What “Will” Happen With Health Reform

November 29, 2009 / Michael D. Miller MD / Access to Healthcare, Information & Communications, Politics / No Comments

With the Senate scheduled to start debating (and likely amending) health reform legislation this coming week, speculation is rampant about what will happen with health reform. Since the title of this blog is “health policy and communications,” I want to focus on the use of language in discussing health issues, studies, proposals and legislation – specifically the word “will.”

The word “will” is very strong and it implies a high degree of certainty about predicting future events, such as “The Sun will come up tomorrow morning.” And while I have no problem with predicting the future – as my friends know, I have a great reputation for predicting the future, particularly about sporting events like fake punts and winning 8 straight games to win a World Series – but using the word “will” to describe the implications of scientific studies, or legislation and policy proposals, can be misleading.…

Thanksgiving Conversations About Health – Engage With Grace Blog Rally

November 24, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Miscellaneous / 3 Comments

For many years I’ve used the Thanksgiving dinner table conversation as a model for discussions about healthcare – but usually I’ve put it in the context of people who work for healthcare companies, (e.g. pharmaceutical or managed care), trying to address, rebuff and rebut the criticisms they might get from family members, (e.g. Aunt Lilly), about the problems with the US healthcare system and the actions or positions of various companies or industries. However, last year – and again this year – several bloggers have been cooperating to promote Thanksgiving weekend discussions about end of life care issues. This effort has been called the Engage with Grace, and last year it was a great success, with over 100 bloggers participating.…

Cost and Coverage c. 1989-91: Part 2 of Historical Perspectives on Health Reform

November 17, 2009 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Economics & Financing, Health System Reform / 2 Comments

As I mentioned in my last post, in going through old files I found many memos and articles about health reform. Some of them from 1989-91 illustrate the long history of the challenge of controlling costs and providing care for more people – and eerie similarities to the current debate:

For example, below are some pieces of text from articles and commentaries published in the New England Journal of Medicine from January 1989 – October 1990:

“A Consumer-Choice Health Plan for the 1990. America’s health care economy is a paradox of excess and deprivation. We spend more than 11 percent of the gross national product on health care, yet roughly 35 million Americans have no financial protection from medical expenses.

…

Historical Perspective on Health Reform – Part 1, Medical Effectiveness

November 16, 2009 / Michael D. Miller MD / Comparative Effectiveness, Delivery of Healthcare, Public Health / 1 Comment

Since the time-line for health reform legislation has continued to be stretched, I recently spent some time cleaning out old files. In my excavations I came across papers, articles, memos and briefing books which demonstrate that no matter how much things change, some aspects of health reform have stayed the same. For example, below are a couple of snippets from memos about a proposed Medical Effectiveness Initiative from circa 1989:

Establishing a Medical Effectiveness Initiative at the OASH [Office of the Assistant Secretary of Health] level. (FY90 request = $52 million) This initiative would assess which medical treatments are cost-effective, and identify inappropriate and unnecessary medical practices.

…

Making More Sense of Health Reform’s Politics

November 5, 2009 / Michael D. Miller MD / Federal Healthcare Reform, Health System Reform, Politics / 1 Comment

As expected, it appears that Tuesday’s elections are clarifying the political thinking for some Member of Congress. Specifically, the losses of Democratic gubernatorial candidates in VA and NJ are blamed on independent voters shifting from the Democratic column – where they predominantly voted last year – to the Republican column this year. While some appear surprised by this movement, it seems very natural – after all, that’s why they’re called “independents.”

The implications of this shift for health reform legislation are that Democratic Members of Congress from more moderate districts – where they depend on more independent voters to get reelected – are probably feeling increasingly nervous about the contentious issues in health reform. …

Making Sense of Health Reform

November 2, 2009 / Michael D. Miller MD / Access to Healthcare, Federal Healthcare Reform, Health System Reform, Politics / No Comments

After spending a week in Washington DC talking to lots of people, and reading all sorts of information, I’m still not sure how to simply explain the the current state of health reform legislation – except to say that it is unfolding pretty much as expected:

It is taking a lot longer than planned, i.e. the August deadline never seemed realistic
There are pockets of agreement, but no solid majorities for a single bill
The Senate and House are operating in parallel, with the Senate being more conservative and focused on issues important to rural communities
Costs and spending are defining the framework within which all the ideas and packages are bouncing – like a 1970s video game
And political motivations and calculations are the firmament for many – if not most – positions and actions

Politics with Elections on 12 Month Horizon
On the last point, there has recently been ample evidence. …

More on Medicare Medical Home Demonstrations

October 28, 2009 / Michael D. Miller MD / Health Policy and Communications Blog / 1 Comment

Last week, I wrote about the new “Advanced Primary Care” (APC) model demonstration announced by the Department of Health and Human Services, and how it might interact with the previously announced – but not yet implemented – Medicare Medical Home demonstrations. In that post I noted that the healthreform.gov fact sheet stated the two demonstrations would move forward together in 2010, and the CMS webpage for the Medicare Medical Home demonstration hadn’t been updated since April. Well, both of those situations have changed. The CMS webpage was updated on Monday stating that the Medicare Medical Home Demonstrations will not be moving forward because the House version of health reform legislation would repeal the Medicare demonstration and replace it with two other medical home demonstrations – one independent practitioner-based and the other community-based. …

Morphing Medical Homes into Advanced Primary Care Model

October 18, 2009 / Michael D. Miller MD / Delivery of Healthcare, Health System Reform, State-Level Healthcare Reform / 4 Comments

The concept of patient centered medical homes (PCMH) has been evolving since it was first presented by 4 primary care medical societies, (AAFP, AAP, ACP & AOA), in March 2007. Since then, the PCMH concept has been endorsed by many other medical societies and interest in PCMHs has grown. Some of the significant steps forward have included:

The National Committee for Quality Assurance (NCQA) created specific requirements and a certification procedure for PCMHs
Several states are moving forward with PCMH pilot projects
Congress passed a law for Medicare Demonstration projects and the Department of Health and Human Services created draft guidelines for these projects – however, these guidelines haven’t been finalized although the demonstrations were scheduled to start in 2010

Steps Sideways
Along with all the interest and activity related to medical homes, there has been a blurring of the definition about what constitutes a medical home. …

Shakespearean Health Reform

October 12, 2009 / Michael D. Miller MD / Health System Reform, Politics / No Comments

With the expected passage of legislation by the Senate Finance Committee this week, Federal health reform prepares to move into the next phase, i.e. merger of bills in the House and Senate followed by a Conference Committee to meld those two versions. While this “process” may seem very straight forward, it probably will have subplots as intriguing and complex as many of Shakespeare’s plays. So below, are some highlight of what may unfold in the coming weeks, (and months), as health reform legislation is finalized and then implemented… perchance.

To Reconcile or Not to Reconcile, That is the Question
The Senate Democrats had set a deadline of October 15th, after which they may use the rules of Reconciliation to pass health reform legislation. …

Off-Label Communications: Is More Less?

October 4, 2009 / Michael D. Miller MD / Delivery of Healthcare, FDA, Information & Communications, Quality of Care & Safety / No Comments

Allergan corporation has filed a law suit against the Federal government challenging the FDA’s limits for companies discussing or promoting off-label uses of approved medicines. This is not a new issue, but the news reports indicate that Allergan is going very old school and basing their legal challenge on Constitutional freedom of speech rights.

The issue is not can doctors and patients use approved medicines for conditions, (or in ways), which are not specifically approved by the FDA, but can companies discuss these off-label uses with physicians or provide them with published information about these off-label uses?

Competing Risk-Benefit Perspectives
The competing risk-benefit perspectives that surround this issue are nearly identical to the trade-offs that all stakeholders in biomedical research and development face – including the FDA, companies, patients, clinicians, and legislators:

Creating a landscape that protects individuals and public safety
Being flexible enough to provide clinicians and patients access to the best available treatment possibilities
Providing companies a reasonable market environment that creates incentives for developing new treatments and investigating new uses for already approved medicines, which also has marketing rules that are as clear as possible so companies can conduct business without being excessively concerned about straying into regulatory gray zones

Off-label use is common in clinical practice – particularly for disease areas like cancer – because it often represents the standard of care. …

Bending the Cost Curve: Trees and Forests

September 25, 2009 / Michael D. Miller MD / Delivery of Healthcare, Economics & Financing, Health System Reform / 1 Comment

Bending the curve of cost growth has been a expanding issue within health policy discussions – as opposed to the public plan option, which has increasingly been the focus of political health discussions. Recognizing how important cost growth is to health reform, the September/October issue of Health Affairs is dedicated to this topic, and it contains great articles describing various factors causing spending to grow faster than the GDP or general inflation, and some solutions to this ongoing conundrum. However, these articles are like trees in the forest, i.e., they are very important, but a close examination of each one doesn’t provide a broad understanding of the whole forest – or in this case, what bending the curve of healthcare cost growth might look like.…

Encouraging Communications About Patients’ Goals

September 18, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, Economics & Financing, Information & Communications, Quality of Care & Safety / No Comments

I attended a great event yesterday where experts discussed how to improve healthcare quality and safety by increasing patients’ involvement in making healthcare decisions.

This seminar, “Patient-Centeredness and Patient Safety: How Are They Interconnected,” was organized by the Kenneth B. Schwartz Center and sponsored by the Massachusetts Medical Society and CRICO/RMF. Don Berwick (President & CEO of the Institute for Healthcare Improvement) was the main speaker followed by a panel consisting of two patient safety leaders from local hospitals and a patient involved with promoting patient engagement in quality improvement.

To start the event, Dr. Berwick discussed how his thinking about healthcare quality had evolved over several decades, and his increasing belief in the importance of patient involvement.…

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