Poll-lution of Health Reform-Repeal

Amid a budget debate that will affect the health care of virtually every family, a new poll finds support for President Barack Obama's overhaul at its lowest level since passage last year. But in a ringing defense of Obama's policies, Medicare chief Donald Berwick pleaded Tuesday for more time on the health care law, and branded a leading Republican plan "unfair and harmful" and "a form of withholding care." The Associated Press-GfK poll showed that support for Obama's expansion of health insurance coverage has slipped to 35 percent, while opposition stands at 45 percent and another 17 percent are neutral.

Kaiser Health News, April 13, 2011

April 13, 2011 - I watch polls as indicators of how the health reform-repeal debate is going. Yesterday’s Associated Press poll is not a happy sign for the Obama Administration, especially when coupled with national poll averages as collected by Real Clear Politics.

RCP Poll Averages.

1) Approval of Democrat – Obama Health Plan (average of 7 national polls)

• For, 39.6
• Against, 52.0

Spread, -12.4

2) President Obama's Job Approval

• Approve, 47.3
• Disapprove, 47.9

Spread,- 0.6

3) Congressional Job Approval

• Approve, 23.6
• Disapprove, 70.4

Spread, -47.2

4) Generic Congressional Poll

• Democrats, 41.3
• Republicans, 50.7

Spread, -9.4

5) Direction of Country

• Right Direction, 27.8
• Wrong Direction, 65.0

Spread, -37.2

Of course, President Obama’s speech today on the budget calling belatedly calling for cuts, for higher taxes on the rich, and bashing Republicans could improve these averages. Until then, there is not a positive poll in the bunch for Democrats or for President Obama, for Congress, the Senate, or the Administration as a whole.

Tweet: If multiple polls are any indication, President Obama’s health plan is in deep trouble and may well be repealed if he is not re-elected.

Bureaucracy as a Barrier to Constructive Physician Health Reform Changes

You will never understand bureaucracy until you understand that for bureaucrats procedure is everything and outcomes are nothing.

Thomas Sowell (1930- ), Hoover Institute, economist, social theorist, political philosopher

Many potentially worthwhile health law provisions - electronic health records, accountable care organizations, medical homes, hospital safety programs – may never come to pass. As I point out in my upcoming book, The Health Reform Maze (Greenbranch Publishers, 2011), for physicians bureaucratic procedural demands may get in the way of outcomes. The means may defeat the ends.

Hard-pressed, sometimes overwhelmed, physicians are busy, harassed professionals. They want to spend more time with patients. Taking care of patients is what they are trained to do. It is what they are good at. Patients are their main sources of satisfaction, of improving health, of restoring life-styles, of achieving cures, and of providing income. How physicians react to bureaucratic procedural requirements is important for the future of health care.

In the minds of many physicians, meeting demands of federal regulations distracts from their work, takes an inordinate amount of time, and generates unnecessary direct and indirect expenses. The unfortunate result is that too many physicians choose to either ignore federal regulations, wait and see what develops, or escape from government and other third party oversight.

Consider a few examples.

• Installing EHR systems to qualify for federal bonuses requires meeting “meaningful use” criteria. Under the government HITECH program, eligible health care professionals and hospitals cannot qualify for Medicare and Medicaid incentive payments until they adopt certified EHR . Establishing and implementing a “certified” and “standardized” EHR system takes time, outside consultants, roughly $50,000 in start-up expenses, and meeting government procedural demands. For many, if not most busy practitioners in small practices, these demands are a “turn-off.”

• Becoming part of an accountable care organization - CMS is in the process of issuing procedural rules before the end of the year for becoming part of ACOs and engaging in joint-ventures with hospitals. To engage in these things requires hiring consultants and lawyers to avoid antitrust issues and being labeled as a hospital-physician monopoly. The run-up to an ACO may entail up to $1 million in expenses and countless meetings and hospital-physician negotiations and trade-offs. These are not things physicians are trained to do or feel comfortable doing and may strangle infant ACOs in the cradle.

Physician time, expense, and income barriers posed by federal bureaucratic procedures may lead to physicians opting out of the system with defeat of desired outcomes.

It could even lead to a market-based outcome envisioned by conservative economist John Goodman, founder and president of the National Center for Policy Analysis,

“President Obama’s health care law will bring a major transformation of the nation’s health care over the next decade in the form of a large migration of patients, doctors, facilities, and services out of the third-party payer system.”

“It will cause a major increase in concierge doctors, concierge facilities, and concierge-type services. It will lead to the creation of new markets where providers are free to repackage and reprice their services without third-party payer approval; where transparency of price and quality becomes the norm for patients; and where suppliers of services compete for patients on price, quality and amenities.”

If this were to happen, it would lead to a major political crisis of unprecedented magnitude – lack of access of Medicare and Medicaid patients to physicians.

Tweet: Government bureaucracy in the form of procedural demands upon physicians may cause thousands of doctors to opt out of Medicare and Medicaid.

Richard L. Reece, MD, has posted 1730 blogs at medinnovation blog over the last four years. His main themes concern health reform and innovation and how they impact physicians and American culture as a whole. He works closely with the Physicians Foundation. His opinions are his alone. He has written eleven books. His latest book, The Health Reform Maze, is now at Greenbranch publishing and will be released in June. Doctor Reece’s website, www.doctorreece.com, is now up and running He invites comments and questions on his blog and will respond to each comment or question on his blog or to him directly at 860-395-1501 or rreece1500@aol.com.

The Medical Home as a Primary Care Solution to Health Reform

April 13, 2011 - In my book Obama, Doctors, and Health Reform (2009, available on Amazon), I have the following chapter, “IBM Puts in Its $2 billion and 2 Cents Worth,”featuring a speech by Paul Grundy, MD, director of health care transformation at IBM.

Dr. Grundy is a driving force behind the medical home concept, an innovation prominently mentioned in the new health reform law.

According to the Engelberg Center for Health Reform at the Brookings Center, the medical home has general strengths and weaknesses:

It supports new efforts by primary care physicians to coordinate care, but does not provide accountability for total per capita costs. It does not necessarily give incentives to hospitals and specialists to participate, encourage global accountability, decrease volume, or put primary care doctors at risk. On the other hand, it requires patient assignment and a per member, per month payment structure.

Chapter Seven , IBM Puts in Its $2 Billion and 2 Cents Worth

Insurers’ corporate customers have been increasingly critical of the value of their health coverage. I.B.M., for example, says the industry is not helping to provide care that’s more cost-effective in helping their workers live longer and more productive lives. The insurers “don’t have a clue about providing what we really want to buy,” said Dr. Paul Grundy, the executive at I.B.M, who oversees its health care efforts.”

Reed Abelson, “Health Insurers, Poised for Round 2,“New York Times, March 1, 2009

If I’m elected President, I will support patient-centered primary care.

Barack Obama, during his successful Presidential campaign, 2008

What follows is the text of a speech delivered by Dr. Paul Grundy, Director of Healthcare Transformation at I.B.M. He’s giving this speech, or variations of it, as he crusades around the country, speaking to legislators, governors, policy makers, physicians and anyone who will listen about the importance of personal primary care physicians for patients, as embodied in the concept of the medical home.

I.B.M. spends $2 billion a year for health care for its employees, and Grundy feels too much of this money flows to specialists for procedures, rather than to primary care doctors, for prevention.

Grundy envisions “transformation” of American medicine to a patient-centered, primary care-system powered by real-time electronic communications between all major health care parties.

Grundy does not think nurse practitioners or nurse “doctors,” skilled, though they may be, will replace generalist physicians. Nurses are trained to be supportive and nurturing, he notes, but have not yet proved to function well or for long in independent accountable practices.

Furthermore, Grundy insists American already has, in effect, a single-payer system. It’s comprised of Medicare, Medicaid, and a private coding update system that favors specialists over primary care physicians. The reimbursement and support system for primary care physicians has to improve to encourage more medical students to enter primary care.
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Last year, Dad died in Houston, Texas, at age 87 of congestive failure with complications. He had multiple specialists but no personal primary care physicians. Dad had no personal doctor to whom I could turn to help me and my family understands the totality of what was going on.

As Director of Health care Transformation at I.B.M., Dad’s death brought home to me why I’m fighting so hard to change the care we buy for our employees and dependents. That change is the patient-centered medical home. The medical home focuses on providing better and more comprehensive primary care. For our employees, this case will serve as a “fence” to reduce the “ambulance fleet” of expensive specialists at the bottom of the expense cliff. Present care costs are unsustainable at I.B.M. and the U.S. as a whole.

In a February 6 New York Times piece “UnitedHealth and I.B.M. Test Health Care Plan “, I called the present care I.B.M, buys as “garbage.” Perhaps “garbage” overstated the case. But the lack of coordination in my father’s case frustrated me.

We have to make health care, institutions, and industries smarter. Not just at moments of crisis like we see today, but integrated into our day-to-day reality. Our current health care processes are simply not smart enough to be sustainable.

Think about how many of the medications we prescribe that go untaken or interact badly with other medications another doctor gives you. We lose tens of thousands of lives every year because we don’t have the data and systems in place to address the simple issue of medication.

Here’s where technology can help. A computer can provide connection and memory for a doctor’s brain. Just as an x-ray allows the doctor’s vision to expand, it’s health IT that allows his mind to expand and be connected in real time to thousands of other minds and to real data that makes a difference.

In truth, the health care system isn’t a “system” at all. It’s antiquated. It doesn’t link diagnosis, drug discovery, health care deliverers, insurers, employers, and employers. Meanwhile, personal expenditures on health now push more than 100 million people worldwide below the poverty line each year.

Smart health care can lower therapy costs as much as 90 percent. That’s what ActiveCare Network, based in Columbia, South Carolina, is doing for more than two million patients in 38 states. ActiveCare monitors delivery of people’s injections and vaccines so they can lead active and independent lives.

The single most important part of healing is the patient-personal physician RELATIONSHIP. It’s health care’s backbone. Smart health care supports that relationship by improving communication, allowing expanded communication with a patient, and empowering the doctor.

Personal doctors tend not to forget to ask an important question, be it about the patient’s personal life or a key fact to the healing process. Smart health care can send little reminders of care compassion and express a doctor’s investment in a person who needs a healer and healing.

A smart health care system can help with compassion by reminding the patient of important things that would otherwise be missed in a busy doctor's life like e-reminders of a visit, or that mammogram that was forgotten to be completed.

Smart health care makes sure that the right drug is used on the right patient at the right time, taking into account the person’s genetic makeup other medications they’re taking. It ensures authenticity of pharmaceuticals and security of patient information. It changes everything from how health care organizations do business to how they enable their employees to collaborate and innovate.

In the U.S., we at I.B.M. estimate that smart health care will generate lots of new jobs in companies small and large, but most will be small. In a recent conversation with the Obama administration, I.B.M.’s CEO Sam Palmisano estimated that widespread adoption of personal health records will create 212,000 jobs.

I’m not just referring to large enterprises, but also to smaller and mid-sized companies— engines of economic growth. When we think about systems like health care supply chains, health care delivery, care management, prevention, we’re really talking how hundreds, even thousands of companies, most of them are small, interact.

In the Mid-Hudson valley here in New York, we’re already on the path to deliver integrated health IT to all doctors and hospitals. This has created small companies like Med Allies in Fishkill, whose 40 employees work with doctors’ offices to get them up and running with health IT and keep them connected in a powerful and useful way for the patient. In North Dakota, there’s a small company called MDdatacore that provides the register for all the doctors in North Dakota. It now employs 42 folks.

Smart health care is giving rise to a new model for primary care, the “medical home.” About three years ago, the people at I.B.M. started talking about all the things that large employers in the U.S. have done to reduce costs and improve quality. We realized we were failing to address a fundamental issue: primary care and the doctor patient relationship.

Shortly after that, I helped found the Patient-Centered Primary Care Collaborative (link PCPCC), a coalition of large employers, consumer organizations and medical providers.

We developed a health care model based on the premise that’s more holistic. Primary care saves money by cutting the incidence of major health problems like heart disease or diabetes later in life. It’s a back-to-the-future approach to the family doctor, enabled by IT.

In the medical home model, a primary care physician acts as a health care coach – leading a team that manages a patient’s wellness, preventive and chronic care needs. The doctor spends more time with the patient in person, is available for consultations via email or phone, and has expanded hours and coordinates across an entire care team – nurses, specialists, pharmacists and hospitals.

A diabetic could give daily blood test readings by phone, email or remote monitoring device and get instructions the moment she needs them, rather than wait for an appointment. Her care team would have a holistic health plan that focuses on diet and exercise as well as monitoring glucose levels.

This is already happening outside the U.S. In the U.K., they have adopted a similar “family doctor” model that makes health care more accessible and effective – and makes patients happier.

Electronic health records – central in the U.S. health care stimulus bill – are pivotal to making medical homes work. Electronic health records are the single source of information that can be shared across a network of providers and specialists. There are other IT tools that can help patients and doctors alike – online portals to make appointments or look up lab results, or e-prescribing.

Health analytics can look across a patient’s history and pick up trends that provide insight into the treatment of a disease. The list goes on. But it’s important and can’t be stressed enough. That technology supports the care and compassion in the doctor patient relationship but will not replace that or even get in the way of it.

Over the next couple of years, there will be winners, and there will be losers. And though it may not be easy to see now, I believe we will see new leaders emerge who win not by surviving the storm, but by changing the game.

The importance of this moment, I believe, is that the key precondition for real change now exists: People want it.
Summary
Trust your family doctor, and think about the concept of the medical home., especially if you work for a corporation paying your health bills. Employers pay 68% of the nation’s total health care bills, and their ideas are to be heeded. When you’re I.B.M.’s Director of Health Care Transformation, Doctor Paul Grundy, you think of your employees’ health from Monday to Sunday. For them you seek better prevention and higher productivity through primary care doctors with overall patient accountability, So you crusade for Medical homes every moment of every day.

The Health Reform Debate: Sad Stories from Both Sides of the Political Aisle

With Republicans determined to disrupt implementation of the new health-care law and promote their own fixes to Medicaid and Medicare, and Democrats hopeful of swaying a stubbornly divided public to embrace the law as it takes effect between now and 2014, no one expects the fight to let up anytime soon. And for Democrats and supporters of the law, the weapon of choice is the compelling individual story, a tool honed by former President Ronald Reagan that has been archived and analyzed, computerized and systematized to new levels for this battle.

N.C.Aizermann, “Individual Stories Weapons of Choice in Fight over Health Care Law, “ Washington Post, April 9, 2011

April 12, 2001 - Expect Democrats and Republicans to feature health care sob stories in the upcoming reform debate.

Democrats are better at this anecdotal game than Republicans. Their base is the “have-nots” and others who depend on Medicare and Medicaid. At Families USA, one of their affiliates, Democrats have collected a vast database of compelling individual stories.

Today, April 12, Democrats will trot out 5 stories from 5 states, to be followed relentlessly by other tales of woe from those who have benefited from the health care law. The personal narrative, as told on video and at Congressional hearings, will be the centerpiece of their political strategy. The White House website contains a clickable map of video testimonials “50 states with 50 stories,” asking viewers to share their experiences on the subject “How is the Affordable Act helping you?”

Meanwhile Republicans are collecting stories on a theme that might be called, “How the Affordable Care Act is hurting you now and in the future.” It will feature stories from people who will say they have had to drop coverage because of soaring premiums, from employers who will say they can no longer afford to cover employers because of increased costs related to Obamacare, and from budget-minded politicians who will say “Your children and your grand-children will left without care” because the nation will be bankrupt.”

ACOs: Another Top-Down Idea, Another Likely Dud

Here’s the problem with ACOs: They are a tool in a big tool box of care and cost management tools but, like all of the other tools over the years like HMOs and IPAs, they won’t be used as they were intended because everybody—providers and insurers—can make more money in the existing so far limitless fee-for-service system.

Robert Lasweski, “Why ACOs Won’t Work,” The Health Care Blog, April 7, 2011. Robert Laszweski currently serves as the president of Health Policy and Strategy Associates of Alexandria, Virginia.

April 11, 2011 - I have spent most of my life as a physician watching Washington-based policy solutions go down in flames and up in costs and bureaucratic smoke, leaving independent physicians in the ashes.

First, it was HMOs,

then, IPAs,

then, physician companies on the stock market,

then, integrated health systems,

then, hospital employment,

now, accountable care organizations.

Each solution requires organizing doctors into business-oriented groups with outside oversight.

Each approach fails because physicians treasure their autonomy and stand more to gain in peace of mind from staying the way they are, as mavericks practicing fee-for-service medicine in order to stay close to and to best serve their patients.

Here, according to the Engelberg Center for Health Reform at the Brookings Institute, a liberal-leaning, influential Washington, D.C. think tank, are the characteristics of accountable care organizations that should be good for the U.S, but are unlikely fail to catch fire.

ACO Characteristics

• General strengths and weaknesses – Makes hospitals and physicians accountable for total per capita costs and promotes coordinated lower-cost care, but does not require patients or physicians to “lock-in” into ACO.

My questions: Why should physicians join n ACO if the ACO intent is to lower physician income and force them into partnerships with hospitals with which they now compete? Anyway, what’s in ACOs for patients?


• Strengthens primary care directly or indirectly - Designed to give physicians incentives to focus on disease management within primary care through medical homes and partial capitation.

My question: Is delayed gratification of sharing savings with hospitals sufficient incentive to overcoming barriers of spending hundreds of thousands of dollars, even a million, for setting up an ACO and installing EHRs to tracking population health?

• Fosters coordination among all participating providers - Designed to provide significant incentives to coordinate among participating providers.

My question: What is the incentive for specialists, who constitute 2/3rds of all American physicians, who are doing just fine outside ACOs, and who stand to lose income by playing second fiddle to primary care physicians and hospital administrators?

• Removes payment incentives to increase volume of patient visits - Adds incentives based on value , not volume.

My question: Do not patients consider hip and knee replacements, coronary stents, cataracts, pacemakers – to be of “value,” as evidenced by the increased volume of these procedures? Gatekeeping and capitation has already been tried and failed, Why would it work now?

• Fosters accountability for total per capita costs – Offers shared savings when total per capita costs are reduced.

My question: For the typical physician and hospital, don’t you think “total per capita costs” is an abstraction that does not apply to them?

• Requires providers to bear risk for excess costs - The present model does not require physician or hospital risk sharing.

My question: Get real. Do you really believe hospital and doctors, who are already paid at 70% to 80% of private plan rates by Medicare, with beds and doctors in short supply, are going to willingly bear risks to join ACOs?

• Requires “lock-in” of patients to specific providers - Allows patients to be assigned on basis of previous patterns of care but includes incentives to provide services within realm of participating providers.

My questions: Why would patients abandon their present pattern of choice of hospitals and doctors for a theoretical concept to follow government mandates that limit those choices? Why would physicians and hospitals abandon the known for the unknown?


Richard L. Reece, MD, has posted 1725 blogs at medinnovation blog over the last four years. His main themes concern health reform and innovation and how they impact physicians and American culture as a whole. He works closely with the Physicians Foundation but his opinions are his alone. He has written eleven books. His latest book, The Health Reform Maze, is now at Greenbranch Publishers and will be released in June. Doctor Reece’s website, www.doctorreece.com, is now up and running He invites comments and questions on his blog and will respond to each comment or question on his blog or to him directly at 860-395-1501 or rreece1500@aol.com.

Health Reform and the Budget Battle: Who Won?

When they say it is the principle, and not the money, it is the money.

Maxim

April 10, 2011 – In the extraordinary budget battle just concluded, who won on the health reform issue ? Obama supporters or opponents?

The consensus is that those who would repeal Obamacare won. At least that’s the opinion of Donald J. Palmisano, MD, JD, former president of the AMA,as expressed in his widely read blog, DJP Update. He and many others felt the main issue in the budget deal was cutting $38.5 billion from the budget, not ending social programs like NPR or Planned Parenthood.

Palmisano gives three reasons why the deal favors opponents of the health reform law.

One, because the deal supports the position of those who say the health reform law is failing as articulated in the new book Why Obamacare is Wrong for America.

Two, because the deal guarantees a Senate vote on repeal of the health care law, gives lawmakers new tools in the form of studies and hearings to demonstrate negative impacts of the law, and denies new funds to the IRS to enforce the law’s mandates.

Three, because the budget battle deal somehow will culminate in a Supreme Court 5-4 decision declaring the health law unconstitutional.

I do not know whether Dr. Palmisano is right or wrong, but I thought it might be worthwhile reprinting the details of the alternatives to Obamacare as set forth in Why Obamacare Is Wrong for America.

It is not sufficient to repeal the law. A reasonable alternative must be offered.

Private Insurance

• Offer people a health credit to purchaser coverage on their own, through an employer, or through other groups.

• Allow greater flexibility in health benefits: consumers, not regulators, should decide what their health plans cover and not be forced into one-size-fits-all, government determined standard plans.

• Provide portability of health insurance and greater competition by allowing cross-state purchase of health insurance.

• Allow states to develop market mechanisms to help consumer find and enroll in the insurance that best meets their needs.

• Ensure more secure renewal of health insurance this is guaranteed so people who have insurance can keep it, and others without it will encourage getting insurance and maintaining their coverage continuously.

• Provide greater financial assistance to the states to create more functional high risk pools or state risk-transfer pools that allow people with preexisting conditions to purchase more affordable health insurance.

• Reform the medical malpractice litigation process at the state level.

Public programs

• Puts the savings from Medicare reform into saving Medicare.

• Convert Medicare for new enrollees into a market-based, consumer-choice program in which the beneficiaries select the coverage that best suits their needs with fixed support from the government.

• Allow people to escape from Medicaid by giving them health credits that they could use to purchase private coverage.

• Provide more flexibility to the states in running Medicaid programs so that can get the best value for taxpayers’ dollars, including allow Medicaid beneficiaries to enroll in state-designed consumer-choice models.

• Provide more options for Medicaid recipients, Medicare beneficiaries, and others on public programs to escape the restrictions that inevitably come from price controls and government micromanagement.

Richard L. Reece, MD, has posted 1725 blogs at medinnovation blog over the last four years. His main themes concern health reform and innovation and how they impact physicians and American culture as a whole. He works closely with the Physicians Foundation but his opinions are his alone. He has written eleven books. His latest book, The Health Reform Maze, is now at the publishers and will be released in June. Doctor Reece’s website, www.doctorreece.com, is now up and running He invites comments and questions on his blog trough his website and will respond to each comment or question on his blog or to him directly at 860-395-1501 or rreece1500@aol.com.