reform 2011


Video Debate: Is RomneyCare Really The Parent Of ObamaCare?

Tonight is going to be all candy, so let’s start the week with a few vegetables, as we sometimes refer to our health policy posts. Not that the above video is lima-bean-like; it’s a lively — though civil — Republican-Democrat debate about whether it’s fair to consider Massachusetts health reform as the “parent” of the federal health overhaul.

As CommonWealth magazine executive editor Michael Jonas introduces it:

We recently launched a new video feature on CommonWealth’s website involving webcam-based discussions between two people. I thought our most recent installment of “Face to Face” might be of interest to you and CommonHealth readers: a discussion of “Romney” and “Obamacare” between two of the people best qualified to chew over the issue that dogs Romney’s campaign perhaps more than any single topic.

Talking over the issue are Tim Murphy, who was Romney’s secretary of health and human services and the administration point-man on the 2006 Massachusetts law, and John McDonough, who was in the thick of the 2006 reform as director of Health Care for All and then went on to serve as senior policy adviser to Ted Kennedy’s Senate Health, Education, Labor and Pensions Committee, where early work on the federal law took place.

Radio Boston Digs Into Health Reform As Public Says ‘Let’s Give It A Shot’

Radio Boston performed a courageous civic service yesterday: It ventured into the numerical weeds of health reform — discussing the new Massachusetts public opinion poll that Martha Bebinger covered here on CommonHealth — and it actually turned a discussion of health policy into interesting radio.

The segment included pollster and Harvard professor Bob Blendon; Joshua Archambault, director of health care policy at the Pioneer Institute; and Brian Rosman, director of research at Health Care For All. It’s a meaty debate that carefully avoids descending into what Brian calls “Wonkland,” and worth a listen. Already, it prompted this striking comment to host Meghna Chakrabarti from “KatyinQuincy” on Radio Boston’s Webpage:

Speak it, Meghna!

We have an HSA insurance account, and see the cost of health care in print- we need to pay most of it out of pocket.

$465 for a 5 minut office visit to reduce my daughter’s arm…

$375 for an infected fingernail…

$1075 for an ER visit that the doc said “she would make if SHE were my child’s mother.” (My baby had a COLD.

I don’t think the DOCS know how much these routine procedures cost.

Oh, and it’s not possible to negotiate a cash cost.

HELP! The people of Massachusetts are drowning in routine health care costs.

(I just have become a much better provider at home. We rarely see the doctor anymore).

The segment also included a call-in from a Newburyport man who was recently in a bike accident, and was so shocked and appalled by the cost of his ambulance and emergency room care — both the total cost and his out-of-pocket costs — that next time, he vowed, he would say “Screw the ambulance” and the health care system altogether. “I’ll recover” on my own.

Do You Know The Name Sheldon Zinberg Yet?

If your answer to the headline is “No” and you care about health reform, I humbly suggest that it may be time to meet him. He seems on his way to becoming a household name — in wonky households, that is.

You can read about him — or rather, the ahead-of-its-time health care organization he helped found, CareMore, in the latest Atlantic Monthly. You can hear more about CareMore on today’s “Here and Now” show here.

And I can share the story that Dr. Arnold Milstein, a prominent health reform researcher, told at a recent Harvard conference on primary care: He said that Dr. Sheldon Zinberg was practicing medicine in a blue-collar California suburb, and the atmosphere of managed care — the restrictions on referrals and more — was driving him crazy. “He said to himself, ‘There has got to be a better way,'” Dr. Milstein recounted. “‘Can’t we figure out how to generate more health and a better patient experience with less money?'”

‘Can’t we figure out how to generate more health and a better patient experience with less money?’

As the Atlantic story describes, Dr. Zinberg answered his own question: He created CareMore. The Here and Now synopsis:

A California-based health care company has found some common sense approaches to improving care while cutting costs for its Medicare customers.

For example, CareMore offers free rides to the doctor’s office to avoid missed visits; they clip toenails to make sure patients don’t trip on rugs; they’ve set up a wound center to ensure a small cut doesn’t lead to an amputated foot in diabetic patients. These sound like little things, but the company says they’ve had a major impact. Continue reading

How Payment Reform Can Be Like Dieting In a Locked Room

I love this analogy. Actually, I love any analogy that can add juiciness to the eye-glazing dryness of health policy, but this one in particular, because the image of locking yourself in a room to avoid food temptation (or health-spending temptation) is so vivid.

Here’s the actual quote, from Dr. Timothy Ferris of Massachusetts General Hospital, a big experimenter on alternative models of care and payment. He’s speaking at the Center for Connected Health symposium now under way in Boston. At about one minute in to the above video, as he talks about how shifting health care payment to global budgets and Accountable Care Organizations is doable but hard, he says that “Maybe we should be trying harder.”

“If you go on a diet, there’s a whole different strategy of going on a diet between saying ‘I’m not going to eat more’ and locking yourself in a room with only a limited amount of food. That’s a fundamentally different way to diet, right? I think there’s a role for locking ourselves in rooms that we carefully think about and plan on, and saying, ‘We’re going to live on what’s in this room for the next three years,’ and use that as a mechanism.”

Wonkish readers, please take this analogy and run with it! My own initial thought is that as the rooms start getting locked, it’s a concern that some of them hold far better-stocked cupboards than others. I’d hate to live for three years on Ramen alone.

Watch the video a bit further to see the response from Dr. Jeff Goldsmith, a prominent skeptic of the ACO model.

Poll: Three-Quarters Of Public Want Government Action On Health Costs

Political leaders in Massachusetts say controlling health care costs is a top priority and they are working on plans to tackle the problem. But what does the public think? A poll out today has the first comprehensive look at public opinion on health care costs since the state passed the 2006 health coverage law. The full report is out here.

Harvard pollster Robert Blendon

Pollster Bob Blendon, of Harvard’s Kennedy School and the Harvard School of Public Health, spoke to WBUR’s Martha Bebinger about this survey of 1002 Massachusetts residents. The poll was funded by the Blue Cross Blue Shield of Massachusetts Foundation.

BEBINGER: Respondents say the high cost of health care is either a crisis (25%) or a major problem (53%). Why does the public say health care costs are too high?

BLENDON: The main reasons were excessive charges by pharmaceutical firms, hospitals and insurers. There was less concern about the things experts always talk about: using too much high cost technology, going to expensive teaching hospitals or not shopping for care. The big takeaway here is that 74% of respondents want the state to take action.

BEBINGER: But 51% of respondents have little or no confidence in state government to lower health care costs even though they want the state to take action? What kind of opening does this create for State House leaders? Continue reading

Will Health Reform Finally Push Doctors To Email And Skype?

Dr. Lester Hartman as seen via Skype

No one could blame 3-year-old Anish for getting hysterical when he saw a doctor. He’d been through open-heart surgery and a skull operation. He knew that white coats often meant pain.

The first time his mother brought him to see Dr. Lester Hartman of Westwood-Mansfield Pediatric Associates, he had such a meltdown in the office that the visit had to take place in the parking lot, with the engine running, Anish in his carseat, and the pediatrician leaning his laptop on the driver’s side window as he took notes.

Clearly, this was not going to work. So these days, unless Anish needs to be physically seen, his parents schedule their appointments for evening hours. They sit at their home computer and they consult with Dr. Hartman, face to face, but not in person — by Skype.

Those Skype visits put Dr. Hartman way far out on the cutting edge of using technology to communicate with patients, even though Skype is now very old news in the general population. But he has high hopes that if health reform plays out as expected in Massachusetts, he’ll be able to ramp up Skype and use other electronic tools more creatively in his practice. (See his guest post below.)

‘Why hasn’t it gone further faster?’

Health care lags dramatically — perhaps “pathetically” is the correct adverb — behind other sectors in the use of the technological tools that now tend to dominate our personal lives — email, Skype, Facebook, smartphones. As Dr. Ronald Dixon of Massachusetts General Hospital put it: “Our patients are all Skyping with their grandchildren, so why can’t they Skype with us?”

But multiplying signals suggest that early adopters like Dr. Hartman may soon get a major boost from a political source: The looming state health reform. It aims to save money by shifting care away from “fee-for-service” payments for each procedure and toward giving doctors a “global” budget for a patient’s annual care.

Health insurers do not generally reimburse doctors for time spent emailing or Skyping or texting. When a doctor is paid for each bit of in-person care, but not for such “virtual” care, that’s a major disincentive to go virtual. On the other hand, if a doctor is paid an overarching annual sum for your care and will get bonuses for keeping you healthier and within your budget, checking in with you by email or Skype may suddenly become much more attractive.

Dr. Joseph Kvedar, director of the Center for Connected Health at Partners Healthcare and a practicing dermatologist, says that under the current health-care payment system, he emails constantly with his patients for free just because he sees it as part of caring for them. But “If the cash register never rang, I wouldn’t have a job. Right now, if you stop coming in to the office, I have a real problem. That won’t be the case anymore two years from now. The time is upon us that it will be as quaint as bank tellers.” Continue reading

Guest Post: Why Health Reform Holds No Fear For One Pediatrician

By Dr. Lester Hartman
Guest blogger

I remember the bad old days. By which I mean, I remember the 1990s era of “capitation” and all its ills — the rigid HMO spending limits that made money come between patients and their physicians.

But I’m not scared that they’re coming back.

Some worry that the coming “global payment” phase of Massachusetts health reform — in which health care providers are put on annual “global” budgets for each patient’s total care rather than paid for each procedure — will mean a return to capitation.

‘The old fee-for-service system has stifled our capacity to be creative.’

That would be terrible. As a pediatrician of 25 years, I remember the problems with capitation. It discriminated against special-needs children. It drove a wedge into the doctor-patient relationship, creating conflicts of interest by making doctors responsible for controlling costs. Access was restricted. Chronic disease management was not a priority.

But I welcome the impending era of global fees. Continue reading

Lawmakers Betting On Gambling To Help Fund Health Reform

This just in: How might casinos help Massachusetts tamp down rising health care costs? WBUR’s Martha Bebinger reports:

Twenty-three percent of the money the state receives from casino and slot parlor licensing fees would go into a new Healthcare Payment Reform Fund.

Supporters of the fund, which is in both the House and Senate casino bills, hope to raise $40 to 50 million for the move to electronic health records and for other costs they say will eventually help the state spend less on health care.

The health care fund would get the largest single share of casino license fees with the balance going to community colleges, transportation, community mitigation and other projects. The House and Senate are still working on major legislation they hope will lead the state to better, more efficient and lower cost health care. But they are betting that some of the money they need will come from casino developers.

Legislative leaders aren’t sure exactly what the fund would be used for — it could also pay to retrain health care workers whose jobs change as the state overhauls health care spending.

The Senate had hoped to release its health care payment reform bill next month, but that schedule looks doubtful now. For letter-of-the-law types, here’s the relevant section of the bill: Continue reading

Hopeful Thoughts On How Doctors’ Groups Could Save Health Care

Dr. Arnold Relman on Youtube

“Multispecialty Groups Could Stem The Growth In Health Care Costs.”

That’s how the New York Review of Books could have headlined its new piece by Dr. Arnold S. Relman, former editor of the New England Journal of Medicine. But what normal person is going to read an article about “multi-specialty groups” — aside from maybe health care staffers who already know what they are?

Even with the nicely enticing headline the Review did choose — “How Doctors Could Rescue Health Care’ — the article may lose many readers through the lengthy wind-up to its main point. Which would be a pity, because how often do we get positive news about the ever-rising, economy-sinking costs of health care?

So let me cut to my take: The national political situation bodes ill for any prospect of cost-cutting health reform originating from the top. But there are signs of a bottom-up movement in medicine that could do the trick: The recent rapid growth of  “multispecialty practices” — heavy on primary care, owned by doctors or hospitals, often not for profit, tending to pay doctors base salaries.

Dr. Relman roughly estimates that such multi-specialty groups may employ as many as one-quarter of the country’s doctors by now. They appeal to young doctors loath to take on more debt to open a solo practice, he writes, and to doctors who want more flexible schedules to spend time with their families.

Why is this good news? The evidence suggests that multi-specialty groups provide good care with the potential to save money, Dr. Relman writes.

There is much reason to believe that such a reformed system could deliver good care for all at considerably less cost and could also control cost inflation—although such a system does not have the remotest chance of being legislated by our national government anytime soon. But what if, as seems likely, the rapid trend toward group practice that I have described were to continue, and almost all medical care were ultimately to be provided through multispecialty group practices? Despite the limitations imposed by the existing health care market, the advantages of organized care might become obvious not only to patients but to business employers and even to legislators and policymakers in Washington.


Continue reading

Partners CEO: A ‘Sentinel Moment’ In Health Reform?

Partners CEO Dr. Gary Gottlieb

(For related news stories, see WBUR here — Blue Cross, Partners Finalize Deal To Slow Premium Hikes — and the Boston Globe here.)

If I were writing the rough draft of current Massachusetts health reform history, this would be my intro:

On Oct. 5, 2011, it became clearer than ever that Massachusetts would indeed march forward toward payment reform, moving away from traditional “fee for service” and toward giving doctors annual budgets for a patient’s overall care.

Whatever now happened in the political arena, the reality on the ground was already shifting dramatically. On Oct. 5, Partners HealthCare — the state’s largest hospital system and largest employer overall — officially announced that it would enter a global payment plan offered by Blue Cross. The behemoth of Massachusetts medicine was throwing its tremendous weight and resources behind the move toward global payments. What had been a growing scatter of promising experiments was now going ever more mainstream.

Rough drafts of history aside, and though only about 200,000 patients will be initially affected, I do have the feeling that this is a significant moment in health reform, locally and perhaps nationally, too. How did this come to be? I asked Partners CEO Dr. Gary Gottlieb. His reply, slightly condensed:

There are two elements. One is that, as we’ve told you, we’ve been working on our strategy since I started, and that has focused on both care redesign and population management. And an essential part of population management is managing high-risk populations.

We believe that in order for health care to be redesigned in a way that is patient- and family-centered, we need to move away from transactional fee for service, and sharing risk with a payer provides the opportunity to use resources more effectively.

‘Do I think Partners’ moving into this is a sentinel moment?’

It has the potential to be able to focus on individual patient needs and to design care in a way that moves away from transactional and disorganized care. And the AQC [The Blue Cross global payment plan] is the first opportunity in that regard.

We need payment mechanisms that are consistent with the appropriate redesign of patient and family-centered, efficient care. Whether it’s patient-centered ‘medical homes,’ in which we’ll manage a substantial amount of population risk — or bundled payments, in which there will be episode payments where we can share the risk with specialists…The more flexibility we have in the way we’re paid, the more we’ll be able to achieve these goals.

So, I asked, would it be correct to say that as you looked at how to contain costs, you came to the inescapable conclusion that the modes of payment had to change in order to cut costs? Continue reading