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From Consumer Anger To The Supreme Court, 2012 In Health Care

From Jonathan Gruber's new book, "Health Care Reform: What It Is, Why It's Necessary, How It Works

What will 2012 bring in health care? Some of these predictions are decidedly tongue-in-cheek. Others could certainly be labeled wishful thinking. All are interesting to contemplate — and when they’re taken together, a picture of public expectations begins to emerge, from the Supreme Court ruling on health reform to cost trends.

Readers, it’s not too late: This post will evolve until 2012 actually arrives. Please post your predictions in the Comments section or click on “Get in Touch.” You can also vote on which prediction you like best. Most popular predictor will get a WBUR prize still TBD. And by the way, oh, yes, you’ll be held accountable. If fate is good, we’ll still be here one year from now and will award a booby prize to the predictor who was farthest off.

MIT economist Jonathan Gruber (The illustration above is from his new book):
National:
•  The U.S. Supreme Court will find the individual mandate [the heart of President Obama’s health law] constitutional.
Public support for health care reform will grow by the end of 2012.
Innovations such as ACOs [accountable care organizations] and PCMH [patient centered medical homes] will grow rapidly, but there still won’t be convincing evidence that they save money in general – we need more time to build the evidence base.
Local:
There will be continued demand for, and growth of, tiered network insurance products and high deductible plans.
This growth will put pressure on the highest cost providers to bring their costs into line.

‘The voice of consumers angry about rising cost sharing and limited choices will continue to grow.’ – John McDonough

 

Josh Archambault, director of health care policy at the Pioneer Institute:
• Continued provider consolidation, both locally and nationally.
Greater cost-shifting from Medicare and Medicaid, as both federal and state government continue to cut reimbursement levels. On a related side note, I think over the next few years you will see cash-based pre-paid practices opening in Boston.
Gains in the use of high-deductible and health savings account plans nationally. The question for 2012 is whether Massachusetts will break out of its status quo and catch up. Continue reading

Your Predictions For Health Care In 2012?

O come, all ye faithful readers of CommonHealth, and share with us your predictions of what will happen in health care in 2012. This is a fascinating moment in medicine; many in the trenches say they’ve never seen so much change in health care — or at least, not for a generation. So what can we reasonably expect to happen in the inevitably eventful year to come???

Please send us your couple-three top predictions for either the national health care scene or Massachusetts or both. Please click on “Get In Touch” below rather than posting them in the comments below this post; that way they’ll be fresh when we publish them, along with predictions from experts, on Monday.

Whoever gets the most popular support for a prediction will get a WBUR prize. And the best part: At the end of 2012, we’ll look back at the predictions and award a booby prize for the prediction that was farthest off…

New Hospital Chief: Mass. Health Care Is 5 Years Ahead — Anxiety Is Natural

Dr. Kevin Tabb, new chief of Beth Israel Deaconess Medical Center

In his first two months as chief of Beth Israel Deaconess Medical Center, Dr. Kevin Tabb has gotten to know the hospital but he has also gone on a Massachusetts health care walkabout. He has circulated through virtually every hospital in Boston as well as some 20 community hospitals, talking to allies and rivals alike.

Nothing like fresh eyes — fresh, informed eyes. (Dr. Tabb made the unusual migration eastward after many years at Stanford.) Here, in a lightly edited chat, he shares his perspective on the state’s health care scene, including his impression that many of us fail to appreciate just how exceptionally rich in excellence we are: “If you take any one of these great institutions alone and put them in any other city, they would be the medical center,” he said, “and we’ve got many.”

Californian colleagues questioned his decision to move to the difficult, competitive health care landscape of Boston, he said — not to mention the nasty weather he would face. His response:

If you really care about effecting change, there has never been a more interesting time, at least in modern history…And Massachusetts is the epicenter of change. We here in Massachusetts are at least five years ahead of the rest of the country in terms of what is going on around experimenting with new models for delivery and health care reform. And the rest of the country will get there but they’re not there yet. I don’t know if people here in the Commonwealth and in Boston understand just how closely the rest of the country is looking at what is going on here as a view of what the future will look like.

Well, certainly, we’re aware that Massachusetts health care has great political resonance, both because of Mitt Romney’s involvement in the state’s health reform and because the federal health overhaul made use of the Massachusetts model.

I’m talking about more than that. Some of what I’m talking about is legislation, but it’s not just legislation. If there were a magic wand and the legislation were to go away tomorrow, hypothetically, you would still see forces here that are forcing really pretty rapid change in health care delivery models that have nothing to do with any single piece of legislation. So it’s a combination of the legislation and regulators, but also of economic forces and, I think, the forces of innovation that exist at this time. Nobody has a monopoly over that. Continue reading

Two Leading Pediatricians: For Children’s Sake, Tax Soda

At the State House this morning, pediatricians and other health-promoters concerned about obesity officially launched a concerted campaign against sugary drinks and candy. Central to their efforts: a bill to remove the sales tax exemption on soda. Here, two leading Massachusetts pediatricians lay out their arguments.

By Dr. Lynda Young and Dr. Barry Zuckerman

Thirty years ago, a typical pediatrician in Massachusetts might see a single obese child in their office every day or so. Now we see as many as five a day and another four to five who are overweight.

Some of these young patients are already suffering from the health effects of obesity: high blood pressure, heart and liver issues, or Type II diabetes. If these trends are not reversed, many of these children will be destined to live shorter lives than their parents.

‘As pediatricians, we have never seen a medical problem of the breadth and scope of obesity.’

As pediatricians, we have never seen a medical problem of the breadth and scope of obesity. Over the last 15 years alone, obesity rates in Massachusetts have doubled, with one in every three children now either overweight or obese, leaving the state with the 33rd worst childhood obesity rate in the nation. Meanwhile, obesity-related medical costs will add some $1.8 billion a year to the Commonwealth’s already strained health care system.

Preventing and reversing the obesity crisis has become a paramount medical concern for pediatricians across the Commonwealth. As physicians and physician-educators, we see the devastating impact of obesity every day, despite our daily warnings to patients, their families and the public about the importance of taking immediate action to prevent unhealthy weight gain.

One opportunity before us right now is legislation to eliminate the tax exempt status on soft drinks and candy. Nearly fifty years ago, when Massachusetts adopted a sales tax, it decided to exempt the sale of food items. Other essentials of daily life, such as clothing, were exempted as well.

Of course, this was years before the obesity epidemic began to sweep the country. Today, soft drinks can hardly be considered essential food items. To the contrary, overconsumption of sugary beverages has become a major threat to public health, and obesity-related conditions will likely eclipse smoking as the leading preventable cause of death. Continue reading

Making Federal Health Reform Not Just Simple But Kinda Cute

I’ve never been tempted to call anything connected to health care reform “cute” before. But the above map is, isn’t it? And when it comes to the Byzantine byways of the American health care system, and the 900-odd pages of the federal health overhaul, cute is fine. Cute can border on simple. Simple is good.

So which are you? Tracy Macy, single, working at a daycare and coping with diabetes? Sue and Stu Santos, married and insured by their employers? Phil Butler, a struggling young graphic artist, uninsured but healthy? This image above is just a screen-grab; if you go to the actual Kaiser Family Foundation site here you can roll your mouse over the various big-headed people or buildings and read about how the Affordable Care Act will affect each, now and in the coming years.

Reader, reactions? If you like the big-headed folk, you can also see them in this Kaiser animated video explaining federal health reform.

Guest Post: Why American Medicine Needs A Moneyball Moment

By John Miner and Brad Stulberg
Students in the Masters in Health Services Administration program at the University of Michigan

John Miner

Brad Stulberg

With baseball season over and “Moneyball” exiting the box-office, we cannot help but wonder: When will American medicine have its Moneyball moment? The story of the Oakland A’s and their “do more with less” approach to baseball can serve as a model for American health care: Health care should start measuring and paying for value instead of simply paying for quantity.

Moneyball tells the fascinating story of how the Oakland A’s management team drastically departed from conventional wisdom in building a top baseball team. Rather than continue in the ways of an inefficient baseball marketplace — where value was neither appropriately measured nor paid for — the A’s developed a system that prioritized data-driven insights along with human judgment to construct their lineup.

While teams like the New York Yankees paid tens of millions for star players that “looked great” or had “beautiful swings,” the Oakland A’s fashioned a method to figure out what player attributes really drove outcomes (in this case, winning baseball games) and then paid players based on those attributes: value-based purchasing, if you will.

When compared to other developed countries, America is like the Yankees in terms of payroll — only without the 27 championships.

The A’s philosophy was in stark contrast to prevailing baseball culture. The franchise’s unconventional success rested upon a restricted budget (A’s ownership capped management spending at a hard amount), transformational leadership, and a change in mindsets and behaviors across the A’s clubhouse. The end result? Oakland, with a payroll two to three times smaller than top contenders, was able to compete with traditional powerhouses.

The analogy to health care is striking. Too often, health care dollars are disconnected from value; decisions are made based on precedent, anecdote, and preference rather than evidence; and new statistics and evidence-based measures are confronted with overwhelming disdain. (In fact, Billy Beane of the A’s has himself written about this parallel, in an op-ed piece with Newt Gingrich and John Kerry.) Continue reading

‘Healthy San Francisco’: A Different — Better? — Model For Health Reform

Let me tear off my provincial Massachusetts blinders for a moment to say: We’re far from the only national laboratory for health reform. And something deeply interesting is going on in that fair city on the left-coast Bay, San Francisco.

So interesting, in fact, that the program, “Healthy San Francisco,” is a finalist for a major award from Harvard Kennedy School, the Innovations in American Government Award given out by the Ash Center for Democratic Governance and Innovation. (Winner to be announced early next year.) The 16-minute presentation above to the award judges provides a succinct overview, but here’s my one-liner: Unlike Massachusetts, San Francisco didn’t try to get everybody insured; it just aims to provide health care to the uninsured people who need it — not just in emergencies, but long-term, primary and specialist care.

I spoke with Berkeley health economist Richard M. Scheffler, who evaluated “Healthy San Francisco” for the innovation awards, about how the program works, and it certainly has its limits — including the city limits: It doesn’t extend beyond them. But what struck me is that, beginning in 2007, the program aimed to address health care delivery issues that we in Massachusetts are only getting to in a sweeping way now, such as the question of whether everyone should have to have a primary-care “medical  home.”

It also struck me that, though employers and taxpayers foot the bill, Healthy San Francisco addresses the problem of the uninsured by focusing mainly on them, and arguably affects the broad population less than in our health-insurance-for-all state. Readers, what do you think? Would something like Healthy San Francisco work elsewhere, beyond the bounds of that famously liberal city? Would you want it to?

‘The mandate is on the employer, not the individual as it would be in Massachusetts.’

My chat with Richard Scheffler, lightly edited:

So what’s so cool about ‘Healthy San Francisco” that it merited being an award finalist? It strikes me as such a dramatically different model from Massachusetts, much more narrowly targeted…?

What’s cool about it is that, as you mention in your question, it’s a very different approach than Massachusetts — or even the Obama plan. The Massachusetts model is fundamentally based on trying to help people obtain health insurance. But it does nothing about the access problem: the plight of safety net hospitals, lack of primary care doctors, overuse of emergency rooms, uncoordinated care. So San Francisco, to compare it to an insurance approach, it’s what you’d call an ‘access approach,’ It’s actually to provide access to health care. Continue reading

Coakley Calls For Patient Cost Estimates, ‘Clout’ Limit, Possible 2015 Caps

Attorney General Martha Coakley

Massachusetts Attorney General Martha Coakley broaches three new tactics — or “pillars,” as she puts it — for containing the state’s health costs in her speech today to the Massachusetts Association of Health Plans. A long swath of the prepared text follows, but here are three key quotes:

•”We are considering requirements that providers disclose the full amount that consumers could be liable to pay, so that patients know in advance what they are agreeing to.”

•”When a provider does reach a certain level of market clout, it should trigger a market impact review to determine whether the provider’s size is having a negative impact on consumer choice, access, or healthy market function.”

•”Starting in 2015, if the market has not corrected unwarranted price variation, the administration should be able to reject health plan contracts with excessive or inadequate provider price variations. Health plans should be prohibited from paying provider rates that differ beyond a certain band. One example would be 20% above or 20% below the plan’s average price for the previous year. Any savings would then be directed to consumers in the form of lower premiums. Finally, I believe we should make this market intervention temporary.”

WBUR’s Martha Bebinger is at the MAHP conference and will be gathering reaction. Please stay tuned, and your opinions are deeply welcome in the comments below. Now for the text, with deep thanks to the Coakley staff for the camera-ready copy: Continue reading

‘No Stick Needed:’ Counter-Proposal For Mass. Health Reform

Massachusetts Governor Deval Patrick

From the moment last February when Gov. Deval Patrick declared his determined push for a new wave of Massachusetts health reform aimed at controlling costs, it was clear that the state’s major health care players would not just passively accept his plan. They formed a coalition to craft an alternative. They began meeting. And now the draft of their counter-proposal is out, as reported here — replete with slide deck — by WBUR’s Martha Bebinger.

It’s a plan of many parts, but what strikes me most is that the health care industry is saying that it should be allowed to pursue new models of organizing and paying for health care without fear of state regulation or penalties, at least for the next three years.

Not to trivialize, but here’s what comes to my mind on an emotional level: A teenager whose parents tell him that he can’t go out unless he finishes his homework, and he replies, “I’m doing it, I’m doing it! You don’t need to threaten me!”

Here are slightly distilled excerpts from Martha’s chat yesterday with Sacha Pfeiffer of WBUR’s All Things Considered, and for more on the draft plan, the Globe’s Liz Kowalczyk reports here.

Sacha: A coalition that includes health care industry leaders in greater Boston and health economists has put together its draft plan for how to get health care costs under control. The message to Gov. Patrick and the legislature is that ‘We can reduce spending without more government regulation.’ The coalition suggests that more regulation might make things worse than they are now. Martha, what does this coalition say it can do on its own, without any government involvement — or maybe what the coalition means is, without any government interference?

Martha: I think that is the message, Sacha. They say they can set goals for spending increases. So right now, we think spending increases are rising at about 7-8 percent a year for health care, and the state’s GDP is down there around 3 or 4 percent. They want to get us down to that GDP level, so to cut it almost in half.

What that means in real terms is that by 2020, they would be saving around $8 billion or 10% of what the state expects to spend on health care that year. It’s a lot of money but they say it’s a realistic goal that would not disrupt the state’s economy…Is it enough money, is one question. The other major question is: Will this coalition hold together?

Sacha: This is a modified version of what Gov. Patrick has already proposed — How is this different? And how is the coalition selling it to the Patrick administration? Continue reading

Your ‘Medical Home’: Will Your Doctors Tussle For The Title?

Don’t miss today’s report from WBUR’s Martha Bebinger on a Worcester community mental health center that aims to be considered its patients’ “medical home.” What’s a medical home? Martha explains:

There is growing support in Massachusetts for making sure that every resident has a medical home, one doctor or center that would coordinate all their care. Supporters say this person would prevent duplicate tests, save money and help patients navigate the health care system.

and:

As the state moves to setting budgets for patients, your budget would go to the place you name as your medical home. The idea of established medical homes started with pediatricians in the late 1960s and was adopted by family doctors. These days in Massachusetts, many specialists say they should qualify as a medical home in the case of diabetics who see their endocrinologist on a regular basis or cardiac patients monitored by their cardiologist.

In other words, your doctors may soon be competing for the title of your “medical home,” as well as tussling at the State House over ground rules on medical homes. Quips, anyone? Perhaps Robert Frost is relevant: “Home is the place where, when you have to go there, they have to take you in.”