Quality health care at lower cost? It could happen

It seems a no-brainer: reward the doctors and hospitals that give the best care, latch on to programs and ideas that offer quality over quantity. But innovation in health care, even when it proves out, has always taken a very long time to work into the system.

In a ‘Talk of the Town’ piece appearing in the latest New Yorker magazine, writer Atul Gawande offers a thoughtful look at some of the hurdles ahead for the newly-passed health bill. They are primarily political: conservatives — even if they’re talking less and less about repeal — will run on pieces they plan to strip out, states will fight the insurance exchanges (such as those that make health coverage near universal in Senator Scott Brown‘s Massachusetts.) And other battle lines will be drawn.

But one primary problem with the dysfunction we are hoping to fix, Gawande points out, is that the current system “pays for quantity of care rather than the value of it.” He illustrates this with a case that makes you cheer, and then feel a little hopeless:

Recently, clinicians at Children’s Hospital Boston adopted a more systematic approach for managing inner-city children who suffer severe asthma attacks, by introducing a bundle of preventive measures. Insurance would cover just one: prescribing an inhaler. The hospital agreed to pay for the rest, which included nurses who would visit parents after discharge and make sure that they had their child’s medicine, knew how to administer it, and had a follow-up appointment with a pediatrician; home inspections for mold and pests; and vacuum cleaners for families without one (which is cheaper than medication). After a year, the hospital readmission rate for these patients dropped by more than eighty per cent, and costs plunged. But an empty hospital bed is a revenue loss, and asthma is Children’s Hospital’s leading source of admissions. Under the current system, this sensible program could threaten to bankrupt it. So far, neither the government nor the insurance companies have figured out a solution.

There is in the new bill, though, a ray of hope:

The most interesting, under-discussed, and potentially revolutionary aspect of the law is that it doesn’t pretend to have the answers. Instead, through a new Center for Medicare and Medicaid Innovation, it offers to free communities and local health systems from existing payment rules, and let them experiment with ways to deliver better care at lower costs. In large part, it entrusts the task of devising cost-saving health-care innovation to communities like Boise and Boston and Buffalo, rather than to the drug and device companies and the public and private insurers that have failed to do so. This is the way costs will come down—or not.

Imagine innovation being rewarded, communities being encouraged to find ways to improve quality of care at lower cost. That’s real reform, and it could just happen.

The next attacks on health-care reform : The New Yorker.

Anthem Blue Cross 'doing the right thing'?

In testimony before the California Assembly Health Committee yesterday, Anthem Blue Cross President Leslie Margolin said of her company, “I think we do the right thing, and we try to do the right thing every day.”

What that means is, turn a profit for the company every day. If you are in business to make money, that is the right thing to do.

On the other hand, when Margolin says the company’s goal is to provide “care, comfort and coverage to those in need,” that is simply not true. Physicians and health care professionals provide care and comfort. Anthem provides coverage which sometimes pays for these things and often does not, if they can help it.

Is there no way to connect those dots? Care and comfort for those who need and deserve it — i.e., every human being — are not going to happen until we get the coverage people out of the equation.

OK, not going to happen any time soon. It could happen in California, except for Governor Schwarzenegger‘s probable veto. It should happen in Washington, except for the money and muscle of the coverage people. In lieu of those realities, a health bill that takes a tiny step in the right direction would be welcome.

Health care reform solution: eliminate insurance

“Insurance? My whole point is I want to kill it.”

Gil Ahrens knows health insurance. One terrible accident. Years of life turned upside down. Denials of payment. Claims argued. Liens placed on property. Throughout a long and arduous struggle to get life back on track, obstacles created by insurance issues stood in the way of what should have been everyone’s focus: care. It is a story familiar, in one variation or another, to millions of Americans.

Author of the recently released Shattered, Shaken and Stirred, Ahrens began his eye-opening journey through the catacombs of our health insurance system almost simultaneously with a devastating automobile accident. He escaped with a badly mangled foot and other injuries, his wife was left paralyzed. Their three-week-old daughter survived intact — but that was about the only good news the Ahrens family would have for a very long time. For the successful California businessman/entrepreneur and his family, life was forever changed; the book tells the years-long challenge of that change.

In recent appearances and radio talks, Ahrens has spoken out against what he describes as a health system “in shambles. In its current state, health care is a bigger threat than terrorism. And needless to say, we are paying through the nose.”

Shattered, Shaken and Stirred, written in the form of a letter to his now-school-age daughter, is part description of unbearable tragedy and misfortune, and part how-to guide for rebuilding one’s spirit. But underlying it all is an unvarnished message to America from one person who has been entrapped in the system: insurance is the #1 evil of American health care.

Elsewhere around the globe are examples of how to do health care right. The world’s top ten livable cities, Ahrens points out, share one characteristic: their citizens have health care. Not health insurance, health care.

“Americans do not want coverage,” Ahrens says; “they want care.

Does that not make sense?

Health Bill Should not Pit Women against Seniors

The health care issue is, one would think, too important for partisan games pitting one group against another. Especially when huge portions of each group are one and the same. But as Robert Pear and David M. Herszenhorn report in today’s New York Times, that seems to be happening.

In a day of desultory debate on sweeping health care legislation, senators appealed to two potent political constituencies on Tuesday, with Democrats seeking additional medical benefits for women and Republicans vowing to preserve and protect Medicare for older Americans.

The Democrats’ first amendment, offered by Senator Barbara A. Mikulski of Maryland, would require insurers to cover more screenings and preventive care for women, with no co-payments.

‘Women often forgo those critical preventive screenings because they simply cannot afford it, or their insurance company won’t pay for it unless it is mandated by state law,’ Ms. Mikulski said.

I met with my oncologist two days ago and decided to have a mammogram. It’s been two years since the last one. She and I agree that, having had breast cancer in 2006 and breezed through a mastectomy, and being fit and healthy overall, my particular situation suggests the potential benefits — catch another cancer early, gain another good decade or so of life — outweigh the risks.  This is what the whole thing is about: every woman is different, every woman should be allowed to decide, with her doctor, on screening and preventive care. The Mikulski amendment will insure that can happen, whatever one’s age and circumstances.

The first Republican proposal, offered by Senator John McCain of Arizona, would strip the bill of more than $450 billion of proposed savings in Medicare. The savings would curb the growth of Medicare payments to hospitals, nursing homes, health maintenance organizations and other providers of care.

‘The cuts are not attainable,’ Mr. McCain said. ‘And if they were, it would mean a direct curtailment and reduction in the benefits we have promised to senior citizens.’

Senators said that debate on the bill, which embodies President Obama’s top domestic priority, would last for several weeks and perhaps continue into January. A vote on Ms. Mikulski’s amendment has not been scheduled but could come Wednesday.

The health care bill would require most Americans to carry insurance. It would subsidize coverage for people with moderate incomes, expand Medicaid and create a government insurance plan, which would compete with private insurers. The House passed a similar bill last month.

Ms. Mikulski’s proposal was prompted, in part, by the recent furor over new recommendations from a federal task force that breast cancer screenings begin later for many women.

The Senate majority leader, Harry Reid, Democrat of Nevada, hailed Ms. Mikulski’s proposal, saying: ‘The decision whether or when to get a mammogram should be left up to the patient and the doctor. That decision should not be made by some bureaucrat, a member of Congress or someone they’ve never met.’

As health costs and insurance premiums rise, Mr. Reid said, ‘more women are skipping screenings for cervical and breast cancer, and doctor visits that can catch problems like postpartum depression and domestic violence.’

Votes on the Mikulski amendment will show whether Republicans “truly want to improve this bill or just want to play games, stall,” Mr. Reid said.

Ms. Mikulski said her proposal would ‘shrink or eliminate the high cost of co-payments and deductibles’ for women who receive screenings for cancer, heart disease, diabetes and other conditions.

Senator Kay Bailey Hutchison, Republican of Texas, criticized the proposal, saying it would ‘allow yet another government agency to interfere in the relationship between a woman and her doctor.’

No, Senator Hutchison, the government isn’t interfering in my relationship with my doctor, nor will it do so by insuring other women’s choices and coverage.

Republicans argued that the bill would be paid for on the backs of older Americans.

‘We are receiving incredible and overwhelming response from seniors all over America,’ Mr. McCain said. ‘They paid all their working lives into the Medicare trust fund, and now they’re in danger of having $483 billion cut out of it.’

Mr. McCain’s proposal would effectively cripple the bill, because Democrats are relying on savings in Medicare to help offset the cost of providing coverage to more than 30 million people who are now uninsured.

This senior would like to add a word to that “overwhelming response” Mr. McCain reports. I paid all my working life into Medicare (which, by the way, was not exactly a gift to America from the Republican party) and I want a decent health bill more than I want every penny of my Medicare coverage protected.

A lot of us have come to terms with the fact that the health bill we may get is a long way from the health bill we so fervently wanted. We are still hoping that something survives the attempts to sink it at any cost.

Senators Pitch to Women and Elderly on Health Bill – NYTimes.com.

Abortion foes winning health concessions

Anti-abortion forces, sensing victory in the health bill, are happily using their clout. They will undoubtedly win big. David M. Herszenhorn and David D. Kirkpatrick report in the New York Times that staunch anti-abortion Representative Brad Ellsworth (D-IN) is likely to get what he wants, which means other leading opponents of a woman’s right to choose, including a few elected representatives and the U.S. Congress of Catholic Bishops, will also get what they want.

Struggling to finish their big health care legislation, House Democratic leaders signaled Tuesday that they were prepared to make several changes to the bill to satisfy abortion opponents, including many Democrats, who had threatened to block it.

The opponents are insisting that tax dollars not pay for health insurance that would cover abortion. That is a tricky proposition given that the health care bill would provide hundreds of billions in federal subsidies to help moderate-income Americans buy health insurance, mostly from private carriers.

But Democratic leaders have little choice but to make some concessions. As many as 40 Democrats have said they might oppose the health care bill without tighter restrictions on abortion – a potentially decisive number.

So okay. We desperately need health reform, and such concessions apparently have to be made.

I just wonder if any of these guys know anything about what it was like in the days before Roe v Wade, which is the scenario to which they wish to see us return.

And I find it interesting that they, who seek to exercise so much control over what a woman may do with her body, are mostly men.

Democrats Near Deal on Abortion Coverage – Prescriptions Blog – NYTimes.com.

Health Reform Geezer Gap

At least one more old geezer — we are legion — is fed up with the Medicare generation getting all the blame for opposing health reform. James Ridgeway writes in his Unsilent Generation blog today that

This health reform debate is about substituting a phony intergenerational war for what ought to be class war – pitting the old against the young, instead of pitting the rich against the poor, or the corporations against the little guy. There WILL be cuts to Medicare, and everyone says this has to happen to keep Medicare from going bankrupt before younger people get to use it. But in fact, if pols were willing to cut the profits of insurance and drug companies, there would be enough for everyone–we could have Medicare for all.

Which does certainly cut to the chase. Ridgeway cites his own earlier writing that applied Dean Baker’s chutzpah definition to today’s economy.

The classic definition of “chutzpah” is the kid who kills both of his parents and then begs for mercy because he is an orphan. The Wall Street crew are out to top this. After wrecking the economy with their convoluted finances, and tapping the US Treasury for trillions in bail-out bucks, they now want to cut Social Security and Medicare because we don’t have the money.

I am still with President Obama on paying for reform through elimination of waste and fraud, though that’s obviously not going to happen overnight and not going to pay for it all by a long shot. But Medicare’s going to survive, as will most Medicare recipients although we are all terminal. The moments of truth will come when the bargaining is over and we learn what the trade-offs really cost. That is, whether Big Pharma and insurance industry negotiations trump the public option, and other details still near and dear to many hearts.

So many trillions, so many sectors looking to save their own skins — or their own trillions, as the case may be — can boggle the mind quickly enough to send Jane Q. Public desperately in search of simplification, and blaming a generation is easy. The Medicares don’t want to lose their benefits, the Boomers worry that there won’t be enough for them (a legitimate worry, in fact) and the people who need health care get lost in the shuffle. Ridgeway fills in a lot of blanks. Check it out.

Pelosi Sticks With Public Option

Speaker Nancy Pelosi at a gathering of interfaith leaders in San Francisco today (Justin Sullivan/Getty)
Speaker Nancy Pelosi at a gathering of interfaith leaders in San Francisco today (Justin Sullivan/Getty)

House Speaker Nancy Pelosi held a press conference in San Francisco this morning at which she reiterated her commitment to a public option in the health reform bill and expressed hope, though with somewhat  lowered optimism, for coverage of end-of-life conversations. She did get in a dig at opponents of the latter: In response to a question about whether voluntary reimbursement for discussion of end-of-life care would stay in the bill, Pelosi said, “You know, the language is almost exactly the same as what the Republicans put into the prescription drug bill.”

The press conference, hosted by the San Francisco Interfaith Council, was an apparent reinforcement of the Democrats’ strategy of  broadening health reform support among members of religious communities. With leaders from the San Francisco Bay Area Christian, Muslim and Jewish communities arrayed behind her, the Speaker made repeated references to health care for all being a moral issue. Responding to the above question, she said, “People of faith, people in healthcare” and others know that “it makes life better if a person has expressed his or her own wishes. The key to this is that it is voluntary; it serves the purpose of saying what is your wish, rather than someone else having to make a decision you might not want. I don’t know what will happen (to the provision); I surely hope it will stay in.”

Pelosi was unequivocal, however, in her response to questions about the public option and to one reporter’s comment that “some Democrats and liberals are frustrated because it seems you are caving in to the far right.” “Is that you?” she repeated, pointing to herself. “The public option is the best way to go. If anybody can come up with a better alternative we’ll consider it. But the President is not backing off. The co-op might work in some states and that’s fine.  There is no way I can pass a bill on health reform without the public option.”

Pelosi was equally emphatic about her intention to retain the 400% of poverty measurement. Hesitantly using the term “seniors,” she said that many people between the ages of 50 and 65 have lost jobs, or may be making just $30,000 to $40,000 per year, and cannot afford needed medical care or prescription drugs. “I believe we have to have the 400% of poverty for them.”

Would the Democrats accept a scaled-down version of health reform? Pelosi repeated her litany of what is needed: reduced costs, improved quality, expanded coverage, affordable care for all; “What are you going to give up? At the end of the day, this is what we must have. And we must have reform of the insurance industry.”

In the small, carefully selected audience assembled at St. James Episcopal Church where her children attended preschool, Pelosi was on her own turf and among friends.  And she was characteristically upbeat. “Have we lost control of the debate? I disagree. I have 218 votes, and expect to have more. I am optimistic, and the President is committed to change.”