Controlling Health Care Costs and Improving Quality with Effective Care Coordination

February 16, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Quality of Care & Safety / 2 Comments

A study published by in the New England Journal of Medicine last week examining the effects of 15 different Medicare care coordination demonstrations received wide coverage by the general media. Unfortunately, much of this focused on the study’s overall finding that these programs didn’t reduce hospitalizations or Medicare spending. For example, the AP story’s headline, “Study finds bid to cut Medicare costs failed,” was used by many papers such as the Washington Times.

However, the actual study had much more complex, important, and useful findings, and the paper’s authors from Mathematica, (which Medicare contracted to do the analysis from this project), deserve a lot of credit for extracting meaningful information from this project.…

High Costs of Cancer Treatments for Patients Not on Medicare

February 5, 2009 / Michael D. Miller MD / Economics & Financing, Health System Reform, Medicaid, Private-Employer Based Health Insurance / No Comments

Last week I wrote about the challenges of people with Medicare getting the best treatments for cancer. Today, the Kaiser Family Foundation released a report examining the challenges people who get insurance through the private system, (i.e. employer based or individually purchased), have affording their cancer treatments. And how the public insurance programs, (i.e. Medicare and Medicaid), have waiting periods or other enrollment requirements that delay or prevent patients from being covered immediately – something which is of particular concern for patients with cancer.

The Kaiser Family Foundation’s report presents an excellent mix of data analysis and individual patient examples. The report’s conclusions are that our health system has a significant number of holes (or cracks) that people can slip into causing them to suffer clinicall and/or financially. …

Managing Expectations for Federal Health Reform

January 28, 2009 / Michael D. Miller MD / Access to Healthcare, Federal Healthcare Reform / 1 Comment

One of the challenges facing health reform legislation are the expectations of different stakeholder groups – many of whom were strong supporters of the Barack Obama’s campaign. Although the new Administration has only been in office a week and a day, a number of signs point to the fact that health reform legislation will not be quickly formed and passed – including an article in today’s Boston Globe titled, “Some fear window is narrow for healthcare overhaul.”

But not rushing health reform was both predictable and a good thing. First, the reasons why it won’t happen quickly:

It takes time for the new Administration and Congress to get organized – and they are rightly prioritizing actions to address the economic “situation”
The US system of government is designed to be deliberative and not speedily make major decisions
For reasons that are not fully apparent, the Senate is taking longer to confirm Tom Daschle as Secretary of HHS – although there are no signs that this won’t happen soon
Senator Kennedy’s health has been a question mark, but his staff has been working diligently to prepare legislative framework and language in conjunction with other Congressional offices such as the Finance Committee
Congressman Waxman’s taking over the Chairmanship of the Energy and Commerce Committee will likely mean some staff turnover in that Committee which also takes time – particularly since Congressman Waxman is known for getting some of the best and brightest staff in Congress

And second, not rushing health reform legislation through the process may be a good thing because no matter what scope and details the legislation eventually includes, getting more groups comfortable with its goals, priorities and specifics will make it more likely to succeed. …

Health Reform and the Economy: 4 Spheres to Consider

January 25, 2009 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Health System Reform / 2 Comments

Many people and pundits have opined on the effects that the economic downturn will have for the likelihood of health reform: On the Federal level, how much money will be available for expanding insurance coverage, and how much money will be included in the “stimulus package” – and for what? And in the States, how much will be cut from Medicaid programs and government employees’ benefits? In addition, there have been news stories about the economic downturn leading to loss of insurance coverage secondary to job-loss, as well as people forgoing direct medical care, healthy activities, and wellness behaviors.

These points illustrate how the multiple parts of our health care “system” interconnect, (particularly financing effecting delivery), and everything existing within the overall economic environment. …

Quality of Care in Medical Practices – Size Does Matter

January 19, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety / 6 Comments

The Journal of General Internal Medicine published a study last month that looked at primary care medical practices in Massachusetts to see how well they were able to provide the quality improving capabilities of Patient-Centered Medical Homes. These structural capabilities represent process measures that assess the quality of care in medical practices. However, these same measures could also help patients select their own primary care physicians.

Study Finds Larger Practices Have More Quality Related Capabilities
Not surprisingly the study found that larger practices, (and to a lesser extent those affiliated with larger networks of practices), provided more capabilities to improve the quality of patient care.…

Health Spending, Health Reform, and Physicians

January 15, 2009 / Michael D. Miller MD / Economics & Financing, Federal Healthcare Reform, Politics / 7 Comments

The Centers for Medicare and Medicaid Services released 2007 US healthcare spending data in late December. Since then several publications have come out analyzing this information. The most comprehensive is probably a Health Affairs article which highlighted a slowdown in the growth in spending for prescription drugs and government administration.

The Center for American Progress also recently issued a paper comparing the US healthcare system in 2007 to the situation in 1994. This paper concluded:

“The status quo of American health care is spending more money to cover fewer people, yielding disappointing outcomes. Effective reforms, which would invest in measures to improve the quality and delivery of care, reform payment to reward outcomes, and provide affordable, accessible, comprehensive health insurance for all Americans, are long overdue.

…

Health Reform – Achieving Universal Coverage

January 5, 2009 / Michael D. Miller MD / Access to Healthcare, Delivery of Healthcare, Health System Reform, Medicaid, Public Health / 5 Comments

During the holidays the Obama Health Transition Team urged people to organize discussions about health care in their homes and communities – and then to report back. Reading about these discussions – including the one that Secretary Designee Tom Daschle attended in Indiana – made me think about what things are going to be needed to make health reform actually work.

My end-of-year reflections and ruminations led me to conclude that one of the most challenging parts of health reform will be to actually get more people enrolled in whatever expanded coverage plans are developed and implemented. Enrollment barriers are not new, but they are frequently not highlighted because they may present great political and fiscal risks.…

Transparency v. PAYGO in Health Reform Legislation

December 18, 2008 / Michael D. Miller MD / Economics & Financing, Federal Healthcare Reform, Health System Reform, Politics / 1 Comment

One of the looming questions for health reform legislation in the 111th Congress is how will it be paid for? Or will that be less of a concern because deficit spending in a recession is deemed to be OK?

In earlier times, (i.e., 1990s), the projected costs of legislation had to be “paid-for” under the so-called PAYGO rules – which stands for “pay-as-you-go.” However, in recent years those rules have lapsed or been waived.

Three recent nuggets of information indicate that transparency in the legislative process may be replacing PAYGO in the coming years. First was the Obama Transition Team’s extra-ordinary level of transparency, exemplified by their policy of having information from all meetings with outside groups being posted on the Change.gov…

Health Reform in a Changed Political and Policy Environment

December 15, 2008 / Michael D. Miller MD / Federal Healthcare Reform, Health System Reform, Politics / 3 Comments

Several pieces of information and events have recently made me appreciate how the policy and political environment for health reform will be very different in 2009 from what we’ve seen before.

First was an article in the November 22nd issue of National Journal, (“The New Power Landscape”), which describes how the process for influencing legislation (a.k.a. lobbying) will be different in the coming years: “On the way in is a more collaborative approach that relies on identifying allies and building coalitions with other interest groups, as well as grassroots organizing.” The article specifically posits that the importance of access to influential people, (i.e.…

Making Physicians Better, and Making Better Physicians

December 10, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Public Health, Quality of Care & Safety / 5 Comments

A few recent reports point to ways for improving the quality of physician delivered care that has little to do with technology or complex interventions. The first involves how physicians interact with patients, and the second examines the work hours for physicians in training.

Etiquette in Medicine
The first article, by Dr. Michael Kahn in the New York Times, describes six recommended actions for physician to create a good rapport with hospitalized patients. Dr. Kahn collectively calls these actions “etiquette-based medicine”:

Ask permission to enter the room; wait for an answer
Introduce yourself; show your ID badge
Shake hands
Sit down.

…

Medical Homes, Hammers and Nails

November 10, 2008 / Michael D. Miller MD / Access to Healthcare, Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety / 2 Comments

Medical homes are being promoted as a way to improve health care delivery by increasing the coordination of patient’s primary and specialty medical care. The goal of medical homes is to ensure that patients’ care is comprehensive, appropriate and patient-focused.

One of the benefits to the patients and the healthcare system is that medical homes can help sort out the confusion that can arise from the phenomenon sometimes described as, “When you’re a hammer, everything looks like a nail.”

In healthcare delivery what this means is that sometimes the diagnoses or treatment recommendations from specialized clinicians will reflect their expertise – and thus their may be inconsistencies or conflicts in the recommendations coming from several specialists.…

McCain Plan Would Tax 100% of Health Insurance Costs

October 23, 2008 / Michael D. Miller MD / Economics & Financing, Federal Healthcare Reform, Health System Reform, Politics, Private-Employer Based Health Insurance / 1 Comment

I had a revelation tonight at an event about women’s health issues in the Presidential election at the Kennedy School of Government’s Institute of Politics. One of the speakers was Gail Wilensky – a Senior Health Care Advisor to Senator McCain’s campaign. I asked her a question about how Senator McCain’s proposal to eliminate the tax deduction for employer provided health benefits would effect non-profit organizations since they don’t pay taxes.

Gail Wilensky’s answer really shocked me. I’ve been doing health policy work for about 20 years, and following the election’s health issues for the last year. What she said was that it wouldn’t matter whether the person worked for a non-profit or a for-profit company, since the employee would be the one paying tax on the entire cost of their health insurance – whether it was their contribution, or dollars coming from their employer.…

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