Health Affairs

Editor’s Note: In addition to Peter Pronovost (photo and biography above), authors of this post include Julius Pham, Assistant Professor, Emergency Medicine, Johns Hopkins University School of Medicine; Sara Singer, Assistant Professor, Harvard School of Public Health,  Department of Health Policy and Management, Massachusetts General Hospital; Jerod Loeb, Executive Vice President for Research, The Joint Commission; Eric Campbell, Associate Professor, Institute for Health Policy; Christine Ann Goeschel, Director Quality and Patient Safety Initiatives, Johns Hopkins University – Medicine, Anesthesiology and Critical Care; and James Bagian, Chief Patient Safety Officer, U.S. Department of Veterans Affairs – National Center for Patient Safety. Health Affairs Blog publishes this post as the nation observes Patient Safety Awareness Week.

Medical devices have saved countless lives and reduced morbidity. Yet, as illustrated by recent news coverage about hazards from radiation therapy, they have a dark side: they sometimes harm, and even kill, patients. Health care needs an industrywide effort to address patient harm caused by medical devices. A public-private partnership modeled after the Commercial Aviation Safety Team could reform the process of developing devices to ensure that user safeguards are included.

As one powerful article in The New York Times about harm from radiation therapy stated: “Americans today receive far more medical radiation than ever before. The average lifetime dose of diagnostic radiation has increased sevenfold since 1980, and more than half of all cancer patients receive radiation therapy. Without a doubt, radiation saves countless lives, and serious accidents are rare.” Yet “a New York City hospital treating [Scott Jerome-Parks] for tongue cancer failed to detect a computer error that directed a linear accelerator to blast his brain stem and neck with errant beams of radiation. Not once, but on three consecutive days.”

The feature in the Times illustrates the striking imbalance between the investments and advances in biomedical research and the underinvestment and underperformance in the science of health care delivery, an imbalance that exposes patients to needless harm. The article describes a rapid change in radiation technology designs that fails to provide sufficient safeguards: many technicians, clinicians, and physicians simply do not know how to correctly and safely use the new machines. As a result, patients across the country like Scott Jerome-Parks are receiving sometimes lethal radiation overdoses, and many of these errors go unreported. Read the rest of this entry »

With apologies to Arthur Miller …

President Obama went back before the cameras again Wednesday, providing yet another recycling of fading rationales for his health reform product that more voters would rather leave on the Capitol Hill store shelves than purchase.  

But “attention must be paid” whenever the president speaks. 

He tried to claim that “we have now incorporated most of the ‘serious’ ideas from across the spectrum about how to contain the rising cost of health care.”  Perhaps that includes compromising on the implementation date for taxing the extra amount of premiums in the most expensive and comprehensive private insurance plans (just short of waiting either “in perpetuity” or “forever;” whichever comes sooner and still meets the approval of organized labor).   Of course, the president’s search for Republican health care ideas he could deem “legitimate” was only slightly more aggressive than O.J. Simpson’s never-ending search for the killers of Nicole and Ron.   He came up with four low-dose remedies that border on homeopathy. Read the rest of this entry »

Many journalists have called and asked me what I have learned from watching the much heralded Health Care Summit at Blair House.

Actually quite a bit, as the discourse there crystallized so clearly the ideological division that makes coherent and comprehensive health reform so difficult in this country, if not impossible.

In thinking about this question, I make a distinction between the policy-making elite and the “American people” — the plebs — for whom, allegedly, the elite makes policy. My counter-question then is: Are either the elite or the plebs actually ready for health reform at this time? I think not.

Let me focus on the policy-making elite first.

Read the rest of this entry »

Editor’s Note: This is the second of 2 posts on the health care summit from Tim Jost. Part 1 looks at insurance reforms, premium rates and more.

Most of the last three hours of the summit was devoted to the effects of proposed legislation on the federal budget deficit (primarily on Medicare and Medicaid) and on expanding coverage.  It seemed to me that the Democrats were stronger in the second half than in the first, less focused on telling stories (although there were still a lot of them) and more on substance.  The Republicans kept to their talking points, but were at a disadvantage because their bills do not really address Medicare or coverage expansions.

Insurance Reform: Risk Pools and Mandates

Before turning to the deficit issue, several Congressmen who were not able to talk before the lunch break offered useful comments on the insurance reforms. Rep. Dave Camp (R-MI) pointed out a problem with the interim national high risk pool in the Senate bill.  At $5 billion, it is not adequately funded and would run out of money well before the 2014, at which point the bill authorizes the Department of Health and Human Services (HHS) to close the pool.  By contrast, the Republican high risk pools are more generously funded, although the Congressional Budget Office (CBO) does not score them as becoming fully funded until 2016.  Rep. Marsha Blackburn (R-TN) noted that the interstate compacts in the Senate bill would require federal approval as well as the approval of each participating state, and would not become effective until 2016.

Democratic Congressmen, on the other hand, ably defended the comprehensiveness of their approach to reform generally, Sen. Tom Harkin (D-IA) noting that if someone is drowning 50 feet away it does not help to throw them a 10-foot rope.  Senator Harkin also drew a parallel between the discrimination based on health status which still defines the health insurance industry and other forms of discrimination long since outlawed in the United States. Read the rest of this entry »

Editor’s Note: This is the first of 2 posts from Tim Jost on the summit. Part 2 looks at budget deficit, Medicare, malpractice, and possible areas of agreement.

The health care summit has now been underway for almost 3 hours.  President Obama established in his opening statement what he hoped would come of the summit, which was to reach agreement on areas of commonality in the need for health care reform.  The President, as well as a number of the Democratic speakers, has stressed these commonalities.  The message is, of course, we both have the same goals and our bill meets these goals, so what is the problem? 

The Republicans are having none of it.  They showed up to reject the Democratic bill and present their own alternatives.  They came heavily armed with facts and figures (some of them plausible, some not), and are in a constant attack mode.  By and large this attack has to do with substance, although in some instances, notably John McCain’s speech, it is an attack on process as well.  They see the bill as a Washington takeover of the health care system, and they are vehemently opposed.

The Democrats are by and large not engaging these attacks.  Rather they are telling stories about how their constituents are suffering under the current health care system, and, like the President, stressing how their legislation embraces Republican ideas.  It is a pity that they are not more aggressively engaging the Republican claims, because they could convincingly do so. Read the rest of this entry »

I live in Texas. Right now, the only health insurance I can buy is insurance regulated under Texas law. But if bills before Congress (most notably, one sponsored by Arizona Republican Congressman John Shadegg), are enacted, I would be able to buy insurance regulated, say, by the laws of Virginia, or the laws of Delaware, or 47 other states.

Proponents claim this would greatly increase competition. Opponents claim it would undermine “consumer protections.” I think both claims are mainly wrong. I would not expect the number of insurance companies trying to sell me insurance in Dallas, Texas to change at all. And if I am worried about consumer protections, I can continue to buy Texas-regulated insurance, just as I did before.

In fact, far from losing consumer protections, I would gain access to all sorts of protections I do not now have. Specifically, I would be able to choose among 50 different regulatory regimes. And because market prices (premiums) would reflect the different regulatory costs, I could weigh cost against benefits in selecting the regulatory regime that best fits my needs.

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Editor’s Note: Timothy Jost, the author of the post below, analyzed the insurance and revenue provisions of the President’s Proposal for Health Care Reform in an earlier post.

Public debate concerning the pending congressional health reform legislation has largely focused on insurance reforms, which were discussed in my first post on the president’s latest reform proposal.  But the health insurance reform provisions make up only one title and one-fifth of the 2,400-page Senate bill on which the final reform will undoubtedly be based, if reform happens at all.  The remaining provisions of the legislation address a wide range of health reform issues—indeed, most of the topics that health reform must deal with to be comprehensive (and perhaps some that could better have been left to a later time).  The House bill addresses each of these issues with comparable, though seldom identical, provisions. This post analyzes the President’s Proposal for Health Care Reform as it affects the topics addressed by these provisions.

I discussed these provisions of the Senate bill in earlier blog posts analyzing the original Senate bill and the manager’s amendment to the Senate bill.  An excellent analysis of these provisions by Karen Davis and others can be found at the Commonwealth Fund website, which also includes a tabular summary of the Senate bill’s health systems reform provisions.   Detailed analyses of Medicare and Medicaid provisions of the bill are available on the Kaiser Family Foundation site.

Medicaid Expansions

Of all of the reforms found in the last four-fifths of the bill, the Medicaid expansions are the most important for extending access to care and are the most integrally related to the insurance reforms of Title I.  Under current federal law and the law of most states, Medicaid eligibility is not based on poverty alone; an applicant must usually also be over sixty-five, disabled, blind, a child, or the parent of a child.  These categories go back to the 1930s, when social welfare assistance was extended only to the “worthy poor.”

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Editor’s Note: Timothy Jost analyzes the insurance and revenue provisions of the President’s Proposal for Health Care Reform in the post below. In a second post, Jost analyzes the other provisions of the proposal.

On Monday, February 22, the White House posted the President’s Proposal for Health Care Reform.  Although the proposal was posted as “a prelude to the February 25 health care summit between Democrat and Republican congressional leadership and the president, it is not a mere ideas piece or discussion draft.  Rather, it is essentially the outline of a budget reconciliation bill that—in tandem with HR 3590, already enacted by the Senate—would complete the task of comprehensive health care reform when adopted by both Houses.  All of the provisions of the President’s Proposal arguably relate to the revenues and outlays of the federal government and should pass muster under the Senate reconciliation rules. 

As widely expected, the bill seems to reflect negotiations between House and Senate leadership that took place in January, prior to the Massachusetts Senate bombshell, intended to split the difference between the House and Senate bills. While those negotiations were presumably comprehensive, however, the President’s Proposal addresses only issues that can be resolved through reconciliation.  It does not, for example, change the Senate bill’s abortion language.  It also tends to follow more closely the Senate’s approach than the House’s, even on issues arguably amenable to reconciliation.  It does not, for example, include a public plan, sides with the Senate on state exchanges rather than a national exchange, and adopts the Senate’s 133 percent ceiling for Medicaid eligibility rather than the House’s 150 percent. 

The position of the White House, of course, is that it is merely putting out a proposal to debate with the Republicans.  Indeed, in the press conference accompanying the release, White House staff stated that Republican fraud and abuse ideas had been incorporated into the President’s Proposal. Republican proposals amenable to adoption through reconciliation could, of course, be added to or form the basis of modification to the President’s Proposal.  Republican proposals that cannot be adopted through reconciliation could be voted on separately at a later date, perhaps as part of a bipartisan package to amend parts of the current legislation after it is adopted by Congress. The president’s approach of merely putting out reconciliation language is, however, politically realistic.   It should be clear to everyone that simply starting over with a clean slate is not politically feasible at this point.  A year’s work has gone into the pending legislation, and this Congress has neither the time nor the good will to do it all over again.

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Editor’s Note: For more on informal caregivers and related issues, see Bridging Troubled Waters: Family Caregivers, Transitions, And Long-Term Care and other articles in the January issue of Health Affairs, titled Advancing Long-Term Services & Supports. 

The primary focus of this analysis is to examine trends and key findings for caregivers of persons 50+, with an emphasis on the older caregivers.  We use the National Alliance for Caregiving (NAC) and AARP’s national surveys of informal caregivers conducted in 2009 and make selected comparisons with the 1997 and 2004 NAC/AARP surveys.  Although each survey consists of a unique sample, there are questions that are consistent across the three surveys and an operational definition of “caregiver” that is used in the screening to ensure that respondents are representative of the same caregiving population.

The 2009 NAC/AARP study reveals a few trends that are both consistent with the caregiving literature and a departure from this literature.  We observe an increasing number of men included in the respondent groups across the three studies, a trend that is consistent with the literature.  Despite the increase of men who report that they are providing care, the majority of informal care continues to be the work of women. 

The percentage of caregivers caring for individuals over 85 years of age has increased across all three surveys.  Parent care continues to be the primary caregiving situation for mid-life caregivers with 70% of the caregivers between the ages of 50 and 64.  While caring for a spouse continues to be the most commonly reported care situation for those over 75 years of age, the 2009 study suggests that a good number of people in this age group are involved in caring for a friend or non-relative (20%), a parent (20%) or a sibling (18%). This finding is somewhat surprising and is likely a factor of older adults relying on peers for the help they need.

The levels of “burden of care” — a proxy for care intensity based on hours and type of care provided — observed for older caregivers are higher than that for younger caregivers and consistent with what we would expect to see for older individuals who are providing intense care to another person.  It is striking to see, however, that the older caregivers are the least likely to have another unpaid person helping them.  The older caregivers, however, are reporting respite service and transportation service use more frequently than younger caregivers. Read the rest of this entry »

Tim Jost’s thoughtful analysis of the state of health reform concluded that the only practical means of accomplishing health reform is to find a short parliamentary path to some melded version of the two bills that passed the respective Houses. In a comment in response to Jost’s Post, I argued that even if the bills were reconcilable politically, they are structurally flawed, fiscally reckless and have irrevocably lost public support.   So Jost rightly asks: What is the alternative?

The options are constrained not only by political circumstances, but fiscal circumstances as well. The recession has seriously diminished the fiscal capacity of the federal government and has damaged the corporate cash flow on which an employer mandate depends.   The true cost of universal coverage is probably somewhere north of $1.6 trillion over ten years, not counting the employer “contribution”.  Capping these bills at a trillion dollars forced Congress to postpone realization of coverage expansion until 2014, left close to 20 million people uncovered after ten years, and placed an unsustainable burden on states, on whom the incremental cost of a 30% expansion of Medicaid would eventually fall. No wonder there was so little public support.   

Even if there were broad popular support for health reform, we just don’t have the money to achieve universal coverage in the present fiscal situation.  Absent universal coverage, the reforms of private insurance underwriting practices contemplated in these bills cannot be achieved without risking an explosive increase in premiums for the 160 million people presently insured.

So what we should do now is:

1. create the infrastructure to support universal coverage based on an individual, not corporate, mandate
2. make a down payment on coverage expansion by targeting two groups, and
3. begin the complex structural changes needed to have a fiscally defensible universal system.

Read the rest of this entry »