Lower Costs and Better Care for Neediest Patients: newyorker.com

Lower Costs and Better Care for Neediest Patients: newyorker.com Atul Gawande reports from Camden, NJ, the one percent of patients account for a third of the city's medical costs. He also recounts the efforts of a Casino Workers Union to reign in health care costs and increase wages.

Accountable Care Organizations

The Affordable Care Act encourages experimentation with a new method of delivering health care called an Accountable Care Organization. Currently, Medicare/Medicaid reimburses under a payment method called fee-for-service, wherein providers receive payment for each visit, hospitalization, and procedure. A criticism of fee-for-service is that it encourages overtreatment and therefore overspending. Former Democratic Party Chairman Howard Dean, also a one-time primary care physician, says of fee-for-service,

Fee-for-service medicine is the No. 1 driver of health-care cost inflation in this country, and everything else is such a distant No. 2 [that] it almost doesn't pay to debate about it. Fee-for-service medicine – that is 'the more I do, the more you pay me regardless of the outcome.' 

Accountable Care Organizations offer an alternative to fee-for-service. Here, Medicare compensates an ACO with periodic payments for each member of a population served, based on that member's age and condition. The ACO would then pass along proportionate payments to its member providers. An ACO itself is more like a network than a formal organization -- think of the ACO as a general contractor and the providers as subcontractors.

The underlying hope is that by removing the fee-for-service incentive to overtreat, ACOs will encourage communication among providers and decrease duplication of services, thus reducing costs. Skeptics note that provider-led efforts to manage costs are historically unsuccessful, and that as currently conceived require too much up-front financial sacrifice from providers and are not close enough to patients.

The Boston Globe has a useful Q&A about ACOs here. Author, consultant, and futurist Ian Morrison offers his take here.

Money Won't Buy You Health Insurance

Donna Dubinsky writes:

This isn't the story of a poor family with a mother who has a dreadful disease that bankrupts them, or a child who has to go without vital medicines. Unlike many others, my family can afford medical care, with or without insurance.

Instead, this is a story about how broken the market for health insurance is, even for those who are healthy and are willing and able to pay for it.

Click here to read Ms Dubinsky's story.

Co-founder of Palm, Inc and Handspring, Ms Dubinsky has been called "one of the most important businesswomen in the United States" for her pioneering work in the development and strategic marketing of handheld computing devices.

The United States of Obesity

Click to enlarge.

Obesity has reached epidemic proportions, and not only in the United States. In the wealthy world, only Finland and Canada have reversed national trends. Here, some estimate that as many as 60% of Americans are overweight and that more than 30% are obese. Obesity is a risk factor in cancer, depression, heart disease, diabetes, and even asthma.

In their article "Halting the Obesity Epidemic: A Public Health Policy Approach,"Marion Nestle and Michael F. Jacobson make a series of public health policy recommendations in areas of education, food labeling and advertising, food assistance programs, health care and training, transportation and urban development, taxes, and policy development. I've selected one from each area to provide an idea of the complexity and extent of an issue that has little to do with individual willpower (see the others on p20, Figure 3 in the article linked above).

• Require instruction in nutrition and weight management as part of the school curriculum for future health education teachers;
• Restrict advertising of high calorie, low nutrient foods on television shows commonly watched by children 
• Protect school food programs by eliminating the sale of soft drinks, candy bars, and foods high in calories, fat or sugar in school buildings
• Require health care providers to learn about behavioral risks for obesity and how to counsel patients about health-promoting behavior change
• Provide funding and other incentives for bicycle paths recreation centers, swimming pools, parks and sidewalks. (Note: We didn't let our kids walk to school, even though we didn't live in anything remotely resembling a high crime area and even though we lived near enough to school for them to walk. But they would have to negotiate too many arterials for us to be comfortable with the idea. So, they rode a bus.)
• Remove sales taxes on, or provide other incentives for, the purchase of exercise equipment.
• Produce a Surgeon General's Report on Obesity Prevention.

Nestle and Jacobson made their recommendations ten years ago. We haven't gotten any thinner since.

Click here to read what the Centers for Disease Control has to say about obesity (and to see more maps).

State Profile: Hawaii

Based on what happened here to me, I don’t think there’s one thing wrong with the American health care system. It is working just fine, just dandy.

-Rush Limbaugh, speaking about his experience with Hawaii's health care system. 

Was the billionaire broadcaster correct about health care in Hawaii? And is it indicative of the health care offered by the other 49 states? Yes and no. According the American Human Development Report (2005), Hawaiians live longer than residents of any other state (81.4 years). According the New York Times, Hawaiians are bullish about a system that leads the nation in breast cancer cure rate and where insurance premiums are among the lowest in the country as well as the lowest Medicare costs per beneficiary, despite Hawaii's high cost of living.

There's another major difference in Hawaiian health care, one that sets it apart from every other state: Employers must purchase health insurance for any employee who works more than twenty hours a week. All in all, about 90% of non-elderly Hawaiians have health insurance. (Elder Hawaiians are, of course, covered by Medicare.) Certainly, some employers duck the requirement by keeping hours under twenty a week or by simply refusing to pay. Others, though, are proud of the generous benefits afforded their employees.

The law is simple enough: Employers provide standardized health plans with no co-pays, low deductibles, and limits to out-of-pocket expenses. This in turn results in low administrative costs of around 7%. Employers purchase either a pre-approved plan, one they select subject to approval, or provide a self-funded plan. They may share costs with employees up to 50% or 1.5% of an employee's gross monthly earnings.

Hawaii does face problems with its health care system: The recession and the accompanying rise in unemployment has increased the number of uninsured, reflecting an inherent weakness in employer-based health care; the small hospitals of the outer islands face serious financial problems; and state health care benefits do not extend to long-term care, which has been plagued by a lack of liability insurance. Moreover, its geographic isolations and lifestyle may boost its outcomes. Nonetheless Hawaii's outcomes combined with its low cost of health care in a high cost-of-living state suggest the health and economic advantages of universal and equal access.

Click here to learn more about health care in Hawaii.

Battle Joined

Jay Inslee

Rob McKenna

Last March, Washington state Attorney General Rob McKenna joined twelve other Republicans and one Democrat in suing to overturn the Affordable Care Act. McKenna, a rare Republican to hold statewide office in Washington state, has been AG for seven years and is regarded as the presumptive nominee for governor in 2012. Should McKenna be elected, he would be Washington's first Republican governor since 1985.

Historically, McKenna has positioned himself as what long-time Washingtonians call a "Dan Evans Republican," after the popular moderate who occupied the state house from 1965-1977. From this light, McKenna's decision to join the lawsuit seemed puzzling: The ACA is by no means unpopular in western Washington, where the great majority of the state's population resides. To be elected governor, McKenna must peel off a significant number of western Washington's Democrats and Independents. Why McKenna has risked alienating them and galvanizing liberal opposition in order to secure an eastern Washington base that he is in no danger of losing remains a mystery. On the other hand, McKenna has long thrived in an area that is a political Death Valley for Republicans, so there's little doubt that he took his position without long consideration.

McKenna's expected opponent, seven-term Congressman Jay Inslee (WA-1), lost no time in attacking McKenna's position on the ACA. (Disclosure: I have known Inslee since his election in 1998.) Warm and thoughtful, Inslee is no mean politician himself: In 1998, he drew attention from around the country when he campaigned against incumbent Republican Rick White's support of Bill Clinton's impeachment. (Arguably, MoveOn.org drew its name from Inslee's campaign.) Inslee defeated White in a close election, then in 2000 became the first Democrat in the history of the First District to win reelection. He has won every race since then by a comfortable margin. Unlike McKenna, Inslee has not positioned himself as a centrist: Inslee is an unapologetic liberal who also happens to be an effective representative.

And, he is a strong supporter of the Affordable Care Act. Inslee has been direct in opposing Washington's participation in the lawsuit and has worked diligently to make McKenna's active support of the suit an early issue. McKenna, Inslee says, wants to have it both ways: He advocates overturning the ACA while claiming to support its key consumer provisions. McKenna responds that the real issue is about the constitutionality of the law:

People sometimes forget what this lawsuit is actually about: the constitutionality of the health care law. That’s what every judge who has ruled on the matter understands. As Judge Vinson most recently observed, the health care law should be revised in order to make sure it does not violate the Constitution.

And as Attorney General McKenna has said, he does not believe that every section of the new law, including protections for those with pre-existing conditions, violates the Constitution.  McKenna supports the need for affordable, accessible health care for the people of Washington and their families—he just doesn’t think we need to violate their Constitutional rights to give it to them.

So far, McKenna has not explained how the consumer protections he supports can be enacted successfully without the compulsory insurance at the heart of the bill.

In any event, the ACA is shaping up as a major issue in the 2012 Washington state gubernatorial election, as the expected main candidates include one of the bill's staunchest supporters and its most visible statewide critic. Both are formidable candidates whose strength will put Washington in the political health care spotlight in 2012.

Emergency Emergency

This afternoon, I went on a hard-hat tour of a satellite emergency facility, expected to open next month as part of my local community hospital's health care system. Besides state-of-the art equipment, the building will house twenty primary care physicians, specialty care, a test lab, and a diagnostic imaging lab. Patients will sit in comfort in chairs that will unfold into examining beds, blood tests will occur on site with results returned as close to instantaneously as possible, and Electronic Medical Records will be instantly synced with the main hospital IT system.

The facility will include a conference room for group consultations -- for example, a dozen diabetics might meet with their doctor and a nurse for instruction in lifestyle changes. Should I have the misfortune to need the emergency room, the expected wait time is 15-17 minutes. This will be at least the fourth such facility in my suburban area to go with three hospitals, each of which has its own Emergency Department.

Obviously, this will be one of the better areas in the country to need emergency care.

Which at first blush makes stories like this all the more perplexing:

A 10-year old boy in Arizona had a severe asthma attack and couldn’t breathe. An ambulance was called, but all the hospitals near his home were full and on diversion, including two children's hospitals. The closest open hospital did not admit children, but opened to take him, even though it was also overwhelmed. While waiting for a treatment room to open up, the child waited in the hallway on the ambulance gurney for several minutes. He died in the hallway, before he could be seen by even a nurse, because all the staff were overwhelmed caring for other critically ill patients...

A patient was boarding in my emergency department, waiting for an inpatient bed to open in the hospital.  His family gathered around him and was forced to make end-of-life decisions with him while he lay dying on a gurney in a hallway...

An elderly man came to the hospital with weakness, pneumonia and new onset of renal failure with very high potassium levels. He arrived at 10 pm and we were unable to move him to an ICU bed until 4 pm the following afternoon. 

All over the country, Emergency Rooms face increasing pressure, although the reasons for this are more complex than one might think. Certainly uninsured people use the ER, but most patients have Medicare or Medicaid. Reimbursements have become so low that many physicians refuse to see Medicaid patients, and so they resort to the ER. The shortage of primary care physicians contributes as well.

Still, at a time when emergency departments are closing and urban wait times increase, it's not an accident that the facility I visited is located in a hospital district with a per capita income of over $100,000 or that there are nearly as many emergency facilities the greater suburban area as in the more populous urban core. At the end of the day, emergency care is rationed, too: The uninsured and underinsured who resort to urban emergency departments because they have no other choice have access of a sort, but it's hardly equal access.