Archive for July, 2009

July 28, 2009

“Stimulating” health care?

The Stimulus Bill – also know more formally as the American Recovery and Reinvestment Act (ARRA) – allocates about $150 billion out of over $780 billion to the health care sector, perhaps the highest percentage devoted to a particular area.  This illustrates, on one level, the importance of health care to the President and Congress, and, on another level, suggests the important economic impact of this investment.  What is the nature of these investments:   Monies for the states to match federal assistance for Medicaid and increased funding for the National Institutes of Health (NIH), health information technology, and comparative effectiveness research.  Is this money being well spent and are these wise investments?

At a time when almost all the states are struggling with budget deficits, the matching Medicaid funds are most welcome, enabling these states to continue serving those on Medicaid.  As needed as these funds are, they do not fundamentally change the system of care for these patients.  Rather it offers both relief and “more of the same.”

The investment in NIH is important because NIH has in recent years lost real purchasing power as its budget has been relatively flat since the doubling of its budget was completed years ago.  The nation must support its premier biomedical research enterprise for many reasons, including the increasing urgency of such research based on scientific progress and the heavy investments many research-intensive institutions have made in science and scientists to ensure America’s preeminence in biomedical science.

Health information technology has been lagging behind in its development in the U.S. and it is thought that the stimulus dollars may get us over the hump.  While these funds may spur some improvement and adaptation of IT, foster some needed efficiencies, and prevent some medical errors, it is important to note that they do offer for the first time potential financial incentives for IT adoption.  The importance of these incentives reflect the need make the adoption of Health IT both cost-effective and competitively necessary, as seen, for example, by the rapid adoption of IT in the restaurant and the airline industries.

Finally, there is the funding for comparative effectiveness research which will ramp up the effort to demonstrate which therapies and therapeutic approaches are most “effective’”  and thereby improve quality of care and presumably incur some cost savings.  But, as I have noted before, the development of guidelines is not enough (see my post below from July 14th) – there must be ways to directly link best treatments with actual clinical practice, something that is currently lacking.  There is also the problem in effectiveness research of assuring that we can conduct the necessary clinical trials which are the backbone of such research.  We have pointed out the increasing regulatory burden on those who conduct clinical trials and the compelling need for reform in this area.  But I am not aware of any concrete efforts to do so.

The overarching theme of the stimulus package as it relates to health care involves the four concrete areas of Medicaid, NIH, Health IT, and effectiveness research.  But it does not address structural reform of the nation’s health system by, for example, creating pilot projects or other mechanisms to consider fresh options for health care delivery.    Rather it serves to support and bolster trends already underway.  How stimulating is the stimulus?

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July 23, 2009

Mr. President: Provide the vision, take command of health reform

Mr. President. The press conference usurped the time slot of So you think you can dance? but you did not command the dance floor. You did not command the attention of the American people by telling them why health care is important to the future security of this nation. You provided no vision last night. You talked about the costs of health care as if you were the director of the Congressional Budget Office. Yes, health care may an important part of  the economic recovery –which you are taking extraordinary steps to address. And the costs of health care are a worry for the government.  But you forgot to tell the people that there are costs that go beyond the numbers on some CBO balance sheet.  There are also the costs of greatness. Without health care, the greatness of the nation is at risk. Health care reform relates to life, liberty ,and the pursuit of happiness for the American people who still believe that the U.S. should be the shining example of what is good in the world.

You did not call  upon the nation last night to think about a new and better way to live, as you have done in the past. Where was the orator last night? You are capable of raising the nation’s heart and soul. It is about the economic future that comes from good health care for each individual. You should be telling us how health care is about individual and national security–about freedom from worry about your child’s health or your mom or dad’s Alzheimer’s disease. Tell us that the nation is only secure if the health of its people is secure–that American greatness is built upon caring for each other.

Mr. President, we want you to  provide the vision that is so lacking in this health care debate. You talked about insurance premiums, employer coverage, and insurance exchange programs. You talked about passing reform at the “lowest cost.” How can health and security be equated to the “lowest cost”? I am not sure the nation wants to hear that, Mr. President.

What can you do Mr. President? Here is my short list. #1. Give us new vision on health care–one that’s about health–not just money and costs. #2. Reframe the debate by getting some new voices in the mix–including the single payers. Don’t close them out. #3.Make sure the nation knows what health reform will mean for the health workforce–and for biomedical research in this nation. Those are real issues for the future. Open the door to new thinking on all fronts. #4. Take control of the debate. The Congress is pushing many agendas and may not be doing what is best for the nation. #5. Take a stand. Tell the nation that the government is a good guy and can solve this problem. #6. Tell the nation that the bureaucrats making decisions about health services do not work for the government but for the insurance industry. It’s time to get creative to find out how the insurers can contribute in new and different ways to the economy. There may be a new world out there for them in job retraining. #7. Be strong and be confident that the nation is behind you.

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July 21, 2009

Who will be taking care of us?

In the growing debate over health care reform, there has been relatively little mentioned about one of the most important aspects of any health system (reformed or not):  the nation’s health workforce of doctors, nurses, dentists, pharmacists, allied health professionals, public health workers, psychologists, veterinarians, and so forth.  It seems that it is taken for granted that whatever does (or does not) happen in health care, there will be an adequate health workforce backbone to take care of us.  But this is, in fact, not clearly the case.  There have been reports and calls alerting us to impending or actual shortages of health professionals.  These shortages are not necessarily profession-specific; they may also involve specialties within a given health profession, such as primary care. Another perspective posits that the principle workforce problem is a maldistribution of the kinds and locations of providers as well as variations in their practice styles.  An additional concern is that the kinds of types of providers that will be needed in the new era of genomic and personalized medicine are probably going to be somewhat different from what we have now.

Yet there is no overarching approach or policy concerning the nation’s health workforce.  We instead rely on a myriad of market forces, agencies, regulatory and accreditation bodies in a patchwork quilt arrangement.  As a result, it is exceedingly difficult to answer the question:  what would be the ideal composition of the U.S. health workforce to best meet our health care needs?   For now, it’s like trying to compute an equation without a denominator.  It’s time for the health workforce discussion to be front and center regardless of the extent of health care reform.

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July 16, 2009

SOS on Regulatory Reform in Health Reform

I read that countless numbers of people are worried about being regulated by government in any reformed health system.   But no one, especially policymakers, seems to be addressing the regulatory infrastructure and the costs of regulation, which might open up a pandora’s box and really shed light on the extent to which the public is benefiting from the regulations developed to protect the American people (which is an issue for a longer discussion).  No one is asking whether the agencies mandated to regulate, including the Centers for Medicare & Medicaid Services,  have the resources to address implementation and enforcement of current and new regulations.  Policymakers should be addressing those resources now.  Policymakers would also do well to look at the costs of compliance for the government and for health care providers.   A 2005 study by the Association of Academic Health Centers  found that the costs of compliance  increased up to 300% in the previous decade and often more than 70% a year at academic health centers throughout the nation. We are hearing of even greater increases at the present time.  No one is denying the need for accountability and protecting quality, safety, and privacy in the health care arena.  But it may be time for the government to ask about the costs and benefits of regulation along with addressing the need for rational and ”smart” regulations.  There is also an urgent need for harmonization within the regulatory environment.  Interagency task forces have done little to ensure there is no contradiction and confusion between regulations coming out of the many government agencies.  If we really want to ensure safety and quality for the public as well as savings in health care delivery, reform of the regulatory world must be addressed now. 

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July 14, 2009

A Guideline is just a….guideline

It’s well known that the practice of medicine is not completely evidence-based; in fact, it is estimated that less than 25% of typical medical practice is supported by rigorous evidence, such as controlled clinical trials.  So it is very welcome that, in considering health care reform, the administration wants to enhance the evidence-base for medical care.  Already, there have been some funds from the stimulus package devoted to this, and the Institute of Medicine has a Round Table on this topic.

This is certainly a good thing, but merely producing the evidence isn’t enough.  The findings then have to become part of everyday clinical practice.  It is a reality that many  guidelines and best practices have yet to be fully adopted into clinical practice, or that it takes an unacceptably long time for this to happen.  I suggest, as we move to build up the evidence base for medical practice, that we concurrently develop strategies to link this research directly and meaningfully to the actual delivery of health care.   A guideline is, after all, just a guideline.

- SW

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July 10, 2009

Michael Jackson and Health Reform

Michael Jackson is being remembered for his extraordinary talent, vision, and  courage.  He changed music,  dance, and culture in the U.S.–and around the globe.  He understood new technology, had a new vision for the entertainment world, and had the courage to take on a music giant, MTV,   forcing the playing of the Billie Jean video and ultimately music by black artists.  He was not satisfied with tradition and the status quo.  His courage resulted in amazing transformations in the entertainment industry–and American society.  Which brings me to health care.  Who on Capitol Hill will be remembered for courage, vision, and talent when it comes to health reform?  Where is the vision?  Where is the courage?   Isn’t everyone  trying to preserve tradition–employer based coverage and the insurance industry?  What will be the achievement that will reshape the nation?Aren’t we seeing a complicated mix and match game built on the current dysfunction in the system.  Is there a Michael Jackson on health reform?  I don’t see one.  Do you?

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July 7, 2009

But wait………there’s more!

I recently learned that a large metropolitan health care institution is offering a “summer special” on coronary calcium CT scans at a reduced price of $99 from the regular price of over $400.  These scans determine the amount of calcium in the coronary arteries.  The result, known quantitatively as the Agatston score, is said to be predictive of the risk for heart disease, although this still needs to be fully worked out.  Since this test is often not covered by insurance, patients who are offered the test must pay out of pocket.

The fact that certain, discretionary medical tests are being offered on “special,” should not be surprising as this is a natural progression of the growing role of market forces in health care.  Some would argue that this is a good example of how market forces positively impact health care by enabling patients and their doctors to make more cost effective health care decisions, rather than relying on passive decisions made by insurance companies.

However, I find it a troubling example as health care becomes increasingly commercialized.   Do we really want the practice of medicine to look like a late night infomercial:  “The first 30 people to sign up for the test will also get a set of Ginsu Knives.”  I recognize that there needs to be a balance between medical professionalism and the free play of market forces.   But that balance is inexorably becoming skewed in the direction of the market.

The patient-provider relationship should be kept at arms-length from market forces so as to ensure that the care delivered is in the patient’s best interest.  The market does not necessarily have the patient’s best interests in mind:  its goal is to seek profit wherever it can be found.  In some cases it does work in the patient’s interests; in some it does not.  But special deals and price incentives for medical tests and procedures by their very nature undermine effective medical care decision making by substituting financial motivation for effective patient care decisions.   Do medical infomercials and their equivalents really have a place in a reformed health care system?

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July 2, 2009

Mr. President: show your courage on public option in health reform

Robert Reich says it better than I do: “Make no mistake: A public option large enough to have bargaining leverage to drive down drug prices and private-insurance premiums is the defining issue of universal health care. It’s the only way to make health care affordable.”  The President must lead—and educate—the  people.  Courage is required.  The President as community activist—unafraid of  the powers that be  and speaking on behalf of the powerless—is  he wants to go down among the greats in the history books.  Selling the  Massachusetts plan and mandated insurance will not define greatness.

The President has to do what he said he would on the campaign trail—not cave to lobbyists and ensure universal coverage with a strong public program.  What happened to the man on the campaign trail who promised that in America a woman dying of cancer will not have to fight with her health plan for coverage? The people know the problem is not solely with physicians and hospitals. There is support for a STRONG government plan and the President has to tap that support. People want social security and  Medicare? Isn’t that the government at work? Roosevelt gave us social security.  It’s time for Obama to give us real health care reform with a strong government program.

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