Post Election: Health Care and The Obama Administration

President-Elect Barack Obama will be taking the reigns on January 20, 2009. He takes office amidst a veritable hailstorm of crises: the financial meltdown, the housing meltdown, the wars, and, according to voters, health care.

Rebecca Ruiz over at Forbes brings us a recap of Obama's plans along with an examination of what the next steps will be and what direct effect we will experience. In one of the first of what will no doubt become an endless stream of speculation between now and January 20, she explores the pros, cons, and unknowns of the subject.

One particularly telling quote in her article comes from John Sheils, senior vice president of the Lewin Group, a health care policy research company in Falls Church, VA:

Sheils' analysis found that Obama's plan would decrease the number of uninsured by 26.6 million beginning in 2010. The estimated federal cost of enacting the plan is $1.17 trillion from 2010 through 2019. By 2010, annual spending on health care is expected to reach $2.7 trillion. But Obama's plan is expected to cut spending by $54.1 billion in the next decade. The savings are important, but regardless, the price tag is staggering.

Another thing that Sheils notes is that one crucial flaw remains unaddressed, a crucial flaw that George C. Halvorson has expounded upon in his most recent book: incentives. Currently, incentives in the health care industry are geared towards care services and procedures performed instead of being based on actual health results.

This article is particularly advised reading, especially for its last few paragraphs where Ms. Ruiz looks at the potential interactions on this subject once Obama is sworn in and the discussion moves to the floor of Congress.

On the whole, it seems like there is positive news in the wind.

SOURCE: "What Obama's Health Care Plan Means For You" 11/05/08
photo courtesy of realjameso16, used under its Creative Commons license

More Does Not Equal Better

The Seattle Post Intelligencer's Cherie Black brings us today's reality check by sharing a recent study from Dartmouth that points to an overabundance of care being a problem in and of itself:

Too much medical care could be harmful to your health.

That's what researchers concluded after examining the nations' hospitals and the care patients receive. Some hospitals and some areas of the country give patients more aggressive care -- meaning more tests, longer hospital stays and more procedures -- than others. And the extra treatment doesn't always translate to longer or better lives.

This brings us firmly back to the issue of our medical system charging per procedure rather than charging for overall results. Billing codes abound, although as we often point out here on the blog, there is not one code for a cure.

The 2008 Dartmouth Atlas of Health Care study, released Thursday, studied more than 4 million Medicare patients at nearly 3,000 hospitals across the country from 2001 through 2005 during the last two years of life.

The patients were 65 years and older and were treated for the top nine leading causes of death, including congestive heart failure, chronic pulmonary disease, cancer, dementia, coronary artery disease, chronic kidney failure, peripheral vascular disease, diabetes with organ damage and severe chronic liver disease.

Since all of these are chronic conditions, they fall into that segment of health care that produces a vast majority of costs incurred in the United States. When you add in the number of Baby Boomers who are hitting this age bracket, the equation becomes more and more worrisome.

The study found that depending on where patients lived and what hospital they went to, there were big discrepancies in how they were treated.

Researchers reasoned all medical care carries some risk, so the longer a patient is hospitalized and the more procedures and tests performed, the greater the risks, in addition to greater costs.

Costs. It seems to always come full circle back to costs, no matter what angle of the health care discussion you approach. Costs keep people from seeing a doctor until it is unavoidable. Costs keep providers from adding more Medicare patients to their rolls. Costs directly affect who can afford insurance. On that note one tool that is immediately useful came online along with the report:

Launched in conjunction with the Dartmouth study, the online tool at ConsumerReportsHealth.org lets consumers compare treatment approaches among hospitals for the nine serious chronic conditions in the study on a scale from 0 percent to 100 percent (the higher the percentage the more aggressive the treatment).

The percentile rank is based on the total number of hospital days and inpatient physician visits over the last two years of life. Next to each of the nearly 3,000 hospitals, there also are the patient out-of-pocket costs over the last two years of life.

While aggressive treatment is not always a bad thing, in some cases, it is the only correct path. There are far too many cases where it is counterproductive and exists simply due to the perverse nature of financial incentives within the health care industry. Ms. Black's examination of the Dartmouth report provides some interesting and unfortunate new statistics to add to the ongoing discussion.

SOURCE: "More health care may not always be better: Study finds extra treatment can mean extra risks, costs" 05/30/08
photo courtesy of Jeff Kubina, used under its Creative Commons license

Baby Boomers and the Shrinking Health Care Workforce

Medical News Today brings us more disquieting news about the state of health care as it relates to the wave of Baby Boomers soon to retire. According to a report from the Institute of Medicine, the health care industry is not only unprepared to meet the health needs of the coming onslaught of retirees, but is also lacking enough staff to provide proper care for them:

The Gerontological Society of America (GSA), the nation's largest organization devoted to aging research, fully supports the publication's call for a labor pool of adequate size and competency to care for a rapidly increasing over-65 population.

"This pivotal report lays out a much-needed strategy for developing a network of health professionals and frontline workers to avert a crisis in quality care for older persons," said GSA President Lisa Gwyther, MSW. "Complex chronic illness is an issue that we all will face with age. The current fragmented system of care desperately requires an increase in better-prepared personnel to sustain itself."

When you combine the number of Americans reaching retirement age in the next few years with the continually extending life expectancy, an uneasy picture emerges. To aggravate the situation, the number of geriatric specialists is shrinking.

Marie Bernard, MD, president of The Association for Gerontology in Higher Education (GSA's educational unit), said policymakers must act quickly to address these problems.

"To meet the needs of our aging parents and grandparents, we need to increase the number of geriatric health specialists - both to provide care for those older adults with the most complex issues and to train the rest of the workforce in the common medical problems of old age," Bernard said.

The elderly already are responsible for a disproportionate amount of health care resources, partly due to the prevalence of chronic conditions that require continual or serial treatments. With the number of people in that age bracket doubling in the next few years, this issue is, like so many that we write about here, critical.

SOURCE: "Looming Baby Boomer Health Care Crisis; GSA Bolsters Call For Stronger Workforce" 04/18/08
photo courtesy of mishajane used according to its Creative Commons license

More Does Not Mean Better: Chronic Disease Care

The uneven distribution of health care costs is a vitally important aspect of the overall reform debate. Five chronic diseases account for 75% of our total national expenditures for health care across the board.

On Monday, the Dartmouth Atlas of Health Care put out a press release (via The Earth Times) about their newest study in which they focus on the part that Medicare plays in this aspect of the ongoing battle for health care reform. Evidently the amount paid by Medicare is highly variable, as is the treatment received:

"This report demonstrates the need to overhaul the ways we care for Americans with chronic illness," said Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation. "The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they or their families actually want or need."

The first image that came into my mind while reading this was that of an auto mechanic advising a complete engine overhaul to treat a set of failing spark plugs. More is not always better.

The new edition of the Dartmouth Atlas of Health Care: Tracking the Care of Patients with Severe Chronic Illness shows that institutions that give better care can do it at a lower cost because they don't over-treat patients. However, the Atlas documents that Medicare and most other payers encourage the over-use of acute-care hospital services and the proliferation of medical specialists thanks to misplaced financial incentives, especially for treating chronically ill people.

This is a serious problem. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. And over-use and overspending is not just a Medicare problem--the health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses.

Misplaced financial incentives, indeed. As George C. Halvorson has pointed out in his book, Health Care Reform Now!, there are over 9,000 billing codes for medical procedures, yet not a single one exists for a cure. The Dartmouth report supports the assertion that it is not the only the cost of care but also the sheer number of procedures prescribed, some necessary and some not, that is at the core of this aspect of the problem.

The Dartmouth Atlas Project studied the records of millions of Medicare enrollees who died from 2001 to 2005 and had at least one of nine severe chronic illnesses. Using those records, researchers benchmarked care nationally to the care provided in the region where Mayo has its flagship clinics and is far and away the dominant health care provider. Total spending for the population in this study was $289 billion over the five years. If the spending per patient everywhere mirrored that in Mayo's home region of Rochester, Minn., Medicare could have saved $50.1 billion, or 17.3 percent of all spending on these patients alone. A benchmark to a higher cost but efficient region such as Sacramento, Calif., where labor costs are the 26th highest of the 306 regions, shows Medicare would still have saved $28.9 billion.

The study paints a picture of a system in disarray over the treatment of these illnesses. There are no good, clear guidelines for when to hospitalize these patients, admit them to intensive care, refer them to medical specialists or--for most conditions--when to order diagnostic or imaging tests..

The numbers are both enlightening and disturbing. The wide variances from provider to provider point to a lack of consensus on proper course of treatment for these ailments as well as the lack of systems thinking in the industry, e.g., lack of across the board standards and measurements of performance.

The links below will take you to the full press release as well as to the Dartmouth Atlas of Health Care site where you can purchase or download the full report itself.

SOURCE:"Press Release: Chronically Ill Patients Get More Care, Less Quality, Says Latest Dartmouth Atlas" 04/07/08
SOURCE:"The Dartmouth Atlas of Health Care"
photo courtesy of Mel B., used under this Creative Commons license