President Obama’s HiTech Act, enacted right after he took office, should produce a major transformation in American health care when it gets going. Along with the health care reform legislation that was dragged kicking and screaming through Congress last spring, the Act could put the planets in alignment for real change in the way care is delivered and paid for, and the way patient outcomes are achieved.

The HiTech Act specifies that every American should have an EHR (electronic health record) by 2014, and receive continuity of care through a regional Health Information Exchange. It even provides coverage for Geek Squads to help providers with the transition to EHRs: finding vendors, deployment, and identifying specific ways to advance care in their own practices. A first set of rules for what constitutes “meaningful use” of these information technology tools has just been released. So things are getting moving to give both patients and providers the information to make better health care choices. But…

These programs always sound good. For example, one new federal program, Beacon, looks at health system change at a community level in a group of demonstration communities, The communities that have been chosen as Beacons have already achieved a high level of EHR adoption and want to find out how they can use the information these records generate to improve health care. The stakeholders in these communities will come together, identify goals, and unleash a range of strategies in service of these goals.

But the programs requires the coming together of four largely separate tribes of crusaders for improvements in health care:

1) Quality improvement fanatics who want fewer accidents and bad outcomes in hospitals
2) Payment reformers who want to change reimbursement from volume to value
3) Consumer energizers who want consumers to be more involved in their own care, and to be given better information
4) Health IT evangelists who want to unleash futuristic tools and applications

For any of this to work, all these tribes have to work together, combining their perspectives and tools.

Fifteen demonstration communities with baseline high EHR adoption rates have already been chosen as Beacons. They’ve already been working through questions such as What do you want your community to look like in three years? Which patients do you want to achieve what outcomes (for example, care coordination for asthmatic children using range of Health IT tools to prevent hospitalizations)? And how do you measure whether you are getting anywhere?

Geisinger, one of the Beacons, is working through the process to get its outcomes identified first, then measures, then tools, then sustainability of its goals. It is trying to extend its best practices outside its boundaries.

It’s a laudable goal to deploy information technology in service of specific payment reforms and clinical reforms. What are the odds that this will succeed, however? Many people have broken their picks on the hard rock of true health care reform.

At lunch yesterday, I was the guest of a group that contained several retired physicians. We listened to a talk by a board member from a large non-profit local hospital system. The speaker, knowledgeable and well-prepared, talked about the cost drivers of health care in America, which he listed as an over-reliance on technology, the practice of defensive medicine because of law suits, heroic measures at the end of life, lack of transparency as to the true cost of procedures, non-standard reimbursements, and a few others.

He pointed out that while we might have reformed health insurance, we had done little to cut costs, because we hadn’t changed the delivery system. And he went on to say that we had to move toward outcomes-based medicine, which he thought would convince doctors to prescribe fewer MRIs, mammograms, and other procedures that had proved to have little effect on patient outcomes.

During the discussion that followed, the comments from the physicians were not at all what I expected. Many were heated but not over the need for higher reimbursement, more tort reform, or loss of power to insurance companies.

No, instead they said we would never reduce costs until we taught physicians to make a diagnosis by taking a complete history and talking to the patient, rather than by opting out and scheduling tests. They said the art of diagnosis has all but vanished from medical school teaching and that students don’t know the simple principle of looking first for horses when hear hoofbeats, and not for unicorns. To these men, the race to adopt new technology hasn’t made the practice of medicine better, it has merely made it more expensive. Many of them are still reading their grandchildren’s X-rays to make diagnoses younger physicians miss. These guys saw diagnosis as an art, now a lost art. Many med students don’t even know how to listen through a stethoscope. Perhaps that is because doctors don’t get paid much for listening.

Personally, I think the introduction of DRG (diagnosis related group) codes has done as much as anything to discourage the art of diagnosis. A DRG code is generated after every patient visit, and allows the doctor to get reimbursed. More complicated codes get higher reimbursements, and some medical staff assign codes according to the profit motive, while others simply code incorrectly out of ignorance. But the standardization of patient codes turns every patient into a statistic. Might as well pick a code that approximates what the patient might have and give him/her some tests instead. The doctors also pointed out that their colleagues who are still in practice will not give up their MRIs easily, because they are in the habit of relying on them, and even tort reform won’t change that.

Now that Nancy Pelosi has her place in history and perhaps the pool table she wants for her birthday, it’s time to sit down and take stock of what we did and didn’t do by passing health care reform.  Here’s what I think we did, besides scaring the spit out of half the country:

1) We increased access to health care for people who previously were uninsured or uninsurable –we are moving toward community rating by age or condition  instead. It will still not be free or necessarily even cheap to get insurance, but you can get it and you can’t lose it if you get sick or have a lifetime cap imposed on you

2) We mandated that the young and healthy support those who are not young or healthy, against the day when they, too, might be similarly unfortunate

3) We made it possible for people to stay on their parents’ policies while pursuing their educations or working their  low-paying entry-level jobs

4) We cut some of the waste and fat from Medicare, re-distributing a base level of care and getting rid of the “advantage” extras. Seniors hate this, but it will keep Medicare solvent for longer

5) We forced the insurance companies to re-think their business models

6) Hopefully, we will reduce the use of  costly emergency room services for primary care by doing the above

But although we almost fell apart as a society doing even these small things, we have only addressed a small part of the complicated health care equation: access to care. We still haven’t adequately addressed cost, or quality. According to a study released by ACCCHS, Arizona’s version of Medicaid, Arizona is projected to have to spend $11.6B in general fund monies, $13 billion overall, between 2011 and 2020 to cover unfunded mandates on expanded coverage. Arizona had just decided to reduce its coverage to close a budget deficit, but is not prohibited from getting rid of KidsCare (our version of SCHIP). Where is Arizona going to get the money? It is going to have to raise taxes, which is anathema to its legislature. After all, this is a state in which John McCain is being challenged from the right.

And Robert Reich points out that this is a very conservative reform bill, because it still allows for free market competition and high deductible plans ($4000 per family, $2000 per individual), which have only recently become part of the insurance landscape. Many people are apt to feel this is still out of reach.

In fact, key elements of the law are right out of the conservative playbook, says the Columbia Journalism Review.

What haven’t we done?

1)We haven’t changed the provider incentives, instituting widespread reimbursement reforms.  We should be reimbursing for outcomes,  not procedures, and we avoided that thorny question, although there are small demonstration programs in the bill that could lead us there through back doors.

2) We haven’t attacked tort reform, although my personal opinion is that would go away if we attacked the quality issue: they are two sides of the same coin. When I hear that hand-washing isn’t effectively enforced at many major hospitals, I wonder why we don’t have MORE litigation rather than less. Even a car mechanic is forced to a higher standard of delivering quality than some medical centers.

3) We haven’t done anything to reign in the high cost of devices and drugs, although many of them are largely ineffective. I’m not sure I know how to propose a solution for that, because biotech and medical entrepreneurship involves a lot of research and very long time-to-market that raises the R&D costs on the front end. And when we try to speed the process from the government end we get studies fraught with conflict of interest and drugs like Vioxx that are rushed to market until they start to kill people.

4)We haven’t changed the model of delivering sick care rather than health care, although I hope  that providers will try to manage costs by trying to promote wellness.

5) We haven’t begun the public health and expectation-setting that we have to do with an aging population and a shortage of resources (both money and talent).

There. Will. Be. Rationing. Get  used to it.

Here’s my take on the health care summit:

• Underneath the talking points, there was a theme from the Republicans: We do not want people with pre-existing conditions to be covered. They had to admit that in public. If you weren’t listening, I’ll try and find you the exact point where it came through loud and clear.
• The President made it clear that his priorities begin and end with those who are left behind. His pointed questioning about whether GOP Senators would be willing to give up their health plans through the Senate for a high-deductible plan with a health savings account. While they said yes, he pointed out that they can afford it with $176,000 in salary, as opposed to those of us who are scraping it together on $40,000 a year.
• Mitch McConnell affirmed that the Republicans have no intention of coming together on health care reform in his press conference afterward.
• The value of this summit was lost in talking points and repetitive distraction. A better use of time would have been to take real-life cases and apply the law to them as exemplars of how reform would impact real people.

I’m sure I have more, but honestly, I’m just so disgusted with the idea that people think it’s okay to discriminate against people who are unfortunate enough to get sick that I really can’t think clearly.

With the introduction of President Obama’s blend of the House and Senate health care reform bills, there’s been a flurry of activity in the Netroots over the missing public option. Several groups are mobilizing for it at the same time that key Senators who supported it in the past are quietly leaving it on the table. Because it is still a cause of controversy and division, I think it’s worth listing the arguments for and against it in as objective a fashion as possible.

Arguments in favor

1. A public option creates competition in the marketplace.
2. A public option saves money.
3. A public option puts downward pressure on premium costs.
4. A public option establishes a framework for a national single payer system in the future.
5. A public option gives individuals a choice not to fund commercial health insurance companies.

Arguments against

1. A public option establishes a new government agency.
2. A public option puts government in charge of making health decisions.
3. A public option duplicates the Medicare framework already in place.
4. A public option will be costly to initiate and manage.
5. A public option may result in providers refusing to participate because of low payment rates.
6. A public option may result in adverse selection; that is, where the oldest and sickest gravitate to the public plan, driving government costs up.

Within this framework, there are individual arguments to be made about whether each point is valid or not. My goal here was simply to list the primary arguments for and against and let the discussion flow from there.

Are there any I missed? Leave a comment and I’ll add to the list.

The Lie

Investor’s Business Daily’s latest salvo comes in the form of an editorial claiming that private insurance is eliminated.

When we first saw the paragraph Tuesday, just after the 1,018-page document was released, we thought we surely must be misreading it. So we sought help from the House Ways and Means Committee.

It turns out we were right: The provision would indeed outlaw individual private coverage. Under the Orwellian header of “Protecting The Choice To Keep Current Coverage,” the “Limitation On New Enrollment” section of the bill clearly states:

“Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day” of the year the legislation becomes law.

So we can all keep our coverage, just as promised — with, of course, exceptions: Those who currently have private individual coverage won’t be able to change it. Nor will those who leave a company to work for themselves be free to buy individual plans from private carriers.

Unfortunately, IBD was just a little bit incorrect about the analysis and the reporting. I suppose, though, that characterizing it as an editorial might exempt them from actually reporting facts.

The Truth

Background: Page 16 defines what coverage will be considered “grandfathered coverage”; that is, coverage in existence today which would not be in compliance with new standards imposed by the law.

What it says: Any individual insurance policy (as opposed to a group insurance policy) that is in effect today will be permitted to remain in effect; however, any new policies issued after the law becomes effective will be required to comply with the standards set out in the section relating to policies offered via the new Health Insurance Exchange.

What it does: The purpose of the provision is to bring policy offerings into line with the minimum benefit tiers and provisions required under the new law. Here are those requirements:

1. Must offer “Basic Plan Benefits”, which means the following: No pre-existing condition exclusions, covers hospitalization, outpatient hospital and outpatient clinic services, physicians visits, supplies, equipment, prescription drugs, rehabilitative services, mental health and substance abuse treatment, preventive services, maternity, well baby and well child care, vision and dental for children under 21.
2. Has co-payments and deductibles not more than $10,000 per year, indexed for inflation.

On page 19, the bill clarifies the grandfather provision further by specifying that any individual health insurance coverage that is NOT grandfathered (e.g. products introduced after effective date of the law), will have to conform and be offered as an exchange-eligible plan.

This is all the grandfather provision does. Nothing more, nothing less. It allows existing products to die a natural death while requiring new products to conform to the basic standards. Those products are still offered by insurers. The public plan that has them all in an uproar is simply one among other offerings.

Why the lie? This provision effectively forces the insurers to sit down and craft policies that compete with each other and the public option in terms of benefits and accessibility. Recissions will be far more difficult and subject to three levels of review. Pre-existing conditions will be a dead term. All of this is great for individuals covered, but for insurers, it shuts down their gravy train. They’ll actually have to use one risk pool instead of tiered risk pools.

They don’t want to do that. They like making record profits while the rest of us are bankrupted. They understand that there will be reform; they just want it to be reform that benefits them instead of the rest of us. To that end, they recruit publications friendly to their cause like Investors’ Business Daily to publish ‘editorials’, which can then be spread via social networks and blogs to scare you into opposing ANY reform.

Now you have the facts. Straight out of the proposed legislation, from a person who has read the actual text of the legislation — all 1,018 pages of it — twice, and has a strong background in how these laws are shaped and come into being.

Do not let them scare you. Arm yourself with the facts.

The full text of the House Bill can be downloaded here. (PDF)

Americans have always loved freedom fighters. After all, it’s in our DNA — our story of the land of the free bought with the spilled blood of our forefathers who rebelled against oppression to create the most powerful nation in the world is a heady and exhilarating ideal. It’s hardly a surprise that so many would be captivated by events in Iran, particularly when viewed through the prism of our own election process and leftover baggage from the 2000 election outcomes.

Inside American idealism, there is a hope – a small burgeoning hope – that Iran will shake itself out from under the rule of the fundamental Muslim clerics – the mullahs — and become a true democracy. As Tom Regan points out, that dream is unlikely to come true, though some nominal change may indeed come to Iran as a result of the unrest over their elections. However, Americans are allowing themselves to become distracted and embroiled in the Iranian dream at the expense of their American dream.

We have our own totalitarian mullahs here in the US. They rule in the form of bankers and insurance company executives, the shadow actors who broker our health at a profit to serve Wall Street and investors while robbing us of the ability to run businesses, get health care at a reasonable cost, and force us to ignore very real health issues for fear of having them become ‘pre-existing conditions’ or causing us to be uninsurable.

If you think we’re free in this country, you’re wrong. We haven’t been free since we bowed down and let our lives and our health be sold at a profit for the benefit of Wall Street, who has not been as forthcoming about sharing the wealth. Make no mistake: If we aren’t healthy, we aren’t free. We become slaves to claim forms and ‘managed care’, we’re made to feel guilty for circumstances which may or may not be within our control, while insurers cover Viagra but leave smoking cessation to the means of the insured.

This isn’t news. Everyone has a story, knows someone with a story, or fears they will become a story. Despite the fact that 3 in 4 people support a public health plan option as part of comprehensive health care reform, the press and the Republicans are successfully trumpeting erroneous numbers released by the CBO (Yes, a failure to factor in the cost savings of competitive pricing in a public plan is a clear and large error) as proof positive that health care reform cannot include a public option.

Without a public option, there is no reform. Repeat that after me: Without a public option there is no reform. The public option is how we remove the health insurance mullahs’ power. There is no other way.

The timid Democrats in the Senate, led by Max Baucus (who has been well-financed by health insurance companies) bowed to the CBO report without so much as a question and removed the public option. House Democrats have included it as the center of their reform bill, which has been negotiated, considered and debated for 6 months.

Here’s the problem: Health insurance mullahs understand that they wield power by making large contributions to friendly politicians like Baucus. They then use the mainstream media as an amplifier to play the “it’s too expensive to have a public option” tune, and pretty soon, real reform dies.

This is how they killed it in the 90′s. It’s how they propose to kill it in 2009. They can do it. They know they can, just like the Iranian mullahs understand the power of religious totalitarianism, control of the message and the police.

When they own the message, they own the outcome.

They don’t have to own the message. We don’t have to let them. But as long as Americans remain focused on events in Iran and continue to romantically tilt at the Iranian mullahs, all power is abrogated to the American Insurance mullahs who wish to control our present and our future. In other words, we’re not watching what’s going on here because we’re focused on what’s happening there, where we have absolutely no power to change what has been set in motion.

Here are some facts. Consider them as powerful as Neda’s death broadcast from Iran on YouTube and now on all the major media outlets. Consider the stories of people dying every single day for lack of access to or ability to pay for health care to be as powerful as the story of one beautiful Iranian woman who was killed for simply being in the wrong place at the wrong time. Consider the suppression of these stories to be how they control the message.

Let this be a challenge and a warning: If we continue to tilt at Iranian mullahs, health insurance mullahs will win. It is time for the 3 in 4 Americans who support the public option to be heard. Here are some ways to take control:

1. Get the message out.  Next Saturday, June 27 has been designated as a National Health Care Day of Service. Click that link. Find a local way to participate and raise awareness.
2. Use the hashtags #hcan #hcr on Twitter, Friendfeed and other social networks. (Yes, I still hate hashtags but understand the value they bring for this moment.)
3. Write the editor of your local paper. Most newspaper websites have an online form you can use to compose your email. Write it. Do it. Don’t self-edit, tell your story.
4. Make signs. Handwritten signs. Put them in your window, write the message on t-shirts. Just like we did with the 2008 election, this is an opportunity to raise awareness by simply wearing, saying, displaying the message. Signs telling neighbors and passers-by to pay attention, to investigate the facts, understand all of the issues, get involved.
5. Call your representatives. Do not underestimate the power of your voice. They may not respond. They may not even listen personally. But your voice is heard, nevertheless. Midterm election campaigns are gearing up. Incumbents who shy away from real health care reform should not be confident of re-election. Hold them to the fire, make them accountable.

Yes, we can. We can depose the insurance mullahs, but not if our heads are turned away from the urgency of now. Now is more urgent than ever. Electing Barack Obama was an affirmation of participatory democracy, on and off line. It wasn’t an end. It was a beginning. Now, more than ever, each and every voice must be heard. We must hold the cowards in the Senate to the promise of actual health care reform. It will not happen if we don’t participate. Please. Participate.

cross-posted to Bipartisan Report