PNHP

The Dartmouth Atlas and ACOs

The Dartmouth Atlas and ACOs

Critics Question Study Cited in Health Debate

By Reed Abelson and Gardiner Harris
The New York Times
June 2, 2010
In selling the health care overhaul to Congress, the Obama administration cited a once obscure research group at Dartmouth College to claim that it could not only cut billions in wasteful health care spending but make people healthier by doing so.
But while the research compiled in the Dartmouth Atlas of Health Care has been widely interpreted as showing the country’s best and worst care, the Dartmouth researchers themselves acknowledged in interviews that in fact it mainly shows the varying costs of care in the government’s Medicare program. Measures of the quality of care are not part of the formula.
The mistaken belief that the Dartmouth research proves that cheaper care is better care is widespread — and has been fed in part by Dartmouth researchers themselves.
The debate about the Dartmouth work is important because a growing number of health policy researchers are finding that overhauling the nation’s health care system will be far harder and more painful than the Dartmouth work has long suggested. Cuts, if not made carefully, could cost lives.
http://www.nytimes.com/2010/06/03/business/03dartmouth.html?hp=&pagewanted=all
A graphic comparing “The Dartmouth Atlas of Health Care” with Medicare’s “Hospital Compare”:
http://www.nytimes.com/interactive/2010/06/03/business/Dartmouth-maps.html

And…

Monarch HealthCare, HealthCare Partners, and Anthem Blue Cross Chosen for Innovative National Healthcare Program

Marketwire
May 25, 2010
Two of Southern California’s leading physician-governed medical groups, along with Anthem Blue Cross, have been selected for participation in a new and innovative, nationally-recognized healthcare model that rewards providers for improving patient outcomes, while slowing cost growth.
Monarch HealthCare, an Irvine, California-based Medical Group and Independent Physician Association (IPA), and HealthCare Partners, a Torrance, California-based Medical Group and IPA, will collaborate with Anthem Blue Cross in an Accountable Care Organization (ACO) pilot project led by the Engelberg Center for Health Care Reform at Brookings and The Dartmouth Institute for Health Policy and Clinical Practice. The selection of the two California organizations furthers the nationwide demonstration project already underway in three other communities. The demonstration project expects to produce a successful model that will be replicable throughout the country.
Jay Cohen, M.D., president and chairman of the board at Monarch, believes “this is a very exciting development for anyone who supports innovative ideas designed to improve healthcare delivery in the communities we serve. Monarch has always been a leader in this regard and is delighted to have been selected as a pilot site for this project.”
http://www.marketwire.com/press-release/Monarch-HealthCare-HealthCare-Partners-Anthem-Blue-Cross-Chosen-Innovative-National-1265703.htm

The Dartmouth Atlas of Health Care has been an important contribution to the health policy literature because it demonstrates that regional variations in health care spending are very real. The reasons for these differences are complex and certainly not fully understood at this time.
In spite of the lack of adequate comprehension of the multiple factors involved, the Dartmouth researchers and the Washington politicians are pushing us into accountable care organizations (ACOs) that would arbitrarily reduce spending in high cost areas even though that spending might be medically appropriate and such reductions could impair health care outcomes.
Examples of other important factors that should be considered include the rates of poverty in the region, the population health status in the region, adequacy of health insurance and other financing programs, prices being charged for health care services, excess or deficient capacities in health care facilities especially for high-tech services, and whether or not the variations in frequency and intensity of services are medically appropriate. All potential factors should be well defined through further study, and then policy decisions should be made on the facts.
Unfortunately, moving forward with ACOs is not based on solid policy science. The prototype already initiated by the Dartmouth Institute and others, as mentioned in the Marketwire article above, is really not much different from the HMO concept.
Each year Jay Cohen, MD, MBA, the president and chairman of Monarch HealthCare, and I coach competing debate teams at the University of California at Irvine School of Medicine. The debate is on single payer versus managed care. I can assure you that the ACO under Monarch HealthCare will be structured based on markets and money, with “accountable” prioritized over “care.” Who in their right mind would ever believe that a new label for an old entity will somehow magically reduce our health care spending?
We do need to proceed with studies that could lead to promising efficiencies, but we should not allow the dubious ACO experiment to divert us from introducing proven efficiencies now. The most obvious would be to introduce a single payer national health program. That would provide us with much greater value in our health care purchasing while slowing the rate of cost growth throughout the future. And, oh yes, it would ensure that all of us would receive the care that we need – a mission not on the agendas of ACOs.

Critics Question Study Cited in Health Debate

By REED ABELSON and GARDINER HARRIS
The New York Times
June 2, 2010

In selling the health care overhaul to Congress, the Obama administration cited a once obscure research group at Dartmouth College to claim that it could not only cut billions in wasteful health care spending but make people healthier by doing so.

Wasteful spending — perhaps $700 billion a year — “does nothing to improve patient health but subjects you and me to tests and procedures that aren’t necessary and are potentially harmful,” the president’s budget director, Peter Orszag, wrote in a blog post characteristic of the administration’s argument.

Mr. Orszag even displayed maps produced by Dartmouth researchers that appeared to show where the waste in the system could be found. Beige meant hospitals and regions that offered good, efficient care; chocolate meant bad and inefficient.

The maps made reform seem relatively easy to many in Congress, some of whom demanded the administration simply trim the money Medicare pays to hospitals and doctors in the brown zones. The administration promised to seriously consider doing just that.

But while the research compiled in the Dartmouth Atlas of Health Care has been widely interpreted as showing the country’s best and worst care, the Dartmouth researchers themselves acknowledged in interviews that in fact it mainly shows the varying costs of care in the government’s Medicare program. Measures of the quality of care are not part of the formula.

For all anyone knows, patients could be dying in far greater numbers in hospitals in the beige regions than hospitals in the brown ones, and Dartmouth’s maps would not pick up that difference. As any shopper knows, cheaper does not always mean better.

Even Dartmouth’s claims about which hospitals and regions are cheapest may be suspect. The principal argument behind Dartmouth’s research is that doctors in the Upper Midwest offer consistently better and cheaper care than their counterparts in the South and in big cities, and if Southern and urban doctors would be less greedy and act more like ones in Minnesota, the country would be both healthier and wealthier.

But the real difference in costs between, say, Houston and Bismarck, N.D., may result less from how doctors work than from how patients live. Houstonians may simply be sicker and poorer than their Bismarck counterparts. Also, nurses in Houston tend to be paid more than those in North Dakota because the cost of living is higher in Houston. Neither patients’ health nor differences in prices are fully considered by the Dartmouth Atlas.

The mistaken belief that the Dartmouth research proves that cheaper care is better care is widespread — and has been fed in part by Dartmouth researchers themselves.

The debate about the Dartmouth work is important because a growing number of health policy researchers are finding that overhauling the nation’s health care system will be far harder and more painful than the Dartmouth work has long suggested. Cuts, if not made carefully, could cost lives.

Looking in detail at Dartmouth’s evidence helps show why.

Criticisms on Spending

A main focus of the Dartmouth Atlas is comparing spending among the nation’s hospitals. To do that, Dartmouth researchers use data on how much hospitals have billed Medicare for patients with a chronic illness who were in their last six months or two years of life.

“We show where the waste is in medicine,” said Dr. Elliott Fisher, a physician who is one of the principal authors of the Dartmouth work and was a frequent visitor to Washington during the long legislative debate. “If everyone could operate like Oregon, Seattle or the Upper Midwest, there’s huge savings.”

But the atlas’s hospital rankings do not take into account care that prolongs or improves lives. If one hospital spends a lot on five patients and manages to keep four of them alive, while another spends less on each but all five die, the hospital that saved patients could rank lower because Dartmouth compares only costs before death.

“It may be that some places that are spending more are actually getting better results,” said Dr. Harlan M. Krumholz, a professor of medicine and health policy expert at Yale.

Failing to receive credit for better care enrages some hospital administrators. But for the Dartmouth researchers, making these administrators uncomfortable is the point of the rankings.

“When you name names, people start paying more attention,” Dr. Fisher said. “We never asserted and never claimed that we judged the quality of care at a hospital — only the cost.”

In interviews, administration officials acknowledged that the Dartmouth Atlas was far from perfect. Mr. Orszag says he does not rely on the atlas alone to prove that huge savings are possible.

“What I have repeatedly said is that a wide variety of evidence suggests there is substantial opportunity for savings, and the challenge is in capturing that opportunity,” he said.

Still, the Dartmouth work remains influential in Washington.

Dr. Donald Berwick, nominated by President Obama to run Medicare, called it the most important research of its kind in the last quarter-century. In March, in response to the Congressional Democrats who would have otherwise withheld their support for the health legislation, the administration made a promise. It said it would ask the Institute of Medicine, a nongovernment advisory group, to consider ways of putting the Dartmouth findings into action by setting payment rates that would punish inefficient hospitals and reward efficient ones.

But if that system penalizes big city hospitals like those at the Ronald Reagan UCLA Medical Center and NYU Langone Medical Center — which look profligate by Dartmouth’s measure but may rank much higher by other quality indicators — a battle over the validity of the Dartmouth work is almost certain in Congress.

In fact, among health policy analysts, that battle has already begun. Critiques have been published in prominent medical journals, and more are on the way.

Differences in Patient Care

In interviews and extensive written comments, Dr. Fisher and Jonathan Skinner, a health economist at Dartmouth who works with him, vigorously defended their work. They berated what they described as “a cottage industry in new studies trying to debunk our findings.”

They say their critics fail to understand the issues and often make significant statistical errors. And they say even if they adjusted more fully to reflect differences in regional costs and patients’ health, the overall effect on the atlas’s findings would be relatively small.

The researchers also say they have made some of those adjustments in some of their other published work. Many other health researchers say Dartmouth should be praised for highlighting the tremendous differences in how patients are treated and for emphasizing that patients often fail to benefit from additional care.

“Dartmouth opened our eyes to something that I believe is real and important,” said Dr. Robert M. Wachter, a professor in hospital medicine at the University of California, San Francisco.

But even those who defend Dartmouth say that failing to make basic data adjustments undermines the geographic variations the atlas purports to show. David Cutler, a professor of economics at Harvard, likens it to failing to account for inflation when looking at gross domestic product. “Nobody in their right mind would talk about G.D.P. growth without adjusting for prices,” he said.

In addition to their hospital rankings, the Dartmouth researchers have also done separate studies of how Medicare spending affects patient care regionally. A 2003 study found tha
t patients who lived in places most expensive for the Medicare program received no better care than those who lived in cheaper areas.

Because some regions spent nearly a third more than other regions without any apparent benefit, the Dartmouth team concluded that at least one dollar in three was wasted by Medicare. When applied generally to the nation’s health care system, that meant about $700 billion could be saved.

But as it began publicly discussing its research, the Dartmouth team often extrapolated beyond this basic finding. Not only do high-spending regions fail to provide better care, the Dartmouth team began to argue, but those regions actually offer worse care.

In just one example of this extrapolation, Dr. Fisher, in testimony before Congress last year, summarized his and others’ work by asking, “Why are access and quality worse in high-spending regions?”

And on Dartmouth’s Web site, a question-and-answer section suggests that this interpretation is appropriate:

“The evidence is that higher utilization does not extend life expectancy, and might be correlated with shorter life expectancy, compared with lower utilization. Therefore, sending people with chronic diseases to higher-efficiency, lower-utilization hospitals for their care could result in both lower spending and increased quality and length of life.”

While a few studies by other researchers have shown that more spending leads to worse health, some others have suggested the opposite — that more expensive hospitals might offer better care. But many have shown no link, either way, between spending and quality.

In other words, there is little evidence to support the widely held view, shaped by the Dartmouth researchers, that the nation’s best hospitals tend to be among the least expensive.

In interviews, Dr. Fisher and Mr. Skinner acknowledged that there was no proven link between greater spending and worse health outcomes. And Dr. Fisher acknowledged the apparent inconsistency between his statements in interviews with The New York Times and those made elsewhere, saying that he was sometimes less careful in discussing his team’s research than he should be.

In any case, the more-is-worse message has resonated with insurers, whose foundations now help to finance the Dartmouth Atlas. Dartmouth researchers also created a company, Health Dialog, to consult for insurers and others on Dartmouth’s findings. Valued at nearly $800 million, the company was sold to a British insurer in 2007 and still helps to finance the Dartmouth work.

Rankings in Wisconsin

Last June, as Mr. Obama campaigned for his health care overhaul, he visited Green Bay, Wis., praising the city for getting “more quality out of fewer health care dollars than many other communities.”

Two of Green Bay’s hospitals, Bellin and St. Mary’s Hospital Medical Center, rank fourth and 11th within Wisconsin on the Dartmouth list.

But again, Dartmouth ranks hospitals only by costs and number of treatments and procedures. A different picture emerges from work done by the Wisconsin Collaborative for Healthcare Quality, a voluntary group of health care organizations that uses both price and quality of care measures. In an analysis of heart attack care, for example, it ranks Bellin second, and St. Mary’s 15th, among the 22 hospitals in the state.

And a Medicare ranking based on its own data that shows how many people die after treatment for certain conditions — statistics that exclude costs entirely — puts Bellin fifth, but drops St. Mary’s to second-to-last: 67th of the 68 hospitals statewide that were measured by both Dartmouth and Medicare.

Do the Green Bay hospitals favored by Dartmouth really offer better care? Maybe not.

Similar problems arise with Dartmouth’s regional data. In Dartmouth’s rankings, for instance, New Jersey comes in dead last because its costs per Medicare beneficiary are the nation’s highest. And yet, for the quality of care offered in New Jersey, independent of cost, federal health officials rank New Jersey second only to Vermont.

Researchers who have examined the Dartmouth Atlas numbers have found other flaws that can distort hospital rankings. Doctors at Cedars-Sinai in Los Angeles, for instance, found that Dartmouth had failed to distinguish two different types of intensive care units the hospital runs. Dartmouth also might have overcounted the number of specialists examining each patient.

The errors, Cedars-Sinai said, meant the hospital probably fared worse in the Dartmouth rankings than it should have. Cedars-Sinai’s chief medical officer, Dr. Michael Langberg, said he had tried to discuss these problems with Dartmouth researchers but had thought they were unresponsive.

Dr. Fisher said he had tried to address Cedars-Sinai’s concerns. But he also argued that while the Dartmouth Atlas was not perfect, it provided useful insights into differences in the way various hospitals treat patients.

“For the past 20 years, my colleagues and I and now many others have been working hard to clarify the causes and consequences of regional variations in practice and spending,” Dr. Fisher said. “The work is challenging and more work needs to be done, but we have learned enough to help guide health reform.”

Discussion in Portsmouth June 10 on national heath program

By Roni Reino
Fosters Daily Democrat
Saturday, May 29, 2010

PORTSMOUTH — The Portsmouth Primary Care Associates will host a discussion with Oliver Fein, president of the Physicians for a National Health Program on June 10.

The PNHP is an advocacy organization of some 17,000 American physicians, medical students and health care professionals who support a single-payer system of national health insurance.

The organization will hold a public forum on health care reform and suggest a solution with single-payer health care that will work for the small business person and the individual.

Single-payer health care is the financing of the costs to deliver universal health care for an entire population. It uses a single insurance pool of insured persons, employers and others.

It is a system in which a single or quasi-public agency organizes health financing, but the delivery of care remains largely private.

According to the PNHP, all Americans would be covered for all medical necessary services including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supplies.

Under their plan, patients would retain free choice of doctor and hospital.

Australia, Canada and the United Kingdom all have examples of a single-payer universal health care system.

A survey conducted by the PNHP found that 81 percent of responding New Hampshire physicians agreed health care should be “available to all citizens as part of the social contract, a right similar to basic education, police and fire protection.”

Dr. Thomas Clairmont of the PNHP advocates for the single-payer system and suggests Americans have the choice of another health care option.

“We need alternative solutions now rather than waiting,” Clairmont said.

He also emphasized health care costs will rise unless the U.S. government does something about it soon, making it more difficult for people to pay for insurance.

“It should be that everyone gets covered,” Clairmont said.

The discussion will be held Thursday, June, 10 from 3 p.m. to 4:30 p.m. at the Frank Jones Center on the Route 1 Bypass in Portsmouth. The forum is open to the public with no registration required and attendance is free.

http://www.fosters.com/apps/pbcs.dll/article?AID=2010705299914

AHIP mischaracterizes NICE alcohol screening recommendations

British Doctors Must Now Ask: Tell Us How Much You Drink

America’s Health Insurance Plans (AHIP)
(Source – Rebecca Smith, The Daily Telegraph)
June 2, 2010

Under new guidelines set by the National Institute for Health and Clinical Excellence (NICE), British healthcare providers are required to inquire about their patients’ drinking habits as a means to curb the nation’s problem with drinking. NICE recommends that doctors and pharmacists alike gauge patient-consumption tendencies through a series of “alcohol screening” questions – the line of interrogation including no less than 10 questions.

http://www.ahiphiwire.org/International/News/Default.aspx?doc_id=589183&utm_source=6/2/2010

And…

PH24 Alcohol use disorders: preventing harmful drinking: guidance

National Institute for Health and Clinical Excellence (NICE)

Recommendation 9: screening adults

Where screening everyone is not feasible or practicable, NHS professionals should focus on groups that may be at an increased risk of harm from alcohol and those with an alcohol-related condition. This includes people:

− with relevant physical conditions (such as hypertension and gastrointestinal or liver disorders)
− with relevant mental health problems (such as anxiety, depression or other mood disorders)
− who have been assaulted
− at risk of self-harm
− who regularly experience accidents or minor traumas
− who regularly attend GUM clinics or repeatedly seek emergency contraception.

Full report (100 pages):
http://www.nice.org.uk/nicemedia/live/13001/48984/48984.pdf

The 10 questions used for screening (page 16 of 35 pages):
http://www.nice.org.uk/nicemedia/live/13001/49023/49023.pdf

About NICE: “NICE produces guidance on public health, health technologies and clinical practice.”
http://www.nice.org.uk/aboutnice/whatwedo/what_we_do.jsp

Comment: 

By Don McCanne, MD

Great Britain’s National Institute for Health and Clinical Excellence (NICE) produces guidance on public health, health technologies and clinical practice. Their efforts are directed at improving value in health care, especially reducing spending for ineffective or inappropriate services and products.

America’s Health Insurance Plans (AHIP) has repeatedly called for government policies that would help control spending. You would think that AHIP would be supportive of the NICE concept, but by distributing today’s release that falsely states, in essence, that British physicians are being required to invade the privacy of every one of their patients by submitting them to a questionnaire on alcohol use, it seems that AHIP is joining forces with the conservatives who have been condemning NICE as a program of socialistic government rationing. Nowhere in the 100 page NICE report does it state that universal alcohol screening is an absolute requirement. Also for a physician to discuss alcohol problems with a patient is no more an invasion of privacy than discussing any other factors that might influence the patient’s health.

The good news is that the United States has taken a step forward by expanding the role of comparative effectiveness research (CER). Although it is unclear as to whether CER would have much impact on total health care spending, there is no question but that it will provide greater value in our health care.

If we really do care about attaining greater value then we need to expand NICE-like policies while eliminating the profound waste of the superfluous insurance industry represented by AHIP.

AHIP mischaracterizes NICE alcohol screening recommendations

British Doctors Must Now Ask: Tell Us How Much You Drink

America’s Health Insurance Plans (AHIP)
(Source – Rebecca Smith, The Daily Telegraph)
June 2, 2010
Under new guidelines set by the National Institute for Health and Clinical Excellence (NICE), British healthcare providers are required to inquire about their patients’ drinking habits as a means to curb the nation’s problem with drinking. NICE recommends that doctors and pharmacists alike gauge patient-consumption tendencies through a series of “alcohol screening” questions – the line of interrogation including no less than 10 questions.
http://www.ahiphiwire.org/International/News/Default.aspx?doc_id=589183&utm_source=6/2/2010

And…

PH24 Alcohol use disorders: preventing harmful drinking: guidance

National Institute for Health and Clinical Excellence (NICE)
Recommendation 9: screening adults
Where screening everyone is not feasible or practicable, NHS professionals should focus on groups that may be at an increased risk of harm from alcohol and those with an alcohol-related condition. This includes people:
− with relevant physical conditions (such as hypertension and gastrointestinal or liver disorders)
− with relevant mental health problems (such as anxiety, depression or other mood disorders)
− who have been assaulted
− at risk of self-harm
− who regularly experience accidents or minor traumas
− who regularly attend GUM clinics or repeatedly seek emergency contraception.
Full report (100 pages):
http://www.nice.org.uk/nicemedia/live/13001/48984/48984.pdf
The 10 questions used for screening (page 16 of 35 pages):
http://www.nice.org.uk/nicemedia/live/13001/49023/49023.pdf
About NICE: “NICE produces guidance on public health, health technologies and clinical practice.”
http://www.nice.org.uk/aboutnice/whatwedo/what_we_do.jsp

Great Britain’s National Institute for Health and Clinical Excellence (NICE) produces guidance on public health, health technologies and clinical practice. Their efforts are directed at improving value in health care, especially reducing spending for ineffective or inappropriate services and products.
America’s Health Insurance Plans (AHIP) has repeatedly called for government policies that would help control spending. You would think that AHIP would be supportive of the NICE concept, but by distributing today’s release that falsely states, in essence, that British physicians are being required to invade the privacy of every one of their patients by submitting them to a questionnaire on alcohol use, it seems that AHIP is joining forces with the conservatives who have been condemning NICE as a program of socialistic government rationing. Nowhere in the 100 page NICE report does it state that universal alcohol screening is an absolute requirement. Also for a physician to discuss alcohol problems with a patient is no more an invasion of privacy than discussing any other factors that might influence the patient’s health.
The good news is that the United States has taken a step forward by expanding the role of comparative effectiveness research (CER). Although it is unclear as to whether CER would have much impact on total health care spending, there is no question but that it will provide greater value in our health care.
If we really do care about attaining greater value then we need to expand NICE-like policies while eliminating the profound waste of the superfluous insurance industry represented by AHIP.

Dilemma of insuring seasonal agricultural workers

Oregon agriculture industry sorts health care

By Harris Meyer
The Oregonian
May 29, 2010

Unlike many agricultural employers, Ken Bailey of Orchard View Farms in The Dalles offers his 85 full-time workers health insurance. The orchard and packinghouse operator pays 80 percent of the premium for workers and their dependents.

But like nearly all growers, Bailey’s company does not offer coverage to the 600 to 700 seasonal workers it hires for about eight weeks each year to pick cherries and pears on its 2,080 acres. It’s estimated that as few as 10 percent of farmworkers nationally have health insurance.

Now, Bailey and other farmers in Oregon and Washington are nervous about the federal health reform law passed in March. It requires employers with 50 or more full-time equivalent workers to provide health coverage starting in 2014 or pay a $2,000 penalty per employee. Bailey, who favored health reform, said he’s comfortable with that. Industry groups say most Pacific Northwest growers are too small to fall under that mandate.

But the new law also may require larger farmers and packers like Bailey who meet the 50-employee threshold to offer insurance to seasonal workers or pay the penalty, depending on how the government writes the rules, according to the American Farm Bureau Federation in Washington, D.C. That would be a major new cost for growers already struggling with the bad economy and lower prices for their products.

“It’s almost impossible for individual growers to cover seasonals,” Bailey said. “It depends on whether there is a reasonable program with a reasonable price.” Farmers might even end up paying for coverage of undocumented workers, he said, since they have no reliable way of verifying their workers’ legal status because so many documents — even Social Security cards — can be faked.

For agricultural employers, though, the biggest concern is whether they’ll be required to cover seasonal workers, whom Pacific Northwest growers depend on heavily for their labor-intensive fruit and vegetable crops. The law excludes seasonals — defined as working 120 days or fewer in a calendar year — from being counted toward the threshold of 50 full-time-equivalent employees that brings employers under the insurance mandate. But a new Congressional Research Service analysis says the law requires employers over that threshold to cover seasonals during the months they are working full-time or pay the penalty.

The seasonal worker issue is just one of many uncertainties facing agricultural employers and workers as the complex new health care law is rolled out.

http://www.oregonlive.com/business/index.ssf/2010/05/oregon_ag_industry_sorts_healt.html

Comment:  

By Don McCanne, MD

This is yet another of the endless examples of how the Patient Protection and Affordable Care Act (PPACA) is so flawed that it cannot ever result in accomplishing the primary reform goal of covering everyone. Seasonal agricultural workers do not fit into a neat slot in the dysfunctional, fragmented financing system that President Obama and Congress have selected for us.

The first question we might ask is should all seasonal agricultural workers in the United States have the health care that they need without having to suffer potentially severe financial consequences? If you support cultural narcissism and reject social solidarity, then go away. You really wouldn’t fit in with a group of people who believe that we should take care of each other, and our views are apt to only make you more angry.

Those who do believe that seasonal agricultural workers should have health care the year around, if they need it, understand how complex the rules will have to be to cover them with a system that includes an employer mandate, an individual mandate, and varying requirements based on previous, current and future employment, or unemployment, and based on the impact of vacillations in income as related to sliding-scale eligibility or ineligibility for various programs.

Just briefly touching on some of the policies inherent in PPACA: employers with over 50 full-time equivalent employees will have to purchase coverage for their seasonal employees or pay a $2000 penalty per employee, even though that may be a staggering bill because of a temporary ten-fold increase in the number of employees; since most seasonal employees are uninsured, moving in and out of coverage during the harvest season results in instability of coverage; many seasonal workers are undocumented and thus ineligible for purchase of plans in the exchanges, defeating the purpose of the individual mandate; seasonal workers might be able to obtain care through community health centers, though that depends on having clinics accessible and may mean that important specialized services may not be provided, and the mere existence of such clinics may not fulfill the mandate requirements anyway; though the workers and their families might be eligible for Medicaid on an income basis, that may conflict with the employer mandate; etc.

One of the structural problems is that this fragmented system attempts to assign an insurance product, whether employer-sponsored, privately purchased in the individual market, privately purchased in the exchange, provided by the government in the form of Medicaid, or provided as a safety-net function such as the community health centers, when the eligibility and ability to pay is highly variable between individuals and at different points in time. Fragmentation, disruptions, and voids in coverage are inevitable. We need to sever the individual link to a specific insurance product.

What would fix this would be a single payer national health program with automatic enrollment for everyone, financed separately though equitable tax policies. For purely ethical reasons, we can’t accept the new status quo of the highly dysfunctional PPACA. We need to dump it and move on with an improved Medicare for everyone.

For the cultural narcissists who read this far, we would hope to enact a system that would ensure that you will always be able to have the health care that you need, but we would also use the tax system to prohibit you from being a free rider, just as the tax system prevents us from not paying our share of the wars that we oppose.

Dilemma of insuring seasonal agricultural workers

Oregon agriculture industry sorts health care

By Harris Meyer
The Oregonian
May 29, 2010
Unlike many agricultural employers, Ken Bailey of Orchard View Farms in The Dalles offers his 85 full-time workers health insurance. The orchard and packinghouse operator pays 80 percent of the premium for workers and their dependents.
But like nearly all growers, Bailey’s company does not offer coverage to the 600 to 700 seasonal workers it hires for about eight weeks each year to pick cherries and pears on its 2,080 acres. It’s estimated that as few as 10 percent of farmworkers nationally have health insurance.
Now, Bailey and other farmers in Oregon and Washington are nervous about the federal health reform law passed in March. It requires employers with 50 or more full-time equivalent workers to provide health coverage starting in 2014 or pay a $2,000 penalty per employee. Bailey, who favored health reform, said he’s comfortable with that. Industry groups say most Pacific Northwest growers are too small to fall under that mandate.
But the new law also may require larger farmers and packers like Bailey who meet the 50-employee threshold to offer insurance to seasonal workers or pay the penalty, depending on how the government writes the rules, according to the American Farm Bureau Federation in Washington, D.C. That would be a major new cost for growers already struggling with the bad economy and lower prices for their products.
“It’s almost impossible for individual growers to cover seasonals,” Bailey said. “It depends on whether there is a reasonable program with a reasonable price.” Farmers might even end up paying for coverage of undocumented workers, he said, since they have no reliable way of verifying their workers’ legal status because so many documents — even Social Security cards — can be faked.
For agricultural employers, though, the biggest concern is whether they’ll be required to cover seasonal workers, whom Pacific Northwest growers depend on heavily for their labor-intensive fruit and vegetable crops. The law excludes seasonals — defined as working 120 days or fewer in a calendar year — from being counted toward the threshold of 50 full-time-equivalent employees that brings employers under the insurance mandate. But a new Congressional Research Service analysis says the law requires employers over that threshold to cover seasonals during the months they are working full-time or pay the penalty.
The seasonal worker issue is just one of many uncertainties facing agricultural employers and workers as the complex new health care law is rolled out.
http://www.oregonlive.com/business/index.ssf/2010/05/oregon_ag_industry_sorts_healt.html

This is yet another of the endless examples of how the Patient Protection and Affordable Care Act (PPACA) is so flawed that it cannot ever result in accomplishing the primary reform goal of covering everyone. Seasonal agricultural workers do not fit into a neat slot in the dysfunctional, fragmented financing system that President Obama and Congress have selected for us.
The first question we might ask is should all seasonal agricultural workers in the United States have the health care that they need without having to suffer potentially severe financial consequences? If you support cultural narcissism and reject social solidarity, then go away. You really wouldn’t fit in with a group of people who believe that we should take care of each other, and our views are apt to only make you more angry.
Those who do believe that seasonal agricultural workers should have health care the year around, if they need it, understand how complex the rules will have to be to cover them with a system that includes an employer mandate, an individual mandate, and varying requirements based on previous, current and future employment, or unemployment, and based on the impact of vacillations in income as related to sliding-scale eligibility or ineligibility for various programs.
Just briefly touching on some of the policies inherent in PPACA: employers with over 50 full-time equivalent employees will have to purchase coverage for their seasonal employees or pay a $2000 penalty per employee, even though that may be a staggering bill because of a temporary ten-fold increase in the number of employees; since most seasonal employees are uninsured, moving in and out of coverage during the harvest season results in instability of coverage; many seasonal workers are undocumented and thus ineligible for purchase of plans in the exchanges, defeating the purpose of the individual mandate; seasonal workers might be able to obtain care through community health centers, though that depends on having clinics accessible and may mean that important specialized services may not be provided, and the mere existence of such clinics may not fulfill the mandate requirements anyway; though the workers and their families might be eligible for Medicaid on an income basis, that may conflict with the employer mandate; etc.
One of the structural problems is that this fragmented system attempts to assign an insurance product, whether employer-sponsored, privately purchased in the individual market, privately purchased in the exchange, provided by the government in the form of Medicaid, or provided as a safety-net function such as the community health centers, when the eligibility and ability to pay is highly variable between individuals and at different points in time. Fragmentation, disruptions, and voids in coverage are inevitable. We need to sever the individual link to a specific insurance product.
What would fix this would be a single payer national health program with automatic enrollment for everyone, financed separately though equitable tax policies. For purely ethical reasons, we can’t accept the new status quo of the highly dysfunctional PPACA. We need to dump it and move on with an improved Medicare for everyone.
For the cultural narcissists who read this far, we would hope to enact a system that would ensure that you will always be able to have the health care that you need, but we would also use the tax system to prohibit you from being a free rider, just as the tax system prevents us from not paying our share of the wars that we oppose.

Anthem Blue Cross has racked up 479 enforcement actions

Anthem Big Outlier In DMHC Actions

Payers and Providers
May 27, 2010

Since the California Department of Managed Health Care (DMHC) began its regulatory mission a decade ago, it has levied nearly 1,200 enforcement actions against health plans, providers and other entities for violating state laws and regulations. The DMHC typically issues penalties for not responding to member grievances or failing to pay claims in a timely fashion.

Among the 170 organizations that have been penalized by the DMHC, Anthem Blue Cross of California stands alone.

The Indianapolis-based Anthem has racked up a remarkable 479 enforcement actions, or more than 40% of the statewide total, according to DMHC records. Some 275 of those actions have been levied against Anthem since early 2009 – including a $2.5 million fine the agency issued last November but has yet to publicize.

Anthem’s overall number is more than quadruple the 102 enforcement actions levied against San Francisco-based Blue Shield of California, the second-largest total.

Anthem Blue Cross equated the number of enforcement actions to its size: “As the state’s largest health benefits company serving more than 8 million people in California each year, it is not surprising that we might have the largest number of inquiries from the DMHC,” the insurer said in a prepared statement. Yet the only insurer of similar size to Anthem in California, Oakland-based Kaiser Foundation Health Plan, has received just 84 enforcement actions from the DMHC. It has 6.7 million enrollees statewide.

“The failure to timely respond to member grievances appears to be due to the lack of administrative capacity,” stated (DMHC spokeswoman Lynne Randolph).

http://www.payersandproviders.com/publications/pp527.pdf

Comment: 

By Don McCanne, MD

A unique characteristic of the U.S. health care system is the profound administrative waste, in a large part due to the administrative excesses of the private insurers and the administrative burden that they place on the providers of health care. The administrative component of just the private insurers alone is so large that Congress has codified the policy that 15 to 20 percent of health insurance premiums will be allocated for the insurers to use for their own intrinsic administrative services.

Currently outrage is being expressed over the very high insurance premium increases which the insurers attribute to increased health care costs. But the insurers are retaining the same high percentages of these ever higher premiums even though their marginal costs for administrative services should not be increasing at the same rate as health care prices. The increased spending on health care has provided a windfall for the private insurers.

So what are we getting for the massive amount of dollars being retained by the private insurers? Administrative services, and in great excesses at that. Yet why has WellPoint’s Anthem Blue Cross had so many enforcement actions levied against it? As the Department of Managed Care’s spokeswoman states, “The failure to timely respond to member grievances appears to be due to the lack of administrative capacity.”

Lack of administrative capacity?! With what we’re paying them for their administrative services?! And President Obama and Congress want to keep this industry in charge?!

This is not the time to sit back and see how the reform plays out. PPACA cannot ever insure everyone, and it cannot control the intolerable increases in spending. Now, more than ever, is the time for activism! Let’s demand a health care program that we can believe in – an improved Medicare for all!

Anthem Blue Cross has racked up 479 enforcement actions

Anthem Big Outlier In DMHC Actions

Payers and Providers
May 27, 2010
Since the California Department of Managed Health Care (DMHC) began its regulatory mission a decade ago, it has levied nearly 1,200 enforcement actions against health plans, providers and other entities for violating state laws and regulations. The DMHC typically issues penalties for not responding to member grievances or failing to pay claims in a timely fashion.
Among the 170 organizations that have been penalized by the DMHC, Anthem Blue Cross of California stands alone.
The Indianapolis-based Anthem has racked up a remarkable 479 enforcement actions, or more than 40% of the statewide total, according to DMHC records. Some 275 of those actions have been levied against Anthem since early 2009 – including a $2.5 million fine the agency issued last November but has yet to publicize.
Anthem’s overall number is more than quadruple the 102 enforcement actions levied against San Francisco-based Blue Shield of California, the second-largest total.
Anthem Blue Cross equated the number of enforcement actions to its size: “As the state’s largest health benefits company serving more than 8 million people in California each year, it is not surprising that we might have the largest number of inquiries from the DMHC,” the insurer said in a prepared statement. Yet the only insurer of similar size to Anthem in California, Oakland-based Kaiser Foundation Health Plan, has received just 84 enforcement actions from the DMHC. It has 6.7 million enrollees statewide.
“The failure to timely respond to member grievances appears to be due to the lack of administrative capacity,” stated (DMHC spokeswoman Lynne Randolph).
http://www.payersandproviders.com/publications/pp527.pdf

A unique characteristic of the U.S. health care system is the profound administrative waste, in a large part due to the administrative excesses of the private insurers and the administrative burden that they place on the providers of health care. The administrative component of just the private insurers alone is so large that Congress has codified the policy that 15 to 20 percent of health insurance premiums will be allocated for the insurers to use for their own intrinsic administrative services.
Currently outrage is being expressed over the very high insurance premium increases which the insurers attribute to increased health care costs. But the insurers are retaining the same high percentages of these ever higher premiums even though their marginal costs for administrative services should not be increasing at the same rate as health care prices. The increased spending on health care has provided a windfall for the private insurers.
So what are we getting for the massive amount of dollars being retained by the private insurers? Administrative services, and in great excesses at that. Yet why has WellPoint’s Anthem Blue Cross had so many enforcement actions levied against it? As the Department of Managed Care’s spokeswoman states, “The failure to timely respond to member grievances appears to be due to the lack of administrative capacity.”
Lack of administrative capacity?! With what we’re paying them for their administrative services?! And President Obama and Congress want to keep this industry in charge?!
This is not the time to sit back and see how the reform plays out. PPACA cannot ever insure everyone, and it cannot control the intolerable increases in spending. Now, more than ever, is the time for activism! Let’s demand a health care program that we can believe in – an improved Medicare for all!

Will the temporary high-risk pool meet the needs for those who are uninsurable?

Health Coverage for the High-Risk Uninsured: Policy Options for Design of the Temporary High-Risk Pool

By Mark Merlis
National Institute for Health Care Reform
May 27, 2010

Among the first tasks required by the recently enacted health reform law is creation of a temporary national high-risk pool program to provide subsidized health coverage to people who are uninsured because of pre-existing medical conditions. While as many as 5.6-million to 7-million Americans may qualify for the program, the $5 billion allocated over four years will allow coverage of only a small fraction of those in need, potentially as few as 200,000 people a year. Policy makers will need to tailor eligibility rules, benefits and premiums to stretch the dollars as far as possible. Another consideration is how the new pool will fit with existing state high-risk pools or other state interventions in the private nongroup, or individual, health insurance market. Policy makers also will need to consider how to manage the transition of enrollees from high-risk pools to the new health insurance exchanges scheduled to be operational in 2014 to prevent adverse selection and encourage insurer participation.

http://www.nihcr.org/High-RiskPools.pdf

Comment: 

By Don McCanne, MD

The Patient Protection and Affordable Care Act (PPACA) allocates $5 billion over four years for a temporary high-risk pool to insure those individuals who have problems obtaining coverage because of preexisting conditions. Although about 7 million Americans fall into this category, this report indicates that only about 200,000 people will be covered by this program, thereby meeting only about 3 percent of the need.

You need to read the full 14 page report to understand the multitude of policy interactions that will result in the failure of this one program. It serves as a proxy for the multitude of other policies contained in PPACA. We haven’t seen anything yet.

This is what happens when members of Congress insist on building health care reform on our dysfunctional, inefficient, highly fragmented system of health care financing. By insisting that we give first priority to protecting and enhancing the role of private insurers, the policy compromises have resulted in a system that will cost more while leaving far too many with inadequate coverage or no coverage at all.

Again, it doesn’t have to be this way. We can still enact a single payer national health program, ensuring all essential health care for everyone.

30 Million WellPoint Shares Voted: Return to Non-Profit!

By Rob Stone M.D.
Director, Hoosiers for a Commonsense Health Plan
The Huffington Post, May 26, 2010

The WellPoint Inc. annual meeting May 18 in Indianapolis was contentious and dramatic. The first story out was about the collapse of Board member William “Bucky” Bush followed by CEO Angela Braly’s sudden adjournment of the meeting while a line of concerned shareholders were still waiting to have their questions answered. That story went ’round the world, even picked up by the Singapore Straits Times, given legs by the irony of Mr. Bush getting assistance from the very doctor who had been regaling the Board minutes before. That physician, of course, was me.

This was the fourth annual meeting of WellPoint that I have attended in my role as “a cheery thorn in [their] side” “ER doc is affable WellPoint activist“.

This year there were four shareholder resolutions on the meeting proxy, and the WellPoint Board recommended a NO vote on all of them. The first – and the boldest – one was ours (which many Huffington readers recall: “WellPoint/Anthem Shareholders Revolt!“), calling on the company to return to its Blue Cross, charitable, non-profit roots.

As I approached the microphone to present the resolution (SEC regulations require that I present it in person) I noticed a WellPoint security woman with an ear bud lurking nearby, obviously there to keep a close eye on me. How close became obvious as I read my prepared comments and she gradually moved in behind me until she was literally breathing down my neck. When I was 5 minutes into my 7 minute statement, she tried to stop me from finishing. It was an outrageous attempt at intimidation and harassment, but I informed her firmly and politely that I would complete my remarks, which I did.

The meeting tone remained tense as the remaining three resolutions were presented, although the others kept their comments brief, and the menacing security woman only glowered at them from a respectful distance.

Finally, the formal meeting was adjourned, and the traditional shareholder Q&A session began, which for the last four years has been Angela’s least favorite part of the day. It immediately turned ugly as the security woman tried to cut off a lawyer from St Louis complaining how premiums on her small business health insurance policy had been jacked up 41%. After several appeals, WellPoint had finally admitted the increase was excessive, explaining they must have made “a fat finger mistake” in their initial calculations. The lawyer was not mollified and came to Indianapolis to press her case.

After just a few more contentious questions, the meeting came to its dramatic and premature end.

Ethan Rome informed Huffington readers about the one resolution that passed that day, “Shareholders Move to Curb Extravagant Pay for WellPoint CEO” but all he knew about our resolution when he wrote his piece (May 20) was that it had not passed. The resolution that did pass is referred to as “Say on Pay”, and a similar proposal was voted down today (May 24) by another insurance behemoth, UnitedHealth. Although “Say on Pay” has been adopted by over 70 corporations, the fact that WellPoint investors passed it is significant.

But there may be an even more monumental story unfolding here. On Friday afternoon May 21, WellPoint released the official tally for the voting from the meeting on the 18th. The resolution for returning to non-profit status received over 30 million votes, 9.4% of the shares voted. That is a jaw dropping vote of no confidence in the management of this company.

The story isn’t over yet. The SEC has proposed a new regulation that would allow shareholders to directly nominate corporate board members called “Proxy Access.” If this goes into effect this fall as expected, I intend to run for the WellPoint board.

In its current draft form, the Proxy Access process for a large corporation like WellPoint would require 1% of the outstanding shares in order to nominate a director. With 430 million shares outstanding, I would need 4.3 million shares for the nomination. 30 million shares just voted for our resolution. You do the math.

http://www.huffingtonpost.com/rob-stone-md/30-million-wellpoint-shar_b_587872.html

A Transatlantic Review of the NHS at 60

By Donald M. Berwick, MD, MPP, FRCP
President and CEO, Institute for Healthcare Improvement, Cambridge, MA
NHS Live:  Wembley:  1 July 2008

Let me begin with thanks – twice.  First, thanks for letting me work with you for almost 15 years; this has been one of the most satisfying journeys of my entire career.  My colleagues in the Institute for Healthcare Improvement feel the same.  Second, thanks for what the NHS does as an example for health care worldwide.

If you’re a cynic, you’ll want to go get a cup of tea about now.  I am going to annoy you, because I am not a cynic. I am romantic about the NHS; I love it.  All I need to do to rediscover the romance is to look at health care in my own country. 

A towering bridge

The National Health Service is one of the truly astounding human endeavors of modern times.  Just look at what you are trying to be: comprehensive, equitable, available to all, free at the point of care, and – more and more – aiming for excellence by world-class standards.  And, because you have chosen to use a nation as the scale and taxation as the funding, the NHS isn’t just technical – it’s political.  It is an arena where the tectonic plates of a society meet: technology, professionalism, macroeconomics, social diversity, and political ambition.  It is a stage on which the polarizing debates of modern social theory play out: between market theorists and social planning, between enlightenment science and post-modern skeptics of science, between utilitarianism and individualism, between the premise that we are all responsible for each other and the premise that we are each responsible for ourselves, between those for whom government is a source of hope and those for whom government is hopeless.  But, even in these debates, you have agreed hold in trust a commons. You are unified, movingly and most nobly, by your nation’s promise to make good on an idea: the idea that health care is a human right.  The NHS is a bridge – a towering bridge – between the rhetoric of justice and the fact of justice.

No one in their right mind would expect that to be easy.  No one should wonder that, as the NHS celebrates its 60th birthday this week – an age at which humans recognize maturity, it seems still immature, adolescent, still searching.

You could have chosen an easier route. My nation did.  It’s easier in the United States because we do not promise health care as human right.  Most of my countrymen think that’s unrealistic. In America, they ask, “Who would assure such a right?”  Here, you answer, “We do, through our government.”  In America, people ask, “How can health care be a human right?  We can’t afford it.”  We spend 17% of our Gross Domestic Product on health care – compared with your 9%.  And, yet we have almost 50 million Americans, one in seven, who do not have health insurance.  Here, you make it harder for yourselves, because you don’t make that excuse.  You cap your health care budget, and you make the political and economic choices you need to make to keep affordability within reach.  And, you leave no one out.

Fragments

In the United States, our care is in fragments.  Providers of care, whether for-profit or not-for-profit, are entrepreneurs.  Each seeks to increase his share of the pie, at the expense of others.  And so we don’t have a rational structure of inter-related components; we have a collection of pieces – a caravan site.  These disconnected, self-referential pieces cost us dearly.  The entrepreneurial fragments create what the great health services researchers, Elliott Fisher and Jack Wennberg, call “supply-driven care.”  In America, the best predictor of cost is supply – the more we make, the more we use – hospital beds, consultancy services, procedures, diagnostic tests.  Fisher and Wennberg find absolutely no relationship – none – between the supply and use, on the one hand, and the quality and outcomes of care, on the other hand.  The least expensive fifth of hospital service areas in the US have better care and better outcomes than the most expensive fifth.  Here, you choose a harder path. You plan the supply; you aim a bit low; historically, you prefer slightly too little of a technology or service to much too much; and then you search for care bottlenecks, and try to relieve them. 

In the US, we favor specialty services and hospitals over primary care and community-based services.  Americans are not guaranteed a medical home, as you are, and we face a serious shortage of primary care physicians.  Hospitals, on the other hand, are abundant, with many communities vastly over-bedded – an invitation to supply-driven care.  Coordinated care – care that keeps people from having to use hospitals – is rare; so are adequate home health care, hospice services, school-based clinics. Community social services and our mental health services are undefended, isolated, and insufficient.  Public health and prevention are but stepchildren.  Here, in the NHS, you have historically put primary care – general practice – where it belongs: at the forefront.   

In the US, we can hold no one accountable for our problems.  Accountability is as fragmented as care, itself; each, separate piece tries to craft excellence, but only within its own walls. Meanwhile, patients and carers wander among the fragments. No one manages their journey, and they are too often lost, forgotten, bewildered.  Here, in England, accountability for the NHS is ultimately clear. Ultimately, the buck stops in the voting booth.  You place the politicians between the public served and the people serving them.  That is why Tony Blair commissioned new investment and modernization in the NHS when he took office, it is why government has repeatedly modified policies in a search for traction, and it is why your new government chartered the report by Lord Darzi.  Government action on the NHS is not mere restlessness or recreation; it is accountability at work through the maddening, majestic machinery of politics.

In the United States, we fund health care through hundreds of insurance companies.  Any American doctor or hospital interacts with a zoo of payment streams.  Administrative costs for this zoo approach 20% of our total health care bill, at least three times as much as in England.   

In the United States, those hundreds of insurance companies have a strong interest in not selling health insurance to people who are likely to need health care.  Our insurance companies try to predict who will need care, and to find ways to exclude them from coverage through underwriting and selective marketing. That increases their profits.  Here, you know that that isn’t just crazy; it is immoral.

Equitable, civilized and humane

So, you could have had a simpler, less ambitious plan than the NHS.  You could have had the American plan.  You could have been spending 17% of your GDP and made health care unaffordable as a human right instead of spending 9% and guaranteeing it as a human right.  You could have kept your system in fragments and encouraged supply-driven demand, instead of making tough choices and planning your supply.  You could have made hospitals and specialists, not general practice, your mainstay.  You could have obscured – obliterated – accountability, or left it to the invisible hand of the market, instead of holding your politicians ultimately accountable for getting the NHS sorted.  You could have let an unaccountable
system play out in the darkness of private enterprise instead of accepting that a politically accountable system must act in the harsh and, admittedly, sometimes unfair, daylight of the press, public debate, and political campaigning.  You could have a monstrous insurance industry of claims, rules, and paper-pushing, instead of using your tax base to provide a single route of finance.  You could have protected the wealthy and the well, instead of recognizing that sick people tend to be poorer and that poor people tend to be sicker, and that any health care funding plan that is just, equitable, civilized, and humane must – must – redistribute wealth from the richer among us to the poorer and less fortunate.

Britain, you chose well.  As troubled as you may believe the NHS to be, as uncertain its future, as controversial its plans, as negative its press, as contentious its politics, as beleaguered as it sometimes feels, please lift your eyes and behold the mess – the far bigger, costlier, unfair mess – that a less ambitious nation could have chosen.

Is the NHS perfect?  Far, far from it.  I know that as well as anyone in this room.  From front line to Whitehall, I have had the privilege to observe its performance and even to help to measure it.  The large scale facts are most recently summarized in the magisterial report by Sheila Leatherman and Kim Sutherland sponsored by The Nuffield Trust called The Quest for Quality: Refining the NHS Reforms.  They find some good news.  For example, after ten years of reinvestment and redesign, the NHS has more evidence-based care, lower mortality rates for major disease groups (especially cardiovascular diseases), lower waiting times for hospital, outpatient, and cancer care, more staff and technologies available, in some places better community-based mental health care, and falling rates of hospital infection.  An important, large scale patient safety campaign has begun in England, as well as among your cousins in Wales, Scotland, and Northern Ireland. There is less progress in some areas, especially by comparison with other European systems, such as in specialty access, cancer outcomes, patient-centeredness, life expectancy and infant mortality for socially deprived populations. In other words, in improving its quality, two facts are true: the NHS is en route, and the NHS has a lot more work ahead.

How can you do even better?  I have ten suggestions:

1.  First, put the patient at the center – at the absolute center of your system of care. Put the patient at the center for everything that you do.  In its most helpful and authentic form, this rule is bold; it is subversive.  It feels very risky to both professionals and managers, especially at first.  It is not focus groups or surveys or token representation.  It is the active presence of patients, families, and communities in the design, management, assessment, and improvement of care, itself.  It means customizing care literally to the level of the individual.  It means asking, “How would you like this done?” It means equipping every patient for self-care as much as each wants.  It means total transparency – broad daylight.  It means that patients have their own medical records, and that restricted visiting hours are eliminated.  It means, “Nothing about me without me.”  It means that we who offer health care stop acting like hosts to patients and families, and start acting like guests in their lives.  For professionals made anxious by this extreme image, let me simply remind you how you probably begin every encounter when you are following your best instincts; you ask, “How can I help you?” and then you fall silent and you listen.

2.  Second, stop restructuring.  In good faith and with sound logic, the leaders of the NHS and government have sorted and resorted local, regional, and national structures into a continual parade of new aggregates and agencies.  Each change made sense, but the parade doesn’t make sense.  It drains energy and confidence from the workforce and middle managers, who learn not to take risks, but rather to hold their breaths and wait for the next change.  It is, I think, time to stop.  No structure in a complex management system is ever perfect.  There comes a time, and the time has come, for stability, on the basis of which, paradoxically, productive change becomes easier and faster, as the good, smart, committed people of the NHS – the one million wonderful people who can carry you into the future – find the confidence to try improvements without fearing the next earthquake.

3.  Third, strengthen the local health care systems – community care systems – as a whole.  What you call “health economies” should become the core of design: the core of leadership, management, inter-professional coordination, and goals for the NHS.  This should be the natural unit of action for the Service, but it is as yet unrealized. The alternative, like in the US, is to have elements – hospitals, clinics, surgeries, and so on – but not a system of care.  Our patients need integrated journeys; and they need us to tend and defend those journeys.  I believe that the NHS has gone too far in the past decade toward optimizing hospital care – a fragment – and has not yet optimized the processes of care for communities.  You can do that.  It is, I think, your destiny.

4. Fourth, to help do that, reinvest in general practice and primary care.  These, not hospital care, are the soul of a proper, community-oriented, health-preserving care system.  General practice, not the hospital, is the jewel in the crown of the NHS.  It always has been.  Save it.  Build it. 

5.  Fifth, please don’t put your faith in market forces.  It’s a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can.  I do not agree.  I find little evidence anywhere that market forces, bluntly used, that is, consumer choice among an array of products with competitors’ fighting it out, leads to the health care system you want and need.  In the US, competition has become toxic; it is a major reason for our duplicative, supply-driven, fragmented care system.  Trust transparency; trust the wisdom of the informed public; but, do not trust market forces to give you the system you need.  I favor total transparency, strong managerial skills, and accountability for improvement.  I favor expanding choices. But, I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.

6.  Sixth, avoid supply-driven care like the plague.  Unfettered growth and pursuit of institutional self-interest has been the engine of low value for the US health care system.  It has made it unaffordable, and hasn’t helped patients at all.

7.  Seventh, develop an integrated approach to the assessment, assurance, and improvement of quality.  This is a major recommendation of Leatherman and Sutherland’s report, and I totally concur.  England now has many governmental and quasi-governmental organizations concerned with assessing, assuring, and improving the performance of the NHS.   But they do not work well with each other.  The nation lacks a consistent, agreed map of roles and responsibilities that amount, in aggregate, to a coherent system of aim-setting, oversight, and assistance.  Leatherman and Sutherland call this an “NHS National Quality Programme,” and i
t is one violation of my proposed rule against restructuring that I have no trouble endorsing.

8.  Eighth, heal the divide among the professions, the managers, and the government.  Since at least the mid-1980’s, a rift developed that has not yet healed between the professions of medicine formally organized and the reform projects of government and the executive.  I assume there is plenty of blame to go around, and that the rift grew despite the best efforts of many leaders on both sides.  But, the toll has been heavy:  resistance, divided leadership, demoralization, confusion, frustration, excess economic costs, and occasional technical mistakes in the design of care.  The NHS and the people it serves can ill afford another decade of misunderstanding and suspicion between the professions, on the one hand, and the managers and public servants, on the other hand.  It is the duty of both to set it aside.

9.  Ninth, train your health care workforce for the future, not the past.  That workforce needs to master a whole new set of skills relevant to the leadership of and citizenship in the improvement of health care as a system – patient safety, continual improvement, teamwork, measurement, and patient-centered care, to name a few.  Scotland announced last week that all its health professionals in training will master safety and quality improvement as part of their qualification.  Far be it for me to suggest copying Scotland, but there you have it.  I am pleased that Lord Darzi’s Next Stage report suggests such standards for the preparation of health care professionals in England.

10.  Tenth, and finally, aim for health.  I suppose your forebears could have called it the NHCS, the “National Health Care Service,” but they didn’t.  They called it the “National Health Service.”  Maybe they meant it.  Maybe they meant to create an enterprise whose product – whose purpose – was not care, but health.  Maybe they knew then, as we surely know now, even before Sir Douglas Black and Sir Derek Wanless and Sir Michael Marmot, that great health care, technically delimited, cannot alone produce great health.  Developed nations that forget that suffer the embarrassment of growing investments in health care with declining indices of health.  The charismatic epidemics of SARS, mad cow, and influenza cannot hold a candle to the damage of the durable ones of obesity, violence, depression, substance abuse, and physical inactivity.  Would it not be thrilling in the next decade for the NHS – the National Health Service – to live fully up to its middle name?

Those are my observations from far away – from an American fan, distant and starry-eyed about the glimpses I have had of your remarkable social project.  The only sentiment that exceeds my admiration for the NHS is my hope for the NHS.  I hope that you will never, never give up on what you have begun.  I hope that you realize and reaffirm how badly you need, how badly the world needs, an example at scale of a health system that is universal, accessible, excellent, and free at the point of care – a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just.  Happy birthday!

http://www2.wales.nhs.uk/sites3/page.cfm?orgId=781&pid=32953