Nice overview of pre-existing condition regs

by Timothy Jost in Health Affairs blog. Big question is how many will sign up for the transitional programs before 2014.

Realistic Spending Level?

What is the realistic level of federal spending in percent of GDP terms? A key question as we seek a long run budget stability. Matt Miller in WaPo worries that Erskine Bowles has short circuited the process by giving an unrealistically low level, lower than even that proposed by Ronald Reagan budgets (which had the baby boomers paying into social security and medicare, not taking out). It will be very interesting to see what the Fiscal Commission proposes, and further to see how much of it the President decides to put forth in his budget next year.

Fools Gold

I have a guest post along with Amy Abernethy at Health Affairs blog today. The story that Atul Gawande beautifully told in his New Yorker piece yesterday can easily lead to someone concluding 'lets just stop futile care at the end of life' and that will certainly address over-spending in our health care system. However, we view a focus on seeking to reduce end-of-life (EOL) spending only as the primary means to achieve great savings in the health care system as 'fools gold' in that is not likely to produce the savings that seem possible from such an approach. It is much more difficult to prospectively identify cases in which care is futile than it is to lament that such care was futile after the fact. Instead, we need a more general increase in asking the question, 'is this care worth it?' across the entire life course, and not just at EOL. There are technical issues in beginning to do this, but the biggest challenge will be for our culture to begin to honestly tussle with these very difficult questions.

Update: Atul Gawande on NPR fresh air talking about his article.

Is she dying?

Atul Gawande has an honest, poignant and important essay in the New Yorker (Letting go: what medicine should do when it can't save your life?). For all the technical issues that need to be worked out in the health care system, the most needed and missing thing is an honest and open cultural discussion about the issues described in the essay. It is a wide-ranging piece, and is better just read than described by me. Update: here is transcript of a live online chat session done by Dr. Gawande on his piece in the New Yorker.

At Duke, we (I am the Co-Principal Investigator along with my colleague Amy Abernethy, an oncologist at Duke who directs the Duke Cancer Care Research Program) recently recieved funding from AHRQ to conduct a study that looks at the care preferences of age-eligible Medicare beneficiaries with Cancer and their family members. The study uses a group decision making process called Choosing Health Plans All Together, that was developed by a colleague from NIH, Dr. Marion Danis and her colleagues at the University of Michigan. CHAT is an approach to discussing difficult questions/decisions and starts with persons giving their individual perspective/choice, moves on to a small group process, then a larger group (8-12 people) in which a consensus decision is made about what types of care are most important. The study sessions then conclude with another individual based 'round' in which each person identifies what types of care they would prefer given that they have advanced cancer. A key aspect of the study is to what degree people's perspectives changed by their participation, and how strongly they feel about the decisions that the group made.

The difficult aspect of the decision posed to participants in the research study is that they cannot choose all possible care, and so they must make hard decisions, at least in this study. In fact, the amount of care available in this theoretical exercise is based on the average amount that Medicare spends in the 6 months prior to death for persons who die from Cancer; this constraint is not now imposed on Medicare beneficiaries. The point it to identify preferences of persons with some experience with cancer as either a patient or loved one. The same type of exercise could be done with persons suffering from other diseases, or other groups, such as younger people.

We are nearly finished with pilot testing of materials and will begin data collection in earnest in August or September, 2010. This project is a little piece of our nation learning how to talk about difficult things in medicine and health care, and better understanding the preferences of patients for the types of care they could receive given a particular situation.

Health Reform Online

WebMD this morning has news of a video starring President Obama that gives an overview of the website healthcare.gov which is designed to give an overview of the benefits of the health reform law. A quick glance at the website shows that its main consumer function is a state-specific portal to get health insurance quotes and ways to determine if you are eligible for transitional assistance via the uninsurable/high risk poll monies until pre-existing conditions will be banned and the state-specific insurance markets fully operational in 2014.

Also, Blue Cross/Blue Shield of North Carolina has a new health reform in NC website. Roughly speaking, the one the Prez is talking about is designed to make clear what the new reform law has done, both immediately and in the near future. The BCBS NC one is designed to mostly say what the law hasn't done (enough to deal with costs, and has too weak an individual mandate) but it is in the guise of we will work it out with you, and does also identify what they (BCBSNC) consider to be the positives of reform (namely expanded access to insurance coverage). More on these sites later as I have a chance to look them over.

Another Reorganization for the NHS

Another government, another round of reorganization and change in the English National Health Service (NHS). When teaching my class in comparative health systems at Duke, one of the things that we highlight about the NHS is the near constant tinkering with the NHS. This tinkering takes place within the context of the overriding big idea of the NHS since its founding in 1948 (care is free at the point of service, with resources distributed based on need). The NHS is primarily tax financed, and they spend about $1 dollar per capita each time we in the US spend $2.50, with societal level outcomes that are certainly more similar than different. One of the primary ways they hold down costs is making access to the primary care part of the system easy, but access to the secondary care (and expensive) portion more difficult. One of the primary tools used to ration services is the use of waiting lists for care.

The most notable thing about the NHS and waiting lists is not that they have them, many nations do, but that they are so explicit and honest about them. For example, one of my children waited 5 months for a diagnostic procedure last year at Duke. I asked the doc about this and he said that the demand for the procedure just outpaced Duke's ability to supply it since it was not an emergency.....that is exactly what a waiting list is. One year in my comparative health systems class I had students research waiting list times in England and at selected hospitals in the US. Waiting lists are much longer in the NHS, but it was often hard to tell. Several students reported encounters like this. How long is the wait to get an X? We don't have waiting lists here. When can I get X? 9 weeks....

One interesting aspect of the NHS for many students is the presence of a private insurance system, in which around 10-15% of the population 'go private' and avoid long waits if they need secondary care that is not of emergency nature. This seems to not only be tolerated, but based on my time as a post-doc in England, it is almost viewed as a way to help out the NHS by getting some secondary care outside of the system. This seems to bother many US undergrads in that it seems unfair. I think it is mostly just a lot more explicit than various differences within the US vis-a-vis health care that are just more subtle. And in any event, the person who lives here gets to do so simply because she was born....so they are in touch with the idea of different social strata.....

Against this backdrop, the new coalition government (Tory and Lib Democrats) has issued a white paper (Liberating the NHS) noting a planned change in policy. This is typical, and most new governments have grand plans for changing the NHS, again within the context of a tax financed system that in one sense is best described as the absence of insurance, and is instead a capitated system in which taxes are collected and distributed from the central government to different levels based on population weighted for certain factors linked to need.

Margaret Thatcher famously claimed to want to dismantle and privatize the NHS; when it was time to run for re-election, she had changed her tune to 'The NHS is safest with us'. John Major, her Tory successor, introduced General Practitioner (GP) fundholding, which introduced a 'purchaser/provider split' and was meant to introduce an internal market into the NHS, with GPs playing a larger role is purchasing hospital care on behalf of their patients. The Tony Blair government focused on modernization and actually explicitly sought to increase spending on a per capita basis, with a goal if increasing the relative spending levels in the NHS to closer to the median for European nations.

The new plan put for by David Cameron, Deputy PM Clegg and their coalition government makes clear the underlying big idea of the NHS is going nowhere. The first point of the document is thus:

*The Government upholds the values and principles of the NHS: of a comprehensive service, available to all, free at the point of use and based on clinical need, not the ability to pay. The second is,

*We will increase health spending in real terms in each year of this Parliament.

This is from the new Prime Minister of the conservative party in England. [As an aside, Margaret Thatcher, beloved of conservatives in the US, would be branded a socialist if she were running for Congress this year, but I digress]

There is lots of typical flourish (Our plan will put patients at the hear of the NHS....), with the actual policy proposals sounding a lot like GP fundholding to me, with a goal of moving control of money from more centralized authorities to groups of GPs who would purchase hospital care for the patients, presumably after and while being more in tune with their patients. The details are still not totally clear. However, it will be the umpteenth round of reorganization and policy change in the NHS. It will be interesting to see what changes are really made,and to what effect.

Here is one source of policy analysis on the White Paper and otherwise, The King's Fund.

Supporting ACA and thinking we need to do more on costs

This is my position on the health reform law and is laid out fairly clearly in the columns I wrote on health reform for the Raleigh NC News and Observer (linked on the sidebar). Austin Frakt has a good short post noting this general position, which by the way is the position of many, many health policy types. The ACA was a good first step, in one sense, because it was a step. First, toward covering everyone which is the only hope you have of truly addressing costs after you get rid of the hidden subsidies of our current system in which uninsured folks do get some care. And second, there are aspects of the law that could slow cost inflation to public payers, notably Medicare. Given the history of health policy in the USA, Medicare changes tend to lead to changes in the private system, so this is very important. But, if the ACA is the last step, we won't have a sustainable health care system, and the nation is headed toward bankruptcy as Medicare is the primary driver of the long term structural deficit.

The real questions are: (1) how well will the ACA be implemented, and notably, can the culture of Medicare be changed to move toward adoption of policy changes more rapidly, and develop a culture of trying new things (there will be mistakes). Here is a thoughtful post on Health Affairs blog discussing how Medicare should seek to reduce spending and expand patient benefit. (2) what are the next policy steps that will be taken, especially to address the rate of cost inflation? Capping the tax exclusion of employer paid insurance (at least) is the obvious next step.

But, the biggest question is cultural. Will we Americans grow up and learn to talk about hard things? And face that there are limits to what can be done? During reform I gave a fair number of speeches and events trying to explain what was happening. The crowds had different political persuasions, but there was one similarity to ALL of them. They all agreed we spent too much on health care and needed to spend less (with spend less defined as slow the rate of inflation; less than what we are projected to spend). And when I laid out policies that had a good chance of achieving the goal they all said they shared, they HATED ALL OF THEM. They essentially wanted health reform Disney World style, saving money but making no changes (Disney, after all, has managed to make rape, pillage and murder in the Pirates of the Caribbean ride, a family friendly event!).


I termed this a few weeks ago a culture of delusion. That, more than anything, has got to change for us to have a hope of moving toward a sustainable health care system.

The ins and the outs

have to match for us to have a balanced budget. The co-chairs of the President's Fiscal Commission (Erskine Bowles and Alan Simpson) were talking with the National Governor's Association yesterday. Grim stuff. The key is that the aspect of the deficit driven by the financial crisis is not the major problem--the structural deficit is. That means the deficit that is inevitable given normal functioning of the economy as the baby boomers begin to retire into social security and Medicare. And here is Jon Kyl of Arizona, a Senate Republican leader yesterday saying that tax cuts don't have to be paid for (offset by spending decreases)....as Ezra Klein says some are actually for balancing the budget while others use it simply as a reason to cut certain spending and tax cuts.

A balanced budget means the ins match the outs.

Committee to review and update identification of underserved areas

I am honored to have been named a member of the negotiated rulemaking committee that will review and update how medically underserved areas (MUA) and health professional shortage areas (HPSA) are identified and designated. Such designations make areas eligible for receipt of community health center funds, placement of a national health service corps provider, and can make physicians eligible for a Medicare bonus payment. The designations are also used for a variety of other purposes. Here is the federal register notice of intent to form such a committee, from May, 2010. Section 5602 of the Patient Protection and Affordable Care Act of 2010 (the health reform law) provided for the HRSA to review and develop a methodology for identifying such areas, and this committee is the beginning of that process.

My dissertation research, directed by Tom Ricketts at the UNC School of Public Health, and carried out at the Sheps Center for Health Services Research in the Rural Health Research Program, focused on identifying underserved areas and I completed a post-doctoral fellowship at the National Primary Care Research and Development Centre at the University of Manchester (U.K). where I spent a year comparing how the US and the UK conceive of, identify, and respond to 'underserved' areas.

Updated: a little historical context.

Interesting on Chinese health reform

Interesting op-ed sent to me by Lisa Croucher and Randy Kramer in Duke Global Health about health reform in China. My recent post on teaching this past June in China, with some comments on health reform in that nation.

Berwick named CMS Director via recess appointment

President Obama will apparently named Donald Berwick to be Director of the Center for Medicare and Medicaid Services (CMS) via a recess appointment later today. This bypasses the need for the Senate to confirm Berwick, but also means that he can only serve in the post until late 2011 at the end of the next Congressional session.

CMS desperately needs a Director to get on with the implementation of the Medicare aspects of the health reform law recently passed, and indeed, many of the demonstrations to be done by Medcare (and Medicaid to a lesser extent) will be tests that will trickle down into the broader health care system as is typical. Most major insurance side innovations in the past 30 years in the U.S. health care system have begun in Medicare and then been adopted by private insurance. Examples include hospice, prospective payment for hospitals and changes in how physician rates have been set.

At a recent health policy conference I attended, there is bipartisan (meaning more liberal and conservative types) that Berwick is a great choice to lead CMS.

More: interesting roundtable discussion hosted by Health Affairs back in April, 2010 about the future of CMS, and issues realted to implementing health reform.