Health for life

How would Ms. Antoinette ponder health orm with her advisors?

While commonly attributed to Marie Antoinette, the phrase may actually be testimony to Jean Jacque Rousseaus genius in using four words to capture an elites inability to grasp the plight of a struggling underclass.  For a more modern depiction of a lifestyle bubble, think of the 1% not getting just how difficult it can be to make a living wage.

And its not just the 1%. African Americans, with some justification, note that whites have yet to grasp "the set of experiences and a history" that perpetuates racial inequality. Its not just the "facts" but how facts are sorted, prioritized and interpreted by a brain wired by decades of being surrounded by like-minded people caught up in their information loops.

But it cuts both ways. When confronted by the hostility of tens of millions of Americans to the Affordable Care Act, liberal-progressives likewise respond with similar puzzlement. Who can blame them for rationalizing things with attempts to provide more "education" or blaming it all on obstinate Tea Bagger and "Birther" wackiness?

Its not that simple.  As pointed out in this The Atlantic article, conservative skepticism about the size, regulatory reach and spending of government was well underway long before Mr. Obama set foot in the White House.  Focus groups have little trouble finding deeply held opposition to expanding government entitlements, middle class dependency, pro-business globalization, wealth transfers and scary levels of deficit spending. Given the big picture,  Obamacare is less of a problem than a symptom. 

As result, even if the White House and its Democratic allies prevail on the shutdown showdown, successfully raise the October 17 debt ceiling, cancel the January 1 2014 sequester and take back the House in November 2014, the opposition to the health care law isnt going to simply fade away.

But, say my liberal friends.....

1. Much of the Affordable Care Act is based on Republican ideas, including the mandate and Romneycare.

The mandate and Romneycare were never intended to be imposed nationally, but adapted by each of the states. 

2.  It will save money.

Health care consumption declined before the passage of the Affordable Care Act. Experts legitimately disagree on the impact on future health care costs but it stands to reason that more people with insurance will lead to increased demand and higher spending..

3.  The health care system is broken

Actually, the part of the system that was broken was the individual insurance market.  This objective OECD Report summary points out that, compared to many other developed countries, U.S. quality has been quite good and our cost trends are lower.  And while its too early to tell, the health insurance exchanges travails combined with multiple other self-inflicted wounds suggest that the cure may end up being worse than the disease.

The point here isnt whos wrong or whos right.  Rather, its clear that skepticism over Obamacares ability to deliver on all its promises is not crazy.  Its critics not only deserve their time in the public square but to have their perences lected in policy and legislation..

Whats more, the Obamacare dust-up is part of a bigger concern over the expanding role of government that tens of millions of Americans find potentially intrusive and unaffordable.  The inability of the DMCBs liberal progressive colleagues to comprehend that may be a less a function of their superior intellect or the stupidity of the opposition than an Antoinette-esque inability to step outside their familiar biases and ponder a different point of view. 

While the Disease Management Care Blog tries to be an equal opportunity cynic and generally sides with policy underdogs and lost causes, it supposes that its conservative leanings sometimes comes through in its writing. 

That was enough to prompt a series of well-written email exchanges with Greg Brown, a retired educator from the Kansas City area. He did a great job of compactly summarizing the views of supporters of the current version of health orm. 

It seems to boil down to five main arguments:

1. Medicare and Social Security: While passage of these landmark safety net programs was likewise met with deep concerns about the erosion of liberty, their ultimate success cannot be denied.  Most of the persons who are against the Affordable Care Act are ironically happy to have the feds appropriate a portion of their income in exchange for economic security in their old age. They cant have it both ways.

2. This is not buying shoes:  One role of the federal government is to step in when markets fail, and that has been amply demonstrated when it comes to health insurance. While its difficult enough to remember to even buy a product that you may not need, shopping for the best value in commercial insurance is practically impossible.  Proposals to expand this unworkable solution are a pipedream.

3. The public good: Keeping people from going bankrupt in the course of an unexpected illness is everyones interest.  Its ultimately a better bargain for society to proactively manage this with near-universal insurance than to deal with poverty after the fact.

4. Purchasing power: To date, Washington DC has chosen to not flex its purchasing power with providers.  Think of how much cheaper drugs would be if Medicare leveraged this for Part D.  Just wait until the happens in the rest of health care system and how much all of us will all benefit. 

4. Status quo: Even if you dont accept the track record of Medicare, the realities of buying insurance, the merits of a public good and the advantages of purchasing power, the status quo has led the U.S., compared to the rest of the developed world, to be a unsustainable per-capita cost outlier.  Something has to change. and theACA is doing just that.

I am not an expert by any stretch. I am just an interested layman. I really wish Obama had pushed for a single payer or at least a strong government alternative delivery system. But here we are and as imperfect as it is, it is the best thing I see on the horizon right now. It does at least attempt some cost controls, it broadens access, and it may lead to better quality with a focus on health outcomes rather than billable procedures. At least it attempts to address all three.

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Your doctor will see you now!

If only the U.S. health care system had the democracy of the French, the efficiency of the Germans, the primary care of the Brits and the common sense of the Swiss. Then wed be able to see our beret-wearing PCPs ad lib, receive care in 9 minute aliquots, mutter "bullocks!" when were told were too old for dialysis and then die old and quietly at home.

Victor Fuchs, writing in the Jan 2 edition of JAMA, has a slightly different perspective.  He notes that American history is dominated by waves of immigrants who came here to escape oppression. We are far more distrustful of government.  We are also less likely to support redistributive public policies. That may be partly due to a more heterogeneous population that is less sympathetic to the less fortunate when they fall outside the right social or demographic class. Last but not least, our system of government is quite inefficient compared, say, to a parliamentary system.

Thats why:

1. Government spending on health care is comparatively lower: 46% in the U.S. vs. 75% in Organization for Economic Co-operation and Development (OECD) countries.  As a result, a) administrative costs are fragmented, and b) there is less ability to negotiate prices with providers and suppliers

2. There is a different mix of services: in the U.S., less top-down control means more high tech, specialists and amenities with relatively less reliance on physicians and hospitals to render health care services.

What is the way forward?  Dr. Fuchs recommends that future health orm efforts not be modeled on Europe.  Instead, Americans should scale back their expectations and focus on what is necessary, not desireable.

If government is to assume a greater share of health care costs beyond the current 46% level, it should probably worry about funding basic care, not all care.  In addition, Americans are less likely to support total equality; they want to preserve the option of "buying up" when they can afford it.  Last but not least, future orm is going to have to find a middle ground between all the advocacy groups, stakeholders and special interests that dominate the mix of services.

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Lets fix it!

While noisy media leprechauns dispense blame and declare winners in the government shutdown imbroglio, the Disease Management Care Blog remains focused on the next steps for meaningful health orm. So are JAMA authors Jack Lewin, Lawrence Atkins and Larry McNeely who, other than one lapse in their editorial, get it mostly right.

Their important insight is that the Bipartisan Policy Center, Brookings Institution, Commonwealth Fund, Kaiser Family Foundation, the National Coalition on Health Care, Partnership for Sustainable Health Care and Urban Institute all have a remarkable degree of overlap in their recommendations for the next phases of health orm. 

Most of these expert organizations agree on the merits of value-based payment as well as insurance orm (pay for quality), information technology, competition, tort orm, evidence-based benefit design (paying when theres evidence that it works), workforce changes (greater efficiency), orming Medicare, changing tax policy (the exemption for health insurance) and instituting regional or local caps (stick to a budget or theres consequences).

The DMCB wholeheartedly agrees and hopes that the bipartisan consensus evident among these think-tank institutions leads Congress (if not this one, the next) and the President (if not this one....) to use these ingredients to build on the successes and correct the many deficiencies of the Affordable Care Act.

And the lapse? 

Jack Lewin et al were missing one thing. The DMCB looked in each of these organizations web sites and found that there was also considerable support for population health management.

To wit:

The Bipartisan Policy Center - while the emphasis of this report is on health information technology, the real dividends are pretty clear when it mentions "population health" 14 times:

This plan should address the development and adoption of policies and standards needed for the delivery of care, the empowerment of individuals, and improvements in population health based on national health and health care priorities.

The Commonwealth Fund:

 Effective population health management requires fundamental change in care delivery that must be supported by changes in payment.

National Coalition

Real orm means engaging consumers in their own health and health care choices. In both Medicare and too many private plans today, benefit design neither supports self-management of chronic disease nor distinguishes between care that is effective and care that is not.

Partnership for Sustainable Health Care - see page 22:

Federal nurse education funding should be ocused to equip registered nurses to assume the roles of case manager and population health coordinator.

The Urban Institute - see page 17 on the topic of Medicaid orm:

States can start in select geographic areas or specific population groups (adults and children or specific chronic conditions), and then incrementally expand them after learning from experience and making program improvements and adjustments. Broader efforts typically mean additional stakeholders, increased collaboration and communication.

Baron Von Munchhausen

Despite host Peter Segals occasionally highbrow insider cleverness, The Disease Management Care Blog remains a loyal fan of NPRs "Wait Wait... Dont Tell Me" radio show.  While the DMCB has its suspicions about the ratio of truly spontaneous wit to pre-planned ripostes, that wont stop it from turning to a part of the show called Bluff the Listener for bloggy inspiration.

BtL has guests try to guess which of three funny stories is based on a real true news report. The DMCB thinks health care is so wacky that itd be more challenging to guess which of the four stories below is false.

Unfortunately, if you win, getting the DMCB to put its voice on your home answering machine is unlikely to impress anyone. However, if you can pick out which story is a complete Munchhausenesque fabrication, you will deserve the respect of your friends and co-workers.

Ready to try to get some bragging rights?


Even doltish man-trolls know better than to try to organize an all-male blogging conference. Unable to reach out to that demographic, HHS Secretary Kathleen Sebelius did whats best: appeared before the annual "BlogHer" Conference in an appeal to women bloggers to tout the benefits of Obamacare. Her outreach supplements plans to rely on celebrities to help with a nationwide drive to increase enrollment through the insurance exchanges. Next up will be effort to recruit motor scooter owners to sport pro-Obamacare ads on the back of their helmets.  Then its on to asking members of the European Beret Society to host recruitment drives at their monthly chardonnay tastings.

Answer here.


Al Lewis and Vik Khanna condemned the wellness industry in a Wall Street Journal editorial when they proclaimed that "workplace programs dont work." They went on to say that they are "ineffective at reducing costs, lack support in the medical literature, are unpopular enough to require incentives and are occasionally even harmful." Yet, the Khanna On Health Blogs “workplace wellness consulting” page suggests the authors’ unique consulting insights can help potential customers “do wellness right.” Did the DMCB mention that both individuals are lawyers?

Answer here.


Writing in a separate issue of the Wall Street Journal, former Vermont Governor and Democratic National Committee Chair Howard Dean actually attacked Obamacare by criticizing its Independent Payment Advisory Board as a rate setting enterprise that is doomed to failure. Brazenly using Tea Party terms such as "bureaucrats" and "health rationing," Dr. Deans liberal-progressive apostasy prompted ACA architect Peter Orszag to curiously opine in a separate article in Bloomberg that the argument favoring IPAB is that it will be a much better rate setting body than Congress. If this keeps up, even labor unions will start criticizing Obamacare.

Answer here.


While partisan blood continues to spill over Obamacare in Washington DC, there is much good news outside the beltway.  Its been announced that the IRS will not only rely on self-reporting of income levels in setting premium subsidies. Even better, individuals who qualify for tax credits while buying their health insurance with the on-line exchanges will get a two-fer: 1) the option of applying the rebates to reduce their monthly premiums, and 2) confidence that there wont be any tax liability "claw backs" should their final income be higher than anticipated. Interest and penalties will be optional.

Answer here

New recipe for capitation?

Readers of Kaiser Health News, Politico and The Hill (here, here and here, respectively) were treated to the faux news of another expert report on the tedious topic of physician payment orm.  While the Disease Management Care Blog is a big fan of the brainy Society of General Internal Medicine (SGIM), this physician compensation communique is another rehash of "misaligned incentives" leading to "quantity over quality."

Yawn.

The good news is that there may be insights that were missed by KHS, Politico and The Hill.  In this instance, the DMCB has been listening closely and found one thing the experts arent saying.

What was said?

Like the many other decrees that have preceded it, the Report of the National Commission on Physician Payment Reform recommends the recalibration and then phasing-out of stand-alone fee-for service (FFS) while transitioning to other payment models that blend FFS with global payment, salaries or "capitation."  It also advocates increasing payment for "congnitive" over procedural services, removing any hospital overhead costs from the fees that are paid for any service that can also be performed at a free-standing facility, rewarding measurable quality, paying for telemedicine, increasing the use of risk adjustment, repealing the sustainable growth rate (SGR) and orming the RUC.  And like everyone else, it assures the reader that paying for the savings from all these orms will more than pay for themselves.

And yes, the word "capitation" was in the report.

What isnt being said is that there is a growing consensus that scuttling of traditional fee-for-service will usher in a new era of capitation.  The DMCB thinks of it as Capitation 2.0.

"Capitation" doesnt necessarily have a good name, but that doesnt mean this new rose doesnt smell as sweet or have fewer thorns. Originally spawned by the go-go managed care era of the 1990s, it was blamed for putting profits before patients by giving physicians an incentive to withhold needed medical services.  While a much younger Donald Berwick reported that the medical literature "did not make capitation out to be the villain that some believe it is," the complex risk taking, a lack of individual physician support and unseemly group practice behaviors undoubtedly fueled the physician backlash and the end of managed care in the 1990s.

 So why is capitation coming back?  The DMCB suspects one reason is that there are only passing erences to it and that its been rebranded with more benign sounding names like "gain-sharing" and "global payments."  Another is Medicare FFS fatigue, caused not only by the SGR but by CMS unending hassles, the uncertainty surrounding PQRS and the dread of having to go through one of those repugnant "RAC audits."  Unwilling (so far) to simply drop out of Medicare altogether, docs are backing into acquiescing to the recommendations of groups like the SGIM.

And why does the DMCB call it Capitation 2.0? Writing in SGIMs Journal of General Internal Medicine more than a decade ago, Thomas Bodenheimer predicted the survival of managed care thanks to the allocation of full capitation to institutions, not individuals. Its then up to those institutions to leverage both FFS and capitation at the individual physician level.  The DMCB would add that a third ingredient is tying any payments under capitation to specific quality goals, like control of chronic illness or maintaining access to care.

The DMCBs conclusions?

What they didnt say: The track record of original capitation or advent of Capitation 2.0 doesnt mean physicians are embracing what their organizations and political allies are saying whats best for them.  They simply dont see an alternative. The 1990s could happen again.

What they got right, sort of: Outside of large organizations that take capitation, we have much to learn about the best combination of FFS and fixed payments when it comes to physician incentives and protecting patients.  Like other reports before it, the National Commission suggests we need 5 years to assess new payment models.  Given the decades of experience with managed cares capitation and Medicares institutional inertia, that may be overly optimistic.

Partly because its a brain tonic for jet lag, the Disease Management Care Blog is trying to come to grips with the "Higgs Boson."

As it understands it, these invisible motes permeate our universe and interact with strangely named subatomic particles in ways that confer mass. The identification of the "boson" apparently explains a lot, like how electrons are so light (little interaction) and why toilet seats are so difficult to raise (much interaction).

Which provides an apt metaphor for Washingtons bosonic permeation of the health care universe.  CMS rates set payment benchmarks, its device approvals determine coverage, IPAB says when a treatment is evidence-based and insurers have little say on the definition of administrative costs. In the meantime, the Federal Register fills space with the microwave radiation of rule-making and now the Supreme Court has set off a Big Bang.

Unfortunately, the DMCB isnt making much progress on the theoretical physics of bosons, photons,leptons, quarks and gluons or, for that matter, on the legal Big Bang physics of mandates, taxes, assessments, collections fines or penalties. If the DMCB is reading Justice Roberts correctly, a low-amount "exaction" that is configured as a "shared responsibility payment" for behavior that is not "unlawful is "within" Congress taxing authority.  Right.

No wonder the Romney campaign is so confused. Without the genius of Peter Higgs or the opaque jurisprudence of John Roberts, theyre as probably perplexed as us normal folks. Better to move on to topics better suited for the rhetoric of the fall campaign, like whether its all really Bushs fault or truly Bushs fault.

Modern political discourse

The Disease Management Care Blog had a Hurricane Sandy choice: either a) leave day before that early A.M. hospital procedure and stay with friends who live close by, or b) stay at home and make the long trip in the wind and the rain to the hospital that same morning.  The DMCB spouse turned to repetitive education to help the DMCB make the right choice.

Does that learning tactic underlie Obamacare supporter Maggie Mahars approach to the latest Health Wonk Review?  Thats what the DMCB thought when it read Maggies posting.

To help the thousands of health orm realists who make up the DMCB readership, Hurricane Maggie repetitively retreads the cost-control talking points from orm architect Peter Orszag, surgeon Golden Boy Atul Gawande and the White House Office of Management and Budget  Rest assured, says Maggie, if you selectively counter the DMCBs fiction with facts, youll realize Washington DCs solutions are the right choice.

The DMCB isnt too sure about that.

Maggie doesnt argue health care costs arent rising, only that the increases are less than widely claimed.  She credits Obamacare.  The Disease Management Care Blog agrees that cost trends are moderating, but it also credits a lackluster economy.
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Maggie says be of good cheer, because the increased costs are delivering correspondingly better value for the health care dollar. The DMCB says value remains an inexact science that is ill-suited to simplistic nostrums and blunt force laws and regulations. The latest examples of this conundrum include mammograms and annual check ups.  There are plenty of others like this.

Maggie points to Massachusettss Atul Gawandes brimming optimism about Massachusetts leading the way with risk and performance contracting as a cost-control panacea.  The DMCB awaits the arrival of hard macroeconomic outcomes data that proves the experiment works.  It also points out that the Bay States recently passed cost control legislation speaks volumes on what that states leaders really think about the savings-success of Romneycare.

Last but not least, not everyone on the blue side of political spectrum shares Maggies optimism.

By the way, the DMCB has received a cost estimate from the unnamed hospital mentioned above. That institution is the flagship part of a nationally recognized integrated delivery system that is a basis for much of Maggie Mahars enthusiasm. The DMCBs planned procedure coupled with OR charges and an overnight stay will result in charges, prior to discounts and contracted rates, in excess of $100,000.

For those of us with a lingering doubt that our political classs health orm sound-bites, nostrums, talking points and pronouncements will cut through all those inconvenient facts, the DMCB recommends this catchy tune.  Youll feel a lot better:



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Thanks to Managed Care Magazine, the Disease Management Care Blog can post this interesting 25 minute interview with Princeton healthcare economist Uwe Reindardt.  Suitable for desk-bound meal-break viewing by overachieving DMCB readers, the modest and insightful Dr. Reindardt gets it mostly right:

No, the slowdown in the U.S. rate of health care costs cannot be ascribed to passage of the Affordable Care Act.  It started wayyyy before Obamacare was passed and is more likely due to the economic slowdown and increased consumer cost-sharing.

Accountable Care Organizations remain an "iffy" experimental proposition because they "dont go all the way like Kaiser."

Republican proposals to let health insurers sell their products across state lines are hardly a health orm panacea, because prices (and theore premiums) are not a function of where the insurer is domiciled, but where the care is rendered.  Texas insurers would still have to pay New York prices.

Americans use fewer pills, occupy less bed-days and see fewer doctors, but we pay more because providers can charge more.  Despite being relatively small vs. the behemoths like Aetna and Cigna, regional hospitals have considerable market power that translates into take-it-or-leave it local single seller monopsonies.   Europeans, in contrast, have lower prices because their system is dominated by single purchaser monopolies.

Were headed toward a three-tier system comprised of 1) the indigent safety-net public programs, 2) the middle class "erence pricing" "networks" where consumers pay the difference if they want to buy up and 3) "boutique" health care for the 5%.

Theres reason to be optimistic about the next five years thanks to a sluggish labor market (making it easier to impose networks and even more cost sharing) and innovation (computational capacity is putting meaningful quality measurement within reach, while techy gizmos are making self-care simultaneously cheap and fun). 

Plus, theres reason to be of good cheer.  Compared to the U.S. education and the legal systems, health care is far more efficient and consumer-friendly.  Stop beating up on yourselves.

(The DMCB didnt quite agree with Dr. Reinhardts views on worksite wellness.  He finds the notion counterintuitive and intrusive, perring that insurers own wellness.  He neglects to mention that the employers who invest heavily in wellness are typically self-insured and that employers have an arguable stake in improving the quality of their human capital.)

Paying for it is a whole new kettle....

Now that the U.S. Supremes have confirmed the Affordable Care Act as the law of the land, the Next Big Step - as the Disease Management Care Blog predicted - is the move from insurance orm to payment orm. While its politically easy to broaden entitlements to cover everyone, figuring out how to pay for it is a whole new kettle of financing fish.

In response, a whos who of Obamacaregineers are stepping up with their Phase II recommendations for payment orm.  While you ponder whether the DMCB summary below is enough or whether you need to follow the link for more detail, ask yourself whats missing......

1. Let public and private payers combine forces to "negotiate" payment rates that aim for global spending targets at a regional level.  Embedded costs for research, training and uncompensated care would be carved out and preserved separately.

 2. Use bundled payment methods for episodes of care that span rehab and post-discharge care, starting out with cardiology and orthopedics. Aim to make this payment approach the rule for 75% of Medicares budget within 10 years.

3. Commoditize medical devices, lab tests and radiology services by forcing suppliers to competitively bid for Medicares business.

4. Encourage tiered insurance products, where consumers can pick progressively lower premiums in exchange for higher out of pocket costs.

5. Leverage state exchanges to ratchet down costs on pain of being "delisted" by forcing them to compete on cost and quality.

6. Simplify administrative costs by establishing a single format for all paper and electronic forms. The latter is the default unless the consumer opts for paper.

7. Make the pricing for medical services public and outlaw gag clauses.

8. Allow non-physicians to take advantage of scope-of-practice  laws to practice medicine autonomously.

9. Close the provider self-erral loopholes that allow docs to provide "in house ancillary services," unless its under a global cap.

10 Start all the above with the Federal Employees Health Benefits Program (FEHBP).

11. Use the "safe harbor" of practice guidelines to protect docs against allegations of medical malpractice.

Whats missing is the usual emphasis on primary care and, in particular, the patient centered medical home.  While it could be argued that global targets and bundled payment methodologies will drive the inclusion of higher value/lower cost non-specialists, the DMCB is shocked, shocked that the experts and editors missed usual nod to primary care.

The DMCB will also point out that the proposal is rich in expert councils (to set spending targets), programs (as in Medicare Acute Care Episode to define the bundling), panels (for the competitive bidding and guidelines) task forces (for the administrative simplification), commissioners (to assure transparency) and, last but not least lawyers (expanding Stark to ban self-erral).  Plato, the champion of Philosopher Kings, would be proud. 

In the meantime, Ayn Rand is rolling in her grave.

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