Reform Homework

By John Ballard

Too little, too late, perhaps, but an avalanche of good information is finally pouring out of broadcast media. Last week Bill Moyers got in the game in a serious way with an interview with Bill Mayer promoting Moyers' book, Moyers on Democracy. This eleven minute clip is a must-see for anyone who wants to be informed. In the short space of a few minutes these two men spill beans all over the floor.Moyers own program has also linked with Maggie Mahar airing the dvd documentary of her book, Money-Driven Medicine.

Morning Edition today aired a smart four minute segment with an unfortunate title,
Taking Doctors' Profits Out Of Medical Care Decisions. Fortunately headlines don't appear on the radio as they do in print. The thrust of the piece is not about taking away doctors' profits, but explaining how the fee-for-service model has been a main factor in runaway health care costs.

Health Affairs Journal put up a list of ten of their most-read pieces which reads like a Who's Who of health care reform experts. Item #7caught my eye, What People Don�t Know About Health Insurance Exchanges. Knowing nothing about "insurance exchanges" except the term, I was interested to find out what was meant and how they worked.

Health insurance exchanges can provide huge value, but they are bound to fail if not structured correctly. PacAdvantage, even though it grew to a large size, failed because of what economists call �adverse risk selection� � the same reason similar programs have failed across the country in the past fifteen years. People with higher medical costs enrolled in PacAdvantage, while lower-risk people obtained coverage outside the exchange where they could find less expensive insurance. This drove up premiums inside the exchange, causing healthier people to drop out. This is known in the insurance business as a classic �death spiral.�

We must learn from these lessons in order to avoid the problems that have doomed exchanges in the past. We must design exchanges to be sustainable and prevent them from being relegated to the dustbin of well-intentioned but flawed health reform proposals not anchored in the real world.

Finally, The Health Care Blog needs to be in everyone's aggregator to stay up to speed. I have a feeling that from this moment forward the discussion will be fast and furious as no one wants to go home without something they can call an imporovement in America's health care. Political stains and bruises will be all over the end product, no matter what comes out. But somewhere in the sausage will be changes of some kind or another.

I can report personally observing changes in the way things are done.

?Earlier this year I had a caregiving assignment in a local nursing home. There for the first time I watched a CNA keying in data for her shift using a touch-screen program which allowed her to call up any resident on the property and procede to go through a sequence of prompts asking questions and recording the results about everything from whether the patient ate and what was his or her mood to whether or not the sheets were changed. The attendant was pecking through the screens like someone working a video game, creating a clear, readable record of each resident. 

?Last week I was at a different nursing home (or "rehab facility" as some call them) and saw an even more elaborate computerized system in use for tracking the administration of medicine and other medical information. When I mentioned the system to the nurse her response was unequivocal: "I'm never going back to paper." Clearly she was pleased to see the end of illegible handwriting and paper records that have to be filed by hand.

?Today I was in a hospital for another client and commented on their shiny new flat-screen systems. I was told that today is "Day Two" of the new system. The nurses seemed to be dealing with it welll. One of them said they had gone to training classes and were already prepared.

?Last week's follow-up to my first annual physical as a Medicare beneficiary was an eye-opener. I had never had an echo cardiogram or stress test and it"s been fifteen years since a colonoscopy. The equipment used looked state of the art and was more than impressive. I found out that the heart "echo" equipment is so sensitive that it picks up that nearly all of us have all four leaking heart valves. After all, it's living tissue (for most of us), not a piece of plumbing. And the reports come back with statistically significant variations highlighted in red so the doctor won't miss them.

In the case of this practice the doctor's assistant said they were "late getting into the electronic stuff" but that came as no surprise to me. I expected nothing else in a place that plays Fox News all the time. 

Incidentally, anyone talking about "Obamacare" is way off base since there isn't any such creation as yet. The president is expected to hone down his expectations in a day or so, but at this point all we have from the president is a slate of very broad proposals with no details. The main criticism of the Clinton plan that got crushed fourteen years ago was that the details were introduced all put together without any (or enough) Congressional input. This time nothing but the bare outlines were advanced and the details have been left up to the House and Senate.

The Kaiser Family Foundation put up a link to excellent pdf documents covering all the proposed plans. The interactive site also has a feature by which specific proposals can be compared side-by-side. I haven't used the site in that way, but I did print out the whole mess a couple months ago, cutting and taping them together in one big spreadsheet that covered the dining table.