Health Affairs

As we embark upon a presidential campaign season, we can anticipate many lively debates on the topics of taxation and spending in this nation.  As health spending in the Unites States accounts for 18 percent of our gross domestic product – a rate often called unsustainable – it is critical that we be clear-eyed in our understanding of the tradeoffs between tax revenues and a sustainable rate of national health spending.

Few have tried to paint a comprehensive scenario of what a sustainable rate of health spending might look like in the United States.  That is what the research team at Altarum institute’s Center for Sustainable Health Spending has endeavored to do in this article.  Only by having a well researched and objective picture of sustainable spending growth can we set measurable targets and track progress toward reaching what should be a national goal of this highest priority.

In an earlier blog on Altarum Institute’s Health Policy Forum, I defined sustainable health spending as a projected growth path of spending that is within what the nation is willing to pay.  I argued that, under the Affordable Care Act (ACA), the protections provided by the federal government reduce the effects of health spending growth on other stakeholders. (See note 1)  Consequently, the sustainability of a given rate of health spending growth largely rests with the federal government’s ability to meet its various health spending commitments, including those added under the ACA.  This, in turn, rests upon the willingness of the citizenry to allocate the necessary tax revenues.  Given the inherent uncertainties regarding the public willingness to pay future taxes, this research is partly hypothetical, but I think it provides insights into the tradeoffs between tax revenues and health spending that contribute to informed decisions about targets for taxes and health spending. Read the rest of this entry »

Americans increasingly distrust what they perceive as poorly run and conflicted government. Yet rarely can we see far enough inside the federal apparatus to examine what works and what doesn’t, or to inspect how good and bad decisions come to pass. Comparing the behaviors of two influential federal advisory bodies provides valuable lessons about how the mechanisms that drive government decisions can instill or diminish public trust.

The Health Information Technology Policy Committee (HITPC) advises the Office of the National Coordinator for Health Information Technology (ONC) on matters pertaining to the ARRA/HITECH legislation. ONC is responsible for deciding how to spend the roughly $25 billion Congress authorized in 2009 to stimulate doctors’ and hospitals’ adoption of electronic health records (EHRs) and other health information technologies. HITPC, a 24-member Federal Advisory Commitee (FAC) as defined and governed by the Federal Advisory Committee Act (FACA), makes recommendations to ONC on many topics – from certification of EHR technology and privacy/security regulations to governance and oversight measures for the Nationwide Health Information Network – that affect how that money will be spent, who is eligible to receive it, and what rewards and penalties will apply in the process.

The Relative Value Scale Update Committee (RUC) is far more influential. Over the past twenty years this group of 29 physicians convened by the American Medical Association (AMA) has been CMS’ primary advisor on how Medicare should value doctor visits and procedures. Many Medicaid and commercial health plans follow Medicare’s lead on payment, so the RUC’s influence on the $2.7 trillion health care economy is sweeping. While the RUC is not formally a FAC, it has been challenged as being a “de facto” FAC, a designation that has legal precedent. Read the rest of this entry »

November 9, 2011. Time fell back three days ago, leaving me one less hour of daylight to enjoy on a gorgeous Indian summer Wednesday. I’m the attending physician on a busy family medicine inpatient service, and it’s been a long week of patient care and meetings. I rush out of the hospital somewhere near 5 pm, hoping to go for a short run before the season changes to winter.

Pulling out of the parking lot, the traffic slows to a crawl as both patients and pedestrians preoccupied with conversation meander through the crosswalk. I open my window to feel the warm fall breeze, reflecting on my day.

7:00 am.  I attended morning report led by our family medicine residents, briefly discussing patients in the hospital and their plans of action.  Oatmeal and raisins, faux egg mcmuffin sandwiches, caffeine and adrenaline fuel much of the conversation,  which focuses on serious problems and crises in management, punctuated by frustrations dealing with care managers and insurance plan medical directors who constantly remind the residents that they need to discharge patients home as soon as possible. Read the rest of this entry »

Last Thursday’s Republican Presidential Debate in Florida included a lively, but not always accurate, exchange on health reform in Massachusetts.  In particular, Senator Santorum reported that one in four Massachusetts residents were going without needed care because of high costs; he also implied that the share of residents choosing to pay the fine for failing to comply with the individual mandate, and the share of residents who were free riders on the system, were serious problems in the state.  None of that is true.

My colleagues and I have been tracking health reform in Massachusetts since 2006, with a summary of our most recent findings published in Health Affairs last week.  As we report, Massachusetts continues to show strong gains in insurance coverage, access to care, and self-reported health status under reform, all important goals of the state’s 2006 legislation.  Currently residents of the Bay State enjoy the highest level of insurance coverage in the nation, with most of that coverage provided through their jobs, as it was before health reform.  As Governor Romney noted, a majority of Massachusetts residents continue to support the state’s reform efforts.

Contrary to Senator Santorum’s claims, very few residents of the state are “free riders” on the health care system in Massachusetts, moving in and out of coverage as they need care.  Based on the most recent data available, nearly all residents of the state (96 percent in 2010) report continuous coverage over the year in the Massachusetts Division of Health Care Finance and Policy’s annual survey (see Table A. 1-1) and nearly all tax filers (92 percent in 2009) report full year coverage as part of the health insurance tax filing to the  Massachusetts Department of Revenue. Read the rest of this entry »

At a recent symposium concerning both saving money and improving patient care, Health Affairs Editor-in Chief Susan Dentzer stated, “It is well established now that one can in fact improve the quality of health care and reduce the costs at the same time.”  This is exactly the principle behind the growing movement toward patient-centered care.  Physicians practicing patient-centered care improve their patients’ clinical outcomes and satisfaction rates by improving the quality of the doctor-patient relationship, while at the same time decreasing the utilization of diagnostic testing, prescriptions, hospitalizations, and referrals.  Patient-centered practitioners focus on improving different aspects of the patient-physician interaction by employing measurable skills and behaviors. This type of care can be employed by physicians in any specialty, and it is effective across disease types.

Patient-centered care replaces our current physician centered system with one that revolves around the patient.  Effective care is generally defined by or in consultation with patients rather than by physician dependent tools or standards.  As an example, orthopedic surgeons employ the Harris Hip Score to judge the success of total hip replacements.  It was designed solely by physicians and does not even ask patients to rate their satisfaction with the procedure; it answers questions important to doctors and thought to be important to patients; however, it is unknown whether almost any physician derived tools, such as the Harris Hip Score, accurately reflect the patient experience with a hip replacement or other aspects of their medical care. Read the rest of this entry »

Editor’s Note: The January 2012 issue of Health Affairs is a thematic volume titled “Confronting The Growing Diabetes Crisis.”

Ariella was a different child, thin and shy, when I first met her about a year and a half ago, just after her 6^th birthday. Her mother had noted her thirst and hunger, and, despite this hunger, weight loss. When she began wetting the bed for the first time in three years, her mother brought her to her pediatrician. Her pediatrician checked her urine for sugar and ketones, and, when both were positive, she sent her to see us at the pediatric diabetes center.

Ariella is an amalgam of my (Michelle Katz’s) patients to better protect their identities. She is exceptional only in how typical her experience is. Her story, recounted in the first half of this post, illustrates the tremendous advances we have made in diabetes care; it also illustrates the equally tremendous challenges we face in assembling and paying for the interdisciplinary support systems needed to help children with diabetes manage their condition and thrive. In the second half of this post, my coauthor Lori Laffel and I address the policy challenges posed by managing a chronic condition in a health care system geared to acute illnesses. Read the rest of this entry »

On January 10^th, the states filed their latest arguments in their bid to have the ACA’s Medicaid expansion declared an unconstitutional coercion.  Following an effort to piece together a coercion doctrine from dicta found in a handful of Supreme Court cases, the states assert that the “[t]he ACA is Premised on the Understanding that It Forces States to Expand Medicaid” (page 33) and that “the ACA revolutionizes Medicaid to make it serve the mandate and the ACA’s broader goal of near-universal coverage.” (page 34)

This revolution, according to the states, is accomplished by the fact that the minimum essential coverage requirement reaches all persons other than those who are exempt as a result of incarceration, covered by a religious or conscience exemption, or not lawfully present in the U.S. (26 U.S.C. §5000A(d))  Furthermore, the states argue, because Medicaid is expressly identified as an acceptable form of minimum essential coverage (26 U.S.C. §5000A(f)(1)(A)(ii)), and because individuals with incomes below 133 percent of the federal poverty level (the upper Medicaid eligibility threshold) are ineligible for advance premium tax credits through state health insurance Exchanges, Medicaid effectively becomes the only option for fulfilling the minimum essential coverage requirement.

In other words, argue the states, “[t]he lack of any contingency plan” (page 35) for the poor means that “Congress transformed Medicaid from a program designed to provide insurance to certain discrete categories of the needy, with substantial state discretion as to eligibility and the level of coverage, into one designed to provide a minimum level of coverage to every needy person.” (page 34)  For this reason, the states claim, “State participation in Medicaid [is] not a matter open to choice.” (page 34-35)

But this argument conveniently ignores several crucial facts. Read the rest of this entry »

In June of 2011, I flew to Washington, D.C. to say good-bye to my friend, Alvin.  I wanted to be there with him and his family during his peaceful passage from this life.  Unfortunately, his end was not peaceful.  It was a nightmare because he, like too many patients being transferred from one level of care to another these days, was lost in the transition abyss.

I had known  Alvin my entire life.  Through his leadership at the Equal Employment Opportunity Commission — where he served as deputy director for many years — he was  an example to me and countless others of what a government agency can accomplish through the efforts of idealistic and empathic individuals.

I knew he was ill with a terminal disease.  We had talked about it together on a number of occasions after he first sought my advice.  Less than a week before he died, Alvin was hospitalized for pneumonia — the most common cause of death in patients with his disease, end-stage pulmonary fibrosis.  He was admitted to one of our nation’s premier academic medical centers, his doctor there a specialist in lung disease.  He was treated with powerful antibiotics and steroids, given 100 percent oxygen to breathe.  His grip on this life rapidly waned.

My friend could have opted for continued life support, to have had a tube inserted into his windpipe while attached to a mechanical ventilator.  Many others might have chosen this route. Read the rest of this entry »

“A child is not a small adult,” but an adolescent is not a large child.  Adult oncologists, reluctant to care for cancer patients under the age of 16, believe that adolescent and young adult (AYA) cancer patients should be within their purview.  We believe younger cancer patients are a special group needing special attention, even as the arbitrarily selected AYA age-break point is debated by clinicians, hospital administrators, attorneys, federal regulators, institutional review boards and the pharmaceutical industry.

We have two concerns about the participation of young cancer patients in clinical research.  First, as difficult as the regulatory environment has become for investigators, sponsors, and human subjects in adult oncology, it is more complex for the pediatric and adolescent populations and their physicians.  Second, the degree to which consideration must be given to the human subject protection issues surrounding informed consent in this population requires discussion, debate, and resolution.  As Morgan et al. point out, “open and frank communication is necessary to create opportunities for two-way information exchange between patient and professional”. Read the rest of this entry »

On November 8, 2011, the Centers for Medicare & Medicaid Services (CMS) solicited the public for feedback on Medicare’s controversial coverage with evidence development (CED) policy. Although CMS did not finalize the CED policy until 2006, the agency first applied the CED concept in 1995 through a national coverage determination (NCD) on lung volume reduction surgery (LVRS).  At the time, CED represented one of the few mechanisms that the agency had to ensure the development of necessary evidence to confirm the clinical benefit of technologies for Medicare beneficiaries.

To date, there have been 15 national coverage determinations (NCDs) that have resulted in the use of CED.  Since 2007, over one in five NCDs has ended with requirements for additional data.

The environment in which CMS initially formalized its CED policy has changed dramatically over the last five years.  CMS was once the only voice technology developers were required to listen to in order to ensure their products were commercially successful in the U.S. market.  The agency outlined its demands of what was needed to understand the real-world effectiveness of FDA-approved products not only by applying CED, but also by hosting Medicare Evidence Development & Coverage Advisory Committee meetings, and commissioning technology assessments by the Agency for Healthcare Research and Quality. Read the rest of this entry »