Rob Coppedge: June 2009 Archives

The advertising wars around health care reform are, as expected, really heating up: 

Whether the advertising reaches the level of 1994 remains to be seen. Then, the health insurance industry ran a series of TV ads featuring a couple, Harry and Louise, that helped to bring down President Clinton's complex plan. 

This week's entries have been the most pointed so far this year. The U.S. Chamber of Commerce ran a full-page ad in Roll Call, a Capitol Hill newspaper, opposing the employer mandate and public insurance plan. "Health care reform that punishes employers would be bad for the economy and jobs," the ad warned.  

For a rundown of big spenders (Rick Scott's Conservatives for Patients' Rights, Health Care for America Now, MoveOn.org) and their initiatives: Advertising wars escalate in health care fight (http://www.usatoday.com/news/washington/2009-06-26-health-care-ads_N.htm)

"You're too smart to go into family medicine." 

A few days ago we pointed out an article about the dearth of primary care doctors in the United States. Here's a different twist on the issue: "No relief: Shortage keeps older docs on the job / Young doctors opt for specialties, fueling looming lack of primary care." (http://www.msnbc.msn.com/id/31507763/ns/health-health_care/) 

The article highlights Dr. Kenneth Spady's story; at 81, he'd like to retire, but there's no one to take his place: 

After more than two years of trying, and several close recruiting calls, there's still no one to take his place in this rural community 100 miles north of Seattle, where the nation's shortage of primary care doctors has landed squarely at Spady's office door. 

"We've probably trotted eight or nine people through here," said Dr. David A. Lynch, president of the Whatcom County Medical Society, which is helping conduct the search. "At this point, we have not been able to get a doctor to commit." 

As the nation's debate about overhauling health care heats up, one truth remains undisputed: There are not enough general care doctors to meet current needs, let alone the demands of some 46 million uninsured, who threaten to swamp the system. 

It's a problem growing worse in Everson and across the country, where more aging doctors are finding they can't retire. In the U.S., there are at least 4,500 primary care doctors older than 75, according to figures from the Physicians Masterfile database maintained by the American Medical Association. Overall, there are about 270,000 doctors practicing primary care, which includes family, general medicine and internal medicine. 

Note: It's worth listening to the audio in the sidebar, a few short snippets with and about Dr. Kenneth Spady. 

As we posted the other day, both sides of the health care debate are clamoring for the attention and support of small business.

Not sure if today's news makes things more clear, but here we go....

Health Care for American NOW! reports that - in several anecdotal examples - small business owners are fed up with... um... everything about the current health care system and want "reform". They assert that there is growing support for the "public option".  We are looking for more polling here and will post what we find.

While over at Market Watch, they report that Micro Businesses (companies with 10 of fewer employees) are having a somewhat different and somewhat more nuanced reaction to the health care debate:

The nation's entrepreneurs are ready for major changes to the American health care system, but are asking the federal government to implement various proposals to help them cope with the costs. When asked for the most important component of health reform, 60 percent of micro-business owners cited cost containment, even over access and choice. Nearly 2,000 micro-businesses, including members of the National Association for the Self-Employed (NASE), took part in this national online survey of their opinions on current health care reform proposals.

...Most entrepreneurs are strongly opposed to a "public option." Rather, they prefer a free market approach, wherein business owners can work with private insurance carriers instead of purchasing a federally managed plan. Seventy-one percent said that they would choose a private insurer when given the choice to purchase the exact same health insurance policy at the exact same price from either a private insurer or the federal government.

"Micro-businesses are distrustful of the federal government and its ability to manage health care," commented Kristie Arslan, Executive Director of NASE's Legislative Offices. "They continue to bear witness to how the government creates inequities in the tax code, increases red tape and poorly manages their budget. If the self-employed were to run their business in the same manner as the federal government, these entrepreneurs would have been out of business a long time ago. Likewise, business owners do not feel that they should put their health care in the government's hands via a public health plan."

Health CEOs for Health Reform and the New America Foundation put out a series of papers recently which we found very interesting. You can find more information here.

It is worth browsing the summary of their proposals - but you can glean a lot from their vision statement:

Our Vision for Health System Reform:

Health care reform must make quality health care and health insurance affordable and accessible to all. Yet meaningful health care reform must also make our health delivery system sustainable for families, employers, providers, and governments. As health care leaders who operate in our current system, we firmly believe that upwards of 30 percent of the resources spent on health care in the United States are a result of too few efforts to coordinate care and not enough attention to quality. We must achieve higher value for our health care dollar to make affordable coverage and high-quality care available for all, including our most vulnerable, for years to come.

We will not control health care costs until we create clear incentives for providers - the people who deliver care - to focus on quality and efficiency.

The Medicare program must convey the seriousness with which it will approach payment reforms that move away from fee-for-service and toward accountable payments. Medicare must articulate clearly its long-term goals to allow providers to prepare for future payment incentives.

The challenge of properly aligning incentives is significant - but many of our physician readers make clear that to suggest (absent such enlightened policy) doctors and other providers aren't already focused on quality misses the real point.

"Quality" is hard to achieve without data and feedback - and as one physician said recently, if half of the money and time being focused by DC on advocating the public option were spent instead on a real plan for interoperable health care data, meaningful subsidies for implementation of interoperable clinical data tools and supporting private sector innovation we might actually get somewhere.

Join this vigorous physician-only debate inside iMedExchange.

(Thanks to Dr. Howard Luks for sharing this link.)

Politico reports Sen. Chris Dodd has acknowledged that

...health care reform may not clear a key committee this week -- the latest logistical speed bump in President Barack Obama's push for new legislation addressing the country's health care crisis.

Dodd said today he would like to finish the process this week but that he was still waiting for cost estimates from the Congressional Budget Office about the cost of the bill.

Medical News Today reports this morning that the White House is planning to roll out a media blitz around their health reform efforts.

Roll Call went further: 

"Some of the events may have been planned before Obama's health care effort ran into difficulties, such as the decision by Senate Finance Chairman Max Baucus (D-Mont.) to delay today's planned markup - possibly until next month - and a suggestion by Sen. Dianne Feinstein (D-Calif.) on Sunday that the votes to pass the legislation do not yet exist."

Given the growing chasm between sides regarding the "public option" and funding options, it is not clear how much closer a media campaign, grassroots advocacy or even a series of rallies(!) will get us to consensus. Perhaps we'll learn more after President Obama's turn as a news anchor on tonight's ABC News Special.

Ashley Halsey at The Washington Post wrote this weekend about the lack of primary care docs to meet our current systemic needs... much less increased utilization under a system providing universal access. Read the article here.

As the debate on overhauling the nation's health-care system exploded into partisan squabbling this week, virtually everyone still agreed on one point: There are not enough primary-care doctors to meet current needs, and providing health insurance to 46 million more people would threaten to overwhelm the system.

Fixing the problem will require fundamental changes in medical education and compensation to lure more doctors into primary-care offices, which already receive 215 million visits each year.

The American Academy of Family Physicians predicts that, if current trends continue, the shortage of family doctors will reach 40,000 in a little more than 10 years, as medical schools send about half the needed number of graduates into primary medicine.

The overall shortage of doctors may grow to 124,400 by 2025, according to a study by the Association of American Medical Colleges. And, the report warns, "if the nation moves rapidly towards universal health coverage" -- which would be likely to increase demand for primary care and reduce immediate access to specialists -- the shortages "may be even more severe."

As reform watchers awaited the Baucus proposal and a plan from House Democrats, attention this past week shifted to the price tag for key reform proposals and sources of funding. Tuesday, the Congressional Budget Office (CBO) put a price of $1 trillion on the Kennedy plan, noting it would reduce the ranks of the uninsured by only 16 million. Release of Sen. Max Baucus' much anticipated plan was delayed after a CBO estimate put the plan's cost at $1.6 trillion. Concern about the price tag for health reform gained momentum last week as notable Senate moderates including Charles Grassley (R-IA) and Kent Conrad (D-ND) indicated they were concerned about costs as well as their belief a public plan would crowd out commercial insurers.

To date, potential sources of funding have been discussed by the White House ($947 billion), as well as key trade and legislative groups. The most notable include:

Small businesses have been vocal proponents of health care reform in the hopes it would make health insurance more affordable. That goal, however, may not be achieved in the legislation now moving through Congress, some business groups fear.

They're afraid the bill being marked up this month by the Senate Health, Education, Labor and Pensions Committee won't do enough to control health care costs, but will go too far in imposing stiff new insurance requirements--including minimum coverage levels--on employers.

They also worry that including a government-run plan as an option in new insurance exchanges would lead hospitals and doctors to charge private insurers more for their services in order to compensate for underpayments they would receive from the public plan.

The U.S. Chamber of Commerce has e-mailed its members, urging them to oppose the Senate HELP Committee's bill, calling it "a dangerous proposal."

Republican opponents of serious health reform like Senator Mitch McConnell love to claim that a public option would hurt small business owners. On the ground, though, the picture is more complex and, if anything, the opposite. Small business owners are suffering under the current system, and many of them strongly support health reform that includes a public option. That's because enacting real health reform would be a boost - not a blow - to America's economy.

In a recent post to his blog, the Atlantic's Marc Ambinder articulates the rationale for how the "public option" could be successful. While I post several key paragraphs below, take the time to read Ambinder's entire argument. It is a strikingly clear presentation of the conditions that would need to exist for the public option to achieve the desired outcomes....

...the public supports a health care plan if they're given information about its intention: by injecting competition, it would force private insurance companies to lower their prices and could possibly drive some out of business. When the public is asked to evaluate the public plan in bleaker terms, like when they're threatened with the loss of their choice of doctor, support drops, unsurprisingly. Unfortunately, policy makers are adding layers of complexity to what is a simpler debate: the public plan is basically Medicare with a different, less baggage-laden name. 

...[reductions in administrative costs are the] the strongest real argument -- for a public plan. The difference between 3% and 20% is the profit motive for the health care industry: that's the money that doctors and providers and insurance companies get above and beyond the cost of the procedure or treatment or administration. Doctors don't want to be forced to accept Medicare-pricing; patients worry about Medicare rules determining what type of coverage they can get, although they seem just as uncomfortable with the bureaucratic decisions made by centralized entities at their private health care plans. Writing in the Wall Street Journal, Abraham Verghese of Stanfordpoints out an axiom that explains why the private sector is congenitally opposed to cost-cutting: "a dollar spent on medical care is a dollar of income for someone." 

That means, he says, that the only way to cut costs to reduce the size of the trough. How do you reduce the size of the trough? You use the power and size of the government to negotiate better prices on prescription drugs, tests, and doctor visits. You do that in a competitive marketplace where the value of goods and services can be somewhat reliably obtained. Right now, only Medicare is big enough to negotiate. 

The more popular solutions, as Alter and Verghese point out, is what we might today want to call the Gawande Model, after the physician/journalist's New Yorker article about the disparity in health care costs in McAllen, Texas and El Paso, Texas. Rightly, Gawande teases out a common symptom: the culture of money and history and tradition that doctors operate in determines or heavily influences how they practice medicine. "Comparative Effectiveness" is seen as the answer. As Alter notes, under this concept, "doctors would be advised that this treatment for a urinary-tract infection or that surgery for back pain was ineffective and should not be used." That might help. But doctors wouldn't be -- couldn't be -- forced to give up their preferred methods of treatment. And the public wouldn't stand for it; they want their doctors to do everything in their power to make them well. There's some evidence that if patients are given information about, say, why expensive, invasive tests like angioplasty aren't terribly useful in certain situations, they'll elect to challenge their doctor about the necessity of the test. Problem is, it's much easier to say no to an invasive test than it is to a CAT scan. Comparative effectiveness works is human beings are rational. When human beings get sick, they're often quite quirky. 

...the point is that if cost-cutting is really a goal of health care reform, then it'll have to come from either patients paying less or doctors, hospitals, drug companies and insurance companies getting less. There's no magic bullet that would keep people employed and healthy and well-compensated at all once....

...a public plan has to be well-designed, has to be big enough to generate competition, can't be too big so as to throw the insurance companies out of business (the competition sustains the innovation), and has to compensate providers well enough without breaking the Treasury. 

Bottom line: if you want to cut costs, you need an agent that can bargain them down. Medicare can be that agent if you change the way it operates. If you don't really want to cut costs, you can drop the public option altogether.

Another very interesting post from Deloitte's Center for Health Solutions - this one giving an overview of a report put out by policy center featuring some heavy hitters (Daschle, Baker and Dole):

"Cross the Lines: Working Together to Reform the U.S. Health System" was released as an effort to forge a middle ground in the health reform debate. Released Wednesday by the Bipartisan Policy Center, the group's recommendations include expanded use of health IT, implementation of a comparative effectiveness system to reduce inappropriate variation, expanded scope of practice legislation for allied health professionals to accommodate needs for a larger primary care workforce, guaranteed insurance coverage regardless of pre-existing condition, development of regional/state level health insurance exchanges, subsidies for mandated insurance coverage for individuals/households up to 400 percent of the federal poverty level, and limits of no more than 15 percent for insurance premiums. The price tag for the plan--$1.2 trillion--would be paid for by improved efficiency in the system and additional taxes. However, specifics of funding were not provided.

(Thanks to Dr. Krueger for this guest post)  

Marc Ambinder's blog for the Atlantic made a very interesting point the other day...

Julius Hobson, former top congressional lobbyist for the American Medical Association (AMA), says President Obama's speech to the AMA yesterday didn't articulate anything new--but that it's significant that Obama appeared before the group at all, and that Obama's coalition-builting tactics mark a notable difference from the Clinton-era reform push.

From a phone interview this morning:

I watched it when he was giving it, and I did not hear anything new that I did not expect to hear. What I thought was different was that he went to the AMA's annual meeting. No president has spoken to the AMA's annual meeting since, I believe, Ronald Reagan...

Hobson notes that Obama is going about health care reform quite differently from the Clintons' strategy in the early 1990s. By bringing major industry players to the table, he won't get support from everyone, but he can win enough support within each group to push reform through.

Tom Curry at MSNBC reported yesterday on the Congressional Budget Office reports which attempted to quantify the budget impact of the health care reform plans currently under consideration. Among the CBO's findings:

"The CBO estimated that if the bill becomes a law, it would cause "a net increase in federal budget deficits of about $1.0 trillion" from 2010 to 2019. But according to the agency, the bill would still leave 37 million Americans uninsured by 2019."

Pretty chilling stuff... and there's more:

"The $2 trillion in savings promised by health care industry executives who flocked to the White House last week "are no doubt welcome," said CBO Director Douglas Elmendorf.

"But, he added, "Most of the proposals are steps that do not require the involvement of the federal government or are not specified at a level of detail that would enable CBO to estimate budgetary savings."

With these disconnects between stated goals and fiscal reality and the seeming inequity in the sharing of "sacrifices", it leads many of our readers to wonder if Washington's current vision of reform is "worth it".  We look forward to hearing from you - join the conversation inside iMedExchange.

Moderate, fiscal-conservative voices on the Hill are finding ways to cooperate across the aisle - in preparation for a political battle where their votes very well could decide the final outcome of the health care reform effort. As Molly Hooper at the Hill reported today:

"Those centrist factions are wary of the proposals their respective leaders will introduce this month. Blue Dogs are leery of the so-called public option in the healthcare reform bill that is expected to hit the House floor this summer. Meanwhile, GOP centrists opted to release their own healthcare plan a day before House GOP leaders are scheduled to unveil their reform package."

The Blue Dog Democrats have been a focus of conservative attention during the opening days of this debate - as our friends at Docs4PatientCare posted on their blog today.

Among the Blue Dogs is Rep. Jim Cooper (D-TN) who was the leading Democratic opponent of Hillary Clinton's health care plan in 1992. As David Brooks of the NYT remembers:
 

Cooper is one of the most thoughtful, cordial and well-prepared members of the House. In 1992, he came up with a health care reform plan that would go on to attract wide, bipartisan support. A later version had 58 co-sponsors in the House - 26 Republicans and 32 Democrats. It was sponsored in the Senate by Democrat John Breaux and embraced by Daniel Patrick Moynihan, among others.

But unlike the plan Hillary Clinton came up with then, the Cooper plan did not include employer mandates to force universal coverage.

On June 15, 1993, Cooper met with Clinton to discuss their differences. Clinton was "ice cold" at the meeting, Cooper recalls. "It was the coldest reception of my life. I was excoriated."

Cooper told her that she was getting pulled too far to the left. He warned that her plan would never get through Congress. Clinton's response, Cooper now says, was: "We'll crush you. You'll wish you never mentioned this to me."

...Hillary Clinton set up a war room to oppose Cooper, who was planning to run for the Senate in 1994....Clinton and her aides believed accused him of crafting his plan in order to raise money from the insurance and hospital industries. They said he was in league with the for-profit hospitals to crush competitors and monopolize the industry. They did this despite the fact that Cooper's centrist health care approach was entirely consistent with his overall philosophy.

Cooper is now a leading Blue Dog and will be a key voice of reason in the debate over the next few months. It will be interesting to watch how his experience in the last major political skirmish over health care reform influences the efforts of the moderate Democrats and Republicans as they prepare for the battle ahead.

(Thanks to Dr. John Krueger for this guest post) 

A recent article in the New Yorker by surgeon and author, Dr. Atul Gwande, has inspired many pundits to chime in with their ideas for health care reform.  Interestingly however, very few of these voices chiming in appear to be doctors.

For example, in a recent editorial the New York Times suggests "Doctors have been complicit in driving up health care costs. They need to become part of the solution." The same editorial bemoans the  "profligate physician behavior" described in the Gwande piece.
 
I wonder if the NYT really has this right.  Is this what the Gwande piece is really about or is this simply more spin, painting the physician community as the proverbial fox in the hen house?

In my opinion, Gwande did a great job highlighting the problem and even took the pains to dig into some important reasons that health care in some areas of the country is vastly more expensive and resource consuming without higher quality than in other areas of the country.

But Gwande stops short of a detailed analysis and scientific dissection of the reasons and confounding factors which might make McAllen, Texas and Miami, Florida the most expensive places for health care. Furthermore, Gwande practically gives private insurers a "get out of jail free" card suggesting that the problems in health care would not be changed simply by changing payor systems.

Gwande's article was followed recently by President Obama's speech to the AMA, where the President declared his intent to avoid a single payor health care system while pledging to oppose medical malpractice reform.  The President acknowledged the hidden costs of defensive medicine but stopped short of offering tangible remedies, suggesting only that physicians should not practice medicine in this fashion (read the NYT view of the speech's treatment of med-mal here).
 
So as this specter of "change" hangs in the air, I cannot help but think that the more things appear to change the more they stay the same. What is staying the same in these debates is that we physicians are being told that it is us who have to change.  Our intentions are being questioned as we are being told it is our obligation to just accept the solutions being offered by politicians and interest groups.

What is missing from this debate, of course, are the opinions and voices of those of us who actually take care of patients.  Amidst all the so-called patient advocates promoting their agendas, the physician needs to claim the position of the ultimate patient advocate.

We work on the front lines of medicine - andI am sure you are discussing these topics with your patients and your colleagues in your offices and hospital wards. I don't know about you, but I find precious few patient advocates there in those wee hours of the morning, holidays and weekends holding patients' hands, taking care of accident victims in the ER or facing the responsibility of telling a patient they have a life threatening disease or terminal illness.
 
This is our job - and I don't have to tell you that medicine is a calling.  Physicians shoulder enormous responsibility and make a significant sacrifices just to become doctors.  It's messy, life consuming and hard...very hard.  And that's exactly the way it should be.  Our patients and the integrity of our profession deserve no less.

As the NYT points out, we can all certainly strive to create a better system. However, we are not the only ones who have to change and sacrifice to save our failing health system.  
 
There has never been a time where physicians (and their patients) needed to be more involved in a political debate.  Failure to transform America's health care system will lead to its eventual collapse - and potentially the undermining of the American economy. However, any attempted reform must respect the trusted, caring relationship between the patient and physician.  It is the essence of medicine and any proposal that fails to appreciate its power is doomed to failure.   
 
I look forward to hearing your thoughts.

Health care entrepreneur (and all around critical thinker) Hal Andrews recently took aim at Dr. Atul Gwande's much discussed New Yorker piece on health care costs.

Here are a few choice bits (I think Hal would advise you to add a few grains of salt as you read):

...the article is further evidence of the Dartmouth Atlas proposition that over-utilization is the crucial issue in health care reform. Putting aside the fact that comparing McAllen to El Paso is like comparing Newton to Wellesley, two things jump out from the article that I believe bear further consideration.

First, as we know in every aspect of our lives, human beings respond to economic incentives. In the past decade, no other profession in America has suffered a decline in inflation-adjusted income like physicians. It is curious that we trust physicians to be smart enough to heal us but assume that they will not attempt to stymie consistent actual and threatened reductions in their income.

Second, in what is increasingly troubling in my view, the Dartmouth Atlas analysis is becoming the blunt instrument of health care reform policies. Assuming that Dr. Gawande believes over-utilization is the crux of the problem, it is also curious that he did not call out the obvious fix to the real issue in McAllen, which is to eliminate physician investments in hospitals, surgery centers and in-office ancillary services. If overutilization is the diagnosis, Stark III is the cure.

In fairness to the Dartmouth research, the fact that Medicare utilization varies widely in the country is undoubtedly true. The corollary that has now become accepted fact in the media is that less is more and better quality. I'm not sure the data supports that.

Here is the key paragraph:

[Our]  Mayo, McAllen and El Paso Market Analysis shows a series of slides for St. Mary's in Rochester (Mayo), two hospitals in McAllen, and two hospitals in El Paso. One is my favorite - the Discharge Destination by Day of the Week. In plain English, this slide depicts where patients go when they are discharged from the hospital. The other slides show the cost and the charge of certain procedures in Rochester, McAllen and El Paso. I will let you draw your own conclusions, but I bet you will struggle to understand why Mayo is a better choice for Medicare patients than the hospitals in McAllen and El Paso. You might also wonder why Mayo costs so much more on a per unit basis than hospitals in McAllen and El Paso.

You can find more of Hal's research here and the full post on Hal's blog (click here).

To make this whole "reform thing" even more complicated, the NYT is reporting on potential conflicts of interest between the Congress and the nearly $3 trillion health care industry:

"The personal financial reports, due late last week from members of Congress, show that many lawmakers hold investments in insurance, pharmaceutical and prescription-benefit companies and in hospital interests, all of which would be affected by the administration's overhaul of health care."

Click through here to read more.

For those who need a primer, Joe Paduda offers a really interesting look back (and review of the current reform landscape)... Click through here.

Thanks to Dr. Luks for sharing this piece.

In thought provoking post yesterday, Shadowfax (an ER Doc from the Northwest) gives his two cents on the compromise needed to get comprehensive reform through the Senate. He concludes with:

"What this means, I think, is that we are very close to being able to pass a pretty good bill.  If there was a big reach necessary to overcome cloture, it would justify a big compromise to get it done.  But being so close, a weak public plan (as opposed to a more robust option, which ironically I think to be worse policy) might be a sufficient compromise to bring the bill to its final up or down vote."

Read the rest of his post here... 

Rick Scott and his organization Conservatives for Patients' Rights offers a deep-dive view on what it is like to be a patient served by a "government run health care system".

In a documentary showing the decision making process of UK's health care rationing body, NICE, we see cost playing the most important role in whether patients receive care.  In a government-run system, one's care is constantly sacrificed for others based on the "value" of one's life. 

For more details, click through here.

We hear that "meaningful use" will be clarified this week. As our friends at Deloitte point out: 

"Much anticipated clarity about the "meaningful use" of electronic medical records will be provided Tuesday, June 16, by the HIT Policy Committee according to John Glaser, senior special advisor at the Office of the National Coordinator for Health Information Technology (ONCHIT). If the panel approves the recommendation, it will be submitted to ONCHIT for evaluation."