Fixing or Fracturing Medicare?

Reducing Medicare spending has been one of the focal points in the debt ceiling negotiations, and it was reported that the President is considering throwing the idea of raising the eligibility age for Medicare into the pot as part of a stone soup recipe that might get enough Congressional Ds and Rs to swallow the end product.

Increasing Medicare’s Eligibility Age is Bad Policy and Worse Politics
While increasing Medicare’s eligibility age to reduce spending makes simple arithmetic sense using the formula Spending = Number of People x Spending per Person, like almost everything in healthcare, what is simple is often 30 degrees wrong.…

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Health Law Is Reforming System Via Market Forces

All the controversial rhetoric about the new health reform law is missing a huge reality:  The law is driving dramatic changes in the real world.  Almost every major health delivery system is preparing to reorganize how they provide care to hundreds of millions of Americans by becoming Accountable Care Organizations (ACOs).

Health Systems are Voting With Their Wallets
The magnitude and level of financial interest in ACOs – and proof that it is not just cautious planning – were dramatically illuminated by recent actions and a Washington Post article:

  • On Thursday, HHS released the long anticipated proposed rule for ACOs and Medicare “Shared Savings.”

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Creating and Implementing Healthcare Innovation – BioPharmaceuticals, Delivery System and Reimbursements

Healthcare innovation is an extremely hot topic right now, ranging from the new Center for Medicare and Medicaid Innovation, FDA’s approach to approving therapies and devices, an entire issue of Health Affairs, and of course patient-centered medical homes and Accountable Care Organizations [Patient-centered medical homes are also known as Advanced Primary Care Model practices, and ACOs are a combination of delivery and reimbursement innovations.]

I’ve been working for many years to create value for patients and society by speeding adoption of these types of innovations by clinicians, other providers, patients, payers, regulators, communities, etc., and have found that healthcare innovations have at least three things in common:

  1. Healthcare innovations occur in steps, with each advance building on the shoulders of what came before
  2. These stepwise advances also produce indirect benefits that can be greater than the innovation’s direct effects
  3. Adoption of innovations doesn’t just “happen.”

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Accountable Care Now

If all arrows in Washington pointed to the same spot for solving the healthcare and Federal spending problems could the politicians, pundits and policy people agree?  Or would it take some new and powerful force to shine a spotlight and focus the collective vision on this solution, and what would that force be?

These are the two questions I’ve been asking myself as the battle over Federal spending has become near white-hot, and as it has become increasingly clearer that long-term Federal solvency and deficit reduction will require addressing the growth in healthcare spending – particularly Medicare.

Federal Outlays and Spending - Medicare - 2010 Pie Chart[Source: Kaiser Family Foundation “Medicare Spending and Financing,” February 2011]

To summarize the highlights of this situation:

  • Cutting non-defense discretionary Federal spending can’t produce the reductions needed to significantly impact the deficit – contrary to the general misunderstanding about how the Federal budget is spent.

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Fundamentals of Health Reform and Transformation

Trying to follow what’s being written about implementing health reform has been like trying to drink a waterfall. Having followed these issues for many years I’ve gleaned some fundamental aspects about many of the ideas and recommendations that simplifies how to approach this flood – including how to evaluate ideas and proposals like Patient-Centered Medical Homes (PCMH), Accountable Care Organizations (ACO), Shared Savings, Health Information Exchanges (HIE), Pay-4-Performance (P4P), etc…

Structure v. Reimbursement Systems/Arrangements
First, discussions and descriptions that don’t  affirmatively recognize the distinction between Structures and Reimbursement Systems can create significant confusion. For example, the requirements for a PCMH to be recognized by the National Commission for Quality Assurance are structural, but how they are reimbursed will strongly influence how successful such practices are for improving quality of care and controlling costs.…

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US Healthcare Spending – 2009

With all the focus on US health spending I thought it would be useful to update the pie chart I’d posted previously that showed 2007 and 2006 National Health Expenditures.  So below is the chart showing US health spending for 2009.


US Health Spending 2009

What can be seen by comparing this chart with the previous ones is that the percentages haven’t changed very much.  Which means that the foci for cost containment still needs to be on hospitals and physician services and how they influence other types of spending.  For example, avoiding hospital admissions, and utilizing clinical services provided by non-physician professionals, etc…. More on this to come in future posts.…

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Smoking, Exercise and Obesity – The Big Three

I’ve been working with a Midwestern community for the past 7 months to improve the quality, efficiency, and value of their healthcare – as measured by public health population status, and the cost and quality of medical services.  This experience has  reinforced what I’ve been hearing repeatedly for the 28+ years I’ve been working with healthcare challenges:  The three most significant areas for improving quality and controlling costs related to illness and healthcare are reducing smoking, increasing exercise, and reducing obesity.  (The latter two are connected, but they also have separate and important benefits.)

While I will be writing more about each of these health problems in the coming weeks, (along with many other health policy issues involving innovation, system transformations, and the ongoing debate about health reform legislation),  I first wanted to lay out some top line perspectives on smoking, exercise, and obesity.…

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Making Health Reform Work

The May issue of Health Affairs focuses on Reinventing Primary Care – a topic that has been part of health policy discussions for at least 20 years. A few things have changed in that time: now there is better evidence about the importance of primary care providers in coordinating care to improve quality and reduce costs; the structural concept of this care coordination has been codified under the new term the “Patient Centered Medical Home,” (which has also been given precise parameters by NCQA); the complexity of medical care has increased so that the need for care coordination is greater; and electronic information storage, analysis, and communications technologies have been developed which – in theory – should make care coordination and the resultant quality improvement and cost control easier and more practical.…

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Health Care Reform (PPACA): By the Numbers and Political Battles Over Numbers

A week ago I ran into a long-time Republican health policy expert who was very excited about the Memorandum the CMS Chief Actuary had released on April 22nd about the financial effects of the Patient Protection and Affordable Care Act (PPACA).  He was very excited because he believes that the Memo has significant information that will support repeal of the new health reform law when the Republicans take over one or both houses of Congress next year.  (FYI – Current credible speculation puts the House as a toss up for Republican control in 2011, but the Senate is less likely to switch party control.)…

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The Internet Solves Everything in Healthcare – – – NOT

Improving healthcare will require people having better information.  That concept is generally agreed upon.  The challenge is getting the right information to the right people at the right time.  That is the interconnected goal of different facets of health information technology – from EMRs and PHRs, to health information exchanges.

People Are Complex
However, the complexity of medical care and individual variability – both human physiology and patient preferences – makes collecting and analyzing health information so that it is useful for individual clinical decisions much more difficult than presenting information about TVs, computers or cameras on a website such as CNET.…

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Regulating Insurance: States v. Federal Roles

One of the fascinating issues within the health reform debate is how to improve the insurance market by changing government regulations.  While large employers who self-insure are except from state regulations, (and must only conform to limited Federal rules under ERISA), individuals, small groups, and others who actually purchase insurance have their policies regulated by individual states.

Both Democrats and Republicans agree that the current system of insurance regulation creates job lock and other socially undesirable effects, and that insurance companies should be able to sell policies across states lines.  However, their solutions are quite different.

Democrats favor national regulation to create a single playing field, and Republicans prefer permitting insurance companies to sell in multiple or all states if they are licensed and regulated in any state. …

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Missing Pieces of Health Reform

At a briefing in Washington DC this morning, two very well respected and reasonable economists talked about how the increasing prevalence of chronic diseases and care delivery in outpatient settings are driving up costs in Medicare.  They also asserted that a greater focus on real cost containment – and possibly cost reduction – should be the focus of health reform, and that this could be achieved by increasing team based care coordination and increasing personal responsibility for care and costs, among other focused initiatives that might require political courage…..which one of them noted appears to be currently in short supply.

Their conclusions and analyses are all well reasoned and reasonable, but having listened to these types of analyses and briefings for more than 20 years I was stuck by two things. …

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