Don’t let anyone but this blog’s readership know, but, I admire Donald Berwick.
The director of the Center for Medicare & Medicaid Services has dedicated the majority of his adult life to studying and improving the delivery of health care. And he stepped up to one of the highest platforms within health care policy knowing the challenges to acceptance he faced. Not that I would dare that he considred such when Obama asked him to take the position. Still, to only small surprise his well versed and verbalized opinions on what health care could be have hampered his service to the Obama administration.
Several people who work with Dr. Berwick at the Medicare agency said they were disappointed that the White House had not done more to promote him. “Everybody here admires Don and the work he’s done, but he is not going to be confirmed,” a supporter said. “That’s inevitable. The Republicans will block him. There’s not a lot of optimism that the White House can do anything about it.”
Berwick, a pediatrician by training, has made an internationally recognized career of his focus on optimizing the delivery of health care and he has, at times, been frank about what such would entail,
“Any health care funding plan that is just, equitable, civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional.”
Although many have this particular Dr. Betwick quote it is hard for anyone, looking at the actual data, to refute such a claim. Or Berwick’s many chides that improving health care will entail a more visible and transparent rationing of such. And rationing, publicized rationing, will be the death of meaningful health care reform at present.
Not that Donald Berwick doesn’t have his supporters, but his detractors in Congress will be the end of his tenure at the head of the CMS under a recess appointment from President Obama.
[H]is past record of controversial statements, and general lack of experience managing an organization as large and complex as CMS should disqualify him being confirmed as the CMS Administrator.
I don’t agree with many of Dr. Berwick’s opinions. Not on their merits mind you but on their implications.
And that’s a troubling position from which to argue with someone. The position that I concede your points but I disagree with you nonetheless. Of course, that has been my long held position. Essentially I concede that if you desire to improve the health of this country, by most population based metrics, then reforming the delivery of care to make access more affordable is important. And to improve access will require a better planned (not that our current system is planned at all) rationing of health care; a more visible rationing.
But challenging Dr. Berwick on his credentials is something else.
Managerial skill is something he has proven not only at the IHI but throughout his professional career. And I’m not sure a career government professional is someone we desire, on that merit alone, to head the CMS as the Senate Republican letter to President Obama implies.
Dr. Berwick’s tenure will have been too short, no matter my opinion of his ideas for Medicare, Medicaid and health care in general. 17 months at the helm may be long in the life of a CMS director,
This is a substantial period of time and long enough to have set a tone at CMS and to have recruited key second and third-tier administrators to work on important pieces of the Affordable Care Act. Berwick has already jump-started the Center for Medicare and Medicaid Innovation, the best hope health reformers have for finding smart ways to cut health care spending. Under Berwick’s tenure, the federal regulation of private insurance was also brought under the CMS mantle, a power consolidation that could have long-range implications.
But arguably shorter than the respect he deserved, no matter your politics.
Medicaid is a matched grant program, wherein the federal government matches money spent by the states, to provide a funding source for healthcare the economically disadvantaged. Medicaid, as can be imagined, has been pushed by the Great Recession.
From 2007 to 2009, Medicaid enrollment accelerated as a result of the recession. During economic downturns, people lose jobs and incomes decline making more individuals eligible for Medicaid at existing eligibility levels. Access to Medicaid coverage remained stable over this period due to protections put in place under ARRA. Increases in enrollment stemming from the recession were the primary drivers of increased spending on Medicaid over this period. Looking over the last decade, Medicaid spending per enrollee has increased more slowly than growth in national health expenditures per capita and growth in private health insurance premiums. Despite the program’s success in holding down per capita cost growth, states are grappling with immediate budget issues related to the economic downturn and related state budget constraints coupled with the expiration of the enhanced federal Medicaid matching funds from the ARRA on June 30, 2011.
Given the level of cost-containment that has already taken place, additional reductions in Medicaid spending growth over time will depend on…broader efforts to reduce health spending across all payers
Enrollment has gone up while state revenues and budgets have been squeezed. In 2010-2011 the federal government increased the funds given to the states, effectively shouldering a greater burden of the Medicaid budget. But that extra money was a one year deal and is set to expire.
And so states, faced with budget deficits in large part attributable to Medicaid (for instance: Wisconsin’s shortfall over the next two years is made up in half by Medicaid costs) continue to struggle. And state lawmakers have been very prominent in vocalizing their displeasure with the situation. One of the problems is some of the restrictions on reducing Medicaid eligibility, basically striking some people from the rolls, that the Affordable Care Act places. Basically,
But what really makes this Medicaid fight different from ones that have come before is the impact of the health overhaul passed last year, which calls for a huge expansion of Medicaid in 2014 to low-income childless adults.
States won’t actually be on the hook for most of those costs; all but 10 percent will be paid by the federal government.
But between now and 2014, in order to get that federal money, governors basically can’t cut back on most Medicaid eligibility. That makes a lot of them, well, not very happy.
“I really believe that the federal government, with their maintenance of effort, have really tied our hands and not given us the flexibility to do what we do,” said Iowa’s Branstad. “I don’t mind being held accountable [but] I’d like to be able to set our own eligibility requirements.”
This part of the Affordable Care Act, and other provisions related to Medicaid funding, has actually been challenged in federal court along with the more media grabbing assertion that the individual mandate oversteps Congress’ authority. However the mixed success opponents, including the state Attorney Generals, have had within the judicial system, it is of note that no court has sided with the plantiffs when it comes to the requirement that the states maintain current Medicaid rolls if they want to be eligible for future federal Medicaid dollars come 2014.
Haley Barbour doesn’t have many nice things to say about Medicaid these days.
He says he’s frustrated with “people [who] pull up at the pharmacy window in a BMW and say they can’t afford their co-payment.”
And, he says, “Forgive me if I think people who work two or three jobs to pay for health care for their families shouldn’t be forced to pay for health care for people who can work, but choose not to.”
The Heritage Foundation, a conservative research organization, estimates Texas could save $60 billion from 2013 to 2019 by opting out of Medicaid and the Children’s Health Insurance Program, dropping coverage for acute care but continuing to finance long-term care services. The Texas Health and Human Services Commission, which has 3.6 million children, people with disabilities and impoverished Texans enrolled in Medicaid and CHIP, will release its own study on the effect of ending the state’s participation in the federal match program at some point between now and January.
Although that is, for all the talk, extremely unlikely,
“I can’t imagine Mississippi opting out,” [Barbour] said at a hearing on Capitol Hill Tuesday. “We’re a poor state, and it’s an important program. We want to run it better for taxpayers and beneficiaries. … I am not an opt-out advocate and I’m just being forthright about that.”
Medicaid is feeling the squeeze from the Great Recession. It will continue chugging along, but the promise of an expanded Medicaid helping to provide insurance to more than half the people theorized to be covered under the Affordable Care Act, well that might be too much to ask,
Obama’s new budget calls for spending $279 billion on Medicaid and the Children’s Health Insurance Program, down from $285.4 billion this year. In plain language, this means stripped-down health care coverage for the poor and bigger burdens for the states.
In a terrible scene in Arizona Representative Gabrielle Gifford and others were shot as she held a meeting with her constituents outside a supermarket. At least six are dead. My prayers are with everyone involved in this, their families and loved ones.
Rep. Giffords suffered, per reports, a single gunshot wound to the head with both an entrance and an exit. From eye witness accounts with a posterior entrance wound.
In the same press conference it is commented that the bullet transversed just one hemisphere. She underwent neurosurgery, although the exact nature of such isn’t clear. Post operatively she was following commands.
Of course, no one but her physicians right now know exactly what is going on but missile wounds to the brain are tough things. There is some optimism but I’m afraid we should probably be more cautious than some of the vibes coming from the media.
I recently talked about what changes came into effect on the New Year under the Affordable Care Act. One of the tangential things I didn’t comment on was an executive Medicare regulation running parallel to congressional efforts which came into effect January 1st and promised to pay providers for any time spent discussing end of life issues with patients.
The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.
Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves.
Section 1233 of the bill passed by the House in November 2009 – but not included in the final legislation – allowed Medicare to pay for consultations about advance care planning every five years. In contrast, the new rule allows annual discussions as part of the wellness visit.
The proposal for Medicare coverage of advance care planning was omitted from the final health care bill because of the uproar over unsubstantiated claims that it would encourage euthanasia.
The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.
Critics decried the new rule as taking control away from patients and devaluing life and setting up death panels.
There is…something at least vaguely disturbing about a government incentivizing doctors to [discuss end of life issues] as part of an expansive regulatory program that has, as one of its primary goals, cost reduction.
At least the linked to criticism at Hot Air,
There is nothing wrong with patients planning for contingencies through advance directives. There is also nothing wrong with doctors discussing those options with patients ahead of those decisions. As the spouse of a patient who has faced life-threatening circumstances on more than one occasion, I certainly understand why these conversations need to take place before the pressures of acute circumstances come into play. This new regulatory effort at least puts the conversation where it belongs, in routine wellness visits, rather than as a five-year set conversation. It also appears to make this a voluntary conversation (at least for now), one the patient can decline without any repercussions.
I couldn’t agree more but I would argue that there should be reimbursement for it at anytime, anywhere.
Lacking a pallative care team there may be no one outside my team, the neurosurgery service, who sees as much end of life issues. Neurotrauma, aneurysmal bleeds, primary central nervous system cancer, bad things. And the choices family have to make in the heat of the moment are gut wrenching and painful and full of angst.
Patients and their physicians need to have conversations with families present concerning end of life issues well before anything happens. The young and the old need to have the conversation. In some ER with a loved one with a massive subdural on Coumadin, with me, is not the place to have the conversation for the first time.
The best way to promote people discussing end of life issues with their physicians is to pay physicians for such discussions. Too bad the political establishment on the right has a problem with that.
Healthcare is a limited commodity. It’s limitations are defined by the numbers of professionals supplying it and their physical limitations on the number of patients they’re able to treat, on availability of biomedical equipment and technology, on availability of physical space to safely provide medical care and, underlying all of these, on the funding for such.
And so, not everyone can get all care they need or want.
And, it is true, no system will even be able to supply such. There will always be limitations. And there will always be some rationing.
The argument from many proponents of reform has long been that at present we covertly ration healthcare and we do it haphazardly and so reform that makes rationing more transparent and planned is actually a positive. Essentially the argument is that, everyone is scared of rationing in health care reform but what many don’t realize is that such is already occurring and we should embrace making rationing more rational with health care reform.
to supply, apportion, or distribute as rations (often fol. by out ): to ration out food to an army.
to supply or provide with rations: to ration an army with food.
to restrict the consumption of (a commodity, food, etc.): to ration meat during war.
It’s a verb, it’s an action. It implies planning and action. Not the haphazardness that defines who currently does and doesn’t get certain care within the American health care “system.”
The Economix piece quotes former CMS head Dr. Mark McClellan later,
“Just because there isn’t some government agency specifically telling you which treatments you can have based on cost-effectiveness,” as Dr. Mark McClellan, head of Medicare in the Bush administration, has said, “that doesn’t mean you aren’t getting some treatments.”
And I agree but it’s important to keep our terminology straight, at least to opponents of rationing and health care reform as defined currently by things like the Affordable Care Act. In that quote above I would claim only the former represents rationing and not the latter.
And the end results are not the same.
Rationing, the centralized distribution of health care resources is vague but for many proponents of current national health care reform efforts essentially it means the most bang for the most people for the buck. An egalitarianistic vision of health care.
However, down the slippery slope, it promises to leave peripheral exotic patients on the sideline and to limit freedom of choice.
By some quantitative quality measures health care, over the whole population, may be better. But in rational rationing these are the physicians you can see, these are the procedures you’re entitled to no matter the nature of your specific disease or your personal means. It could potentially stifle innovation in health care and certainly will limit choice.
Currently your economics and your social status influence the care you receive and they choices you have. In a rationed system, as envisioned by many proponents of current health care reform, the care you receive and the choice you have are influenced by some centralized entity who determines such. The latter is certainly more rational and has the potential to improve some measurements of health in this country but it holds the potential to inherently redefine the notion of choice within your means, of freedom upon which (and I don’t mean to be hyperbolic here) the American dream has been based. Or at least the mythos that is the American dream.
The healthcare reform law comes into effect piecemeal, as the provisions of so many laws do. Today, the first of 2011, marks the coming of age of new provisions. The most notable of first may be a national medical loss ratio cap.
Today , many insurance companies spend a substantial portion of consumers’ premium dollars on administrative costs and profits, including executive salaries, overhead, and marketing.
Thanks to the Affordable Care Act, consumers will receive more value for their premium dollar because insurance companies will be required to spend 80 to 85 percent of premium dollars on medical care and health care quality improvement, rather than on administrative costs, starting in 2011. If they don’t, the insurance companies will be required to provide a rebate to their customers starting in 2012.
[...]
Over 20 percent of consumers who purchase coverage in the individual market today are in plans that spend more than 30 cents of every premium dollar on administrative costs. An additional 25 percent of consumers in this market are in plans that spend between 25 and 30 cents of every premium dollar on administrative costs. And in some extreme cases, insurance plans spend more than 50 percent of every premium dollar on administrative costs. This regulation will help consumers get good value for their health insurance premium dollar.
Essentially the law requires 80% of premiums coming from individual plans to go to actual policyholder health care costs. For those in large employer based plans the law requires an even higher medical loss ratio of 85%. Dollars falling short of that must be given back to policy holders.
MegaLife…threatened to leave Maine if the new loss ratio is imposed.
“Based on preliminary discussions I had with [MegaLife],” Kofman wrote in her July letter, “the company … would probably need to withdraw from this market if the minimum loss ratio requirement were increased.”
[...]
In November, Sen. Olympia Snowe added her support to Kofman’s waiver request, reiterating the concern about losing what little competition exists for Maine’s individual insurance market. Still, there has been no answer from Washington, D.C. Snowe could not be reached Friday for comment.
To be fair a lot of states require certain medical loss ratios already, but few at levels like the Affordable Care Act requires. I’m not sure how tenable the medical loss ratio requirement will be at 80-85% if the individual health insurance mandate doesn’t survive come 2014.
We All Know How I Feel About Reform, And The Medical Loss Ratio Requirements In Particular
There are other new provisions coming into force. Maybe none as significant as the national, standardized restrictions on what health insurers can spend their revenue on but important none the less. You can look over some of the other provisions here.
Medicaid and SCHIP are federal grant programs. The federal government encourages states to cover their citizens, of certain eligibility, under Medicaid and SCHIP by funding 60% of the cost of the programs. But the states could turn down that federal money and simply not participate in the programs and, potentially save themselves the 40% of the costs that they shoulder.
As the Texas Tribune says,
Moderate Republicans are studying it behind closed doors. And the party’s advisers on health care policy say it’s being discussed more seriously than ever, though they admit it may be as much a huge in-your-face to Washington as anything else.
[Says] State Rep. Warren Chisum, R-Pampa,“This system is bankrupting our state….We need to get out of it. And with the budget shortfall we’re anticipating, we may have to act this year.”
The two questions are whether those currently served by Medicaid and SCHIP get worse care should those programs be replaced by something else and how much could Texas actually save by pulling out of Medicaid and SCHIP.
State Rep. John Zerwas, R-Simonton, an anesthesiologist who authored the bill commissioning the Medicaid study, said early indications are that dropping out of the program would have a tremendous ripple effect monetarily. He is not ready to discount the idea, he said, but he worries about who would carry the burden of care without Medicaid’s “financial mechanism.”
“Because of the substantial amount of matching money that comes from the federal government, there’s an economic impact that comes from that,” Zerwas said. “If we start to look at what that impact is, we have to consider whether it’s feasible to not participate.”
You would have to believe that Medicaid and SCHIP would have to be replaced by something. But it’s difficult to imagine the state providing something on the order of similar health care access for a similar number of people with substantial savings. You’d have to sacrifice the former for any sort of budget benefit I would imagine. But I guess we’ll see as this new legislature comes together in Austin.
The most important component of malpractice costs is defensive medicine. The Harvard authors put this at $46 billion, or nearly 80 percent of the total, but this is pure guesswork. Researchers cannot agree on the extent of defensive medicine. The Harvard authors base their estimates on seminal studies by Kessler and McClellan. Their work is seminal largely because it was first, not because it was definitive, and later studies often find far less evidence of defensive practice. The Harvard authors try to be conservative by using the low end of the Kessler/McClellan cost estimates. But truth would have been better served if they had stated that the cost of defensive medicine could just as easily be $16 billion or $76 billion.
Dr. Dranove, writing at THCB, has some fine points. As he says any full evaluation of tort reform must consider not only what it may save in medical costs but what it may do to the quality of medical care delivered.
What we need now is evidence on how tort reform affects quality. Until we get that evidence, all the hullabaloo about the new Health Affairs study is really much ado about nothing.
80% of verdicts for the defendant in cases of poor outcomes after poor care is unacceptable. So is 20% of verdicts for the plantiff in cases where the level of care should never be classified as malpractice.
Malpractice reform should not only seek to improve quality and lower costs but, just as importantly, make the system more just.
er·ror
/ˈɛrər/ Show Spelled[er-er] Show IPA
–noun
1. a deviation from accuracy or correctness; a mistake, as in action or speech: His speech contained several factual errors.
2. belief in something untrue; the holding of mistaken opinions.
3. the condition of believing what is not true: in error about the date.
4. a moral offense; wrongdoing; sin.
A contextual error occurs when a physician overlooks elements of a patient’s environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.
The above appears in a work by Weiner, et al in the Annals of Internal Medicine last month. I’m terribly poorly read on healthcare QA and medical errors but it appears to be a relatively novel concept. A search by title or keyword for “contextual error” in Medline reveals a total of three articles. The two other than Weiner’s have nothing to do with the idea as his group defines it.
I like the idea; I think it raises important considerations.
I don’t like the way Weiner’s group designed a study to document the prevalence of contextual errors.
He sent undercover patients into doctor’s offices with regular complaints: a diabetic with blood sugar out of control. Raging asthma. Need for a hip replacement. They functioned as the “secret shoppers” of health care.)
In each case the actors could present a standard version of the problem, or versions where they offered a clue to an extra fact, something all physicians would agree should change the plan of care, if it were known. For the patient with raging asthma, one clue was “it’s been worse since I lost my job.”
A smart doctor would ask if new financial problems meant the patient could not pay for medicines. With that information in hand, the doctor could readily change to cheaper medications or identify a source of support. If a doctor fails to pick up on that clue, however, then they are likely to add new prescriptions. That would be the wrong decision.
Physicians only asked follow-up questions about those clues to good care about half the time. When there was a problem in the patient’s life situation, like inability to afford medicines, doctors only came up with an appropriate plan of care one time in five. Four times out of five, the patient left the office without receiving good care.
I’m not sure the example given represents a mistake on the part of the physician. Not in full. Not enough to claim,
That error rate is unacceptable.
Patient non-compliance with therapy is a failure of the medical system, but it is largely a patient side error. I’m not denying the responsibility of providers to promote social health and situations that facilitate patient compliance. But a patient who presents to a physician with worsening of his symptoms and doesn’t offer the fact that he’s been non-compliant with the recommended therapy because he can’t afford it, well, that is fully on the patient.
Telling physicians they’ve made a mistake for not ferreting out the complex situations in which patients aren’t compliant during a fifteen minute office visit is bollocks.
