PNHP

Landmark study of spending and quality in Ontario hospitals

Landmark study of spending and quality in Ontario hospitals

Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals

By Therese A. Stukel, PhD; Elliott S. Fisher, MD, MPH; David A. Alter, MD, PhD; Astrid Guttmann, MD, MSc; Dennis T. Ko, MD, MSc; Kinwah Fung, MSc; Walter P. Wodchis, PhD; Nancy N. Baxter, MD, PhD; Craig C. Earle, MD, MSc; Douglas S. Lee, MD, PhD
JAMA, March 14, 2012
The extent to which better spending produces higher-quality care and better patient outcomes in a universal health care system with selective access to medical technology is unknown.
Numerous studies have investigated whether higher health care spending produces better patient outcomes and higher quality of care. Evidence from the United States and other countries has been conflicting. Several studies focusing on short-term outcomes within a given state found that being treated in higher-spending hospitals was associated with better in-hospital or 30-day mortality. In contrast, a national study found that regional differences in spending intensity were largely attributable to use of the hospital as a site of care and greater overall use of specialists, imaging, and diagnostic testing but that patients treated in regions with higher spending intensity did not have better survival or quality of care. Whether these findings would hold true in a country with universal access to health care but a far lower supply of specialists and more selective access to medical technology is unknown.
Our objective was to assess whether acute care patients admitted to Canadian hospitals that treat patients more intensively (and at higher cost) have lower mortality and readmissions and higher quality of care.
We found that higher hospital spending intensity was associated with better survival, lower readmission rates, and better quality of care for seriously ill, hospitalized patients in Ontario in a universal health care system with more selective access to medical technology. Higher-spending hospitals were higher-volume teaching or community hospitals with high-volume or specialist attending physicians and having specialized programs, such as regional cancer centers, and specialized services, such as on-site cardiac catheterization, cardiac surgery, and diagnostic imaging facilities. The study also points to plausible mechanisms through which higher spending may be associated with better outcomes.
Benefits appeared early, suggesting an acute-phase hospital effect. For acute conditions, timely access to preoperative and in-hospital specialist care, skilled nursing staff, rapid response teams, cardiac high-technology services, and regional cancer centers, all found in the higher-spending systems, are related to better outcomes. These systems also provided consistently, but not strikingly, higher levels of evidence-based care and collaborative ambulatory care, both shown to improve care.​ Higher spending on evidence-based services delivered in the acute phase of care for severely ill hospitalized patients—by far the largest component of spending for our cohorts—is indeed likely to be beneficial.
To place the study in context, the United States has a 3- to 4-times higher per capita supply of specialized technology, such as computed tomography and magnetic resonance imaging scanners, but a similar supply of acute care beds and nurses. Ontario 2001 population rates of cardiac testing and revascularization lagged behind corresponding 1992 US rates and paralleled the supply of cardiologists and catheterization facilities. It is therefore possible that Canadian hospitals, with fewer specialized resources, selective access to medical technology, and global budgets, are using these resources more efficiently, especially during the inpatient episode for care-sensitive conditions. Canada’s health care expenditures per capita are about 57% of those in the United States. At this spending level, there might still be a positive association between spending and outcomes.
We cannot rule out the possibility that higher-intensity hospitals coded more aggressively, but there is less incentive to do so in a system with global hospital budgets.
This study shows that in Ontario, a province with global hospital budgets and fewer specialized health care resources than the United States, outcomes following an acute hospitalization are positively associated with higher hospital spending intensity. Higher spending intensity, in turn, is associated with greater use of specialists, better patient care, and more use of advanced procedures. These results suggest that it is critical to understand not simply how much money is spent but whether it is spent on effective procedures and services.
http://jama.ama-assn.org/content/307/10/1037.abstract
eAppendix – to article above (15 pages):
Costing Data Sources
The following is an excerpt from Guidelines on Person-Level Costing Using Administrative Databases in Ontario that describes the costing methodology for acute inpatient hospitalizations, emergency visits (ED), and physician services, based on Ontario healthcare utilization data. Total costs (direct costs and overheads) for acute care and ED are available from the Ontario Ministry of Health and Long-Term Care (MOHLTC) Health Data Branch and are based on Ontario Cost Distribution Methodology (OCDM). Fees associated with physician visits are available directly from the Ontario Health Insurance Plan (OHIP) Schedule of Claims and Benefits while fees paid to physicians are tracked in the OHIP physician billing database.
http://jama.ama-assn.org/content/suppl/2012/03/07/307.10.1037.DC1/JWE20016_03_14_2012.pdf

And…

No Free Lunch: The Relationship Between Cost and Quality

By Karen E. Joynt, MD, MPH; Ashish K. Jha, MD, MPH
JAMA, March 14, 2012
Editorial
For the past 30 years, research from investigators at Dartmouth has demonstrated large and persistent variations in costs and quality across the US health care system. Beyond simply showing that cost and quality vary by geography, the Dartmouth Atlas has demonstrated that in many communities, care is so fragmented and ineffective that greater spending on Medicare beneficiaries often leads to worse outcomes because some patients receive services that are redundant and low value and that may even have substantial risks.
However, some US policy makers have misinterpreted the Dartmouth research and in the troves of data have found what they believe to be a free lunch: given the inverse relationship between costs and quality, it follows that it should be possible to simultaneously reduce spending and improve care. Although this notion is attractive, much of the subtlety of the Dartmouth work has been lost in translation. What Dartmouth investigators have documented through careful work is that dysfunctional systems produce expensive, poor-quality care.
Data from Dartmouth researchers and others have thus led policy makers to feel comfortable with broad payment reductions, in many cases targeting hospitals as a major source of savings for the Medicare program. The Affordable Care Act requires that the Centers for Medicare & Medicaid Services (CMS) make a series of payment reductions to hospitals, and CMS has proposed other reductions. Nearly every proposal to reduce Medicare spending, from Democrats and Republicans alike, seems to contain reductions in Medicare payments to hospitals. The notion that payments to hospitals can be reduced while maintaining or improving the quality of care delivered at these hospitals has become so ingrained in policy circles as to be a given.
Recently, however, an increasing amount of evidence has emerged that should counter this misperception. Several studies suggest that higher spending at the patient or hospital level may in fact be associated with better clinical outcomes.
What are federal policy makers to do? One lesson is that although broad-based reductions in hospital reimbursement may spur some institutions to innovate and eliminate waste, others will surely cut costs indiscriminately, eliminating exactly those services that are vital for good hospital care. Given that many hospitals may not have a clear sense of how to make these reductions without compromising on important services and personnel, patients will likely be negatively affected. An alternative approach is to target poor coordination, wasteful spending, and ineffective care more directly through programs such as bundled payments and accountable care organizations, which encourage coordination and integration first and spending reductions second. Ultimately, the best way to save money on hospital care is to more aggressively target preventable hospitalizations by bolstering primary care. These kinds of efforts are more likely to be successful in eliminating waste without jeopardizing patient outcomes. Although paying hospitals less may appear to be a good strategy to save money, the findings reported by Stukel et al serve as a timely reminder that this approach is likely to have negative consequences for patients.
http://jama.ama-assn.org/content/307/10/1082.full?etoc

This is a landmark study. Among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates. Let’s see if we can learn the right policy lessons from this.
With our very high levels of health care spending, yet mediocre quality and outcomes, attention has been directed to attempting to identify the basis of these discrepancies, especially by looking at the Dartmouth findings which have suggested that all too frequently there is no relationship or perhaps even an inverse relationship between greater spending in hospitals and high quality outcomes. This task has been made difficult by the fact that several other studies have shown that greater spending has improved outcomes.
The authors of this new study decided to look at hospitals in Ontario, Canada to try to identify more precisely whether or not increased spending does improve quality and outcomes. Although they didn’t state this as a reason, this was an astute move since Canadian hospitals are globally budgeted – a fact that dramatically reduces the incentives to increase the intensity of services for the purpose of increasing revenues. Attention is given to using resources to benefit the patient, without the perverse motive of increasing income by adding services of negligible or negative value.
In this environment, it worked. If patients needed more care, they got it, and they were better off for it. Incidentally, even with this extra care, they spent much less per patient than we do in the United States.
In the JAMA editorial accompanying this article, the authors indicate that this confirms further that there is “no free lunch” in trying to recover higher costs while improving quality. They suggest a few policy lessons.
Of great importance, efforts to reduce spending in high cost hospitals should not be indiscriminate since that risks eliminating “exactly those services that are vital for good hospital care.” Such reductions can negatively affect patients.
They suggest targeting “poor coordination, wasteful spending, and ineffective care more directly through programs such as bundled payments and accountable care organizations, which encourage coordination and integration first and spending reductions second.” Integrated, coordinated care is a great idea, and likely accounts for much of the improved outcomes in Ontario hospitals. But can we in the United States really achieve this through bundled payments and accountable care organizations?
Only certain clinical scenarios are subject to bundling. Even when bundled, the cost containment is achieved by providing a discount to the bundled package. Not only are there pricing issues, such as possible inadequate funding of the services, there is the much greater problem that this does nothing for total global spending. It more likely results in not much more than mere cost shifting. That won’t correct the fundamental dysfunctions in U.S. health care financing.
Much has been written about accountable care organizations. Unfortunately, as they are evolving, it looks like they won’t be much more than a replay of managed care innovations such as physician-hospital organizations, or loose provider networks under an HMO umbrella – except all dressed up in new clothing. It is particularly difficult to understand how the organization can be accountable for the care of the patient, when that patient is free to obtain care anywhere and may not even be aware that they are assigned to one organization. Again, integration and coordination are great, but that should occur throughout the medical community at large rather than through isolated, commercialized entities.
A most important policy lesson advanced by the editorialists is that “the best way to save money on hospital care is to more aggressively target preventable hospitalizations by bolstering primary care.” In fact, Canada has a much more robust primary care infrastructure than the United States, which is likely another contributor to getting the right patients into the Ontario hospitals at the right time. We need to do much more to reinforce primary care in the U.S. – far more than the meager measures in the Affordable Care Act.
The paramount take home policy lesson is that a single payer system such as that in Canada not only has vastly superior methods of financing and distributing health care resources efficiently and equitably, it also creates a milieu in which the patient is placed at the pinnacle, and the health care system is positioned to serve that patient optimally.

CBO update on coverage under ACA

Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act

Congressional Budget Office
March 2012

In preparing the March 2012 baseline budget projections, the Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) have updated estimates of the budgetary effects of the health insurance coverage provisions of the Affordable Care Act (ACA).

CBO and JCT now estimate that the insurance coverage provisions of the ACA will have a net cost of just under $1.1 trillion over the 2012–2021 period — about $50 billion less than the agencies’ March 2011 estimate for that 10-year period.

CBO and JCT’s projections of health insurance coverage have also changed since last March. Fewer people are now expected to obtain health insurance coverage from their employer or in insurance exchanges; more are now expected to obtain coverage from Medicaid or CHIP or from nongroup or other sources. More are expected to be uninsured.

Compared with prior law, the ACA is now estimated by CBO and JCT to reduce the number of nonelderly people without health insurance coverage by 30 million to 33 million in 2016 and subsequent years, leaving 26 million to 27 million nonelderly residents uninsured in those years.

http://www.cbo.gov/system/assets/drupal/cbofiles/attachments/03-13-Coverage%20Estimates.pdf

Comment: 

By Don MCCanne, MD

So the projected federal spending on the Affordable Care Act over the next decade will be $50 billion less than previous projections. Directing attention to that flimsy fact hides the real news in this report. Instead of 23 million individuals being left uninsured, as the CBO previously predicted, it is now estimated that 26 to 27 million will have no insurance at all.

These numbers are approaching the 34.7 million uninsured in 1990 – a time when health reform was pushing its way back to the top of the political agenda. It was a national disgrace that we had allowed ourselves to become world leaders in both health care spending and health care injustice!

So now we finally have passed health reform legislation, but what have we actually accomplished? Higher costs, deterioration in the protection afforded by insurance, and projected uninsured rates close to those when we began this whole process.

Wasting the next decade or two tinkering with the Affordable Care Act, pretending that we’re making real progress, just won’t cut it. There are no adequate policies in the ACA model on which to build substantial reform. We need truly efficacious reform that covers absolutely everyone equitably in a universal program – a single payer national health program.

Every year that goes by without acting brings us ever more health care tragedies, not to mention financial hardship. We can’t wait around while we watch the unfolding of the failure of the ACA experiment. We need reform now. It’s an absolute moral imperative!

CBO update on coverage under ACA

Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act

Congressional Budget Office
March 2012
In preparing the March 2012 baseline budget projections, the Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) have updated estimates of the budgetary effects of the health insurance coverage provisions of the Affordable Care Act (ACA).
CBO and JCT now estimate that the insurance coverage provisions of the ACA will have a net cost of just under $1.1 trillion over the 2012–2021 period — about $50 billion less than the agencies’ March 2011 estimate for that 10-year period.
CBO and JCT’s projections of health insurance coverage have also changed since last March. Fewer people are now expected to obtain health insurance coverage from their employer or in insurance exchanges; more are now expected to obtain coverage from Medicaid or CHIP or from nongroup or other sources. More are expected to be uninsured.
Compared with prior law, the ACA is now estimated by CBO and JCT to reduce the number of nonelderly people without health insurance coverage by 30 million to 33 million in 2016 and subsequent years, leaving 26 million to 27 million nonelderly residents uninsured in those years.
http://www.cbo.gov/system/assets/drupal/cbofiles/attachments/03-13-Coverage%20Estimates.pdf

So the projected federal spending on the Affordable Care Act over the next decade will be $50 billion less than previous projections. Directing attention to that flimsy fact hides the real news in this report. Instead of 23 million individuals being left uninsured, as the CBO previously predicted, it is now estimated that 26 to 27 million will have no insurance at all.
These numbers are approaching the 34.7 million uninsured in 1990 – a time when health reform was pushing its way back to the top of the political agenda. It was a national disgrace that we had allowed ourselves to become world leaders in both health care spending and health care injustice!
So now we finally have passed health reform legislation, but what have we actually accomplished? Higher costs, deterioration in the protection afforded by insurance, and projected uninsured rates close to those when we began this whole process.
Wasting the next decade or two tinkering with the Affordable Care Act, pretending that we’re making real progress, just won’t cut it. There are no adequate policies in the ACA model on which to build substantial reform. We need truly efficacious reform that covers absolutely everyone equitably in a universal program – a single payer national health program.
Every year that goes by without acting brings us ever more health care tragedies, not to mention financial hardship. We can’t wait around while we watch the unfolding of the failure of the ACA experiment. We need reform now. It’s an absolute moral imperative!

The Effect Of Physicians’ Electronic Access To Tests: A Response To Farzad Mostashari

By Danny McCormick, David Bor, Stephanie Woolhandler, and David Himmelstein
Health Affairs Blog, March 12th, 2012

Our recent Health Affairs article linking increased test ordering to electronic access to results has elicited heated responses, including a blog post by Farzad Mostashari, National Coordinator for Health IT.  Some of the assertions in his blog post are mistaken.  Some take us to task for claims we never made, or for studying only some of the myriad issues relevant to medical computing.  And many reflect wishful thinking regarding health IT; an acceptance of deeply flawed evidence of its benefit, and skepticism about solid data that leads to unwelcome conclusions.

Dr. Mostashari’s use of a government website to critique our paper, will, we hope, open a fruitful dialogue.  We trust that in the interest of fairness he will also post our response on his agency’s site.

Our study analyzed government survey data on a nationally representative sample of 28,741 patient visits to 1187 office-based physicians.  We found that electronic access to computerized imaging results (either the report or the actual image) was associated with a 40% -70% increase in imaging tests, including sharp increases in expensive tests like MRIs and CT scans; the findings for blood tests were similar.  Although the survey did not collect data on payments for the tests, it’s hard to imagine how a 40% to 70% increase in testing could fail to increase imaging costs.

Dr. Mostashari’s statement that “reducing test orders is not the way that health IT is meant to reduce costs” is surprising, and contradicts statements by his predecessor as National Coordinator that electronic access to a previous CT scan helped him to avoid ordering a duplicate and “saved a whole bunch of money.” A Rand study, widely cited by health IT advocates including President Obama, estimated that health IT would save $6.6 billion annually on outpatient imaging and lab testing.  Another frequently quoted estimate of HIT-based savings projected annual cost reductions of $8.3 billion on imaging and $8.1 billion on lab testing.

We focused on electronic access to results because the common understanding of how health IT might decrease test ordering is that it would facilitate retrieval of previous results, avoiding duplicate tests.  Indeed, it’s clear from the extensive press coverage that our study was seen as contravening this “conventional wisdom”.

Nonetheless, Dr. Mostashari criticizes us for analyzing the impact of physicians’ electronic access to imaging and test results, but not other aspects of electronic health record (EHR) use.    We did, however, analyze the relationship of EHRs to test ordering in a subsidiary analysis.  While physicians use of a full EHR was associated with a 19% increase in image ordering, as we noted in the paper this finding was not statistically significant.  While we cautiously (and properly) interpreted this as a “null” finding, these data are inconsistent with Mostashari’s optimistic view that use of a full EHR reduces costs.

He asserts that our 2008 data are passe, and that health IT meeting today’s “meaningful use” criteria definitely saves money. The data we analyzed were the latest available data when we initiated the study.  While the proportion of outpatient physicians utilizing health IT has grown since 2008, we are unaware of any “game changing” health IT developments in the past four years that are would produce substantially different results if the study were repeated today.  The EHR vendors that dominated the market in 2008 remain, by and large, today’s market leaders, and their products have undergone mostly modest tweaks.  Mostashari’s contention that 2012  EHRs  – incorporating decision support and electronic information exchange – save money in ways not possible in 2008 should be tested through additional research but remains merely a hypothesis. We hope that some day his predicted savings can be achieved.

Dr. Mostashari offers his own explanation for our findings, suggesting that doctors who are inclined to order more tests are also inclined to purchase health IT for viewing test results electronically rather than on paper.  He offers no evidence for this assertion and ignores the fact that we explored (and rejected) this explanation by analyzing subgroups of doctors who are unlikely to be the decision maker for IT purchases – e.g. employed physicians, those working in an HMO setting etc.  In other words, electronic access to results predicted more test ordering whether or not the ordering physician was responsible for health IT purchases.

He incorrectly states that our analysis did not take into account patients’ severity of illness, physicians’ level of training, and the nature of physicians’ financial arrangements.  In fact, we reported subsidiary multivariate analyses that included several serious diagnoses; all of our models included physician specialty (which we specified in several different ways); and all models included adjustment for an extensive list of indicators of financial arrangements (e.g. whether the physician owned the practice or was an employee; the type of office; whether the practice was owned by a hospital; whether the physician was a solo practitioner; whether the physician’s compensation was based, in part or whole on “profiling”; and whether the practice was predominantly prepaid).  We also performed a series of subsidiary analyses that explored whether physicians with a proclivity to “self refer” patients for imaging tests accounted for our finding; they didn’t.

Dr. Mostashari criticizes us for failing to assess whether health IT improved the quality or appropriateness of care.  Of course, these were not the topic of our research.  Those are different studies for a different time.  However, we would note that other large-scale studies have found no, or trivial quality improvements associated with HIT outside of a few flagship institutions4-6.

Dr. Mostashari’s strongest claim is that observational studies like ours (and most other health policy studies, including some by Dr. Mostashari himself) cannot prove causation. This is surely true.  As long time teachers of evidence based medicine we took care to couch our conclusions in cautious terms, stating only that “Computerization, whatever its other benefits, remains unproven as a cost control strategy.”

But Dr. Motashari is less cautious, asserting that the case for HIT is closed.  The paper he cites to buttress this claim (authored by members of his own agency) culled studies reporting any impact of HIT on virtually any aspect of care, and accepted authors’ claims of benefit without regard to study quality or statistical niceties.  Thus, a focus group’s impressions of benefit are accorded the same weight as nationwide studies of Medicare data showing virtually no impact of computerization on quality measures.  Reports of a reduction from 70% to 38 % in “missed bi
lling opportunities” or a $7,000 reduction in office supply costs are among the 92% of studies judged “positive”.  While the literature review he cites is interesting, nothing in it contradicts our findings.

Dr. Mostashari is also correct in reiterating that randomized trials are the best way to assess health IT.  In fact, no randomized trial has ever been published that examines patients’ outcomes or costs associated with off-the-shelf health IT systems that dominate the U.S. market.  No drug or new medical device could pass FDA review based on such thin evidence as we have on health IT.  Yet his agency is disbursing $19 billion in federal funds to stimulate the adoption of this inadequately evaluated technology. Dr. Mostashari is perhaps the only person in our nation who commands the resources needed to mount a well done randomized controlled trial to fairly assess the impact of health IT, and the comparative efficacy of the various EHR options.

Finally, Dr. Mostashari’s unbridled faith in technology is mirrored by his belief that ACOs are the next panacea for health costs and quality.  That health policy flavor-of-the-month also remains wholly unproven.

HHS hands exchange control to insurers!

Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers

Department of Health and Human Services
Federal Register publication date: March 27, 2012

Final rule, Interim final rule.

Excerpts from pages 34-37

Summary of Regulatory Changes

If the Exchange is an independent State agency or not-for-profit entity established by the State, we proposed that its governing board meet the standards outlined in §155.110(c)(1) through §155.110(c)(4) of the proposed rule, which included: the Exchange accountability structure must be administered under a formal, publicly-adopted operating charter or by-laws; the Exchange board must hold regular public meetings; representatives of health insurance issuers, agents, brokers, or other individuals licensed to sell health insurance may not constitute a majority of the governing board; and, all members of the governing board must meet conflict of interest and qualifications standards.

Several commenters urged HHS to apply conflict of interest standards to eligible contracting entities.
 
Response: We generally defer to States to establish conflict of interest standards for eligible contracting entities beyond the prohibition of health insurance issuers being eligible contracting entities, as established in section 1311(f)(3) of the Affordable Care Act and codified in §155.110(a)(1)(iii). We believe that many States have existing conflict of interest laws, have appropriate expertise in this area, and can support Exchanges in the development of conflict of interest standards for such entities.

Commenters suggested broadening the list of groups identified as having a conflict of interest in proposed §155.110(c)(3)(ii) to include: health care providers; anyone with a financial interest; anyone with a spouse or immediate family with a conflict of interest; major vendors, subcontractors, or other financial partners of conflicted parties; members of health trade associations and providers; and, health information technology companies. Commenters recommended that such groups be limited or prohibited from participation in an Exchange. Other commenters recommended that individuals with ties to the insurance industry participate through technical panel or advisory group instead of through board membership.

Response: As proposed, §155.110(c)(3)(ii) ensures as a minimum standard that the groups with the most direct conflict of interest cannot form a majority of voting members on a governing board. We believe that further definition of conflict of interest may create inconsistencies with State law and other existing State standards, but note that Exchanges may expand the list or further define conflict of interest. For example, a State may elect to prohibit any conflicted members from serving on the board.

Final rule, Interim final rule. (644 pages):
http://www.kaiserhealthnews.org/~/media/Files/2012/Exchange%20Standards%20For%20Employers%20March%202012.pdf

HHS release:
http://www.healthcare.gov/news/factsheets/2011/07/exchanges07112011a.html

Reulatory impact analysis:
http://www.kaiserhealthnews.org/~/media/Files/2012/Exchange%20Regulatory%20Impact%20Analysis%20March%202012.pdf

Comment:

By Don McCanne, MD

Skim reading this 644 page HHS rule on the state insurance exchanges to be established under the Affordable Care Act makes you realize even more how unnecessarily complicated this legislation had to be merely to accommodate the private insurance industry. If you are suffering from euphoria, read this rule and it will cure you.

As everyone knows, the Affordable Care Act was written by and for the private insurance industry. Just to show how much the insurance industry’s influence extends into the Obama administration you merely need to look at the rule on the governing board composition and conflict of interest, to wit, “representatives of health insurance issuers, agents, brokers, or other individuals licensed to sell health insurance may not constitute a majority of the governing board.”

Absolutely astounding! The private insurance industry can occupy up to one-half of the seats on the governing board! Amongst all of the other members of the board, they need only one friend. Watching the reform process take place it is clear that they have friends everywhere!

During the comment period, many expressed concern about this obvious conflict of interest, suggesting even that insurers participate as an advisory group rather than through board membership. And HHS’s response? “We believe that further definition of conflict of interest may create inconsistencies with State law and other existing State standards.”

This is an outrage! Mobilize the forces!

Primary Care: Can Seeds Of Innovation Take Root?

By Thomas Bodenheimer
Health Affairs, March 2012

“Breaking Point: How The Primary Care Crisis Endangers The Lives Of Americans”
by John Geyman
Friday Harbor (WA): Copernicus Healthcare, 2011
234 pp.; $18.95

Many innovations in health care falter. New drugs, hastily approved, can disappear in a flurry of bad outcomes. Medical devices (some metal-on-metal hip replacements, for instance) turn into disasters for those who have them. Certain attempts to improve quality might be oversold and fail to live up to their initial hype; pay-for-performance comes to mind. In health policy, so-called tipping points[1]— times when new ideas spread rapidly to become the norm—are few and far between.

An innovation that “tipped” successfully into place in the recent past is the hospitalist movement, in which hospital-based general physicians handle care for hospitalized patients in place of the patients’ primary care physicians. It took the nation by storm in the 1990s and, for better or worse, changed the way both in- and outpatient care are delivered. Coming now to the innovation forefront is the patient-centered medical home—also known as “transformed primary care,” “twenty-first-century primary care,” and “the primary care of the future.”

John Geyman is someone whose opinion on this new innovation counts. In the 1970s he was one of the founders of the new specialty of family medicine, and he has enjoyed a long and productive career in his beloved primary care.

“Breaking Point,” Geyman’s new book about primary care, reviews the promise and problems of primary care. His analysis leads the reader to wonder whether the medical home will reach a tipping point (success) and permanently transform primary care or a breaking point (failure) and be a short-lived blip on the health policy radar screen. Despite the book’s title and recounting of the difficulties facing primary care, the author seems cautiously optimistic that primary care will grow and thrive. The book has a clear point of view, which is that a single-payer system is a prerequisite to a strong primary care sector. It is well written, informative, evidence-based— and an important book for everyone concerned about the U.S. health care system.

Geyman begins by reviewing the evidence base and essential elements of primary care—much of it on the basis of work by the field’s intellectual giant, the late Barbara Starfield[2]—and primary care’s role as the foundation of any health care system. From there, Geyman turns to the serious barriers facing primary care today in the United States: a growing physician workforce shortage in the area of adult primary care, poorly organized primary care practices, and the impossibility of primary care’s being able to provide accessible, high-quality care when doctors have overly large patient workloads.

But “Breaking Point” is not a despairing or complaining book. After laying out the challenges to building a viable primary care foundation for U.S. health care, Geyman goes on to highlight examples of the enormous energy for improvement that infuses hundreds, if not thousands, of primary care practices around the United States: “The Organized Team Model is ideal for building primary care capability to care for populations in a wide range of practice settings.…[It] offers concrete ways by which year round 24/7 primary care can be provided to populations on a sustained basis.” He continues, “Despite decades of deterioration, some promising developments portend a brighter future.”

This outpouring of innovation and energy that Geyman writes about leads primary care advocates like me to believe that the patient-centered medical home—by whatever name it is called—will, indeed, reach a tipping point and spread widely and well throughout the country.

The early adopters of transformed primary care are community health centers and integrated health care delivery systems. Programs such as the Vermont Blueprint for Health and Group Health in Washington State—both known for their improvements in access, prevention, and quality—are two of the innovations described by Geyman that are showing the way. Yet Geyman is cautious about innovation alone, noting that although “these new grassroots efforts to bring primary care into the 21st century give us some hope of their success, much broader system reform will be required to gain that result.”

His larger prescription includes single-payer universal health insurance, primary care teams, giving doctors a generalist orientation during their medical education, and payment reform. On the specifics of payment reform, Geyman argues that insurers’ payments to primary care practices should not reimburse doctors alone but should also should pay for the work of the entire team. Payments also should recognize primary care’s contribution equally with that of specialty practices.

Geyman does not provide details on how primary care practices might transform themselves. A useful addition to the book might have been a more detailed description of high-performing, well-organized practices—whether a small community health center in South Carolina or a huge integrated system in California—because they are remarkably similar in how they transform themselves.[3]

The bedrock needed for this transformation to succeed is continuity of care, which is well known to improve patients’ and clinicians’ satisfaction, improve quality outcomes, and reduce costs. Patients are affiliated with a specific primary care clinician (a physician, nurse practitioner, or physician assistant) within a group practice, and as often as possible they see that clinician, forming a relationship of trust that also improves outcomes.

Not only does this transformed primary care practice place a priority on continuity, it also ensures prompt access for patients. The capacity needed to meet the growing demand for primary care services is created by having a team—consisting of both professional and nonprofessional providers—deliver health care for a group of patients. In high-performing practices, patients transfer their trust in the doctor to trust in the entire team.

Yet, as Geyman emphasizes, these changes are not easy to accomplish; they require the larger system change cited earlier. “Breaking Point” provides information on both the promise and the challenges of primary care and then gives readers the confidence that transformed primary care can reach a tipping point and become the standard way in which primary care is provided in the United States.

Thomas Bodenheimer (TBodenheimer@fcm.ucsf.edu) is a primary care internist who was in full-time practice for thirty-two years. He is a professor of family and community medicine at the University of California, San Francisco.

NOTES

1 Gladwell M. The tipping point: how little things can make a big difference. Boston (MA): Little Brown and Company; 2002.

2 Starfield B. Primary care: balancing health needs, services, and technology. New York (NY): Oxford University Press; 1998.

3 Bodenheimer T. Lessons from the trenches—a high-performing primary care clinic. N Engl J Med. 2011;365:5–8.

doi: 10.1377/hlthaff.2011.1389

Regional health care approach is needed

By Alan A. Pfeffer and Richard Propp
Letters, Albany (N.Y.) Times Union, March 9, 2012

The Feb. 26 articles “State to reclaim patients” and “Superior care comes at a cost” demonstrate one of the misdirections taken by the state Medicaid Redesign Team.

The state knew that the needs of people on ventilators, people suffering from traumatic brain injuries and people with Huntington’s disease could not be met by the nursing homes within the state. Instead of first creating the needed special units that are required, it decided to try and “repatriate” them back into regular nursing homes.

This was done at the request of the Healthcare Association of New York State, a lobbying organization, so its clients will have a greater stream of business. We argue that people are not business commodities.

This situation would not exist if we had a national single-payer health care system where all people, regardless of their age, employment status or disability, have access to long-term care.

Plans for this were published by the Physicians for a National Health Program 20 years ago. Their plan called for a right to long-term care, universal coverage and a continuum of social and medical services aimed at maximizing functional independence.

The entire population would finance it. Instead, we are burdened with state rivalries rather than what we need, regional interstate consortiums.

Alan A. Pfeffer of Glenmont and Richard Propp of Albany are members of the Capital District Alliance for Universal Healthcare Inc.

http://www.timesunion.com/opinion/article/Letter-Regional-health-care-approach-is-needed-3395854.php#ixzz1ojFjhR8v

Health care 'reform' doesn't solve deep-seated problems

Single-payer system is better option for U.S.

By Bernie Fetterly
Ithaca (N.Y.) Journal, March 9, 2012

We know that the Affordable Health Care Act was written by the insurance companies for the insurance companies. It does not deal with the rising cost of health care and it increases under- insurance for just about everybody. Also, 23 million Americans will remain uninsured. Can we really wait two more years and still have a bad health care plan that will cause many to die needlessly and also cause many to go bankrupt?

President Barack Obama is trying to make his bad health care plan look good in his campaign for re-election. We may be forced to re-elect him, but we should not make the mistake of thinking his Affordable Health Care Act is a good one.

Unaffordable under-insurance

Americans are being confronted with the emergence of a new stage in America’s downward slide on health care. “‘Unaffordable under-insurance” is rapidly becoming the new standard in the United States.

One of the most telling symptoms of the “new normal” is that visits to physicians’ offices have dropped a stunning 17 percent from the second quarter of 2009 to the second quarter of 2011, according to a recent Kaiser Family Foundation report. This drop illustrates how the ever-growing burden of health care costs — in the form of out-of-pocket deductibles and co-pays — is making Americans reluctant to seek care despite having the supposed protection of health insurance. We know that a lot of people are foregoing beneficial treatments for conditions such as diabetes, or not getting vital preventive services such as Pap smears. It’s scary.

As people’s health conditions deteriorate because of a lack of preventive care, the eventual cost of treatment will be much more costly and the chances of a healthy outcome reduced. With high- deductible insurance plans proliferating among pattern-setting large employers, a pattern of unaffordable under-insurance will be well-established by the time the Affordable Care Act, which will include state-level health care exchanges, is fully implemented in 2014.

The various levels of coverage offered under the ACA will leave working families with the same problem of increasingly skimpy insurance coverage that is too expensive to actually utilize.

The “bronze plan” will have an “actuarial value” of 60 percent, meaning that people will be paying 40 percent of their health care costs. Government subsidies and maximums on out-of-pocket costs will provide some assistance, but it still appears that the “bronze plan” will mean that consumers pay about 40 percent.

“The silver plan” covers 70 percent (in other words, it does not cover 30 percent) of health care costs, but the premiums will be higher and most consumers will probably be drawn to the bronze plan. But there is little likelihood that health insurance premiums will remain stable under the bronze plan or any other option under the new federal legislation.

Even with usage of insurance declining, fueling huge profits, insurers in California and elsewhere have been jacking up premiums. Corporations have been able to force workers to swallow the premium increases, with workers’ share of health care costs rising 63 percent between 2003 and 2007. With no effective cost controls contained in the Affordable Care Act — which, after all, was drafted by Wellpoint insurance lobbyist Liz Fowler working alongside the insurers’ pets in Congress — the problem of “unaffordable under- insurance” is only going to snowball as we enter the new era of “reform.”

Disappointing so far

While the ACA has raised hopes that some of the worst abuses of the for-profit insurance industry will be curbed, most “improved Medicare for all” supporters caution that insurers are likely to circumvent regulations and that the ACA won’t be able to keep health care affordable.

The much-vaunted insurance regulations — for instance, ending denials on the basis of pre-existing conditions — are riddled with loopholes, thanks to the central role that insurers played in crafting the legislation. For example, the ACA’s program for people with pre-existing conditions has enrolled a mere fraction of those expected to sign up, as insurance remains prohibitively expensive.

Many single-payer (“improved Medicare for all”) supporters say we appear to be headed toward a new health crisis in which most people find themselves among the ranks of the “unaffordable under-insured” and health care is increasingly delivered in a rigidly tiered system based on ability to pay.

Poor people depending on Medicaid will be especially hard hit as the cash-strapped conservative governors and some Democrats slash Medicare and Medicaid rolls. The limitations of ACA-style reform — which the Obama administration chose to build around the mammoth and unproductive bureaucracy of the for-profit insurance industry — are becoming increasingly apparent.

Some of the most highly-touted features of the ACA features contain built-in problems, Physicians for a National Health Program leaders noted last year. For example, older people can be charged up to three times more than their younger counterparts, and large companies with a predominantly female workforce can be charged higher gender-based rates at least until 2017. Moreover, about 23 million people will remain uninsured nine years into ACA’s existence.

At the same time, the affordability and coverage of those with insurance will continue to deteriorate until the bottom 99 percent start to rebel against a health system shaped to maximize the profits of insurers who seek to minimize care. The Occupy movement offers a hopeful sign that Americans are recognizing that the health care system, like other U.S. institutions, functions to benefit the top 1 percent at the expense of the vast majority.

Health professionals from PNHP say the downward spiral in health care will finally end only when the United States installs a Canadian-style “Medicare for All” single-payer system. It is ideal for the United States, with its very large risk pool, which includes the rich, the middle class, the poor and the elderly. The solution is to have everybody involved and working together.

Hopefully, Obama will change once re-elected, but we don’t have to believe and should not believe that the Patient Protection and Affordable Care Act is a good health care plan for America. A single-payer plan is what we need; it’s a job stimulus and it saves billions of dollars. We can do better. We have to do better.

Bernie Fetterly is director of the Tompkins County Health Care Task Force.

http://www.theithacajournal.com/article/20120310/VIEWPOINTS02/203100307/Guest-Viewpoint-Health-care-reform-doesn-t-solve-deep-seated-problems

Health care ‘reform’ doesn’t solve deep-seated problems

Single-payer system is better option for U.S.

By Bernie Fetterly
Ithaca (N.Y.) Journal, March 9, 2012

We know that the Affordable Health Care Act was written by the insurance companies for the insurance companies. It does not deal with the rising cost of health care and it increases under- insurance for just about everybody. Also, 23 million Americans will remain uninsured. Can we really wait two more years and still have a bad health care plan that will cause many to die needlessly and also cause many to go bankrupt?

President Barack Obama is trying to make his bad health care plan look good in his campaign for re-election. We may be forced to re-elect him, but we should not make the mistake of thinking his Affordable Health Care Act is a good one.

Unaffordable under-insurance

Americans are being confronted with the emergence of a new stage in America’s downward slide on health care. “‘Unaffordable under-insurance” is rapidly becoming the new standard in the United States.

One of the most telling symptoms of the “new normal” is that visits to physicians’ offices have dropped a stunning 17 percent from the second quarter of 2009 to the second quarter of 2011, according to a recent Kaiser Family Foundation report. This drop illustrates how the ever-growing burden of health care costs — in the form of out-of-pocket deductibles and co-pays — is making Americans reluctant to seek care despite having the supposed protection of health insurance. We know that a lot of people are foregoing beneficial treatments for conditions such as diabetes, or not getting vital preventive services such as Pap smears. It’s scary.

As people’s health conditions deteriorate because of a lack of preventive care, the eventual cost of treatment will be much more costly and the chances of a healthy outcome reduced. With high- deductible insurance plans proliferating among pattern-setting large employers, a pattern of unaffordable under-insurance will be well-established by the time the Affordable Care Act, which will include state-level health care exchanges, is fully implemented in 2014.

The various levels of coverage offered under the ACA will leave working families with the same problem of increasingly skimpy insurance coverage that is too expensive to actually utilize.

The “bronze plan” will have an “actuarial value” of 60 percent, meaning that people will be paying 40 percent of their health care costs. Government subsidies and maximums on out-of-pocket costs will provide some assistance, but it still appears that the “bronze plan” will mean that consumers pay about 40 percent.

“The silver plan” covers 70 percent (in other words, it does not cover 30 percent) of health care costs, but the premiums will be higher and most consumers will probably be drawn to the bronze plan. But there is little likelihood that health insurance premiums will remain stable under the bronze plan or any other option under the new federal legislation.

Even with usage of insurance declining, fueling huge profits, insurers in California and elsewhere have been jacking up premiums. Corporations have been able to force workers to swallow the premium increases, with workers’ share of health care costs rising 63 percent between 2003 and 2007. With no effective cost controls contained in the Affordable Care Act — which, after all, was drafted by Wellpoint insurance lobbyist Liz Fowler working alongside the insurers’ pets in Congress — the problem of “unaffordable under- insurance” is only going to snowball as we enter the new era of “reform.”

Disappointing so far

While the ACA has raised hopes that some of the worst abuses of the for-profit insurance industry will be curbed, most “improved Medicare for all” supporters caution that insurers are likely to circumvent regulations and that the ACA won’t be able to keep health care affordable.

The much-vaunted insurance regulations — for instance, ending denials on the basis of pre-existing conditions — are riddled with loopholes, thanks to the central role that insurers played in crafting the legislation. For example, the ACA’s program for people with pre-existing conditions has enrolled a mere fraction of those expected to sign up, as insurance remains prohibitively expensive.

Many single-payer (“improved Medicare for all”) supporters say we appear to be headed toward a new health crisis in which most people find themselves among the ranks of the “unaffordable under-insured” and health care is increasingly delivered in a rigidly tiered system based on ability to pay.

Poor people depending on Medicaid will be especially hard hit as the cash-strapped conservative governors and some Democrats slash Medicare and Medicaid rolls. The limitations of ACA-style reform — which the Obama administration chose to build around the mammoth and unproductive bureaucracy of the for-profit insurance industry — are becoming increasingly apparent.

Some of the most highly-touted features of the ACA features contain built-in problems, Physicians for a National Health Program leaders noted last year. For example, older people can be charged up to three times more than their younger counterparts, and large companies with a predominantly female workforce can be charged higher gender-based rates at least until 2017. Moreover, about 23 million people will remain uninsured nine years into ACA’s existence.

At the same time, the affordability and coverage of those with insurance will continue to deteriorate until the bottom 99 percent start to rebel against a health system shaped to maximize the profits of insurers who seek to minimize care. The Occupy movement offers a hopeful sign that Americans are recognizing that the health care system, like other U.S. institutions, functions to benefit the top 1 percent at the expense of the vast majority.

Health professionals from PNHP say the downward spiral in health care will finally end only when the United States installs a Canadian-style “Medicare for All” single-payer system. It is ideal for the United States, with its very large risk pool, which includes the rich, the middle class, the poor and the elderly. The solution is to have everybody involved and working together.

Hopefully, Obama will change once re-elected, but we don’t have to believe and should not believe that the Patient Protection and Affordable Care Act is a good health care plan for America. A single-payer plan is what we need; it’s a job stimulus and it saves billions of dollars. We can do better. We have to do better.

Bernie Fetterly is director of the Tompkins County Health Care Task Force.

http://www.theithacajournal.com/article/20120310/VIEWPOINTS02/203100307/Guest-Viewpoint-Health-care-reform-doesn-t-solve-deep-seated-problems

HHS hands exchange control to insurers!

Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers

Department of Health and Human Services
Federal Register publication date: March 27, 2012
Final rule, Interim final rule.
Excerpts from pages 34-37
Summary of Regulatory Changes
If the Exchange is an independent State agency or not-for-profit entity established by the State, we proposed that its governing board meet the standards outlined in §155.110(c)(1) through §155.110(c)(4) of the proposed rule, which included: the Exchange accountability structure must be administered under a formal, publicly-adopted operating charter or by-laws; the Exchange board must hold regular public meetings; representatives of health insurance issuers, agents, brokers, or other individuals licensed to sell health insurance may not constitute a majority of the governing board; and, all members of the governing board must meet conflict of interest and qualifications standards.
Several commenters urged HHS to apply conflict of interest standards to eligible contracting entities.
Response: We generally defer to States to establish conflict of interest standards for eligible contracting entities beyond the prohibition of health insurance issuers being eligible contracting entities, as established in section 1311(f)(3) of the Affordable Care Act and codified in §155.110(a)(1)(iii). We believe that many States have existing conflict of interest laws, have appropriate expertise in this area, and can support Exchanges in the development of conflict of interest standards for such entities.
Commenters suggested broadening the list of groups identified as having a conflict of interest in proposed §155.110(c)(3)(ii) to include: health care providers; anyone with a financial interest; anyone with a spouse or immediate family with a conflict of interest; major vendors, subcontractors, or other financial partners of conflicted parties; members of health trade associations and providers; and, health information technology companies. Commenters recommended that such groups be limited or prohibited from participation in an Exchange. Other commenters recommended that individuals with ties to the insurance industry participate through technical panel or advisory group instead of through board membership.
Response: As proposed, §155.110(c)(3)(ii) ensures as a minimum standard that the groups with the most direct conflict of interest cannot form a majority of voting members on a governing board. We believe that further definition of conflict of interest may create inconsistencies with State law and other existing State standards, but note that Exchanges may expand the list or further define conflict of interest. For example, a State may elect to prohibit any conflicted members from serving on the board.
Final rule, Interim final rule. (644 pages):
http://www.kaiserhealthnews.org/~/media/Files/2012/Exchange%20Standards%20For%20Employers%20March%202012.pdf
HHS release:
http://www.healthcare.gov/news/factsheets/2011/07/exchanges07112011a.html
Reulatory impact analysis:
http://www.kaiserhealthnews.org/~/media/Files/2012/Exchange%20Regulatory%20Impact%20Analysis%20March%202012.pdf

Skim reading this 644 page HHS rule on the state insurance exchanges to be established under the Affordable Care Act makes you realize even more how unnecessarily complicated this legislation had to be merely to accommodate the private insurance industry. If you are suffering from euphoria, read this rule and it will cure you.
As everyone knows, the Affordable Care Act was written by and for the private insurance industry. Just to show how much the insurance industry’s influence extends into the Obama administration you merely need to look at the rule on the governing board composition and conflict of interest, to wit, “representatives of health insurance issuers, agents, brokers, or other individuals licensed to sell health insurance may not constitute a majority of the governing board.”
Absolutely astounding! The private insurance industry can occupy up to one-half of the seats on the governing board! Amongst all of the other members of the board, they need only one friend. Watching the reform process take place it is clear that they have friends everywhere!
During the comment period, many expressed concern about this obvious conflict of interest, suggesting even that insurers participate as an advisory group rather than through board membership. And HHS’s response? “We believe that further definition of conflict of interest may create inconsistencies with State law and other existing State standards.”
This is an outrage! Mobilize the forces!

Krauthammer and Kahn convinced; Salam wants to hear more

Columnist: If 'Obamacare' implemented, single-payer is next

By Don Finley
San Antonio Express-News, March 9, 2012

If President Obama’s health care reform act is fully implemented over the next two years, it will evolve into a Canadian-style single-payer system that will forever change the social contract between Americans and their government, a nationally syndicated columnist and physician predicted.

“It will change the country. If it is not repealed, we will be a different country when ‘Obamacare’ is fully implemented,” (Washington Post columnist and Fox News commentator Charles) Krauthammer said in an interview after speaking Thursday to a receptive crowd of mostly physicians and other health care professionals at a breakfast sponsored by the San Antonio Medical Foundation.

In his speech, Krauthammer predicted the complexity of the law eventually would doom it to failure, which would lead to a single-payer system within a decade.

“This is a new reform that when it kicks in within a couple of years will make the practice of medicine a nightmare,” he said. “If it’s not repealed, I guarantee you that within a decade we will have a single-payer system. And if I had to choose between Obamacare and a Canadian or British system, I’d choose the single-payer system. At least it would be rational.”

http://www.mysanantonio.com/news/local_news/article/Columnist-If-Obamacare-implemented-single-payer-3392700.php

And…

On the $1,000 Genome and the Future of Health Systems

By Reihan Salam
National Review Online, March 8, 2012

Back in 2009, I wrote a column that pivoted off of a really good 2007 column by economist Stephen Cecchetti which argued that the genomics revolution made single-payer inevitable. At the time, I argued that while the genomics revolution didn’t make single-payer inevitable, it would push health systems in the advanced market democracies towards a more coherent system for protecting against chronic illnesses and catastrophic medical expenditures.

Razib Khan, my go-to writer on these matters, adds the following: (Comments on the $1000 genome available at the link below)…

That is, the $1,000 genome will accelerate the growth of a broader innovative ecology that will transform medicine. Razib, incidentally, is a rare right-of-center supporter of single-payer health systems, and I’d love to hear his thoughts on the subject.

http://www.nationalreview.com/agenda/293003/1000-genome-and-future-health-systems-reihan-salam

Comment: 

By Don McCanne, MD

Many conservatives have a good understanding of the beneficial features of the single payer model of health care financing, and several believe that it may be an inevitable imperative. As Charles Krauthammer states, “And if I had to choose between Obamacare and a Canadian or British system, I’d choose the single-payer system. At least it would be rational.”