Email and Your M.D.

Among American doctors, less than a third use email as a health care tool. Alicia Chang of the Associate Press takes a look at this strange deficiency:

"People are able to file their taxes online, buy and sell household goods, and manage their financial accounts," said Susannah Fox of the Pew Internet & American Life Project. "The health care industry seems to be lagging behind other industries."

Doctors have their reasons for not hitting the reply button more often. Some worry it will increase their workload, and most physicians don't get reimbursed for it by insurance companies. Others fear hackers could compromise patient privacy — even though doctors who do e-mail generally do it through password-protected Web sites.

Once again, we see an example of how embracing Internet technology, even in its most basic form, can improve the overall health care crisis our nation faces. The studies available state that not only is response time quicker from doctors who use email, but it also helps to reduce costly office visits and repeated phone calls.

For example, a 2007 University of Pittsburgh study published in the journal Pediatrics followed 121 families who e-mailed their doctors. Researchers found 40 percent of e-mails were sent after business hours and only about 6 percent were urgent. Doctors received on average about one e-mail a day and responded 57 percent faster than by telephone.

A separate study by health care giant Kaiser Permanente published in the American Journal of Managed Care last year found patients who used its secure Web system were 7 to 10 percent less likely to schedule an office visit. Patients also made 14 percent fewer phone calls than those who did not use the online services.

In Chang's article she adds a human face to the equation: Suzanne Kreuziger, R.N. Kreuziger works for a doctor who chooses not to utilize email. Kreuziger stresses the ability to have a documented virtual paper trail that she can go back to at any point as a key element of why email can be such an incredibly useful tool for both physicians and patients. Being able to simplify basic needs such as asking for prescription refills, setting appointments, and getting medical test results would be a boon to all involved.

She also points out that the complaint on the part of providers that time spent emailing is not billable seems to hold little water as phone calls are also not billable, and take a greater amount of time in most cases. Chang provides a wonderful look at this minor but important aspect of American health care.

It's not the first time the medical field has been slow to embrace technology. When the first telephones became widely available in the late 1800s, doctors were concerned about being swamped with calls.

Would YOU like to be able to communicate with your doctor via email? Share your thoughts.

SOURCE: "It's no LOL: Few US doctors answer e-mails from patients" 04/22/08
photo courtesy of Mzelle Biscotte, used according to its Creative Commons license

Sin Tax For Health

Many states have considered enacting additional taxes -- so-called "sin taxes"-- on tobacco products to help defray the skyrocketing cost of health care. The Kaiser Family Foundation has just released a report on this very subject that should prove of interest:

Several states have sought to increase their tobacco taxes to fund health care programs and address budget deficits, but efforts to increase tobacco taxes in some cases have prevented the passage of health care proposals, the New York Times reports.

According to the Tobacco Merchants Association, in 2008, 22 state legislatures have considered bills that would increase tobacco taxes. Last year, 11 states enacted such legislation, according to the National Conference of State Legislatures. R.J. Reynolds Tobacco estimates that state tobacco taxes raise $14.5 billion in revenue annually and that the federal tobacco tax raises $7.3 billion in revenue annually.

"For some states, tobacco taxes are seen as a kind of magic bullet that are really quite different from less popular kinds of taxes," Richard Cauchi, a health policy analyst from the National Conference of State Legislatures, said, adding, "Legislators are able to argue that it's a sin tax, and the voters seem more accepting if they know the funds are going to be earmarked for some kind of health initiative."

The report goes on to detail recent efforts along these lines that various states have put on the table. California, New York, South Carolina, and Massachusetts efforts are detailed on their site.

As always the arguments pro and con have a familiar ring to them:

• "It will help prevent underage smoking."
• "It is an unreliable source of revenue."
• "It is unfair to smokers"
• "It will generate the revenue we need."

It is no secret that the tobacco companies are against this, and they bring an amazing advertising budget with them when they engage the battle for public support. California Speaker Fabian Nunez has been quoted many times across the media as saying that "Big Tobacco" killed health care efforts in California. The question truly is whether this is a viable approach or not. Will diminishing sales in areas that do enact a tobacco tax provide enough revenue to make an impact on the health care system as it stands?

SOURCE: "Kaiser Daily Helath Policy Report" 04/21/08
photo courtesy of Porcelin Girl used according to its Creative Commons license

Dropping the Ball in 21st Century Health Care

Today I'd like to direct your attention to an article in the Health and Wellness section of AlterNet by Niko Karvounis. Karvounis is a Program Officer with The Century Foundation in New York City where he works on issues of socioeconomic inequality and health care. He is also a regular contributor to the Foundation's health care blog.

In his article, he examines a chronic health issue, but not diabetes or obesity, instead he casts his eye upon the mistakes made when a patient is transitioned from one health care provider to another.

Even the most common hand-off -- your standard referral from primary care physician to specialist -- is not risk-free. As Dr. Bob Wachter recently noted in his blog, "in more than two-thirds of outpatient subspecialty referrals, the specialist received no information from the primary care physician to guide the consultation." Sadly, the radio silence goes both ways: "in one-quarter of the specialty consultations," Wachter says, "the primary care physician received no information back from the consultant within a month."

These missteps are indicative of what can go wrong during the hand-off, such as, according to QSHC, "inaccurate medical documentation and unrecorded clinical data." Such misinformation can lead to extra "work or re-work, such as ordering additional or repeat tests" or getting "information from other healthcare providers or the patient" -- a sometimes arduous process that can "result in patient harm (e.g., delay in therapy, incorrect therapy, etc)."

In the era of our nations "non system" of health care, the discontinuous and fragmented nature of treatment poses many opportunities for mistakes to enter the process, often to the detriment of the patient.

Kourvanis delineates a pattern in which most of the gaps in care are communications failures and most of those are on the part of primary care physicians. To provide context, he does examine the plight of primary care doctors, doctors whose workload is mammoth and pay miniscule by comparison to others in their profession. Combined with the fee for service system currently in place, these inequities are a recipe for disaster.

He examines a variety of possible changes that could improve the system, in the end reaching this conclusion:

But for all that these ambitious changes hold promise, the hand-off will always exist -- which means reformers need to dig deeper and develop protocols at the operational level. Luckily, they're doing just that. Kaiser Permanente, for example, has created a procedure meant to formalize communication between health care teams when a patient is transitioning from one provider to another.

He goes on to look at a variety of situations and programs designed to minimize or eliminate these errors. He looks at post discharge coaching, electronic medical records, Kaiser's SBAR program and more.

Go give it a read. His article is packed not only with food for thought, but also with an amazing a array of data and hyperlinked resources.

SOURCE: "21st Century Medicine Wrought with Miscommunication and Human Error" 03/20/08
photo courtesy of Ninjapoodles, used under this Creative Commons license

Health Care by Lottery??

91,000 residents of the state of Oregon are watching the lottery. It is not dollar signs that attract them, but rather the hope that a winning number will provide them with health insurance that they do not currently have. One of those residents is Melvin Trosies, a man whose heart attack of a month ago has resulted in escalating medical bills that currently have exceeded the $200,000 mark. William Yardley of The New York Times reports:

“They said they’re going to draw names, and if I’m on that list, then I’ll get health care,” said Mr. Tsosies, 58, a handyman here in booming Deschutes County. “So I’m just waiting right now.”

Despite the great hopes of people like Mr. Tsosies, only a few thousand of Oregon’s 600,000 uninsured residents are likely to benefit from the lottery anytime soon. The program has only enough money to pay for about 24,000 people, and at least 17,000 slots are already filled.

While the national average is 16% of the population uninsured, on the eastern side of Oregon's Cascade range in Deschutes County the number is roughly 19%. Many of those suffering a lack of coverage are seasonal or service workers, including many construction workers who are suffering from a slowdown within their industry.

Chris Coon, the outreach manager for the Community Clinic of Bend and the two other clinics, is quoted as saying that resorting to health care by lottery is a sign of "profound desperation," in response to the overwhelming need.

The lottery was born out of a consensus among state officials and advocacy groups that small steps can help. As part of the state’s Medicaid program, known as the Oregon Health Plan, the lottery is intended for low-income adults who lack private insurance and do not qualify for Medicaid or Medicare. Although the plan once served more than 100,000 people, budget cuts in 2004 reduced the number to about 17,000.

This situation is quite disturbing when you consider the fact that in the late '80s through early '90s, the state was a leader in health care reform. The Oregon Health Plan had reduced the number of uninsured to 11% of the population by 1996. Everything seemed to going smoothly until a major recession hit the state earlier this decade.

“Oregon was way ahead of everyone else,” said Charla DeHate, the interim executive director of Ochoco Health Systems. “And then we went broke.”

SOURCE: "Drawing Lots for Health Care" 03/13/08
photo courtesy of St A Sh, used under this Creative Commons license

Health Care: This Time It's Personal!

Eric Stoner is writer for The Huffington Post. He also suffers from cystic fibrosis (CF), a genetic disease that attacks the digestive and respiratory systems. Despite major advances in medicine, most CF sufferers do not live far past 40, often dying from everyday infections that become life-threatening.

There are roughly 30,000 documented cases of CF in the United States. Since it is a relatively uncommon ailment, the market for treatments and medication is quite small. Stoner quotes his annual prescription costs at $60,000 per year! As he points out, this makes him a dream customer for the pharmaceutical companies and a nightmare client for the insurance companies:

I'm the worst kind of member to have on the rolls: someone with a chronic illness whose medical expenses, as long as a cure remains elusive, will always be exorbitant. I show no profit potential.

Not surprisingly, then, navigating the health care system has never been easy for me. Even when the system is working as smoothly as it can, I have had to jump through countless hoops. Those are an unavoidable and exhausting part of this tortuous circus. But my experience in insurance company hell reached a new low last year. Last November, I spent weeks politely jostling my inept doctor's office and insurance provider to get one of my prescriptions filled. Nobody seemed to take me seriously or put any priority on my case, even as I stressed that I was quickly running out of my medicine. To my disbelief, I began to realize that I did not have intrinsic value in their eyes, but had effectively been reduced to a "member number" and data on their seemingly endless medical forms. And when your needs become too expensive -- since the price of life apparently can now be calculated -- the companies find every possible way to dodge their obligation, playing the role of absentee landlord or deadbeat dad to perfection.

Stoner then goes on to share his disturbing and demoralizing adventures navigating the byzantine bureaucracy of insurance and health care. His experience resonates with many who have been subject to the "non system" of American health care.

He recounts the extensive phone calls with his provider, including a four-day stretch where he was on the line literally all day each day. As each obstacle was overcome, it was replaced with another, a seemingly endless stream of complications, requirements, and red tape. On several occasions, he was told to go to the emergency room.

After reaching the point of desperation, Stoner got in touch with a lawyer friend who agreed to apply pressure on his behalf. Oddly enough, the very next day he was contacted by the suddenly helpful provider with full approval for his treatment.

There was no explanation. The extensive documentation that they had been demanding was, in the end, unnecessary, as I suspected. I rushed to the pharmacy. But by the time I was able to fill the prescription, I had already gone three days without it.

My fragile health was put at risk because some faceless suit wanted to save a buck and was testing to see how much of a fight I would put up. (I was told more than once by people who had their own horror stories with health insurance that companies hope you'll just give up. Whether it's true or not, that is definitely how it feels.) It was an emotionally exhausting process that I hoped I would never have to endure again.

The unfortunate part is that this only covers the beginning of his outlandish odyssey. A mere few weeks later, the same provider once again refused to authorize medication prescribed by Stoner's doctor. Only the threat of legal action was able to cut through the red tape involved.

Not only is this an important view of the incredibly convoluted processes involved in attempting to get health care, but Stoner's blog entry also has a very interesting set of reader comments that further amplify discussion of the issue. Go give it a read and let us know your thoughts.

SOURCE: "Criminal Health Care" 03/10/08
Artwork: "Red Tape Machine" by Dustin McGahan, courtesy of grifray, used under this Creative Commons license

Ethnicity and American Health Care

The concept that different ethnicities view their health care experiences in very different ways is one that just keeps surfacing. Less than a month ago, I was posting about the inadequacies of American health care as seen from the perspective of our country's Asian and Pacific Islander communities. Now Kevin Freking of the Associated Press examines the issue.

Before he digs down into the hard numbers, Freking notes that there has long been the view amongst researchers that improved patient perception of care is extremely important and can influence the outcome of health care issues. The reasoning is that if someone has a bad experience with their provider, they will tend to spend less time with that provider. Negative interactions can also contribute to poor communication between the patient and their medical professional (a subject I addressed in my post a month ago).

The foundation of the article is a survey done by researchers from Harvard University and the Robert Wood Johnson Foundation. 4,334 adults were interviewed last year and asked a variety of questions such as how quickly were they able to get appointments when injured and whether the doctor explained things to them in a way they could understand.

The results show an average of 10 - 20% percent lower positive responses from ethnic minorities.

When it came to getting an appointment, about 63 percent of whites were able to get an appointment on the same day or the next day after they became sick or injured. That percentage dropped to 42 percent for Cuban-Americans and 39 percent for African-Americans born in the Caribbean.

One major difference in how this particular study was conducted is that it used much more detailed categories. Prior studies of ethnic disparity in health care looked at the major ethnic groups, even though there can be marked differences between members of the same group due to country of origin. The Harvard study aimed a microscope at these groups, breaking them down into smaller cultural subsets. Instead of surveying all African Americans as a single ethnicity, the study broke them down into three sub groups based on country of birth: Caribbean, African, or American born.

Dr. Anne Beal, assistant vice president at the Commonwealth Fund, said the latest study results are consistent with previous research of how minority patients view the quality of their health care. She said perception is reality when it comes to patients being treated with respect.

"Because the findings are so consistent, it's not something where we can say it's just about the patients," Beal said. "They are reporting their experiences and the results should be taken seriously."

SOURCE: "Health Views Differ Along Ethnic Lines " 03/10/08
photo from Louisville African American Think Tank's Health Summit (Feb 8-10, 2008) courtesy of Sprigley, used under this Creative Commons license

Massachusetts Health Care: The Country is Watching

James Roosevelt, Jr., is a man who knows health care fairly well. He is President and CEO of the Tufts Health Plan, and when not engaged with that, he acts as the chairman for the Massachusetts Association of Health Plans. Roosevelt was kind enough to share his opinion of the current state of health care affairs in Massachusetts with Boston's WBUR 90.9 recently:

When the topic turns to access to health care, we should prepare ourselves to hear Massachusetts’ efforts for health care reform referenced as either visionary or as a cautionary tale of misguided public policy. While I continue to be unwavering in my support of health care reform, the true answer on its success is really yet to come.

In order to succeed, what we must do next is grapple with health care costs in a manner that hasn’t been done before. Massachusetts is the perfect laboratory in which to create real change.

He exhorts the provider community, the Commonwealth's Quality and Cost Council, and many other groups to come together in an effort to "leverage their common goals for the greater good."

He also speaks highly of the efforts of Senate President Therese Murray for taking decisive action in that regard. Her focus on funding electronic medical records and pledge of $25 million per year to implement them is only the beginning. He applauds her efforts to bring transparency to both providers of health care and insurance in order to identify the segments of health care that truly drive cost increases.

Using wellness programs enacted in the Tufts Health plan as illustrations he calls for individuals to take a more active role in their own health. Wellness programs are an important factor, he states, in reducing overall health care costs.

While many of these points are familiar to readers of this blog and to those who have been following the health care debate, Roosevelt presents them as part of a clarion call to the citizens of Massachusetts. After all, as he correctly states it, "The country is watching."

SOURCE: "HEALTH REFORM SUCCESS DEPENDS ON OUR WILLINGNESS TO GRAPPLE WITH HEALTH CARE COSTS " 03/10/08
photo courtesy of altemark, used under this Creative Commons license

Coverage and Care: Two Very Different Things

Monday provided us with a wonderful opinion piece in The Philadelphia Enquirer. It was written by a physician and lawyer who is also a visiting scholar at the Georgetown University Law Center named Caroline Poplin.

Have you noticed that presidential candidates assume that universal health insurance means universal health care? They use the terms interchangeably. They assume that once the law enables or requires everyone to buy health insurance, everyone will have adequate health care.

But anyone who has been seriously ill or cared for a sick relative knows that while health insurance may be the solution, too often it is part of the problem.

In fact, health insurance and health care are two different products for two different markets. Health insurance is for healthy people. Health care is for the sick. What we need to lead full, productive lives is good health care.

Dr. Poplin goes on to address the oft invoked example of auto insurance. While it has come up repeatedly in debate, I am not aware of a more concise comparison than the one presented here.

There was a time when health was like driving. Illness or injury was sudden, unpredictable and brief. You either recovered, or you died. Medical care was not expensive, and (surgery apart) not terribly effective. Insurance did not cover doctor visits for minor problems or for physicals, any more than car insurance covered routine repairs.

Since then, medicine has been transformed. Many people no longer die from heart attacks, pneumonia, cancer, even HIV/AIDS; they may live many years if they are treated promptly, aggressively and often long-term.

These patients are no longer average drivers. They have "pre-existing conditions" and are thus at high risk for predictable, serious, expensive, often chronic complications. A diabetic patient is at high risk for heart attacks and kidney failure. Many cancer patients are at high risk for pneumonia. Even someone with uncomplicated high blood pressure is at increased risk for heart attack and stroke.

Commercial insurance was never designed for situations like this. No one sells flood insurance for a house that regularly floods.

So insurers routinely exclude pre-existing conditions from coverage. Most commercial health insurance, like car insurance, is intended for one-time, unpredictable expenses.

But people with pre-existing conditions, the chronically ill, are exactly the people who need health care the most. They can get it now only if they qualify for public programs like Medicare, or they work for large employers who can spread their expenses over a large, mostly healthy, workforce. The chronically ill are disproportionately uninsured.

Since five chronic diseases account for 75% of all health care expenditures, this should be cause for alarm. As noted in Health Care Reform Now!, management of chronic conditions is cheaper by several orders of magnitude than emergency room visits. Asthma, for instance, requires only a few hundred dollars per year to manage, but one ER visit caused by an asthma attack can skyrocket past the $20,000 mark.

SOURCE: "Health insurance and health care are not the same" 02/25/08
photo courtesy of takomabibelot, used under this Creative Commons license

Republican Debate Ignores Health Care Elephant

The Republican presidential candidate debate was a union of traditional and new media as CNN and YouTube joined forces. This should have been a major step forward in the political process, allowing the public to directly engage potential U.S. presidential candidates. It was certainly colorful and interesting, but troubling as well.

You see, despite repeated studies (like this one from the Washington Post) that place health care as one of the three topics of most concern to American voters, there was absolutely no mention of it in the debate. This lack of attention to an issue of such wide reaching importance already has people typing away on the subject, blogging about the omission.

Roger Simon at Politico.Com minces no words:

One of those woes, by the way, is not a lack of affordable, dependable, effective health insurance that you can retain for life.

Americans must already have that. Because not a single question was asked about it in the entire two hour-plus debate.

The disbelief is spreading across the web as the pundits and bloggers ponder this puzzling omission. The Daily KOS enters the fray with a brief post from nyceve:

I waited.

And waited.

And kept waiting.

But a single question about the plight of 47 million uninsured Americans, or the rest of us who have to wage an unending true holy war against the for-profit insurance industry, just didn't make the CNN cut.

Joe Brewer, a fellow of the Rockridge Institute, has a written a response to this oversight that is being syndicated in a variety of places across the web. Here is a sampling:

It certainly begs the question of why CNN chose to overlook all 40 YouTube questions about health care. Is it perhaps because they know that the Republican candidates don't have much to say about health care? After all, every general Democratic debate has included discussions of candidate plans.

Even CNN was on the ball when the same moderator for both debates, Anderson Cooper, introduced health care at the earlier Democratic YouTube debate with "One of the most popular topics that we got questions on was health care. We, frankly, were overwhelmed with videos on health care, so we put several of them together."

Why did he let the Republicans off the hook?

Think about it. We are in the midst of a health care crisis and a major media source leaves us in the dark about the views of presidential hopefuls who, presumably, will represent all Americans in the White House if they are elected.

I am sure that monitoring the mainstream media, the pundits and the bloggers in the near future will yield a wide variety of comments and conjectures on this subject. The one thing that everyone can agree on, however, is that health care was not a topic in the debates.

SOURCE: "GOP debate Misses The Mark"11/29/07
SOURCE: "I Guess CNN Must Think Healthcare is a "Gotcha" Question" 11/28/07
SOURCE: "Joe Brewer: Where's the Healthy Debate, CNN?" 11/29/07
photo courtesy of irrational_cat, used under this Creative Commons license

List of Nasty Nursing Homes Made Public

Kevin Freking of the Associated Press brings us the story of fifty four nursing homes around the United States that have been placed on a public list of the worst in their states.

Lawmakers and advocacy groups have been pushing the Bush administration to make it easier for consumers to identify poorly performing nursing homes. They complain that too many facilities get cited for serious deficiencies but don't make adequate improvement, or do so only temporarily.

Today being Thursday I believe a link is in order, so here is the aforementioned list. Now that we have that handy, let us return to Mr. Freking:

The homes in question are among more than 120 designated as a "special focus facility." CMS [Centers for Medicare and Medicaid Services] began using the designation about a decade ago to identify homes that merit more oversight. For these homes, states conduct inspections at six month intervals rather than annually.

The homes on the list got not only the special focus designation, but also registered a lack of improvement in a subsequent survey.

The nursing homes to be cited come from 33 states and the District of Columbia, according to a list obtained by The Associated Press. There are about 16,400 nursing homes nationwide.

Later on in the article he clarifies what the Special Focus designation means, as well as sharing the perspective of a U.S. Senator from Iowa:

Every nursing home receiving federal payments undergoes inspections about once a year. In such inspections, surveyors assess whether the facility meets standards focused on safety and quality of care. Among the things inspectors look for are giving residents the proper medicine, assisting them with daily living activities such as bathing, and assisting them with their medical needs and diet, as well as the prevention of accidents and infections.

Typically, homes that get the special focus designation do show improvement. Federal data indicate that about half the special focus homes improve their quality of care significantly within 24-30 months. However, about 16 percent are terminated from Medicare and Medicaid.

Sen. Charles Grassley, R-Iowa, said he's concerned about those homes in between — the ones that don't make much improvement but still continue operating.

"The federal agency responsible for nursing homes is doing the right thing by letting the public know which homes yo-yo in and out of compliance with the minimum requirements of care," Grassley said. "It gives these nursing homes the incentive to get off of that list, and it lets consumers know what they're getting into."

This is concrete progress towards a more standardized and publicly accessible measurement of how health care for the elderly is performing. The AARP thinks so, too. They have issued a statement applauding release of the list.

Last month, the AARP's Public Policy Institute issued a new research report on Nursing Homes written by Ari Houser that is chock-full of info for seniors. In Health Care Reform Now! Mr. Halvorson offers the following as a major component of an "Optimal Health Care Market":

Consumers should have complete and easy electronic access to the information they need to make informed decisions about their care and caregivers.

This is a positive step in that direction, although not a perfect one. There are some concerns over unevenness in the rating process. Mr. Freking's AP article includes a few statements on the subject of fairness:

One of the homes on the government's list was Franklin Hills Health & Rehab Center in Spokane, Wash. Brian Teed, the facility's administrator, said he did not have a problem with Medicare publicizing the list. But he said regional differences play a huge role in how nursing homes are graded. He said he recently helped run a facility in Portland, Ore., and nursing homes were graded much easier there. He took over the Spokane facility in September, and found it to be well run.

"In the Portland, Ore., area, this facility would be deficiency free or close to it. Instead we got 15 tags. We got tagged because there was bird poop on the bench outside," Teed said.

"I would put my mother in here," he added.

Publicizing lists of underperforming nursing homes is another step toward greater transparency in health care. One day, if we're lucky, we'll be reaching nursing home age ourselves and glad for the efforts made today to review and rate these facilities.

SOURCE: "Government Outs Chronically Underperforming Nursing Homes" 11/29/07
SOURCE: "Certification and Compliance- Nursing Homes"
photo courtesy of borya and used under this Creative Commons license

Obama, Clinton Square Off on Mandates

Political columnists everywhere have been having a field day as U.S. Presidential hopefuls Sen. Hillary Rodham Clinton of New York and Sen. Barack Obama of Illinois spar on the issue of health care reform. Both of the candidates have pledged to achieve universal health coverage, Clinton stressing a mandate (requiring the purchase of health insurance much as we do with automobile coverage) and Obama pressing affordability as the main issue.

Mike Dorning at the Baltimore Sun shares Sen. Obama's comments at a Littleton, NH event:

"Sen. Clinton still hasn't explained what this mandate is: What's she going to do if somebody doesn't purchase health care? Is she going to fine them? Is she going to garnish their wages?" Obama said.

"One of the problems with her approach is that she hasn't been straight with the American people about how she's going to impose this mandate. And without an enforcement mechanism, there is no mandate. It's just a political talking point," he continued...

Shortly after Obama spoke, his campaign sent out a memo noting that in Massachusetts, the only state so far to require residents to buy health insurance, hundreds of thousands of people have not purchased insurance despite a fine levied on those who fail to do so through their tax returns.

As the only Democratic candidate who does not support a mandate Obama has good reason to keep a close eye on the Massachusetts plan (originally set in place by Republican Presidential hopeful Mitt Romney, who does not now support a national insurance mandate). According to this morning's New York Times article by Kevin Sack, implementing mandated coverage may not be quite as easy as it seems.

More than 200,000 previously uninsured residents have enrolled, but state officials estimate that at least that number, and perhaps twice as many, have not.

Those managing the enrollment effort say it has exceeded expectations. In particular, state-subsidized insurance packages offered to low-income residents have been so popular that the program’s spending may exceed its budget by nearly $150 million.

But the reluctance of so many to enroll, along with the possible exemption of 60,000 residents who cannot afford premiums, has raised questions about whether even a mandate can guarantee truly universal coverage.

Additional concerns have been generated by projections that the state’s insurers plan to raise rates 10 percent to 12 percent next year, twice this year’s national average. That would undercut the plan’s secondary goal of slowing the increase in health costs.

He goes on to share each of the Democratic frontrunners' views on the subject of mandated health care:

“The sad reality is that the uninsured don’t just struggle with costs themselves, they impose costs on the rest of us,” Mrs. Clinton said in September. “It’s a hidden tax: the high cost of emergency room visits that could have been prevented by a much less expensive doctor’s appointment, the cost of unpaid medical bills that lead insurance companies to raise rates on the rest of us.”

Mr. Edwards echoed those remarks a week later. “The reason the mandate is necessary is because you cannot have universal health care without it,” he said. “Does not exist, and anyone who pretends it is, is not being straight.”

Senator Barack Obama of Illinois sees it a different way. He argues there is danger in mandating coverage before it is clear it can be affordable for those at the margins. While Mr. Obama does not rule out a mandate down the road, his emphasis is on reducing costs and providing generous government subsidies to those who need them. He would mandate coverage for children.

Mr. Sack's article then looks at the penalty system set in place by the Massachusetts plan for those who refuse to get coverage. This year, state residents who do not purchase insurance will lose their tax exemption (approximately $200), next year that penalty will rise to half the cost of the least expensive insurance policy available (with a probable minimum of $1,000). In his interviews he finds that many were not purchasing insurance because they either did not feel the need for it or because the penalty was not yet high enough to force them to do so.

“At 27, it’s not like I’m thinking, ‘Oh, man, what if I need an operation down the line?’ ” said Samuel B. Hagan of Lenox, a courier who remains uninsured. “Furthest thing from my head.”

John E. McDonough, executive director of Health Care for All, an advocacy group based here, said he found it breathtaking that political leaders were calling for an individual mandate well before there was any way to measure the success of the Massachusetts experiment.

"As goes Massachusetts, so goes the Nation?" The pitfalls and successes of that state's health plan will figure largely in future dialog on the subject.


SOURCE: "Obama challenges Clinton on health care" updated
SOURCE: "Massachusetts Faces a Test on Health Care" 11/25/07
photo courtesy of patriarcha12, remixed and used under this Creative Commons license

Health Care Reform: Availability vs. Affordability

Now that the Thanksgiving break is over and turkey sandwiches are the rule of the day, it's time to resume our health care blogging. We hope that all our readers had a healthy and happy holiday!

As the U.S. presidential election brouhaha escalates and the candidates get more vicious in their rhetoric, the subject of health care, like so many others in modern America, comes down to money. Over the holiday this has become a recurring theme as more and more analysts, bloggers, and reporters take a look at the out of pocket expense of health care in our nation.

Lets start with the fellow health care blogger Alan Katz, whose Health Care Reform Blog offers a post on this subject from an underwriters perspective:

At the end of the day, access is about affordability. If families can't afford coverage it doesn't matter what's available to them. If the state can't afford its health care programs, all the public proclamations mean nothing. It's about cost.

Most significant for those who would reinvent the health care system is the reality that the rate of health care cost increases has outpaced the growth rate of the economy as a whole since at least the 1970s. Without exception (not necessarily every year, but every decade). The cumulative effect is substantial: from 1970 through 2005, the nation's Gross Domestic Product grew by 7.4 percent; nominal national health expenditures grew by 9.8 percent. Perhaps 2.4 percent doesn't look like much, but over 30 years it means health care costs doubled compared to the economy's growth. That this trend is unsustainable is indisputable. That there's no clarion call for change is disappointing.

Brad Warthen, editorial page editor of South Carolina's The State gives us a personal perspective on the cost vs. income question:

I make more money than most people do here in the wealthiest country in the history of the world, and I live paycheck to paycheck, in large part because of the cost of being an extremely allergic asthmatic, and needing to do what it takes to keep enough oxygen pumping to my brain to enable me to work so I can keep paying my premiums and co pays. My premiums in the coming year - we're going to a new plan - will be $274.42 on every biweekly check, not counting dental or vision care. And I'm lucky to have it. I know that, compared to most, I've got a sweet deal!

I'm in the top income quintile in the U.S. population, and we can't afford cable TV, we've never taken a European vacation or done anything crazy like that, we haven't bought a new car since 1986, and aside from the 401(k) I can't touch until I retire (if I can ever afford to retire), we have no savings.

Yet I will pay my $274.42 gladly, and I will thank the one true God in whom I actually do believe that I have that insurance, and that I am in an upper-income bracket so that I can just barely pay those premiums, and that neither my wife (a cancer survivor) nor I nor either of the two children (out of five) the gods still let me cover is nearly as unhealthy as the people I see whenever I visit a hospital.

While the majority of the debate seems to focus on the uninsured youth of America or the plight of our elderly, more and more editorials and blogs are recounting the plight of the "average Joe." One recent comment left on this blog stated that the person leaving it was in immanent danger of losing her home due to health care costs. This is not an issue that is isolated to any particular demographic.

Another interesting take on the situation is this morning's post on the Huffington Post by GOOD magazine's Daniel Brook. It addresses the health care plight of that quintessentially American entrepreneur: the freelancer.

The people I know who are worried sick about coverage work for themselves, many in creative fields. Most of these freelancers and entrepreneurs are in the cross hairs of our health-care crisis--and you wouldn't know it from watching the presidential campaign...

The problem with our health-care debate isn't just that it glosses over a huge portion of people who are affected by the crisis, but that by not taking them into account, we may end up achieving universal coverage without unleashing the talented and entrepreneurial. Just requiring everyone to have health insurance won't solve the problem. That's what Massachusetts recently did statewide and what some candidates are suggesting on a national level. But under such a system, unless you're very poor, you still pay more if you have a family; you still have to pay a flat fee unrelated to your business income; and you still have the catch-22 of paying more when you get sick and are earning less. Without a solution funded through progressive taxation, simply requiring everyone to get insurance will still hold back our millions of would-be entrepreneurs. Health-insurance payments will continue to act as an "ambition tax."

The issue of health care reform is a large and complex one. It involves many aspects from the economic and the political to the practical and the ethical. For the average American, as these stories point out, health care reform is not just a matter of availability -- it is about affordability as well.


SOURCE: "Some Affordability Data" 11/24/07
SOURCE: "'Health care reform?' Hush! You'll anger the Insurance Gods!" 11/25/07
SOURCE: "Freelancers Need Universal Health Care, Too" 11/26/07
photo courtesy of yomanimus, used under this Creative Commons license

Forbes, HFMA on Improving Patient Billing Practices

Anyone who has had medical care in the United States is already familiar with the large array of forms and bills that can be generated by even a short and simple procedure. This morning Richard Clark, president and CEO of the Healthcare Financial Management Association (HFMA) shares his experiences with medical bills and his thoughts on the subject in a column for Forbes. He begins by recounting the tale of helping his mother handle the mountain of medical paperwork left by his father's demise.

What a mess.

I developed a spreadsheet, downloaded benefit descriptions from my father's supplemental insurance company, visited Medicare's beneficiary's web site, and made a lot of phone calls. In the end, I helped my mother work though the bills (some of which were received for the first time some 12 months after my father's death). In short, I lived the nightmare of our current health care billing system.

It was this unpleasant experience that drove him to begin the project know as "Patient Friendly Billing," which provides tools and data to clinics and hospitals to streamline communication with patients. He reaches many of the same conclusions as our own Mr. Halvorson concerning both the need for unified standards and the impact of economic incentives on health care.

Almost everyone agrees the current method of paying for health care services is broken. It fosters fragmentation of care, rewards inefficiency, and doesn't distinguish between high-quality and low-quality providers. It's a mess. And there is strong evidence that the payment system drives decision making, including the level, frequency, and venue of care. The payment system creates most of this nightmare and must be fixed before any real progress can be made to improve health care in this country.

In Health Care Reform Now! Mr. Halvorson notes that there are over nine thousand billing codes for procedures and yet not a single one to denote an actual cure. He also observes that there are currently no uniform standards or measurements of performance within the industry.

Mr. Clark focuses on revamping the payment system itself as the answer to these woes. Since there seems to be an absence of guiding principles upon which to base this proposed retooling, he has been working through the HFMA to develop some. To do so they have solicited input from many involved sources including government, employers, care providers, insurance agencies, and community groups.

Some of the guiding principles discussed in his column include:

• Quality and safety.


• Simplicity and standardization.


• Fairness and efficiency.


• Community benefits and innovation.


• Transparency.

After noting "most if not all," of these principles are violated by the current system he goes on to briefly examine some possible solutions involving "out of the box" thinking.
All of these potential fixes are aimed at untangling the Gordian knot of our current billing system, with a stress laid on simplification and consolidation.

I believe it is not necessary to move away from our system of public and private insurance coverage, and public and private care providers to improve our health care system. If we design and implement payment methods that achieve a set of principles that are designed to provide high quality, safe, and efficient care, we will go a long way to improving what ills the system. It's time to wake up from the nightmare and fix the mess that is the health care billing and payment system in the U.S.

SOURCE: "The Health Care Billing Nightmare" 11/14/07
photo courtesy of unk's dumptruck, used under this Creative Commons license

Americans Study Netherlands Health Care Program

In the Netherlands universal healthcare is not only the standard but also involves a healthy amount of market competition. Kerry Weens, a senior U.S. Department of Health official, recently lead a delegation of Americans examining the Dutch health care system:

"We're intrigued by many of the ideas that we see, such as moving toward more market based solutions. In general I think there's a lot of consistency between the Dutch system and the US system."

John Tyler and Reinout Van Wagtendonk of Radio Netherlands report on the American delegation’s visit.

Mr. Weens was referring to a recent overhaul in the way Dutch people purchase health insurance which have made the Dutch system more competitive. Two years ago, a new law went into effect requiring every resident of the Netherlands to purchase their own health insurance, while the insurance companies were forced to embrace open market laws and offer competitive prices for their insurances. But unlike in the United States, for those who can't afford insurance, the Dutch state still chips in to cover part of the cost.

Insurance companies are required to provide coverage for anyone who applies for it, so no one can be refused due to pre-existing health problems. To help insurance companies cover some of the costs involved with selling coverage to all comers, the government has a formula in which it contributes to the cost incurred in certain cases.

So while competition has been introduced into the system, the Dutch system is not a completely market-based approach. The taxpayer still subsidizes a not insignificant percentage of care in the Netherlands. But competition helps keep overall costs down.

In Health Care Reform Now!, George Halvorson advocates finding a uniquely American path to universal coverage while learning what we can from other nations who already have their own systems of universal coverage. This sort of fact finding mission is exactly the type of research that needs to be done in order to synthesize our own uniquely American solution.

The Dutch approach also share’s Mr. Halvorson’s views on preventative care and transparency.

"We pay a lot more attention to prevention -- we have a coordinated, multidisciplinary approach. In Holland there's quite a lot of proactive action attached to that aspect of health care," said Nolene Berkhout, a nurse practitioner who served as one of the hosts of the American delegation.

A number of recent changes are meant to improve the quality of care here in the Netherlands. Doctors and hospitals are now required to publish information every year about their performance. That information is available to the public on a website, but it is still too soon to see how much effect it has on patients' choices.

SOURCE: "U.S. Officials Impressed by Dutch Healthcare System" 11/12/07
photo courtesy of Pear Biter, used under this Creative Commons license

Questionable Claims in the Health Care Debate

On Monday, October 29th, Presidential hopeful and former New York City Mayor Rudy Giuliani debuted a new campaign advertisement centering on health care. Using his own experience battling cancer as the basis of the ad, he drew an unfavorable comparison between American health care and its government run counterpart in the United Kingdom. It was this comparison and the questionable statistics it contained that began to draw fire, as John Whitesides, a political correspondent for Reuters reports:

Giuliani, who has suffered prostate cancer, has taken criticism from British and U.S. health officials for saying in a radio ad this week the U.S. survival rate for the disease was 82 percent while the survival rate under Britain's "socialized medicine" was 44 percent.

Health officials in both countries say the most recent statistics show five-year survival rates for prostate cancer are 99 percent in the United States and 74 percent under Britain's National Health Service.

Giuliani told reporters he was using statistics from 2000 and said "those statistics have changed slightly today" -- but he did not back away from the broader comparison.

This thirty percent variance has raised eyebrows both at home and abroad. The British reaction reported in this same Reuters article is hardly surprising in light of difference.

British Health Secretary Alan Johnson said on Thursday Giuliani's figures were wrong and complained about his attacks on Britain's National Health Service.

"The British NHS should not become a political football in American presidential politics," Johnson told The Times newspaper in London.

Cancer survival rate statistics depend on the number of cancers that are detected and when they are reported, and therefore may not necessarily reflect how well a health-care system performs at preventing cancer deaths overall.

The Times said roughly the same proportion of men -- 25 out of 100,000 -- died of prostate cancer in the United States and Britain each year.

John J. Thyng, Jr., The State Director of New Hampshire for Health Care, attacks the ads in his blog on the Huffington Post:

As early as the day the ad was released -- Monday, October 29th -- ABC News reporter Rick Klein reported that "the data Giuliani cites comes from a single study published eight years ago" and "is contradicted by official data from the British government."

As reporters asked more questions, the Giuliani campaign refused to admit their mistake.

When we issued a call for the ad to be taken down, his campaign still refused.

But we're not backing down. The next time Mayor Giuliani is in town we intend to deliver the message that we expect the campaigns to present strong, accurate statistics when making the case for how they will ensure access to quality, affordable health care for every American.

Health Care Voters will be there to call on him to remove the ad, and to remind him that 67,000 people intend to vote for a Health Care President - one who presents real facts, and doesn't use falsehoods to deflect attention from the lack of any personal ideas about how to fix the health care crisis.

Further analysis of this story is easily found on the New York Times, Washington Post, MSNBC, and Salon.Com websites.

SOURCE: "Giuliani Takes Another Shot at British Health Care" 11/02/07
SOURCE: "Rudy Needs to Pull His Dishonest Health Care Ad Now" 11/02/07
photo courtesy of Traveler54, used under this Creative Commons licence

Digital Medicine

While the pros and cons of SCHIP dominate the news and the blogosphere, a quiet little press release snuck onto the web this morning offering news of advances in the field of electronic medical records (EMRs).

CNNMoney reprints the original Siemens press release:

Siemens Medical Solutions is fulfilling the demand for a workflow-oriented, patient-centric approach to healthcare with its Enterprise Document Management (EDM) and Soarian(R) Healthcare Information Management (HIM) solutions, which are helping healthcare institutions enhance patient care, improve patient safety initiatives, and reduce healthcare costs.

Why would this drive the costs of health care down?

Accessible from any location, EDM and Soarian HIM coordinate processes within and between departments, as well as tasks between users. With their Web-based intuitive user interfaces, the solutions host concurrent and multi- user access, helping to eliminate multiple trips by clinicians and patient financial services staff to the HIM department to access patient data. When patient charts are virtual, costs and time associated with chart storage and retrieval are reduced. Many EDM and Soarian HIM customers are seeing positive outcomes as a result of use at their facilities.

So....

Transparent and portable medical information, eh? Good idea, sounds familiar. According to the release the implementation of these digital sstems has driven down costs while improving efficiency and accessibility. Photocopying costs are a good example. The cost of making copies of medical records was reduced by $100,000 annually for CaroMont Health of North Carolina. and $45,000 for the Mountain States Health Alliance after the implementation of HIM solutions.

The release presents some specific examples on a case by case basis:

CaroMont Health has reduced the number of record requests by 30 percent, its record analysis by 50 percent, its medical records delinquency rate by 84 percent, unbilled accounts receivables by 50 percent and photocopying costs by $100,000 annually.

You can rest assured that we will be returning to this story when there is more to report.


SOURCE: "
Siemens Soarian Health Information Management is Widely Adopted by Leading Healthcare Institutions in 2007: Leading Healthcare Institutions Embrace Technology That Enables Free Flow of Patient Documentation Throughout the Enterprise
" 10/08/07
Image by George Williams

Lilly CEO Calls for Reform and EMRs

While the health care reform community is focused on President George W. Bush’s imminent veto of the children's health insurance bill, a major announcement about Electronic Medical Records (EMRs) has evaded the spotlight.

Sidney Taurel, CEO of pharmaceutical giant Eli Lilly put forth a call for development of a health information technology system. His proposed system would be a collaborative effort of both public and private sectors and would involve the U.S. government, the health care industry and the medical community as active participants.

The aim is tracking both actual effectiveness and side effects of drugs that have been released into the market. This "real world" data will enhance the safety profile of drugs first established through standard drug trials.

CNNMoney reports on Taurel's address at the Cleveland Clinic:

Although traditional drug trials will continue to test new hypotheses about medicines after they have reached the market, Taurel outlined how a well-functioning health IT system could serve not only to frame hypotheses for so-called "Phase IV" clinical research, but also become the practical equivalent of massive, real-world trials. Such a system would collect detailed data from day-to-day medical practices and feed insights quickly, seamlessly and at a lower cost to doctors, regulators, and drug manufacturers. The result would be a more accurate picture of a drug's safety and efficacy than exists today.

Once again we see the importance of developing portable, transparent records as Kaiser-Permanente CEO George Halvorson outlines in his book, Health Care Reform Now!

The CNNMoney article goes on to describe the current collaboration along these lines:

Taurel explained that as EMR systems build out, they provide what amounts to a 'commons' in which organizations can collaborate to share health information.

For example, Lilly, Pfizer, and Johnson & Johnson are collaborating with 'e-Health Initiative' - a not-for-profit health information technology group - as well as with the Indiana Health Information Exchange and the Partners Healthcare System in Boston. The goal is to test how safety signals can be located and understood using existing data, potentially leading to a better understanding of the risk and benefits of medicines.

SOURCE: "Lilly’s CEO Calls For Reform of Nation’s Drug Safety System" 10/02/07
photo courtesy of Uh…Bob

VEBA in Spotlight of Health Care Reform

The fallout from the UAW-GM agreement shifting retiree health care benefits into a VEBA (Voluntary Employee Beneficiary Association) keeps coming.

In a quick, penetrating article, BusinessWeek reporters David Welch and Nanette Byrnes enlighten readers about how many VEBAs are already around (about 12,000 nationwide), who's using them (employers with large, unionized workforces), and how well they are holding up:

In 1998, the equipment giant [Caterpillar ] set up a similar type of health-care trust to defray increases in retiree medical costs. By October, 2004, it ran dry, and retirees saw as much as $281 extra taken from their monthly pension checks. Now the retirees, union, and company are in litigation.

The article quickly explains the benefits of VEBAs to both business and labor:

For employers with aging workers and lots of retirees, a VEBA may be the only way, short of an elusive national health-care plan, to strip crushing liabilities from their books... For unions, a trust can provide an opportunity to safeguard members from losing benefits in the event of a corporate bankruptcy.

Meanwhile, New York Post reporter Paul Tharp is taking a more jaundiced, historical look at VEBAs:

General Motors is saving its financial neck and ending a surprise strike by using a century-old shelter device originally invented to quell the labor riots of the 1920s... VEBAs were created as tax shelters for giant coal and steel companies at the turn of the century to help pay for worker injuries and widows' benefits.

One thing is certain, you'll be hearing a lot more about VEBAs on this blog and in the U.S. Presidential Election campaign in the months ahead.

SOURCE: "Is GM's Health Plan Contagious?" by David Welch and Nanette Byrnes, BusinessWeek, September 27, 2007.
SOURCE: "GM's $nazzy New Model: VEBA," by Paul Tharp, New York Post, September 27, 2007.
photo courtesy of Abandoned In Place at Flickr

Clinton Care Chaos

The media and blogosphere are abuzz about what many are calling "HillaryCare 2.0." The presidential hopeful laid out her approach to health care reform yesterday in Iowa. It was shortly afterwards that her new ad debuted.

The attacks and analyses began immediately, with a frequent refrain being about Clinton's stance on the insurance companies. Clinton makes many references to not allowing the insurance companies to control health care prices. That adversarial tone is seemingly quite at odds with the way her plan is being assessed in some quarters. This excerpt from The Nation is a good example:

The Clinton plan maintains the current system of for-profit, insurance-industry defined health care delivery. The only real change is that, in return for minimal requirements regarding coverage of those with preexisting conditions, the government would pump hundreds of billions in federal dollars into the accounts of some of the country's wealthiest corporations. The plan's tax credit scheme would buy some more coverage for low-income families, which is good, but it would do so at a cost so immense that, ultimately, Clinton's plan will be as tough a sell as the failed 1993 "Hillarycare" proposal.

America is ready for health care reform.

But it is not ready for more bureaucracy, more expense and more revenue for insurance companies.

Criticism abounds from all sides of the debate with both Republicans and her fellow Democrats rushing to add their own critiques. Does this avalanche of criticism denote a defensive posture amongst her detractors?

ABC News summarizes the reactions from other candidates and comments on the overall state of the playing field:

Clinton's plan is "European-style socialized medicine" (Mitt Romney); straight out of Michael Moore's "Sicko" (Rudy Giuliani); an "imitation" advanced by a flawed saleswoman (John Edwards); inadequate and advanced by a flawed saleswoman (Barack Obama -- but how would he cover more people without requiring coverage?); and automatically bad because Clinton herself "set back our ability to move toward universal health care immeasurably" back in 1994 (a very aggressive Chris Dodd).

All the attention is a form of flattery; just about any other candidate would have had himself hospitalized (maybe even in Cuba) to be attacked like this when he offered his plan. The obsession with "Hillarycare 2.0" speaks to the control that Clinton exerts over the entire field, as the one person who at this moment looks like she has the best shot of being elected president (and who represents the match-up the Republican base craves the most).

SOURCE: "Clinton's Prescription for Another Health Care Reform Failure" 09/17/07
SOURCE: "Hillary '07 Battles Hillary '93" 09/18/07
photo courtesy of valentinapowers on Flickr.

Engelberg Center for Health Care Reform Launches

Earlier today, The Brookings Institution announced the creation of the Engelberg Center for Health Care Reform.

The newly named director, Dr. Mark B. McClellan, is a former commissioner of the Food and Drug Administration and administrator of the Centers for Medicare and Medicaid Services.

The Engelberg Center's agenda will focus on four key priorities for long-term change: improving the quality of medical care, increasing access to affordable coverage, encouraging development of more personalized medicines, and reducing costs for public and private programs.

Alfred B. Engelberg, one of two Brookings trustees who gave generous donations for the creation of the Center, says of McClellan:

"[His] proven ability to create and implement important health care reforms, combined with Brookings's long history of thoughtful impact on public policy has the potential to make a real difference in the steps that are taken to fix our broken health care system," said Mr. Engelberg.

More information about the Engelberg Center can be found at the Brookings Institution website.

SOURCE: "PR Newswire"