Prevent insurers from overcharging doctors for their malpractice insurance.
15. Increase state and local preparedness for terrorist attacks and natural disasters.

Collective Intelligence & Codified Rules

I am currently making my way through Jerome Groopman's How Doctors Think, and so far I am very impressed. It's a highly recommended read.

Throughout the early part of the book (as I am only 3 hours in via audio CD), Dr. Groopman supports his hypotheses with anecdotes that describe, often in profound detail, how a particular doctor behaved when confronted with an ill patient. What's interesting is that his analysis is just that: a series of personal anecdotes. He presents very little in the way of hard facts, numbers, and data. At least so far, his conclusions have been anecdote-driven, rather than data-driven.

This comes as no surprise, as Dana Blankenhorn observes:

"Under the current system a doctor uses their own instincts, and their own reading of the literature, deciding independently whether to follow the latest guidelines and directives or not.

What Klepper and Kibbe want to do is make this doctor-patient interaction routine, but also set down what doctors should do, based on an immense body of evidence rather than what any doctor might see in their own practice."

In these statements, Mr. Blankenhorn, whose blog provides consistent insight into all facets of health IT, really drives home the importance of decision support systems at the point of care. Using our collective intelligence, codified in a series of automated rules and treatment guidelines, will be able to move away from our reliance on anecdotes? Is it only a matter of time?

The Feminization of Poverty

This morning, the National Journal’s Health Care Experts blog posed the following questions:

What early health care victories should President-elect Obama and Congress seek before Washington works on broad health care reform legislation? What health care measures should be included in an early economic stimulus package? Federal Medicaid help for cash-strapped states? Legislation to lower drug costs?

The first respondent, Drew Altman, President and Chief Executive Officer of the Henry J. Kaiser Family Foundation, provides the following commentary:

“Federal relief for states provided in the form of additional federal Medicaid matching funds will… help women who will not benefit as much from other forms of stimulus spending such as spending for construction projects; women represent three quarters of adult Medicaid beneficiaries…”

What Drew is alluding to here, is the feminization of poverty, a concept to which I have had little prior exposure. There is a very good introduction to the topic, available here.

Healthcare Reflections

Life and its many diversions have hitherto prevented me from blogging regularly on a topic that has gripped me for quite some time: the state of health care in the United States. And now, with gracious support from friends and family, I have finally resolved to test the waters and begin blogging.

I am both a student and a young professional with a career interest in improving health care in the United States. I graduated four years ago from a small, liberal arts college with dual degrees in the social sciences. I promptly began my career working for a mid-sized, non-profit health insurer operating in greater New England. It is here where I acquainted myself with the problems and complexities facing our current health care system, and it is here where I cultivated an enduring passion for the health care industry.

What this blog is:

• Commentary on topics that interest me, a student of health care policy.
  
• Reflections on ideas that are novel to me, as a young professional interested in improving health care in the United States.

What this blog is not:

• Opinion from a seasoned health care executive.
• Affiliated with any established company or institution.

With this in mind, the mission of this blog is to actively engage its readership with the questions, topics, and trends that concern students of health care in the United States. I hope you enjoy it.