Wednesday, September 30, 2009

Public support for health reform rebounds

After a summertime of town hall meetings featuring loud opposition to health reform, (regardless of whether you think that the anti-health reform demonstrations were spontaneous or organized), Congress is buckling down to tackle health reform. The silly season is over, which raises the question: what do Americans now think about health reform?

According to a latest Kaiser Health Tracking poll, “public support for health reform ended its summer slide, reversed course and moved modestly upwards in September.” According to Kaiser, 57 percent of Americans now believe that tackling health care reform is more important than ever—up from 53 percent in August. Despite the uptick, a substantial share of the public (47%) favors taking longer to work out a bipartisan approach to health reform, compared to 42 percent who would prefer to see Democrats move faster on their own.

Substantial majorities of Americans continue to say they back individual reform components designed to expand coverage, including an individual mandate (68%), an employer mandate (67%) and an expansion of state programs such as Medicaid and the Children’s Health Insurance Program (82%). The component that draws among the strongest support across the political spectrum is the provision requiring that health insurance companies cover anyone who applies, even if they are sick or have a pre-existing condition, which garners 80 percent support.

Even health reform support among seniors has increased in the past month, Kaiser found. Seniors are still more skeptical than other groups that health reform will benefit them, but the share of seniors who think their family would be better off if reform passes climbed 8 percentage points from August, from 23 percent to 31 percent. Twenty-eight percent thought they would be worse off, and 33 percent said it wouldn’t make a difference. Fifty-five percent of seniors said they were “confused."

On the other hand. So, clearly, Americans are feeling more positive about health reform, right? Not so fast, according to a recent Rasmussen survey which shows that public support of health reform has reached a new low. Who do you believe, the reputable political pollster or the reputable healthcare pollster? Can they both be right?

With all the public misinformation and confusion surrounding health reform, some experts believe that legislators should not rely on polls at all. As an example of public misinformation/confusion, one poll asked respondents whether the federal government should stay out of Medicare—which is impossible—and 39 percent agreed that it should stay out of it.

In short, Americans say they favor health reform, except when they don’t, if the polls are to be believed. Is it any wonder that our elected officials seem to be all over the place when it comes to health reform? Maybe they’re just reflecting the views of the general public.

Tuesday, September 29, 2009

Improved Care And Compensation Key To Budget Balance

Health insurance reform opponents maintain that we cannot afford to expand coverage without saddling our children and grandchildren with a huge tax bill for many years to come. Many experts point out that reorganizing and improving care nationwide to eliminate or drastically reduce the waste of unnecessary medical services could help finance expanded access to cover uninsured. We’ve covered a similar topic, reducing medical errors, in a previous blog post.

Physician Elliott S. Fisher, from the Dartmouth Medical School, and colleagues from the Dartmouth Institute for Health Policy and Clinical Practice, discussed the cost reduction solution in the article “Getting Past Denial — The High Cost of Health Care in the United States,” in the September 24 New England Journal of Medicine. These researchers’ conclusions are based on the Dartmouth Atlas of Health Care, first published in 1973 by Dartmouth’s Jack Wennberg, also a physician. The Atlas continues to rigorously examine patterns of medical resource intensity and utilization across the United States.

Doctors and other medical providers often claim that their greater use of services and higher costs are due to sicker, poorer patients. But sicker, poorer patients do not account for the spending differences. Physician Atul Gawande provided an excellent illustration in the case of high cost McAllen, Texas.

When the Dartmouth group reexamined regional differences in price-adjusted health care spending and intensity of care taking into consideration patients’ risk factors, they found that health status accounts for $593 of the $3,280 difference between the lowest- and highest-intensity regions, or just about 18% of the difference. Differences in poverty and income levels in regions accounted for little, if any, of the variation in the cost and intensity of care.

More than 70% of the differences in spending “cannot be explained away by the claim that "my patients are poorer or sicker,"” Dr. Fisher and colleagues wrote.

The Dartmouth Group’s previous extensive research on medical practice patterns across the United States has shown that “discretionary decisions by physicians seem to account for most of the regional variation in spending.” For example, “compared with Medicare beneficiaries in the lowest-spending regions, patients in the highest-spending regions spend more time in the hospital (an average of 2.1 days vs. 1.4 days), have more frequent physician visits (14.5 vs. 10.7 per year), and undergo more magnetic resonance imaging (MRI) procedures (21.9 vs. 16.6 per 100 beneficiaries) and computed tomographic (CT) scans (61.4 vs. 46.9 per 100 beneficiaries).” These differences are not reflected in worse outcomes or in rationing for patients in the lowest-spending regions.

Less intensive, invasive, and more cost-effective services, do require more management time from primary care doctors, nurses, or even specialists, although currently, they are not reimbursed for such time. Instead, physicians are compensated according to the number and complexity of services they provide.

“The implications for health care reform efforts are clear,” Dr. Fisher and colleagues concluded. “Health is indeed a critical determinant of health care spending. Efforts to improve the health of the public and to reduce the burden of chronic illness should be pursued. And because caring for sicker patients costs more, payment reforms will have to be carefully designed. Health systems such as academic medical centers and safety-net providers that care for disadvantaged patients or those with complex conditions will need to be reimbursed fairly with the use of careful case-mix adjustment in order to reduce the likelihood of harm to either patients or the institutions themselves.”

“We should recognize that so much discretionary care is provided in the United States that we could easily afford to expand coverage without increasing taxes — or rationing care — as long as we couple coverage expansion with a commitment to rapidly test and broadly implement successful reforms in payment and delivery systems,” Dr. Fischer and colleagues emphasized. “We should not let denial get in the way of acceptance of the need to move forward on fundamental reform of the U.S. health care delivery system. We can't afford the alternative.”

Nearly all human resources and benefits executives surveyed by the Towers Perrin consulting firm view cost containment for employers and employees and improving health care quality as top priorities for health care reform. The question is, how do we get the other players in this equation on board?.

Monday, September 28, 2009

Scenes from a bill mark up

Sometime ago we discussed how difficult it can be to comprehend legislative language. This issue came up again, briefly anyway, as the Senate Finance Committee spent several days (and nights) last week wading through the more than 500 amendments filed by various Senators (both Republican and Democrat) to the "Chairman's Mark" (that is, the 200-plus page version of health care reform legislation offered by Chairman Baucus (D-MT)). (Mark-up hearings continue this week.)

Senator Bunning (R-KY) offered an amendment that would have required that the actual legislative language of the bill be completed and posted on the Internet 72 hours before the committee votes on the bill. (The 200-page Chairman's Mark is actually a plain language (or, per the Senators, "conceptual language") summary; no actual legislative language is available yet.)

Bunning and other Republicans supporting the amendment argued that it would promote transparency. The Democrats' response? Such a requirement would slow down the process, legislative language is difficult to understand, and, anyway, committee precedent is on their side--SFC apparently always uses a plain language summary as its basis for committee votes. After a spirited debate, the amendment was voted down, almost on party lines--13 to 10. However, Chairman Baucus agreed that a plain language version of the final bill (plus cost estimates from the Congressional Budget Office) would be made available to the public prior to the committee's final vote.

Not surprisingly, the conservative part of the blogosphere had some fun with this one--see here and here for examples. Why not surprising? Well, their side lost. And (ironically) it's an issue that a layperson can understand, unlike many of the issues raised by other amendments on the table (take this one, offered by Sen. Kerry (D-MA): "adjustment to FMAP language to include individuals covered under section 1115 waivers". Only wonks can get worked up about that one (without research, anyway)). Finally, in fairness, there is something odd about the group of people charged with writing the laws being unwilling to grapple with the language of the very statutes they are now trying to change.

So, will this issue matter in the long run? Probably not, though at least one observer thought Senator Snowe (R-ME) was genuinely irritated by the Democrats' position. No doubt the Dems would have preferred to avoid that: Snowe's vote may be very important in the weeks ahead.