High Performance Health Care

So long as the Senate Finance Committee does not report out a reform bill, there is the possibility of reform we can believe in this year. The Finance Committee has used a bi-partisan and, frankly, way above average transparent legislative process while the Senate HELP committee – without Ted Kennedy – and the House – with Pelosi and Waxman – have been marking out the liberal boundary lines. But only if Democrats like Baucus, Rockefeller, Conrad and Wyden can find some common ground with Republicans like Grassley and Snowe will the Senate have a chance to define real reform. President Obama had promised again that the reform policy will pay for the coverage policy over 10 years. Nothing in the reported bills demonstrates that's possible. CBO says it's just the opposite.

Baucus and Grassley are pushing the health insurance industry on real marketplace reform. They can push much harder, and get much more that's scoreable by CBO, if they are willing to drop the public plan or even the co-op with insurance exchange. There's lots of "quality and effectiveness" language in the liberal bills. But they can't be scored for savings. The only way to get savings is through differential payment by regions of the country pegged to competitive bidding or to some budget baselines and financial incentives to lower insurance costs by driving down supply-induced overutilization. Another way to do it is through capitation payments to accountable care organizations to take effect, say, four years out. Getting Medicare off the current Part B physician payment system with its volume penalties is the most important reform Congress can make – so long as it is linked to real financial results region by region.

DON'T SCORE SAVINGS FROM MEDPAC AS NATIONAL HEALTH BOARD
The president still believes it feasible to elevate the Medicare Payment Advisory Commission (MedPAC) into an independent effort at setting medical industry prices. As an advisory committee to the Congress, MedPAC has tried its very best to remain above special interest politics and to serve the needs of payment policy reform. But no matter how the Congress sets up appointment authority for MedPAC (it is currently the head of GAO, the fairly independent Comptroller General), the big medical interests that live on health policy find a way to the Congress, either in the appointments process or in the actual implementation of commission recommendations. It is impossible for Congress to ever fully delegate its power to an unelected agency and, with $3 trillion a year at stake, health financing policy isn't where a breakthrough is likely.

REAL HEALTH POLICY REFORM IS NOT IN THE OBAMA CARDS
My thoughts on the subject are included in the July 21, 2009, Minneapolis Star Tribune. But Janet Adamy in this Monday's Wall Street Journal nicely summarizes why this Congress is incapable of delivering on cost-saving health policy changes. If you can't change the way we pay doctors, you can't change the cost curve. If you have the endorsement of the American Medical Association (AMA), you haven't changed anything. You have the AMA endorsement not because America's lowest common denominator practice experts had a change of heart, but because the Congress and the White House have agreed to buy them off with a Part B "bail-out," which will cost taxpayers $245 billion over ten years.

Posted by Dave Durenberger at 10:49 AM | Permalink | Comments (0)

"It's more important to get it right than to get it done."

The High Performance Health Care Blog is pleased to announce that former Senator Dave Durenberger will be a regular guest contributor. He will share his observations and insights into the latest health policy reform efforts.

Dave Durenberger launched a 30-plus year career in health policy by helping create the original BHCAG in Minneapolis, went on to three terms as a health policy expert on the U.S. Senate Finance and HELP committees and is now a Health Policy Fellow and chair of the National Institute of Health Policy at the University of St. Thomas. He has also served on various national health commissions and boards, including the Medicare Payment Advisory Commission (MedPAC). He currently serves on the Board of the National Commission on Quality Assurance (NCQA) and the Kaiser Commission on Medicaid and the Uninsured. No one knows health care policy reform better than Dave, as his nationally circulated Commentary suggests.

Posted by Dan McLaughlin at 03:09 PM | Permalink | Comments (0)

On Thursday, June 18, the University of St. Thomas was proud to host Dr. Kent Bottles, president of the Institute for Clinical Systems Improvement (ICSI). His presentation was part of the Quarterly Lecture Series of the American College of Healthcare Executives MN Chapter, in partnership with the Center for Health and Medical Affairs at the University of St. Thomas. Dr. Bottles spoke to a crowd of over 100 on “Leadership Tools that Work in Times of Rapid Change.” (Click here for video of the presentation and Dr. Bottles’ slides.)

According to Dr. Bottles, leaders do four things: They establish a vision that can inspire others; they translate the vision into strategies and tactics; they make the assignments to the right people; and they hold the assigned people accountable. His talk focused only on the first: establishing a vision that can inspire others, utilizing an environmental assessment of opportunities, risks, and challenges. Specifically, he spoke to three key issues that leaders will need to know how to interpret and respond to during this period of rapid change:
• Election of Barack Obama as President
• Health 2.0
• “Disruptive Innovation,” as described by Clayton Christensen in The Innovator’s Prescription

Dr. Bottles provided an extensive number of resources to further explore each of the issues discussed.

Election of Barack Obama as President
Dr. Bottles outlined a number of key sources he feels shed significant light on Barack Obama’s views on health care:

Ezekiel Emanuel’s $2 Trillion
A bioethicist with the National Institutes of Health and brother of White House Chief of Staff, Rahm Emanuel, put into perspective the more than $2 trillion spent on healthcare in the U.S. every year. “People don't have any idea of what a trillion is," said Emanuel, pointing out that health care's steady increase will theoretically consume the entire economy one day. His math lesson:
• 1 million seconds: less than 2 weeks ago
• 1 billion seconds: 1974
• 1 trillion seconds: 30,000 BC

Medical problems contributed to 62.1% of personal bankruptcies in 2007, according to the American Journal of Medicine. Most were middle class, had health insurance, were homeowners, and had gone to college.

Atul Gawande’s “The Cost Conundrum,” The New Yorker, June 1, 2009
• Details a study of McAllen, TX, which is one of the most expensive health-care markets in the country. CMS spent $15,000 per enrollee, twice the national average (Income per capita is $12,000), and ranks worse on 23/25 metrics of quality of care than in El Paso, TX. Seen as a clear example of over-utilization. Article became “required reading” for congress (see “Health Care Spending Disparities Stir a Fight” below).

Atul Gawande’s “battle for the soul of medicine."
• In a graduation speech to students from the University of Chicago’s Pritzker School of Medicine, Dr. Gawande offered some very specific examples of how doctors can “resist the tendency to see patients as a revenue stream.“ (Read the complete speech.)

“Health Care Spending Disparities Stir a Fight,” Robert Pear, NY Times, June 8, 2009
• “He (President Obama)… took that article (Atul Gawande’s) and put it in front of a big group of senators and said, ‘This is what we’ve got to fix.’”

Obama Interview, D. Leonhardt, “After the Great Recession,” NY Times Magazine, May 3, 2009
• The importance of using comparative-effectiveness studies as a way of reining in costs
• “If it turns out that doctors in Florida are spending 25% 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…--I think that conversation will ultimately yield some significant savings and some significant benefits.”

“The Big Fix,” David Leonhardt, NY Times Magazine, February 1, 2009
• “You never want a serious crisis to go to waste.”
• Doctors who spend more don’t get better results than their conservative colleagues; Patients of aggressive doctors stay sick longer and die sooner because of risks of aggressive care

"Money Talks,” Ryan Lizza, The New Yorker, May 4, 2009
• Budget Director Peter Orszag: Health-care reform is deficit reduction. “At the core of both the stimulus bill and the Obama budget is Orzag’s belief that a government empowered with research on the most effective medical treatments can, using the proper incentives, persuade doctors to become more efficient health-care providers, thus saving billions of dollars.”
• “Obama is in effect betting his Presidency on Orszag’s thesis.”

Health 2.0
Dr. Bottles discussed both trends and examples of how “Health 2.0” is shaping the health care landscape. While “web 1.0” is characterized by users searching for and reading information, “web 2.0” is characterized by regular people creating content on line. Although physicians tend to be reluctant to engage in social networking with their patients, patients are increasingly supplementing the traditional patient-physician relationship with Health 2.0 technologies. Dr. Bottles referred to the following articles and studies:

Docs and Social Media

Nielsen Online: Time on Social Networks
• Number of minutes Americans spent on social networks grew 83% from 4/08 – 4/09

“The Social Life of Health Information,” Pew Internet and American Life Project, June 2009

Online, ‘a Reason to Keep on Going,’ Stephanie Clifford, NY Times, June 1, 2009
• “The new future of old age is about staying in society, staying in the workplace and staying very connected. Technology is going to be a very big part of that, because the new reality is, increasingly, a virtual reality. It provides a way to make new connections, new friends and senses of purpose.” Joseph Coughlin, MIT AgeLab

Cell Phones and Medicine: Cell phones are largely replacing the need for laptop computers. There are over 35,000 applications for the iPhone and both providers and users are finding unique uses for them:
• www.personalpediatrics.com : “A national network of dedicated physicians who are reinventing the lost art of pediatric house call medicine using wireless technology and state-of-the-art recordkeeping software.”
• http://mobilehealthnews.com/2401/interview-dr-hodge-the-first-iphone-doctor/ An article detailing “iPhone doctor” Natalie Hodge.
• “When the Cellphone Teaches Sex Education,” Jan Hoffman, NY Times, May 3, 2009

Patient Social Networking Sites are growing increasingly popular for patients to connect with others that share their condition. Examples include: www.Diabetesmine.com ; www.Patientslikeme.com;and www.MedHelp.com
Connecting Patients to Doctors. Patients can now find doctor referrals, specialists, ratings, appointments, and even access to physicians on-line at sites like: www.angieslist.com; www.ZocDoc.com; www.americanwell.com; www.apexmd.com; and www.healthworldweb.com

Dr. Bottles emphasized that Health 2.0 brings up many questions and ethical concerns, from the auctioning of a kidney on eBay, to a Pro-Anorexia online movement. Questions such as, Who owns online communities? What legal claims can be made over them? Does an MD consultant to a website have ethical/legal obligations to visitors? At what point is there a patient/provider relationship? There are clearly no easy answers.

Disruptive Innovation
Clayton Christensen, author of The Innovator’s Dilemma, has turned his attention to the health care industry in a new book, The Innovator's Prescription. Dr. Bottles outlined his main themes, although time constraints did not allow him to go into each in detail:

Disruption in business models makes products more affordable and accessible. Examples:
• IBM….DEC….Dell….iPhone
• Ford….Toyota….Chevy
• Macys….Wal-Mart….Amazon

Disruption enablers include:
• Business model innovation
• New value networks
• Simplifying technologies such as genetics profiling, imaging, and data mining

Expertise becomes commoditized
• Experimentation and problem solving
• Pattern recognition
• Rules based processes

Hospitals are expensive combinations of three different business models:
• Shops (consulting firms, law firms, diagnostic activities): fee for service
• Chains (manufacturers, education, food services, medical procedures): fee for outcome
• Networks (telecommunications, eBay, Sermo): fee for membership

Who will benefit from disruption of health care industry?
• Integrated fixed-fee providers such as Mayo, HealthPartners, Intermountain, VA, Kaiser
• Major employers such as Quad/Graphics (Briggs & Stratton, Rockwell), Perdue Farms, Pitney Bowes, General Mills, Sprint, Qualcomm

By Cindy Lorah

Posted by Erica Lyons at 11:14 AM | Permalink | Comments (0)