By John Ballard
Boring. Really boring. The nitty-gritty details of health care reform are about as interesting as reading the yellow pages, but like all important human enterprises good results don't happen by accident. Edison's line about ninety-nine percent perspiration and one percent inspiration applies. This post is an update...
?Whatever happened with tort reform?
Good question. The short answer is "nothing" but that doesn't meant the fears and interests behind the issue have been ignored. Igor Volsky at the Wonk Room tells what happened.
Republicans like to talk about capping non-economic damages in malpractice suits. But since that�s failed to significantly reduce health care spending or lower the use of unnecessary treatments, some reform advocates have looked to other alternatives that would lower lawsuit abuse while also reducing the practice of defensive medicine. One such option is a �disclose and apology� model, which encourages providers to �deal with medical mistakes: [r]ather than stonewalling patients and relatives.� As the New America Foundation�s Joann Kenen explains these programs are reducing lawsuits and improving care in some hospitals:
Disclose and apologize doesn�t mean the hospitals or doctors say to a patient or family, �Something went wrong. We�re sorry. Here�s a check. Ciao.� It means, or should mean, they say something like, �You had a bad outcome. We are sorry. We will try to help you while we investigate what happened. If it was our fault, we will take financial and moral responsibility. We will do our best to make sure it never happens again to anyone else.�
Maggie Mahar makes one additional observation about the advantages of this model to the traditional conservative approach of simply capping rewards: �More importantly, tort reform does nothing to improve hospital safety. By contrast, hospitals that �disclose� also �fix.� No one pretends that that the hospital makes no mistakes. They trace what went wrong, (often it�s a system error) and repair.�
Those links to Maggie Mahar and Joanne Kenen flesh out the change of emphasis from litigation to patient safety. This is from Joanne Kenen at New America Foundation.
I also spoke briefly about this topic to Dartmouth Atlas researcher Dr. Elliott Fisher. Malpractice isn�t his major area of research, but he has considered its effect on the regional variation on health spending and utilization that Dartmouth has mapped. He estimates that malpractice -- or more accurately doctors� perception of the malpractice threat -- contributes to up to 10 percent of the regional variation. Not 10 percent of the medical cost. Ten percent of the variation. And based on the data we have so far, if you were to superimpose a map of the states with malpractice caps over the Dartmouth maps of high and low intensity regions, there would not be a clear correlation. In other words, the places with caps aren�t the places practicing the most efficient and cost-effective medicine. But these perceptions are real. Doctors believe them to be true. And as I wrote in American Prospect a few months ago, these perceptions can get in the way of doctors making and accepting the kinds of changes (including new payment incentives) we need to make health reform work. As Dr. Fisher said, �We ought to do something� to address physicians� fears of lawsuits. And by alleviating their fears with smart and fair malpractice reform, Fisher said, �we should take away that excuse� from change-averse physicians.
?ACO and Medical Home update...
These two new health care terms now being used by the pros will one day soon be as much a part of your vocabulary as organic or green or OMG
ACO means Accountable Care Organization and Medical Home is another way of looking the same thing from a client/patient's perspective. The fee-for-service model will never go away completely but over time as medical care shifts the emphasis from disease management to health management a different payment and health maintenance model will take root. Dr, Halamka explains and provides an example.
As Accountable Care Organizations and medical homes start thinking about alternative quality contracts that reimburse for keeping patients healthly and not for delivering more care, it's likely that wellness care will include home telemonitoring between clinician visits.
Devices will include electronic scales for measuring fluid retention in CHF patients, blood pressure measurement for refractory hypertension, glucometers for diabetics, and home spirometry for patients with COPD or asthma.
Say what? You don't want a bunch of documents telling your doctor every time you binge drink, get stoned or skip daily exercise? Well get over it. If the gps devices in your phone and car keep track of your whereabouts and your credit card knows when you buy sex toy, what's the big deal?
Fee schedules for insurance, Medicare and Medicaid reimbursement rates will reflect different payment reimbursement rates aimed at bending costs and managing good health at the same time by nudging both clients and professionals into ACO/Medical Home arrangements. (Pay attention to that word "nudge" by the way. It looks harmless enough but it is as central to the Obama approach to everything as gravity is to a yo-yo.)
Check out Dr. Halamka's review of his new toy, the Withings Internet Connected Body Scale.
After taking the scale out of the box, you connect it to your USB port (only used during setup) and launch the scale configuration website. You specify the wireless access point and security settings to use and link the scale to a web-based account. You set up users in your account and provide basic height/age/preferred method for body mass index calculation. Technologies used - WiFi with WEP or WPA security, HTTPS, and USB.
Once the scale is associated with your account, using it is simple. When you stand on the scale, it wirelessly uses a RESTful protocol to compare your weight with the list of known scale users on your account, probabilistically choosing the right user by matching weights. It retrieves demographic information, calculates body mass index, and % body fat, then sends the data to the user account.
?Can government find its ass with both hands?
Good question. Micah Sifrey at Tech President tries to be polite about it but the answer is pretty clearly "Nope." Fortunately it is a qualified "No" because the government may not be good at organizing, but in the computer age it is getting easier than in the past to find needles in haystacks. If the Obama administration has done nothing else right it has started moving the aircraft carrier a few degrees in the direction of better transparency.
At first glance, yesterday was a big day for open government in Washington, DC. Responding to the White House's Open Government Directive of last December, 29 departments and agencies published detailed plans describing how they are going to make themselves more transparent, participatory and collaborative. The "flagship initiatives" highlighted by the White House include:
- Involving the public in developing the Forest Service's new forest planning rule;
- An interactive dashboard for visualizing and understanding Medicare spending;
-- A new legal framework to allow NASA to accept open source software from non-NASA developers
- A bunch of new data hubs in development by the Departments of Education (ED Data Express), HUD (tracking and predicting homelessness), Justice (FOIA Dashboard) and State (HumanRights.gov), to point to the ones that most caught my attention.
But before we all pat ourselves on the back about all the cool stuff in the pipeline, let's remember that announcing a plan isn't the same thing as getting the job done, and that god is in the details....
He proceeds tp cite DHS and DOD for efforts in the right direction but concludes there is more left undone at this point than finished. I kinda like that god (lower case, and not The Devil) is in the details as he concludes (t)he work of actually opening government has just begun.
?HCR takes place among the states more than in Washington.
That lack of transparency, though unintentional, may be part of the reason that Kathleen Sibelius, speaking at the National Press Club, was careful to shift much of the burden of health care reform back on the states. If all those screams about "government takeover of health care" calm down long enough and pay attention they will understand that their various states will have far more input than they want to admit into how much and how well their respective home states do or do not take part.And where politically uncomfortable changes must be made, Washington will take the heat.
...during a speech at the National Press Club, Health and Human Services Secretary Kathleen Sebelius laid out the path forward for implementing the new health care law. The Secretary promised that HHS would serve as a �help desk� for Americans confused about the new legislation and would guide seniors and small businesses in taking advantage of the immediate benefits from reform.
Already, the IRS has compiled a fact sheet about which companies are now eligible for the new tax credit and �starting on June 15th, seniors who have hit the prescription drug donut hole will get a $250 rebate check to help them afford their medicines this year.� Here are some of the things HHS is doing/has yet to do to implement the new measure:
Allow states to apply for Medicaid expansion funds: States can already apply for federal funding to expand their Medicaid programs to cover low-income people earning up to 133% of the federal poverty line ($14,404 for an individual and $29,326.50 for a family of four). This benefits states like Maine, Washington, Minnesota and a handful of others that already offer expanded coverage for low-income people but pay for it out of their own pocket.
Establish high-risk pools: HHS has already asked states to decide whether they will participate in a new high-risk health-insurance pool, build on an existing program (if they have one), establish a separate state-based high risk pool with federal funding or do nothing at all, in which case the federal government would come in and administer the program.
- Define medical-loss ratio: Secretary has to define what constitutes direct medical care so that insurers can begin meeting the new medical-loss ratio requirements. The new law �requires that insurers spend at least 80% of customers� premiums on medical care in the individual insurance market, and 85% in the employer/group market.�
Establish which benefits insurers can set annual limits for: Insurers can place annual or lifetime limits per beneficiary limits on non essential benefits and can establish limits on the dollar value of essential benefits only as the Secretary shall determine. So, the Secretary has to define essential benefits and decide which benefits can be restricted this year.
Issue regulations to protect children from pre-existing condition ban: Since the law only protects children who are already enrolled in a health care plan, the Secretary have to issue regulations that prevent insurers from denying coverage to newly enrolled children.
Define the rules for 26 yr olds to stay on their parents� policy: The Secretary has to establish guidelines for this provision, which goes into effect on September 23. Some potential challenges/questions: Will there be a special enrollment period for new dependent children? How will dependents be defined? Will insurers be able to jack up rates once adult dependents join the policy?
More protections for seniors in Medicare Advantage: CMS has issued new guidelines that will protect seniors and people with disabilities from discriminatory cost sharing. They�ll also be to better compare plans in 2011.
...reform is �actually a very state friendly bill.� �Many of the key reforms will be carried out by the states,� she said. �That�s why states will have the option to oversee the development of the insurance exchanges, regulations, and consumer protections�:It�s true that part of the law makes health care coverage a partnership between the states and the federal government. That expansion starts in 2014. For the following three years, the federal government picks up the entire bill. After that, the states start paying up a share, which rises to ten percent by 2020. So there will be some new costs. But those costs are balanced by new benefits, including less spending on uncompensated care, savings from reduced insurance paperwork, more resources to cover children, and more money to crack down on fraud and abuse.
I'm looking forward to seeing how the politicians who jumped into the "repeal the bill" and "this law is unconstitutional" quicksand will plan their escape.
?Britain's National Health Service will NOT run the US Health Insurance Exchange after all.
The following analysis has since been discredited.
Buried deep within the 2000+ page health reform bill is a paragraph that called for sealed bids from potential vendors interested in managing the national health exchange component of health reform, bids that would have to exceed certain standards in order to be considered. Those standards, when closely examined, are the operating metrics used by Britain's National Health Service's External Markets Programme.
As no American company or not for profit organization has the necessary experience required by the law, it certainly appears as if this provision was intended to allow, if not require, HHS Sec. Kathleen Sibelius to award the contract for administering the National Insurance Exchange to the NHS.This isn't as far-fetched as it may sound. The NHS was awarded a similar contract two years ago in India, and is currently managing the health systems in the BVIs, Barbados, the Falkland Islands, and most recently is reportedly close to a deal to revamp Iceland's troubled health system.
Details are scarce; as one might imagine the Administration is loathe to provide any information at a time when refom opponents are in full voice and the media is following reform very closely. Don't expect to hear anyone in Washington speaking on the record about this anytime before July; with Congress out of session and vacations in full swing any uproar will be kept to a minimum.
As if that wasn't enough, sources within HHS have confirmed the long-circulating rumors that Dr. Sir James Watson, former head of Britain's NICE program, will be heading up the federal government's medical guideline development project. Watson is reknowned for his ability to identify the most cost-effective procedures with minimal data, a talent that will serve him well in the grossly-underfunded new department.
This will come as a genuine disappointment to a few, but no one will be as crestfallen as those who were punked by Joe Paduda's April Fool's Day joke. Check out yesterday's The Terrible Burden of SOHDS (Sense Of Humor Deficit Syndrome) at Joe Paduda's place.
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