Health reform: Are we there yet?

Nancy Pelosi is known around San Francisco — and in a few other spots — as one tough politician. She likes being Speaker of the House, and she doesn’t much like losing. So this week’s do-or-die health reform bill is going to get all the muscle she can manage. It is, Pelosi has declared, “a moral and political imperative.”

Okay, it’s not what we hoped, it’s too complicated and too fraught, it’s going to be full of little gifties given to get votes. If we don’t get something America will be stuck with a non-functional system and millions will remain without health care at all. So I for one am on Pelosi’s side.

The plan is for the House to pass the Senate version and send it to Obama for his signature and enactment. Certain fixes the House is demanding for passage of the more conservative Senate bill will be included in a separate, special measure that will go to the Senate for an up-or-down vote that avoids a filibuster.

But once the House passes the base legislation and Obama signs it, the measure becomes law regardless of what the Senate does.

Democrats do not yet have the votes in hand and Pelosi will not call a vote until they do. Liberal lawmakers have deep reservations about the Senate bill, and fights over abortion and immigration have yet to be resolved. But Pelosi has set the legislative train in motion, even as Republicans have publicly begun to express doubt that they can stop it.

Pelosi laid down the law to wavering Democrats who are threatening to bolt. “It’s not about abortion, it’s not about immigration,” she said. “The only reason, therefore, to oppose the bill is that you do not support health care reform.”

A lot of people don’t support health care reform. The Republicans, the insurance industry, the anti-abortion folks and the anti-immigration folks and more than a few people who feel pretty much okay with what they’ve got and frankly don’t care a lot about what others don’t have.

But health care reform is a moral imperative.

Pelosi: Dems will have votes to OK health care.

The doctor is in… cyberspace

Getting health care — whatever happens with the health care bill — is no longer just a matter of getting to the doctor. Issues of comfort, efficiency and cost control increasingly point to the use of telemedicine, which is coming, ready or not. And one recent report suggested the medical profession isn’t ready. Pauline Chen, M.D. , writing recently in the New York Times, cited resistance by doctors and nurses alike to what some consider long-distance health care.

Telemedicine has the potential to improve quality of care by allowing clinicians in one “control center” to monitor, consult and even care for and perform procedures on patients in multiple locations. A rural primary care practitioner who sees a patient with a rare skin lesion, for example, can get expert consultation from a dermatologist at a center hundreds of miles away. A hospital unable to staff its intensive care unit with a single critical care specialist can have several experts monitoring their patients remotely 24 hours a day.

But despite its promise, telemedicine has failed to take hold in the same way that other, newer, technologies have. Not because of technical challenges, expense or insufficient need. On the contrary, the most daunting obstacle to date has been a deeply entrenched resistance on the part of providers.

Tech industry writer/elder care advocate Laurie Orlov thinks those concerns are a thing of the past. Since data was gathered for the study Dr. Chen cited, Orlov points out in her Aging in Place Technology blog, doctors, patients and technology have come a long way. “Forget the JAMA study”, Orlov says, “here come the virtual visits.”

Medical practices, hospitals, clinics are well aware of a much-changed world and consumer health care costs that can be breathtaking. American Well’s virtual visit platform use is growing, as are other virtual platforms discussed in our 2009 Calibrated Care report. They have read about transformation of self-care and virtual visits in Denmark. Given the geographic distribution of people — and the distance required to get to doctors in some states and rural areas, given the availability of technology that was barely known or completely unknown in 2006, these are going to happen, reimbursement has begun, criteria for the use has emerged, and the JAMA study (and its much-syndicated press coverage) is already irrelevant.

On a technologically lower level is the use of PC programs long in place for Kaiser patients. They haven’t asked for a testimonial, but here’s one, with enthusiasm. The e-mail your doctor program allows doctor-patient communication at the convenience of each (my primary care doc, oncologist and other specialists almost all answer queries within 24 hours or less); test results are posted immediately and can be viewed via charts or graphs to show how you’re doing; drug information or other Q&A’s are immediately accessible through personal accounts. All of the above save time, money and patient angst.

Doctors in cyberspace could be good medicine indeed for U.S. health care.

The cost of trying to live forever

Why is this not an encouraging word? In a front page article, part of a Months to Live series,  New York Times writer Reed Abelson leads with a glimpse into the Ronald Reagan U.C.L.A. Medical Center, a top-rated academic hospital noted for extensive, aggressive end-of-life care (and very high costs):

‘If you come into this hospital, we’re not going to let you die,’ said Dr. David T. Feinberg, the hospital system’s chief executive.

Feinberg’s commitment to “success” might be admirable, but the statement is patently false; people die at U.C.L.A. Medical Center. This is what people do: we die. Until this culture gets its act together on that subject our health care system — whatever the reform bill eventually looks like — will continue to flounder.

Difficult as it is to talk dollars when you’re talking lives, the issue of cost has to be factored in. There are only so many dollars, and there are countless lives needing care those dollars can buy: infants, children, young adults, boomers, elderly. In each of those care-needing groups, some die.  Feinberg’s philosophy somewhere has to encounter reality.

…that ethos (keep testing, treating, keeping alive no matter what) has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

No one, not the doctors, not the patients, not the best crystal ball reader around can guarantee that this patient will die or that patient will live. If there is a good chance a patient will survive — and it would be nice to add “with a reasonable quality of life” here — everything possible, and affordable, certainly should be done. Abelson’s carefully balanced article details the arguments for going to extraordinary lengths to save lives, as well as the arguments to draw the line on end-of-life expenses.

According to Dartmouth, Medicare pays about $50,000 during a patient’s last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

“One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical,” Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. “We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.”

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients’ final year of life account for about a quarter of the program’s total spending.

So…. to spend that $25,000/$50,000 or not to spend? Unless we the people somehow face the reality that living forever is not a human option, the dilemma will continue.

The benefits of coming to terms with non-optional dying could be huge. We could focus on quality living. On palliative care and hospice care and end-of-life peace and comfort. Advances in palliative care now make it possible for most of us to spend final months at home (or in special hospital rooms), in comfort, surrounded by loved ones; given the choice, would you prefer a few weeks or months in a bright-lit sterile room with a lot of tubes and wires keeping you alive? U.C.L.A. now offers the choice of palliative care. Not everyone in charge, however, is convinced.

Dr. Bruce Ferrell, who helps lead the palliative care program, recalls a patient two years ago who got a liver transplant but developed serious complications afterward and remained in the hospital for a year. “He had never, ever been told that he would have to live with a ventilator and dialysis,” Dr. Ferrell said. “He was never told that this is as good as it’s going to get.”

Dr. Ferrell talked with the patient about whether he might want to leave the intensive-care unit to go home and receive hospice care. But when the surgeon overseeing the case found out, he was furious.

“We do not use the h-word” — hospice — “on my patients,” the surgeon told Dr. Ferrell. “Don’t ever come back.”

The patient chose to leave.

But lately, Dr. Ferrell says, more of the transplant surgeons appreciate the value of what he is trying to do.

“We’re not the bad guys,” he said. “We offer options.”

We the people would do well to quit being the bad guys. To quit behaving as if death were always preventable. We could learn about the options to spending all those thousands of dollars on exhaustive, often futile treatment. We could talk about what we would or would not want for ourselves, write things down, make choices.

If more of us would do that for ourselves, the House and Senate wouldn’t have such a time trying to do it for us.

Safeway carrot-stick plan a boon to reform

There was a little local pride in a key segment of the Senate Finance Committee’s health care bill reported today by Andrew S. Ross of the San Francisco Chronicle:

It’s not every day a local grocery has a congressional amendment named after it. Such an honor has been bestowed on Pleasanton’s Safeway Inc., whose stick-and-carrot health insurance program is the model for a “wellness provision” in a health care reform bill that passed the Senate Finance Committee last week by an unusually bipartisan 18-4 vote.

“Yes, it’s quite fair to call it the ‘Safeway amendment,’ ” said a spokesman for Sen. John Ensign, R-Nev., who co-sponsored the amendment with Sen. Tom Carper, D-Del. “He’s a big advocate of the Safeway program.”The provision, designed to “incentivize Americans to lead healthy lifestyles in order to lower their overall health care costs,” would allow companies with self-insurance programs to reward employees with bonuses and/or premium reductions of up to 50 percent if they follow health guidelines, like undergoing regular screenings, quitting smoking, losing weight, taking cholesterol-reducing medications and so on.

While some question the accuracy of reported cost savings, the measure has strong support among key politicians up to and including President Obama.

As a beneficiary of Kaiser‘s “wellness” program — a constant push toward healthy lifestyles and preventive medicine — I hope this piece of the legislation stays. As long as he’s not going to resign, Senator Ensign might as well be doing something useful over there.

via Safeway plan part of Senate health care debate.

Some Women's Views of Health Reform

First Lady Michelle Obama is making the news in support of her husband’s health plan, hoping to tap into the energies of one group who voted for Obama in large numbers: women. Reform is everyone’s concern, but in many ways it occupies a specific gender niche. As reported by Voice of America’s Kent Klein,

Mrs. Obama says health care reform is a women’s issue. “Women play a unique and increasingly significant role in our families.  We know the pain, because we are usually the ones dealing with it,” she said. The first lady spoke Friday to a gathering of women near the White House, and said the state of the U.S. health care system is unacceptable. “For two years on the campaign trail, this was what I heard from women:  That they were being crushed, crushed by the current structure of our health care.  Crushed,” she said.

A host of women’s groups, blogs, newsletters and web writers have also recently joined in. Posting in the National Women’s Law Center blog, Outreach Manager Thao Nguyen told the poignant story of hearing from a friend that she’d just married her long-time hesitant boyfriend. The marriage news was good news, but its terms took the joy out: having lost her job, it was the only way she could get health insurance.

Her point seemed so logical, but the entire idea was couched in such an insane reality I was simply speechless. Lucy is in her early 30s but she has a pre-existing condition so buying individual health insurance and the unfair, overpriced premiums that come with it was out of the question. Lucy has been living with Dan for 10 years, but unfortunately, he works for a company that doesn’t offer domestic partner benefits.

I couldn’t help but think: is this what our broken, unstable health care system means for millions of Americans around the country? As the economy continues to struggle, employers continue to shed jobs, and every day 14,000 more Americans wake up realizing that they are now uninsured and just one illness away from financial ruin. Are reluctant bachelors around the country going to put away their Megan Fox posters, cancel the “poker nights” (aka X-Box marathons we’re on to you), and start settling down?

My own run-in with healthcare weirdness is minor in comparison to most, but I still remember the shock. Making a routine call to renew the prescription for a bone-building drug I had taken for years to stave off osteoporosis, the message center person said she probably should warn me that rather than the $24 co-pay I’d been having per quarter my cost would now be $230. I do need these bones, but couldn’t see them worth $920 a year. I hung up and started drinking more milk. Had to get breast cancer, for which I now take a covered post- cancer drug which my oncologist prescribes… mainly to keep my bones healthy. Something is bizarre here.

Or maybe we women might bend the old macho adage a little: It’s broke, fix it.

VOA News – Michelle Obama Joins Health Reform Campaign.

Hospital Safety 101: Didn't Mom Teach You to Wash Your Hands?

San Francisco Chronicle Washington Bureau writer Carolyn Lochhead reported today on a new idea somebody had about making hospitals safer: get folks to wash their hands. Hello?

The president of a leading medical standards organization announced a new program Thursday that is designed to improve health care safety practices, starting with a rigorous approach toward hand-washing by hospital staffers.

And this is serious business.

Hand-washing failures contribute to infections linked to health care that kill almost 100,000 Americans a year and cost U.S. hospitals $4 billion to $29 billion a year to combat, said Dr. Mark Chassin, who leads the Joint Commission, which sets standards and accredits hospitals and health care organizations.

Chassin’s announcement came after Hearst Newspapers published the results of an investigation, “Dead by Mistake,” which reported that 247 people die every day in the United States from infections contracted in hospitals.

Anyone who has ever come home from surgery with an infection, or more specifically anyone whose spouse has come home from surgery with an infection (nasty-wound-tending not having been fully explained in those for-better-or-for-worse lines) will applaud the new program, but it’s hard not to wonder what has taken the medical profession so long. Hospitals have found, Lochhead reports, that “caregivers washed their hands less than 50 percent of the time when they should.”

If there’s ever been a good example of potential savings to pay for universal health care, this is one to top the list. Consumers, we who would do well to wash our own hands when visiting or inhabiting hospitals, owe a debt of gratitude to the Joint Commission (and to Hearst Newspapers for the excellent ‘Dead by Mistake’ series.)

Maybe more sinks will be adorned with the sign that gave my husband and me a healthy chuckle during a recent visit to the Kaiser emergency room:

“Hand-wash unto others” it read, “as you would have them hand-wash unto you.”


Hospitals urged to strictly enforce hand-washing.

Health Reform: The Mystery

Facebook friends of mine in the past few days have been turning up with a status line that reads, “No one should die because they cannot afford health care, and no one should go broke because they get sick. If you agree please post this as your status for the rest of the day.”

Well, I do agree. I haven’t posted it as my status yet, mainly because my True/Slant posts get posted as my status, and enough is probably enough. But I’ve been curious because friends who are not even Friends of friends have been posting it, some with additions (“I’m just sayin’…”) or (“E-mail your representatives!”)

So I just checked out Open Salon, and there’s OESheepdog’s blog reading “From my friend Leigh Bailey: “No one should die because… etc” followed by a long list of affirmative reactions. My personal favorite was John Blumenthal’s comment, “You’re right, of course, but I wouldn’t lose any sleep if someone took Glenn Beck’s insurance away. Pre-existing stupidity.”

But the question remains, Did OESheepdog’s friend Leigh Bailey start the whole movement? Kathleen Sebelius? Nancy Pelosi?

I’m just askin’.

Reforming US health care is not the end of the world – OEsheepdog – Open Salon.

Healthcare: Sorting Fact from Fiction

House legislation on health reform is a win-some-lose-some proposition for those over 65. Especially, as outlined in The New York Times yesterday, when it comes to Medicare drug benefits.

Medicare beneficiaries would often have to pay higher premiums for prescription drug coverage, but many would see their total drug spending decline, so they would save money as a result of health legislation moving through the House, the Congressional Budget Office said in a recent report.

Premiums for drug coverage would rise an average of 5 percent in 2011, beyond the level expected under current law, and the increase would grow to 20 percent in 2019, the budget office said.

“However,” it said, “beneficiaries’ spending on prescription drugs apart from those premiums would fall, on average, as would their overall prescription drug spending (including both premiums and cost-sharing).”

The Congressional Budget Office report set off an immediate battle between Republicans and Democrats, each side eager to convince seniors — those vocal voters — that the other was representing the devil incarnate. Republicans swear the House bill will threaten Medicare beneficiaries in order to cover the uninsured, Democrats say the bill will help them by eliminating a gap in Medicare drug coverage.

On this particular segment of the impossibly complex bill, maybe seniors would do well to listen to their own purported champion:

Nancy LeaMond, an executive vice president of AARP, the lobby for older Americans, welcomed the report as evidence that “health care reform will lower drug spending.”

“Opponents of reform may use today’s projections to try to stall reform,” Ms. LeaMond said, “but we hope they will look at all the facts before jumping to a false conclusion.”

And there, some would suggest, is the problem. The facts have been virtually obscured by misstatements, misrepresentations and outright lies. Death panels? A lie that served its scary purpose. Rationing? It’s already here, folks; it’s done by insurance companies that deny coverage in sometimes arbitrary ways. Socialized medicine? Hello? Does anyone over 65 remember those screams before Medicare was signed into law in ’65? When half the population over 65 had no insurance coverage at all?

Set aside the fact that providing healthcare for all is simply the right thing to do. Millions of American seniors (whether you begin that definition at 65, 60 or — to their horror as it sometimes happens — 55) were motivated to support President Obama by not only their hearts but also their brains. If those brains can be called into play to sort fact from fear-mongering, we may yet get the health reform common decency requires of this otherwise civilized nation.

Health Bill Would Cut Drug Spending for Many on Medicare, Budget Office Says – NYTimes.com

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