February 25, 2008 14:49
Where does much of our news content come from these days anyway? I’ve seen a dozen op-eds this month reporting authoritatively that Hillary and Barack have nearly identical health reform concepts. Where do these lame analyses come from? The two candidates have very different approaches, with different strengths, weaknesses and implications for medicine.
Hillary proposes that all Americans must have coverage in five years through a pluralistic private sector approach. Her plan involves an individual mandate for uninsured persons, means to strengthen existing employer coverage and a commitment to take on the fight for major insurance reforms. She also supports somewhat unspecified quality of care improvements. While she proposes subsidies for lower income families, she would basically require everybody to pay their fair share of coverage costs, with nobody freeloading anymore.
Obama meanwhile proposes covering only kids 0 – 18 through expanded public coverage and then proposes to get costs down for everybody else by voluntary negotiations with insurers. (Whoever advised him negotiations will produce friendlier, more socially responsible for-profit insurers needs their meds adjusted.) Mr. Obama expects more people to voluntarily buy insurance. If this doesn’t work — and it certainly won’t without insurance reform with teeth — he favors a single payer system in the future, while Ms. Clinton has specified she does not favor that goal.
The only real commonality I see in the two approaches is that both propose to pay for the public costs of their ideas by reducing the Bush tax breaks to wealthy individuals. (Meanwhile, on the R side, Mr. McCain has no major access expansion or reform plan other than his desire to increase tax credits for individual coverage to incentivize greater coverage. He has not yet mentioned insurance reforms.)
Regardless, Mr. Obama is now the likely Democratic nominee, with good old Ted Kennedy advising. One take-home: We’d better focus carefully on what Medicare reform looks like, because it could be a much bigger program in five years. Another take-home: There really is no politically viable plan for reform on the table yet, giving us more time to help suggest one.
February 22, 2008 14:52
Jack Wennberg, M.D., and the Dartmouth Health Atlas team have been trying to send a message to the profession for 25 years: Measured variations in costs by geography and facility are not due to patient risk factors, differences in quality of care or socioeconomic community status. He’s starting to have a major impact.
Congress is getting a geography lesson this week from its own CBO agency. Congressional Quarterly reports that the Congressional Budget Office (CBO) is now seriously looking at this data, in anticipation of doing something about it. CBO says reducing variations not related to quality or risk adjustment justifies payment systems in Medicare based in part on “efficiency” — not to be confused with “effectiveness.”
It’s hard to argue that some genuine effort is not needed in these regards. But, we should take it on.
Wennberg doesn’t feel his measured variations are deliberate or greed-oriented. Some increased costs, for example, occur in response to malpractice-induced defensive medicine. He does believe however that a lot of this is due to supply side factors — “if we build it, we use it (more often),” at least as it pertains to hospital bed and technology use. He also shows data suggesting that per capita numbers of specialists are directly related to proportionate increases in specialty services and costs.
There’s no associated measured improvement in quality or health status that comes along with that surplus of specialists. This will definitely be part of the upcoming system reform and payment reform discussions.
February 19, 2008 14:54
Finally! The AHRQ has published proposed rules for the Patient Safety and Quality Improvement Act of 2005. The proposed regulations describe how an entity may become a Patient Safety Organization. Sections of the proposed regulations also explain how clinicians will be able to report patient safety events confidentially, how this data will be shared with others while remaining private, and how clinicians and other health care organizations will receive feedback on ways to improve patient safety. This is really very good public policy.
Members of the public are invited to comment on the set of proposed rules within the next 60 days. The Notice of Proposed Rulemaking can be viewed here. I encourage you to comment. Rules like this one, that will affect both quality and confidentiality, must be written with physician input. But this has a lot to be positive about.
February 11, 2008 15:37
As the ACC ramps up its multi-year “Quality First” outreach campaign around Health System Reform, we are looking for volunteers to serve as “Quality First Ambassadors” and speak at local Chapter meetings and/or other ACC or quality-related events. We’re basically talking about putting our ACC-AHA Guidelines and Performance Measures into practice. We’re also launching two pilot projects (paired with the NCDR) aimed at improving patient medication compliance. Leading in promoting quality gets us a “seat at the table” for health system reform, but we can’t do it without your help. If you are interested in participating in this very worthy endeavor, contact email@example.com.
February 8, 2008 15:34
The Office of Clinical Standards and Quality (OCSQ) at CMS informed us this week that the NCDR™ has been selected for its pilot program exploring the use of registry data to meet PQRI requirements. The NCDR is one of 12 nominations selected out of over 30 received by the OCSQ.
The pilot will test two options: submitting patient level data to CMS, and submitting aggregate level data to CMS. This is an exciting step forward for the NCDR — and for our quest for quality-based health system reform.
February 7, 2008 21:47
The Boston Globe reported recently that Blue Cross and Blue Shield of Massachusetts wants to stop paying doctors and hospitals simple FFS for most individual patient visits, and instead offer a flat sum per chronic disease patient each year, adjusted for age and sickness. Providers who improve care would also receive a significant bonus. Blue Cross expects patients could see dramatic changes, such as quicker access to the doctor, same-day appointments, home visits by nurses, and smoother transitions between hospital, rehabilitation center and home.
This system is designed to incentivize health care providers to work together to achieve higher quality, cost effective outcomes. That’s the good news. The not-so-good news, in ACC member Joe Drozda’s words: “If you simply impose the new reimbursement systems on providers who are organized to provide services under the old system, you are not likely to succeed. You can't force fit reimbursement methodologies.” But, this is a fascinating development nonetheless, representing payment both for coordinating care and for higher quality. Payment reforms are a-coming — and are needed (think SGR). But we need to propose how this could happen fairly.
February 4, 2008 21:45
Today’s the last day to chow down with abandon before Lent, and also to predict the low down on the Presidential primary process before the big 20-state vote. From the health policy point of view, nothing huge is likely to change between today and tomorrow, as Clinton and Obama will both still be in the running, but the R side could be down to McCain only. Attendees at our ACC Health Reform Summit last weekend heard from the campaign leaders representing all three of these candidates in some detail. We have major and bipartisan issues to get on the table regarding quality and CV care, no matter who prevails tonight.