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.
Saturday, July 10, 2010
Friday, July 9, 2010
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.
Wednesday, July 7, 2010
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.
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.
Tuesday, June 15, 2010
Teaching in China
Just back from teaching for the second year in Duke University's joint (along with Peking University) certificate in Global Health, held in Beijing, on the campus of PKUs health science campus. This is the same campus with PKU's "Third Hospital" and just inside the fourth ring road, about 5 minutes by taxi (or 45 minutes depending on traffic) from the Olympic village, Bird's Nest stadium, the water cube, etc. Professor Yan Guo directs the certificate from PKU's end and she is a delightful colleague, who got her start in public health and medicine as a barefoot doctor in rural China.
Around 40 students from all over China took this course. Some of the students were still full time students, while others were physicians, epidemiologists working for the Chinese CDC, and the Office of Quarantine and international travel; the folks who were front and Center dealing with the H1N1 virus and China's response last Summer, and other organizations.
I was teaching a course in comparative health care systems....essentially an overview in financing and structure of how nation's around the world deal with the two 'laws' that govern all health systems in the world: (1) everyone eventually dies; before that (2) the healthy subsidize the sick. The essence of health policy is figuring out how (2) above is done. We began as I always begin my comparative course at Duke, by saying that you cannot copy another countries health system, simply because such systems exist in a particular historical and cultural reality, time and space. But, it can be useful to see what other nation's do, and how it seems to work for them.
China recently announced a plan to move toward covering all Chinese persons with health insurance in January, following 3 basic guiding principles: (1) improve health status; (2) spread financial risk/expand insurance coverage of some type; (3) do 1 and 2 in a manner that improves satisfaction of the Chinese people with their health care and health care system.
China is profoundly on a 'different part of the curve' than is the USA in beginning their reform. The per capita expenditure on health care in China is around $400, with an avg. Life expectancy at birth of around 73 years; the USA has per capita expenditures of over $8,000 per year with life expectancy at birth of around 78 years. So, one thing that China plans to do is spend more, perhaps even much more, on health care services. And they are at a point at which increased expenditures will likely pay off with large health status gains quickly.
As with any per capita expenditure, that doesn't mean that each person gets exactly $400 spent per year on their health care. China probably has upwards of 500 Million people living in very remote rural areas where expenditures are more like $5 per capita (the USA has 310 Million total people). In the large cities of Beijing, Shanghai, and Guangzhou (up the Pearl river from Hong Kong) there are well developed health care delivery systems for persons with either government civil service or private employer based insurance. I think most Americans probably assume that a Socialist nation must have a one-size fits all top/down health care system, but it is really quite the opposite. Many different arrangements, depending upon geography, history, working status and the like. A very common phrase used by students in the course last week was 'we will have to have flexibility to work it out according to local circumstances.' This was especially true when students talked of the rural parts of China. Again, this is the exact opposite of what most Americans would assume.
And Professor Guo explained to me over dinner one evening that at the founding of the People's Republic of China, that the health policy from Mao Tse-Tung held that especially in rural areas, the local people had to decide exactly what type of system they wanted, and they had to fund it themselves. This lead and has lead to wide disparities and spending levels across parts of China, and particularly across different rural portions of the nation. And allowing such local variation and 'working it out' seems to clearly be a part of China's future in health policy.
We talked a great deal in the course about different ways to finance health care services and to collect and pool money (how the healthy subsidize the sick; same idea as car insurance, by the way, and in one sense is simply the definition of insurance). One tremendous demographic change that is underway is China's relaxing of the one child policy. A large increase in the size of a birth cohort would make payroll taxes an attractive way to increase spending, especially for older persons. We walked through the downsides of this approach, especially if later a one child policy is restored....that would make the baby boomer generation look like a small event.
A few other cultural observations, some that relate to health policy, others that do not. First, I enjoyed walking and running in the mornings and evenings and tried to use this time to explore and 'people watch.' There is a huge urban park nearby the PKU health sciences campus and at night, and especially sunday night, there are thousands of people out doing vaguely wholesome things like Karaoke, line dancing, hackey sack, a 50 person brass band playing Presbyterian Hymns, and people singing patriotic songs.
Second, in the mornings, there are many older persons out doing Tai Chi, oftentimes in large groups, especially of women. One thing I admired about this was the seeming lack of self consciousness of the people in doing this in public....I think Americans would feel quite self conscious if out doing such.
Third, there was an empty lot nearby the campus last August when I was there and last week there was a 20 story building there. The rate of construction and development is fast, and there was a construction sight nearby that I am fairly sure was working 24/7.
Fourth, last week had some very large economic events, namely a strike at a plant that supplies Honda with parts for Accords in a southern industrial city. The government appears to have tolerated this strike and to have essentially said that the workers have a point. This along with the widespread report of the doubling of wages in an iPhone factory that had many person's commit suicide appears to signal that the Chinese people are interested in reaping more of the benefits of their rapid economic development. And that the Chinese government either agrees and/or views this as inevitable. This is not surprising, and it part of a transition of China toward a higher income society.
Fifth, I noticed that most obese person's that I saw in China in my walks were young (elementary and middle school age kids). There are some alarming statistics about type II diabetes in China and India and some evidence that type II is onsetting among persons who are not very obese and that it be less amenable to diet and exercise as is the disease in the US. This is also a part of the transition of China to a higher income society.
Sixth, my colleague from Duke, Kate Whetten, taught the course Introduction to Global Health, which is essentially an introduction to health care in low income nations, as well as to a focus on health inequalities in higher income nations. The students were slower to be convinced of the need or benefit of China being involved in the rest of the world. We talked about some of the issues related to criticism of the Chinese government for being slow to respond to the Haiti earthquake...simply put, as China becomes more of an economic leader, the rest of the world expects them to be involved in the rest of the World. My biggest conclusion for the students last week was that China has a tremendous opportunity to not only reform its own health care system, but to be a model for the low income nations of the world who also would like to move to expand financing and expenditure on health care services. Because China is such an economic power, with lots of central infrastructure and ability to implement new polices (it will be slightly easier for Hu Jintao to get what he wants in health reform that it was for President Obama), if China will evaluate what happens and share this with the rest of the world, they have a great chance to be a model and a guide for the nations of Africa, Asia and South America in health reform.
Seventh, they don't have Chinese John Wayne. The hotel I was in only had 1 English TV station and you can only take so much of a business news station so I watched some war movies (there were two or three stations that always had war movies on, with Japan being the primary adversary). The bottom line that was easy to pick up was that the Chinese hero always seemed to die, the city was laid waste, and the concluding scene was one of lament. I kept waiting for the Chinese John Wayne to show up, but he does not exist.
Similarly, last year we went to Chinese opera at the 'egg' which is the name (not the actual name, but you see why they call it this) for the national opera house down by Tiannamen Square. It was a story about a man and his daughter traveling the silk road and his daughter was kidnapped by Middle East traders and she was taken away and married into Middle Eastern royalty. The dad searched for her his entire life and when he found her, filled with rage, he killed her husband, the Prince. Of course, this was his daughter's husband, and filled with sorrow, she killed herself and the story then just ended.
Compare this to the new movie the Karate Kid which I took my kids to see on Sunday....there was never any doubt who would win the last match. If this was a Chinese movie, the karate kid's leg would have been broken, the bad teacher would have killed Mr. Han, and the mom would have committed suicide due to the shame of her son's loss. There is a profound cultural difference between the USA and China in the stories that we tell about ourselves. I am not sure exactly what it means, but I am pretty sure it is important to understanding the relationship betwen the USA and China.
Finally, my bottom line take away from two trips to China and my readings about China is that China defies categorization. It is a jumble of contradictions and unlike any place else in the world. It is simply China. And in thinking about my kids future, when it comes to picking a foreign language to learn in school, there are only two choices that make sense: Spanish or Chinese.
Around 40 students from all over China took this course. Some of the students were still full time students, while others were physicians, epidemiologists working for the Chinese CDC, and the Office of Quarantine and international travel; the folks who were front and Center dealing with the H1N1 virus and China's response last Summer, and other organizations.
I was teaching a course in comparative health care systems....essentially an overview in financing and structure of how nation's around the world deal with the two 'laws' that govern all health systems in the world: (1) everyone eventually dies; before that (2) the healthy subsidize the sick. The essence of health policy is figuring out how (2) above is done. We began as I always begin my comparative course at Duke, by saying that you cannot copy another countries health system, simply because such systems exist in a particular historical and cultural reality, time and space. But, it can be useful to see what other nation's do, and how it seems to work for them.
China recently announced a plan to move toward covering all Chinese persons with health insurance in January, following 3 basic guiding principles: (1) improve health status; (2) spread financial risk/expand insurance coverage of some type; (3) do 1 and 2 in a manner that improves satisfaction of the Chinese people with their health care and health care system.
China is profoundly on a 'different part of the curve' than is the USA in beginning their reform. The per capita expenditure on health care in China is around $400, with an avg. Life expectancy at birth of around 73 years; the USA has per capita expenditures of over $8,000 per year with life expectancy at birth of around 78 years. So, one thing that China plans to do is spend more, perhaps even much more, on health care services. And they are at a point at which increased expenditures will likely pay off with large health status gains quickly.
As with any per capita expenditure, that doesn't mean that each person gets exactly $400 spent per year on their health care. China probably has upwards of 500 Million people living in very remote rural areas where expenditures are more like $5 per capita (the USA has 310 Million total people). In the large cities of Beijing, Shanghai, and Guangzhou (up the Pearl river from Hong Kong) there are well developed health care delivery systems for persons with either government civil service or private employer based insurance. I think most Americans probably assume that a Socialist nation must have a one-size fits all top/down health care system, but it is really quite the opposite. Many different arrangements, depending upon geography, history, working status and the like. A very common phrase used by students in the course last week was 'we will have to have flexibility to work it out according to local circumstances.' This was especially true when students talked of the rural parts of China. Again, this is the exact opposite of what most Americans would assume.
And Professor Guo explained to me over dinner one evening that at the founding of the People's Republic of China, that the health policy from Mao Tse-Tung held that especially in rural areas, the local people had to decide exactly what type of system they wanted, and they had to fund it themselves. This lead and has lead to wide disparities and spending levels across parts of China, and particularly across different rural portions of the nation. And allowing such local variation and 'working it out' seems to clearly be a part of China's future in health policy.
We talked a great deal in the course about different ways to finance health care services and to collect and pool money (how the healthy subsidize the sick; same idea as car insurance, by the way, and in one sense is simply the definition of insurance). One tremendous demographic change that is underway is China's relaxing of the one child policy. A large increase in the size of a birth cohort would make payroll taxes an attractive way to increase spending, especially for older persons. We walked through the downsides of this approach, especially if later a one child policy is restored....that would make the baby boomer generation look like a small event.
A few other cultural observations, some that relate to health policy, others that do not. First, I enjoyed walking and running in the mornings and evenings and tried to use this time to explore and 'people watch.' There is a huge urban park nearby the PKU health sciences campus and at night, and especially sunday night, there are thousands of people out doing vaguely wholesome things like Karaoke, line dancing, hackey sack, a 50 person brass band playing Presbyterian Hymns, and people singing patriotic songs.
Second, in the mornings, there are many older persons out doing Tai Chi, oftentimes in large groups, especially of women. One thing I admired about this was the seeming lack of self consciousness of the people in doing this in public....I think Americans would feel quite self conscious if out doing such.
Third, there was an empty lot nearby the campus last August when I was there and last week there was a 20 story building there. The rate of construction and development is fast, and there was a construction sight nearby that I am fairly sure was working 24/7.
Fourth, last week had some very large economic events, namely a strike at a plant that supplies Honda with parts for Accords in a southern industrial city. The government appears to have tolerated this strike and to have essentially said that the workers have a point. This along with the widespread report of the doubling of wages in an iPhone factory that had many person's commit suicide appears to signal that the Chinese people are interested in reaping more of the benefits of their rapid economic development. And that the Chinese government either agrees and/or views this as inevitable. This is not surprising, and it part of a transition of China toward a higher income society.
Fifth, I noticed that most obese person's that I saw in China in my walks were young (elementary and middle school age kids). There are some alarming statistics about type II diabetes in China and India and some evidence that type II is onsetting among persons who are not very obese and that it be less amenable to diet and exercise as is the disease in the US. This is also a part of the transition of China to a higher income society.
Sixth, my colleague from Duke, Kate Whetten, taught the course Introduction to Global Health, which is essentially an introduction to health care in low income nations, as well as to a focus on health inequalities in higher income nations. The students were slower to be convinced of the need or benefit of China being involved in the rest of the world. We talked about some of the issues related to criticism of the Chinese government for being slow to respond to the Haiti earthquake...simply put, as China becomes more of an economic leader, the rest of the world expects them to be involved in the rest of the World. My biggest conclusion for the students last week was that China has a tremendous opportunity to not only reform its own health care system, but to be a model for the low income nations of the world who also would like to move to expand financing and expenditure on health care services. Because China is such an economic power, with lots of central infrastructure and ability to implement new polices (it will be slightly easier for Hu Jintao to get what he wants in health reform that it was for President Obama), if China will evaluate what happens and share this with the rest of the world, they have a great chance to be a model and a guide for the nations of Africa, Asia and South America in health reform.
Seventh, they don't have Chinese John Wayne. The hotel I was in only had 1 English TV station and you can only take so much of a business news station so I watched some war movies (there were two or three stations that always had war movies on, with Japan being the primary adversary). The bottom line that was easy to pick up was that the Chinese hero always seemed to die, the city was laid waste, and the concluding scene was one of lament. I kept waiting for the Chinese John Wayne to show up, but he does not exist.
Similarly, last year we went to Chinese opera at the 'egg' which is the name (not the actual name, but you see why they call it this) for the national opera house down by Tiannamen Square. It was a story about a man and his daughter traveling the silk road and his daughter was kidnapped by Middle East traders and she was taken away and married into Middle Eastern royalty. The dad searched for her his entire life and when he found her, filled with rage, he killed her husband, the Prince. Of course, this was his daughter's husband, and filled with sorrow, she killed herself and the story then just ended.
Compare this to the new movie the Karate Kid which I took my kids to see on Sunday....there was never any doubt who would win the last match. If this was a Chinese movie, the karate kid's leg would have been broken, the bad teacher would have killed Mr. Han, and the mom would have committed suicide due to the shame of her son's loss. There is a profound cultural difference between the USA and China in the stories that we tell about ourselves. I am not sure exactly what it means, but I am pretty sure it is important to understanding the relationship betwen the USA and China.
Finally, my bottom line take away from two trips to China and my readings about China is that China defies categorization. It is a jumble of contradictions and unlike any place else in the world. It is simply China. And in thinking about my kids future, when it comes to picking a foreign language to learn in school, there are only two choices that make sense: Spanish or Chinese.
Thursday, May 27, 2010
Hospitalists
One of the strongest trends in health care delivery is the rise of the hospitalist. They are docs who work only in hospitals. There are many reasons that the old model of community doc who sees patients in their office and in the local hospital are going away. And the rise of the hospitalist is also driving an increase in the number of physicians who are paid a salary. There is evidence of decreased length of stay and reduced readmission with hospitalists, and they are present to the hospital at all times. Issues related to the hand off of the patient from the hospital setting back to the community exist.
Monday, May 17, 2010
Good presentation about budget situation
The CBO Director has new presentation up and available here. Note especially slides 7 through the end, with slides 10 and 11 giving the expected makeup of the 2020 budget. All of these are shown assuming the 2001 and 2003 tax cuts are extended and the AMT indexed, and then assuming this doesn't happen. This is well said, from his slide 13:
"The United States faces a fundamental disconnect between the services that people expect the government to provide, particularly in the form of benefits for older Americans, and the tax revenues that people are willing to send to the government to finance those services."
Yep.
"The United States faces a fundamental disconnect between the services that people expect the government to provide, particularly in the form of benefits for older Americans, and the tax revenues that people are willing to send to the government to finance those services."
Yep.
Saturday, May 15, 2010
Rounding errors
Eric Cantor (R-Va) who is the minority whip in the House of Representatives has announced a new budget cutting discussion (YouCut) being sponsored by the House Republicans. You can vote on one of the 5 programs to cut as offered by the House GOP; the winning cut will be introduced for an up or down floor vote in the House of Representatives if they take over the House (actually the web site seems to say they will introduce it now, but I am not sure about that). The budget deficit and the general unsustainability of our current fiscal state as a nation is the top priority as i see it. In one sense, you could say any discussion of priorities and what could be cut is good. However, the programs identified as the 5 choices are laughably small. They are:
*End Presidential Election fund, cut $260 Million
*tax preferences for Unions, cut $600 Million
*end HUD doctoral dissertation fellowships, cut $1 Million
*change TANF reforms, cut $2.5 Billion
*limit community block grants to high income areas, cut $2.6 Billion
The fiscal year 2009 federal budget was around $3 Trillion dollars. That is 3,000 Billion. In one year. The budget categories go like this:
*Social Security 22%
*Defense discretionary 20%
*Medicare and Medicaid 21% (14% medicare)
*Net interest on Debt 8%
*Non defense discretionary 16%
*Other 12%
They have proposed miniscule cuts to the non defense discretionary portion of the federal budget. Now, maybe they are just pacing themselves.....but these proposed cuts are laughable unless you get to the big boys: Social Security, Defense, Medicare and Medicaid.
Anyone telling you they have a plan to reduce the budget deficit but who does not mention reductions in at least one of: Defense, Social Security, Medicare/Medicaid and/or some increase in taxes either does not understand the situation or is dishonest. The long term structural budget deficit is almost completely driven by Social Security and Medicare and Medicaid.
You can also submit your own idea to the website: I submitted the following. Raise the eligibility of Medicare by 1 month per year starting in 2014....in 2025 the Medicare eligibility age would then be 67, saving between $50-$60 billion over 10 years. The Medicare age would then be unified with the planned increases to the Social Security retirement age. The out year savings (years 11 to 50) would be in the Trillions.
Now if they want to really get the discussion about potential budget cuts started, lets have an up or down vote on that.
*End Presidential Election fund, cut $260 Million
*tax preferences for Unions, cut $600 Million
*end HUD doctoral dissertation fellowships, cut $1 Million
*change TANF reforms, cut $2.5 Billion
*limit community block grants to high income areas, cut $2.6 Billion
The fiscal year 2009 federal budget was around $3 Trillion dollars. That is 3,000 Billion. In one year. The budget categories go like this:
*Social Security 22%
*Defense discretionary 20%
*Medicare and Medicaid 21% (14% medicare)
*Net interest on Debt 8%
*Non defense discretionary 16%
*Other 12%
They have proposed miniscule cuts to the non defense discretionary portion of the federal budget. Now, maybe they are just pacing themselves.....but these proposed cuts are laughable unless you get to the big boys: Social Security, Defense, Medicare and Medicaid.
Anyone telling you they have a plan to reduce the budget deficit but who does not mention reductions in at least one of: Defense, Social Security, Medicare/Medicaid and/or some increase in taxes either does not understand the situation or is dishonest. The long term structural budget deficit is almost completely driven by Social Security and Medicare and Medicaid.
You can also submit your own idea to the website: I submitted the following. Raise the eligibility of Medicare by 1 month per year starting in 2014....in 2025 the Medicare eligibility age would then be 67, saving between $50-$60 billion over 10 years. The Medicare age would then be unified with the planned increases to the Social Security retirement age. The out year savings (years 11 to 50) would be in the Trillions.
Now if they want to really get the discussion about potential budget cuts started, lets have an up or down vote on that.
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