by Mike Thompson, originally uploaded by the Health Advocate.

I choose Thompson’s cartoon this week because it is such a stark contrast to the recent behavior of the most powerful health industry organizations. They once did seem to be a fortress unable to be penetrated. What about now? Leave a comment and tell me what you think.

by White House Photographer Pete Souza

As summer (and Congress’ August recess) approaches, events continue to emerge suggesting in this iteration of health care reform, all stakeholders want to make sure that they are included in the discussion, rather than refusing to negotiate as they did during the early nineties.  So when the White House announced it’s receipt of a letter from the chairmen of Americas’ Health Insurance Plans (AHIP), American Hospital Association (AHA), American Medical Association (AMA), Advanced Medical Technology Association (AdvaMed), Pharmaceutical Research and Manufacturers of America (PhRMA), and the Service Employees International Union (SEIU) proposing approximately $2 trillion savings over the next decade, I saw it as the latest maneuver to ensure a seat at the roundtable on health care reform.  These six organizations pledge to adhere to evidence-based best practices and right-sizing the use of health system resources in accordance with several strategies already proposed by the administration.  I was surprised to see SEIU join with the providers and payers of the health care industry.  Yet, this is not the first union of seemingly unlikely organizations.  Just last month PhRMA united with the consumer health group Families USA (an ideological adversary) to promote the expansion of Medicaid.  With a newly planned lobbying and media campaign, the strategic partnership seeks new policy to cover more low-income families, provide income-adjusted subsidies for middle-class families and cap out-of-pocket expenditures for people with insurance.  President of PhRMA, William Tauzin explained the strategy in this way, “We got a new team in town who could, I guess, pass what they wanted to…our job is to make sure that what they pass has as many elements of our principles in them as possible, and that means being at the table.”  This, I believe explains it all.

Sources:
Frates, C. Adversaries Team Up on Health Care: Families USA, PhRmA Focus on Medicaid.  (2009, April 20).  Politico, p. 4.

Krugman, P. (2009, May 10).  Harry, Louise and Barack. The NewYork Times. Retrieved May 11, 2009 from http://www.nytimes.com/2009/05/11/opinion/11krugman.html

by RJ Matson

Tuesday with the Council on Foundations, Sebelius made her first public address since she was confirmed and quickly installed as the administration’s Secretary for Health and Human services last week.  To highlight the urgency of the crisis, she states, “Approximately 30 cents of every health care dollar [is] spent on billing, overhead and administration. Spending on the uninsured and the health care bureaucracy takes up nearly one half of every health care dollar and results in a system where we all pay more and get worse results.”  The new Secretary went even further to say,  [T]he old opponents of reform have joined our effort to change the status quo. Groups and organizations that were once fierce enemies have come to the table and embraced the call for real health care reform.”

Indeed, there is great momentum (as so deftly illustrated by Matson above) for this issue right now and many conservative stakeholders are attempting to be proactive in their approach to stay ahead of that momentum.  Yet, to say old opponents have joined the effort could be an overstatement.  It leads me to say skeptically, “We shall see…”  Tell me what you think?  Will there be work and consensus building to get health reform out of committees by June?  Will the democrats simply be forced to rely on their numbers as they did in passing the Recovery Act?

Source:

Healthcare Reform Is Top US Priority – Sebelius.  Reuters Health Information via Medscape Today. Cited on May 6, 2009.  Available at http://www.medscape.com/viewarticle/702385.

Think Tank Thursdays. New York has publishing and fashion, LA has television and movies and DC…well, DC has influence and policy. On any given day in this town, you have seasoned professionals going about the business of influencing thought. Influencing whom you ask, influencing the legislative staffers and ultimately policy makers regarding any myriad of issues for which legislation is being crafted. Many are familiar with the lobbyist who work for law firms and associations and use their tremendous budgets to influence lawmakers and by extension policy.  There is yet another class of influencers that exist in Washington who exert their power of influence in a far more nuanced fashion. They are the Think Tanks, repositories for scholarly inquiry and research on any number of policy issues.  Think Tanks use their brain trust of scholars and research to contribute to and advance the debate on policy issues. And yes, ultimately influence the policy crafted.  With this periodic series, Think Tank Thursdays, I will give you a look inside selected institutions and the research they set forth.

As I continue my examination of health reform in the Obama Era, my agenda for Monday led me to consider Academic Medical Centers (AMC) by attending The Path Forward for Academic Medical Centers: Innovation, Economics, and Better Health, a panel discussion at the Brookings Institute.

The Importance of the Academic Medical Center

AMCs are vital to our health care system because they educate the next generation of health care and biomedical research professionals, they receive the majority of extramural funds allocated for basic science and applied research, and ultimately, they nurture the expertise to successfully treat and sometimes cure the medical maladies that plague us.  These nonprofit organizations serve a disproportionate share of lower-income and uninsured patients in addition to individuals whose illnesses have the greatest degree of medical complexity.  In his introduction, Dr. Mark McClellan of the Brookings Institution observed that members of the Council of Teaching Hospitals and Health Systems

• provide 41% of all charity care
• receive 56% of all NIH extramural awards (along with AAMC medical schools)
• and train 76% of all residents physicians.

Reforms in the health care system leading to the failure of AMCs would result in a subsequent loss of the essential services previously discussed.  Because they play a vital role in the system, their voice at the table of stakeholders in health reform is significant.

What Should Be the Vision for the Future of AMCs

Economic pressures of the last two decades in particular, have challenged AMCs to implement sustainable business models.  Presidents from three organizations attempted to answer the question, “What should be the vision for the future of AMCs?”  Using Duke University Health System as a model, the CEO, Victor Dzau discussed an overall vision.  Elaine Ullian, CEO of Boston Medical Center discussed the future of AMCs from the perspective of the hospital and health system.  Baylor Health Care System CEO, Joel Allison discussed the future of  AMCs from the provider prospective.  There were recurring themes among the presentations (available below).  There is a strong focus on improving health care delivery.  Organizational changes like the shift from tertiary care hospitals to integrated health care delivery systems are a common theme as AMCs look for ways to add value to their community in ways they previously had not.  Additional strategies include changing medical education and implementing professional training to help health care providers and allied health professionals perform more efficiently as health care delivery teams.  Specific examples that panelists referenced were the use of the medical home model, as well as the use of  hospitalist physicians and physician champions. All of these are implemented with the intention of placing the patient at the center of care.  There is also a focus on improving health care value through comparative effectiveness research, widespread use of evidence-based medical interventions, and the use of personalized medicine.

What Is a Sustainable Business Model for the Future AMC

There was a consensus from the panel that a payment structure providing incentives for prevention, disease or care management, and population health rather than a collection of interventions for unrelated each episode of care is preferred. Yet, redesigning the payment system can be a nuanced endeavor.  Dr. Gary Gottlieb, President of Bringham & Women’s and Faulkner Hospitals and panelist when he observed,

“It’s important to realize that these are very, very complex organizations, and that unwinding them just for the focus specifically to get best value of purchase of unit service in one area may, in fact, unwind and have other unintended consequences that will have severe outcomes. These places are academies, they are research institutes, as well as the providers of a lot of care, some of which needs to be in our venues and some of which needs to be elsewhere, so that payment reform needs to consider each of those issues very, very carefully.”

Indeed, the very design of integrated health care delivery systems emphasized in the Duke and Baylor health system presentations are intended to improve the ability of the AMC to deliver what Mr. Allison phrased as “the right care, at the right time in the right place and the right amount”.  The appropriate use of health promotion, disease prevention and screening interventions yields a higher quality of life and better health care value.  Dr. Reed Tuckson, Chief of Medical Affairs for UnitedHealth Group and panelist  uderscored this point when he asked of his fellow panelist,

“I was very encouraged by your reorganization models, and I wonder…Given that the things that are coming into your door is  obesity, diabetes, preventive cardiovascular-related, do you have another box in your new vision that incorporates…real community intervention, that creates a new science, a new model, a new paradigm, new providers, assets that really get at that stuff in a way that is transformative and that gets a higher proportion of your revenue than it gets today?”

But even as AMCs are reorganizing to better deliver care to a community and manage the health of defined populations, I stil wonder if this is a sustainable business model.  While executives from Duke and Baylor cited examples of community initiatives, this does not change the fact that private health insurers continue to selectively market in an attempt to maximize a covered population that is younger with the least amount of catostrophic, complex and/or chronic illness possible.  Ullian, Boston Medical Center CEO and panelist put it this way,  “I have been told…when the economy was strong or weak…what you do is somebody else’s problem, and we’re really glad you do it, but we’re not going to give you a dollar for a dollar worth of care.”  Since Massachusetts reformed its health insurance, Boston Medical Center has seen a drop in reimbursement such that it receives $0.64 for every $1.00 it spends on caring for its patients.  After so much shopping for the optimal patient mix, the sickest and most complex cases are covered by Medicaid and Medicare which still operate under a fee-for-service payment structure that contains perverse incentives.

Here’s the take home message.  Because of their unique mission and the services they provide, AMCs must remain viable.  They must continue to reorganize such that they provide maximum value through delivery of appropriate health promotion and disease prevention in the community setting, better coordination of care, and faster translation of innovations from the research setting to the community setting.  Payers must immediately restructure reimbursement systems so that they align with high value, integrated health care delivery.  Leaving public payers responsible for the most medically complex individuals is destructive to the health care system as a whole.

Sources:

Medical Center Presentations

McClellan, M.  The Path Forward for Academic Medical Centers: Innovation, Economics, and Better Health.  Power Point Presentiation on April 27, 2009 at The Brookings Institution.  Washington, DC.

The Path Forward for Academic Medical Centers:  Innovation, Economics, and Better Health. Transcript. April 27, 2009.  The Brookings Institution. Washington, DC.

by M. Wuerker (in Politico March 5, 2009)

Many stakeholders and special interest groups may become uneasy as the Administration makes progress towards reforming health care. Considering the current state of the system, can we really make things worse or is there nowhere to go but up? Leave me a comment and tell me what you think about this week’s satire feature.

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Melody Barnes, Director of Domestic Policy during the White House Forum on Health Reform (photo by Pete Souza)

ARRA and You (Part I).  The “fierce urgency of now” is the concept that President Barack Obama used to explain why he would run for president. Yet it can also be used to characterize his motivation and subsequent actions in the push to reform health care.

With the new legislation, American Recovery and Reinvestment Act of 2009 coverage for millions was protected or extended.

1. Health insurance coverage for 7 million Americans was extended via insurance premium assistance for COBRA benefits.
2. Families are no longer in jeopardy of loosing current benefits from Medicaid and CHIP due to $15 billion in Federal Medical Assistance Percentage funding allocated to states.

Without pause, the President continues to move forward his agenda for reform. The release of a budget blueprint, proposes a $634 billion reserve fund to extend coverage to some of the 47 million Americans who are currently uninsured. “This is the first step towards getting health care reform done this year,” White House domestic policy adviser Melody C. Barnes told allies on one conference call. “We can’t underestimate the importance of rallying around this budget. It serves as a footprint for something bigger.” In contrast, others express doubts about the prospects for overhauling health care. For example, Sen. Mike Enzi, the senior Republican on the Senate Health, Education, Labor and Pensions Committee stated, “It needs to be done up front and quickly. I’m not so sure that we haven’t already lost that, with so many other things coming in and weighing us down.” As was the case in bringing a stimulus package into law, it appears the President will remain undaunted and continue to seize the opportunities created by environment, his political capitol, his strategic leadership and timing to accomplish the essential goals of his health agenda:

1. providing affordable, comprehensive and portable health coverage for every American;
2. modernizing the U.S. health care system to contain spiraling health care costs and improve the quality of patient care; and
3. promoting prevention and strengthening public health, to prevent disease and protect against natural and man-made disasters.

As he so aptly noted in his address to a joint session of the Congress,

“[Health-care costs are] one of the major reasons why small businesses close their doors and corporations ship jobs overseas…This is a cost that now causes a bankruptcy in America every 30 seconds. By the end of the year, it could cause 1.5 million Americans to lose their homes. ….Given these facts, we can no longer afford to put health-care reform on hold.”

So it is no surprise that on the following Thursday, March 5 the administration convened the White House Health Reform Summit. The event sought to convene the varied stakeholders in the health care reform debate and ultimately, get buy-in. The President stated, “I want to be very clear, at the outset, that while everybody has a right to take part in this discussion, nobody has the right to take it over and dominate.” Participants included leaders from the (American Medical Association) AMA and other medical specialty societies; trade groups for drug makers, insurance companies and hospitals; CEOs of companies including Pfizer and General Mills; advocacy groups such as the American Heart Association and American Diabetes Association; and unions such as SEIU and the Teamsters.

Lawmakers also met on Thursday as they have been given the task of working out the details and writing the actual legislation around several key principles set forth by the President:

• maintaining choice of insurance and doctors,
• ensuring affordable coverage,
• protecting Americans’ financial health,
• investing in prevention and wellness,
• improving patient safety and quality of care.

If you missed the live coverage on CSPAN, you can find a summary and important document links at the White House blog and continue to follow the entire process of health care reform at the newly launched HealthReform.gov. Opponents to the progress of health care reform will have take notice of “the fierce urgency of now” momentum and perhaps much more are already on the President’s side. Regional White House Forums on Health Reform are currently under way to expand upon what was gained at the White House forum.

Sources:

Obama Has Big Challenges In Overhauling Health Care {Obama Has Big Challenges In Overhauling Health Care (2009, February 21) [Electronic Version]. The Washington Post} and Obama Proposes $634 Billion Fund For Health Care {Connolly, C. (2009, February 26) Obama Proposes $634 Billion Fund for Health Care [Electronic Version]. The Washington Post, A01} and Brown, CB. Obama wants Congress to Weigh In (2009, March 6) Politico, p. 3 (Volume 3: Number 24)

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Health and the 44th Presidential Administration (Part III). In three nearly back-to-back announcements, President Obama is working prodigiously to fill his leadership roster for health care. Of course, the most newsworthy was his selection of Kansas Governor Kathleen Sebelius as Secretary-designate of the Department of Health and Human Services (HHS). The White House Office of Health Reform, however will be lead by Nancy Ann DeParle who headed up the Center for Medicare & Medicaid Services during the Clinton administration. The administration may deem DeParle, a Beltway-insider, as having a greater amount of political clout to handle what is sure to be high-stakes negotiation within the White House Office of Health Reform. Both women have a depth of experience in health care financing and health insurance, a stakeholder group incidentally with a powerful voice in previous rounds of the health reform debate.

The Office of National AIDS Policy is set to be led by Jeffrey S. Crowley. With a background in public health, Crowley will bring the appropriate knowledge for managing the health of populations and the dynamics of epidemics in leading the effort to set an appropriate national policy. He will also serve as a member of the Domestic Policy Council. The President stated the following:

“In [AIDS and disability policy], we continue to face serious challenges and we must take bold steps to meet them. I look forward to Jeffrey’s leadership on these critical issues.”

Mary Wakefield has been appointed Administrator of the Health Resources and Services Administration (HRSA). President Obama made the following comments regarding her appointment:

“As a nurse, a Ph.D., and a leading rural health care advocate, Mary Wakefield brings expertise that will be instrumental in expanding and improving services for those who are currently uninsured or underserved. Under her leadership we will be able to expand and improve the care provided at the Community Health Centers which serve millions of uninsured Americans and address severe provider shortages across the country.”

For even more insight into this health braintrust, check out what’s on the bookshelf (a widget to the right) featuring books and articles with references and contributions from these political appointees. Several leaders are now in place and not a moment too soon. With the American Recovery and Reinvestment Act of 2009 now signed into law and the more recent unveiling of the budget proposal for 2010, there is plenty of (health care) work to be done.

Sources:

Sebelius at HHS at the White House Blog and Administrator of HRSA Announced and Obama Names Head of AIDS Policy Office and Obama Picks Kansas Governor Sebelius as Health Secretary – washingtonpost.com.

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44 to increase portions of health insurance and cover more currently uninsured children

Last week, by a margin of 66 to 32 votes (including 9 Republicans), the Senate approved expansion and reauthorization of SCHIP and today, President Obama signed that bill into law. This legislation was resurrected and revised after two vetos by former President Bush and began making its way through the Congress once again scarcely a week before the Inauguration. The critical health insurance program administered by the states, expands medical coverage to some 4 million children nation-wide whose parents do not qualify for Medicaid. This is estimated to bring the total number of children enrolled in the program to 11 million. Many of these families are newly unemployed or part of the legions of working poor in this country. With the passage of this law, we can count this as the first victory in the Obama plan to reform health care in this country.

Watch: Video of the signing ceremony at the White House

Sources:

Obama Views Children’s Health Bill as Step One at washingtonpost.com

Senate Approves Children’s Health Bill at NYTimes.com

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Health and the 44th Presidential Administration (Part II). The New York Times editorial is believed to have crystallized the issues of the current political climate and helped former Senator Tom Daschle choose to remove his name from further consideration and confirmation as Secretary of Health and Human Services.

Despite Daschle’s legislative policy expertise and significant history working on health policy issues, his work at Alston & Bird, LLP (though not as a registered lobbyist) and the mounting opposition from Senate Finance Committee Republicans may have ultimately proved an albatross to great to bear. Perhaps, it is ironic that the very attributes that would suggest former Senator Daschle would be a tremendous asset to shepherding and ultimately passing health care reform in America (ie. legislative policy expertise and significant familiarity with policy and industry stakeholders) is also the gauntlet that forced the President’s nominee and friend to fall short of the new ethical standards placed upon this administration.

What does this mean to the average health consumer?

Substantively, the elements of the Obama health plan will not change as the remainder of the President’s braintrust for health remains in tact. If former Senator Tom Daschle were the heart of that effort, then his former co-author, Dr. Jeanne Lambrew is (if at least in part) the brains of the effort. Only time will tell as elements of health reform begin to make their way through the legislative process if there exist another health care champion with the political moxie to accomplish what the Clintons could not back in the 1990’s—reform America’s health care system.

Read:

Editorial – The Travails of Tom Daschle – NYTimes.com.

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Earlier this week, President-elect Obama announced former Senator Tom Daschle as his designated nominee for Secretary of the Department of Health and Human Services. This Washington Post article discusses the dual role Daschle will serve not only as top administrator of the executive branch health care programs and services but also as the lead architect in the reform of the system as well. This is an enormous task, to say the very least. Yet it is one that the President-elect has identified as being a key element toward our economic recovery.

During the press conference Obama states, “Now, some may ask how, at this moment of economic challenge, we can afford to invest in reforming our health care system. Well, I ask a different question — I ask how we can afford not to.

Right now, small businesses across America are laying people off or shutting their doors for good because of rising health care costs. And some of the largest corporations in America — including major American car makers — are struggling to compete with foreign companies unburdened by these costs. Instead of investing in research and development, instead of expanding and creating new jobs, our companies are pouring more and more money into a health care system that is failing too many families.

So let’s be clear: if we want to overcome our economic challenges, we must also finally address our health care challenge.”

Sources:

HHS Will Be Shepherding Health-Care Reform – washingtonpost.com.

President-elect Obama Nominates Senator Daschle as Secretary for HHS, press conference transcript