Thursday, October 28, 2010

Mr. Roger's (Medical Home) Neighborhood

My image of Pittsburgh has been one of a blue-collar, rough-and-tumble town: perogies, Heinz ketchup, steelworkers, football, and Roberto Clemente. But an exhibit in Pittsburgh's airport the other day informed me that Pittsburgh also is the home of the iconic Mr. Roger's Neighborhood, the gentle PBS show that entertained toddlers for generations. Mr. Rogers always started the show off with the following verse:

"It's a beautiful day in this neighborhood,
A beautiful day for a neighbor,
Would you be mine?
Could you be mine?

It's a neighborly day in this beautywood,
A neighborly day for a beauty,
Would you be mine?
Could you be mine?

I have always wanted to have a neighbor just like you,
I've always wanted to live in a neighborhood with you.

So let's make the most of this beautiful day,
Since we're together, we might as well say,
Would you be mine?
Could you be mine?
Won't you be my neighbor?

Won't you please,
Won't you please,
Please won't you be my neighbor?"

Fittingly, the same week that I was reminded of Mr. Roger's Neighborhood, the American College of Physicians released its "medical home neighborhood" position paper. The paper was developed by a workgroup of ACP's Council of Subspecialty Societies (CSS), which is comprised of representatives of internal medicine subspecialty societies and related organizations.

The paper proposes ways that internal medicine subspecialty practices can be recognized as Patient-Centered Medical Home Neighbors (PCMH-Ns). A specialty/subspecialty practice recognized as a PCMH-N engages in processes that:

- Ensures effective communication, coordination, and integration with PCMH practices in a bidirectional manner to provide high-quality and efficient care;

- Ensures appropriate and timely consultations and referrals that complement the aims of the PCMH practice;

- Ensures the efficient, appropriate, and effective flow of necessary patient and care information;

- Effectively guides determination of responsibility in co-management situations;

- Supports patient-centered care, enhanced care access, and high levels of care quality and safety; and

- Supports the PCMH practice as the provider of whole-person primary care to the patient and as having overall responsibility for ensuring the coordination and integration of the care provided by all involved physicians and other health care professionals.

The paper proposes a set of "aspirational principles" for developing "care coordination agreements" between the PCMH-N and the PCMH to "define the types of referral, consultation, and co-management arrangements available." ACP also proposes that incentives be aligned to support PCMH-Ns, including "some form of enhanced payment to cover the time and infrastructure costs of providing services consistent with the PCMH-N definition."

I think that the PCMH-N concept is critical to building a health care system that supports the value of primary care provided in a PCMH, but also recognizes that the model cannot work without the engagement of specialists in working together with the medical home to deliver the best care possible. It belies the notion that the PCMH is only for primary care physicians, or that ACP is uninterested in helping its subspecialist members.

If the paper's vision is realized, subspecialists should be able to give a resounding "yes" when asked by a primary care physician, "Won't you please, Won't you please, Please won't you be my neighbor?"

Today's question: What do you think of the Patient-Centered Medical Home concept as proposed by ACP's Council of Subspecialty Societies?

Tuesday, October 19, 2010

Breaking through the legislative firewall

Anyone who has taken the time to contact members of Congress has probably found it to be a wholly unsatisfactory experience. Old-fashioned "snail mail" letters are sent for irradiation to a facility in New Jersey to kill possible anthrax spores (really) before being delivered to congressional offices, meaning that it may be many weeks before the letter is even read, and many more weeks before you get a "canned" response.

E-mail will get the message to them faster, but "canned" emails prepared by interest groups won't get as much attention as a personalized email. Even if personalized by you, though, this doesn't mean you will get a personalized response. Congress gets so many emails that you might only receive a standard reply. Don't bother writing to members of Congress outside your own district and state, since lawmakers consider such emails the moral equivalent of spam, and most will automatically filter them out.

Phone calls are better. If you are persistent and polite, you should be able to get through to your lawmaker's "legislative assistant" who will take notes on your conversation. At times when a key vote is scheduled and Congress is inundated, you may only get through to a receptionist.

But no matter how you choose to express your views, a well-run congressional office will make sure that someone at least is keeping a running total of the views expressed by constituents, especially when it is as simple as counting how many voters support or oppose a particular bill.

The best way to get your views across is to develop a relationship with your legislators. If you are known to the lawmaker and are viewed as a respected opinion-leader, your calls will be returned and your emails answered (and you may even be fortunate enough to get your member’s personal email or cell phone number). Such relationships can be created by showing up at town hall meetings (but be polite!) and/or volunteering for the lawmaker's health care advisory committee (if they don't have one, you could offer to help them form one). Constituents who contribute to a politician's campaign, either as an individual or through a Political Action Committee, will have an easier time developing the kind of relationship that ensures that your views are given particular attention.

National and state membership societies usually will get more attention than an individual constituent, and they have tools and programs to help their own members get their views across, such as ACP's key congressional contact program.

It is especially hard to get your voices heard when it involves a recurring issue, like the Medicare Sustainable Growth Rate (SGR) formula, where everything seemingly has been said so many times before. Politicians don't expect to hear anything new from constituents, and constituents get tired of sending yet another email or letter, when it seems likely that the result is more of the same.

But how about trying new ways to break through to Congress, which would combine old-fashioned story-telling, email, and the kinds of short video links popularized by YouTube?

Last month, the American College of Physicians asked its state chapter leaders (ACP governors) to record a short video message, using an inexpensive hand-held "flip" camera, which would explain in their own words the impact of the Medicare SGR cuts on their patients, practice, colleagues, and community. The videos were edited to no more than a minute or two by ACP's public affairs staff using free Microsoft Movie Maker. Each of the ACP chapter leaders then personally emailed the health staffer for their members of Congress to consider their plea on the SGR: 1) by viewing the personal video clip from the physician, which was included in the email as a URL and 2) by reviewing the "ask" (what action they want their Senators to take) which was included as an attached PDF, ACP's congressional affairs staff (lobbyists) then followed up with each Senator's legislative assistant. View the SGR videos for Nevada, Kentucky, Ohio, and California.

The videos may not be as entertaining as standard YouTube fare, but I think they make an extraordinarily heartfelt and effective case on why Congress needs to stop the Medicare SGR cuts. Realistically, I don't expect that a single video from a constituent will break the decades-long impasse on the SGR. But stories from constituents can be the most effective of all advocacy tools, and ACP's new "Video Advocacy Project" offers a simple and creative way to bridge the legislative firewall between constituents and their elected lawmakers.

Today's questions: What methods have you found to be effective in getting through to Congress? And what do you think of ACP's new "Video Advocacy Project"?

Monday, October 18, 2010

Record Number of Uninsured, While Millions More Look to the Government for Help

Last month, the U.S. Census Bureau released its annual survey on health insurance coverage. The results were startling, yet few politicians seemed to take notice.

- The number of people with health insurance declined for the first time ever in almost two decades. In fact, as reported by CNN this is the first time since the Census Bureau started collecting data on health insurance coverage in 1987 that fewer people reported that they had health insurance: "There were 253.6 million people with health insurance in 2009, the latest data available, down from 255.1 million a year earlier." The percentage of the population without coverage increased from 15.4 percent to 16.7 percent.

- Almost 51 million U.S. residents had no health insurance coverage at all, a record high, and an increase of almost five million uninsured from 2008.

- Fewer Americans received health insurance coverage through their jobs, continuing a decade-long trend. The number covered by employment-based health insurance declined from 176.3 million to 169.7 million, reports the Census Bureau. Based on the Census numbers, the Economic Policy Institute observes that "the share of non-elderly Americans with employer-sponsored health insurance declined for the ninth year in a row, down from 61.9% in 2008 to 58.9% in 2009, a total decline of 9.4 percentage points since 2000."

- More people than ever relied on government programs for coverage and fewer on the private sector. The number with Medicaid coverage increased from 42.6 million to 47.8 million. According to the Census Bureau: "Comparable health insurance data were first collected in 1987. The percentage of people covered by private insurance (63.9 percent) is the lowest since that year, as is the percentage of people covered by employment-based insurance (55.8 percent). In contrast, the percentage of people covered by government health insurance programs (30.6 percent) is the highest since 1987, as is the percentage covered by Medicaid (15.7 percent)."

These are the facts on the ground, folks, no matter how much the politicians choose to ignore them. Without Medicaid and Medicare, many tens of millions more Americans would be without health insurance. Financially-strapped states already are picking up much of the tab of enrolling millions more in Medicaid. And the Great Recession has shown us that most of us are just a lay-off away from losing our health insurance.

The Affordable Care recognizes the unreliability of our current health insurance system and fills the gaps. If it is allowed to be implemented, the ACA would give people who don't have job-based coverage access to subsidized and affordable private health insurance. The federal government would pay the states more for enrolling low-income people in Medicaid (100% of the cost initially, dropping to 90% by 2020); this would be money the states would be able to count on, instead of being buffeted by higher Medicaid costs whenever there is an economic downturn.

The Great Recession should also have taught us that lack of health insurance isn’t someone else's problem, but everyone's concern. The fact that "nearly every demographic and geographic group posted a rise in the uninsured rate" last year shows how vulnerable we all are to losing our health insurance coverage. The Affordable Care Act isn't perfect, but at least it would provide coverage to 95% of all U.S. residents, a far cry from the record number of uninsured in 2009.

Today's question: What is your reaction to the Census Bureau findings and what does this mean for health reform?

Tuesday, October 12, 2010

"Clowns to the left of me, jokers to the right ... Here I am stuck in the middle with you."

While driving in my car the other day, I came across this chorus from a 1970s hit song by the long-forgotten British band, Stealers Wheel. It reminds me of the sad state of American politics today. Voters seeking a sensible center instead, find themselves caught between the "clowns" and the "jokers:" the talking heads from the right and left alike who take delight in the most extreme politics and rhetoric imaginable.

Senator Susan Collins (R-ME) writes in Sunday's Washington Post that, "It's a tough time to be a moderate in the U.S. Senate. Sitting down with those on the opposite side of a debate, negotiating in good faith, attempting to reach a solution -- such actions are now vilified by the hard-liners on both sides of the aisle. Too few want to achieve real solutions; too many would rather draw sharp distinctions and score political points, even if that means neglecting the problems our country faces."

She's not alone in her concern. 130 former members of Congress, from both political parties, have taken the unprecedented step of urging all current members to work across the aisle:

"The divisive and mean-spirited way debate often occurs inside Congress is encouraged and repeated outside: on cable news shows, in blogs and in rallies. Members who far exceed the bounds of normal and respectful discourse are not viewed with shame but are lionized, treated as celebrities, rewarded with cable television appearances, and enlisted as magnets for campaign fund-raisers. Meanwhile, lawmakers who try to address problems and find workable solutions across party lines find themselves denigrated by an angry fringe of partisans, people unhappy that their representatives would even deign to work with the 'enemy'."

William Galston, a policy adviser in the Clinton administration and elections expert for the Brookings Institution, tells the New York Times that "The center has disappeared."

A new poll by the Washington Post, Kaiser Family Foundation, and Harvard University finds that, "Although Democrats and Republicans have rarely seen eye to eye, the gap between the two has widened significantly over a decade of partisan polarization..." Yet the same poll also shows that the electorate's views on government aren’t easily labored as right or left. While confidence in the federal government is at an extraordinarily low level, "support for government action on such issues as national defense, health care and fighting poverty remains high, in some cases just where it was a decade ago..."

The poll finds the electorate deeply divided over health care reform. "The polarizing debate over health care has left its mark on Republicans and independents far more than on Democrats. Ten years ago, three-quarters of independents said they favored more government involvement to ensure access to health care coverage. Today, half do. Among Republicans, the falloff is more dramatic, sliding from 53 to 21 percent."

Henry J. Aaron, a senior policy analyst at the Brookings Institution, opines that the continued partisan split over health care reform doesn't bode well for the country. He notes that most Republicans have pledged to repeal the Affordable Care Act, but President Obama likely would use his veto pen to block repeal.

"Perhaps the more likely - and in some ways more troubling - possibility is that the effort to repeal the bill will not succeed, but the tactic of crippling implementation will" he observes. "The nation would then be left with zombie legislation, a program that lives on but works badly, consisting of poorly funded and understaffed state health exchanges that cannot bring needed improvements to the individual and small-group insurance markets, clumsily administered subsidies that lead to needless resentment and confusion, and mandates that are capriciously enforced.

Such an outcome would trouble ACA opponents: their goal is repeal. It would trouble ACA supporters: they want the law to work. But it should terrify everyone. The strategy of consciously undermining a law that has been enacted by Congress and signed by the president might conceivably be politically fruitful in the short term, but as a style of government it is a recipe for a dysfunctional and failed republic."

A sensible center would instead try to find a way to bridge the differences over heath care reform and make improvements. But as the former members of Congress sadly observed in their letter a politician who tries to "find workable solutions across party lines [would likely] find themselves denigrated by an angry fringe of partisans, people unhappy that their representatives would even deign to work with the enemy."

And you wonder why the refrain "Clowns to the left of me, jokers to the right ... Here I am stuck in the middle with you" keeps replaying itself in my mind?

Today's questions: Do you think the center has disappeared from American politics? And what do you think of Henry J. Aaron's view that the continued partisan polarization over health care reform could lead to "zombie legislation" and "is a recipe for a dysfunctional and failed republic?"

Wednesday, October 6, 2010

Should Medicare pay less for less effective care?

From its inception, Medicare has been agnostic about the effectiveness of different treatments when it sets payment rates. Once a treatment is found to be "reasonable and necessary," Medicare establishes a payment rate that takes into account complexity and other "inputs" that go into delivering the service. But it is prohibited by law from varying payments based on how well an intervention works.

This would change under a "dynamic pricing" approach proposed by two experts in this month's issue of Health Affairs. The article itself is available only to Health Affairs subscribers, but the Wall Street Journal health blog has a good summary. The researchers propose that Medicare pay more for therapies with "superior" results and the same for two therapies with comparable effectiveness. A new service without any evidence on its relative effectiveness would be reimbursed in the usual way for the first three years, during which research would be conducted on its comparative effectiveness. If such research found that the service was less effective than other interventions, Medicare would have the authority to reduce payments; if it was found to be more effective, Medicare could pay more than for other available interventions. The WSJ blog gives an example of how this would work:

"They [the authors] use intensity-modulated radiation therapy, which was rolled out in the early 2000s, as an example. Medicare's reimbursement for the treatment was set at about $42,000 for prostate cancer treatment, compared to $10,000 for an older form of radiation - though there were no gold-standard studies comparing the risks and benefits of the two procedures. Hospitals bought the spiffy new equipment ... and Medicare spent an estimated $1.5 billion more on prostate cancer treatment, the authors write. If that reimbursement rate had been guaranteed only for three years before being revisited, there'd have been an 'incentive for manufacturers and clinicians to perform the research needed to evaluate the clinical performance of the new therapy in comparison to the standard three-dimensional treatment,' the authors write."

Arguably, such dynamic pricing could save Medicare (and taxpayers) many billions of dollars and improve outcomes by encouraging more research on effectiveness and rewarding physicians and hospitals for providing more effective treatments. Such a radical departure from Medicare agnosticism on clinical effectiveness, though, would almost certainly be opposed by manufacturers and providers with a vested interest in sustaining higher payments. Consumers and patients might worry that Medicare would use pricing to reduce their access to potentially beneficial services s just to save money. Physicians might chafe that the government is cutting their reimbursement based on population-based research that might not take into account the unique circumstances of their own patients. Politicians likely would scream that the government would be allowed to use its new pricing authority to "ration" care. (The accusation that Comparative Effectiveness Research could lead to "rationing" resulted in Congress writing language in the Affordable Care Act to expressly prohibit Medicare denials based "solely" on such research.)

On the other hand, at a time when rising health care spending threatens to break the (federal) bank, can the country afford Medicare's agnosticism in what it pays for services of differing effectiveness?

Today's question: Do you think Medicare should pay less for less effective treatments and more for more effective ones?

Friday, October 1, 2010

Yabba Dabba Doo! (And health care too)!

Like most kids who grew up in the 1960s, I spent many a night watching the adventures of Fred, Wilma, Barney and Betty, the coolest cavemen ever (sorry, GEICO). It is hard to explain the appeal of the Flintstones, which yesterday celebrated the 50th anniversary of its first broadcast. Its animation was primitive, the stories campy and cliché, and it was horribly sexist - but the characters were lovable, the dialogue funny, and who could not love the way it depicted "modern conveniences" (like washing machines) using only stone-age technologies (bones, stones and dino-power)?

What does Fred Flintstone have to do with health care? Not much, really, although Fred was the victim of a medical error. According to, "A 1966 episode had Fred can't stop sneezing, so he goes to the doctor for some allergy pills. The prescription gets mixed up with another package of pills which, when taken, transform Fred into an ape! Only Barney witnesses this metamorphosis, and naturally he can't convince anyone what is happening ... until a fateful family outing at the Bedrock Zoo." (Of course, this all might have been prevented if they had e-prescribing in those days.)

But the Flintstones weren't the only cartoon to make the news yesterday; a new one came out to explain health care reform. No, it wasn't a case where Fred decided to pull an Andy Griffith and endorse health care reform (despite his unfortunate encounter with the health care system) since Fred is way too media-savvy to risk his popularity! Instead, it is "YouToons" characters explaining the Affordable Care Act in a 10 minute animated film, Health Reform Hits Main Street, released by the Kaiser Family Foundation. It is the best, most entertaining, and balanced explanation of the law I have seen, and I highly recommend it to anyone who is confused about the Affordable Care Act (and who isn't?).

Today's questions: Did you watch the Flinstones, and if you did, what was your favorite episode? What do you think of the new animated film on the Affordable Care Act?