Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments (1)

Hot Topics In Healthcare Reform: A Primer

For those of who believe there is a pill for every ill, the recent flurry of legislation and ensuing debates on health care reform may be just too big a pill to swallow.

You’ll need a very large glass of water for sure.

“There’s a lot to consider and not everyone is going to like everything about this legislation,” Rep. Lois Capps (D-CA) told participants at Avalere Health’s conference on Raising the Bar:  Payment Reform and CV Disease on Friday, June 12 in Washington.  Capps, a 20 year veteran school nurse, co-chair of the Democratic Heart and Stroke Caucus and member of the House Energy & Commerce Health Subcommittee describes the pending legislation in terms of “choice” and “a balance” but readily admits that finding a way to pay for it will be difficult.

For those who might not feel up to speed on the latest buzz on health care reform, here’s a quick primer:

Public Option. To cover the 47 million uninsured or underinsured Americans, the President is asking for a public plan that would compete within the insurance market place either directly on cost, or indirectly with clout.  Supposedly, this plan (yet to be included in the Senate HELP health reform legislation introduced last week but rumored to be coming in the markup) will be subject to the same rules and regulations of the private health insurance market.  It could be an extension of Medicare, Medicaid or a hybrid of approaches involving capitation and integrated systems for physicians and hospitals.

The debate about whether or not to introduce a new public option to the current health insurance system involves more than a sense of fairness or simply closing the gap.  The private insurance business is strongly tied to state regulations and competitive forces that will remain as long as 15% of Americans purchase their insurance out of pocket and another 40% have insurance through employment .  Designing the right form of public assistance that can compete with private insurance but not control the market place is surely to reflect the strong differences between political parties.

Centralists in Congress, namely Sen. Kent Conrad (D-ND), have proposed co-ops as a third approach between a public option and the status quo.  Co-ops are membership-owned and operated non-profit organizations that adhere to state laws for health care coverage and provide health insurance for individuals and small businesses.  Reaction has been mixed but some believe co-ops will hit the right balance of competition and public assistance needed for passage in the Senate.

Comparative Effectiveness. Comparative effectiveness research seeks to compare the clinical effectiveness of two alternative therapies for the same condition.  It’s rooted in the idea that our system of paying for the volume (e.g., “fee-for-service”) should be replaced with payment for effectiveness and value that is based on the best science possible.  Recent examples of comparative effectiveness research include trials comparing bare metal coronary stents to drug-eluting stents and comparing older versus newer drugs for treatment of schizophrenia.   All this can be extremely valuable to clinicians and patients trying to decide between alternative courses of treatment.  And to the extent that comparative effectiveness research improves the quality of care, it can also reduce costs.

But clinical data alone cannot reflect patient preferences or whether a treatment course for the overall population is the best one for an individual.   The hot button here is how to encourage clinical research that can help physicians and patients make the best treatment choices yet safeguard it from being used by insurance companies and the government to deny coverage or set payment.  What, exactly, will be compared needs close scrutiny.

Accountable Care Organizations (ACOs). An ACO is a combination of one or more hospitals, primary care physicians and possibly specialists, who are accountable for the total Medicare spending and quality of care for a group of Medicare patients.   Various carrots and sticks are being discussed, but the idea is to control Medicare spending and improved quality of care.  While most physicians recognize the need to move away from Medicare’s fee-for-service approach, the incentives and infrastructure needed to coordinate among providers isn’t apparent.  What about rural areas where coordination of care is a misnomer?  This may be a hot topic for systems change, but practitioners are skeptical.

Patient-Centered Care. It’s hard to imagine that the American College of Cardiology felt the need to launch a new initiative, the “Year of the Patient” or the British Medical Journal depicted tango dancers on its cover story, “Partnering with the Patient” but re-infusing the health care debate from the patient’s perspective is long overdue.   Look for it in every piece of legislation, new commission and advisory group.  Raising the voice of a few on a plum commission or panel discussion  is a laudable start, but we’re all, at one time or another, patients.  We’re all consumers of health care and drawing upon our own experiences to improve our professional stance will be necessary.

Gateways. The Senate HELP Committee’s legislation introduces the concept of “gateways” or “exchanges”, a clearinghouse of sorts on a state level to help consumers parse through insurance plans and public services.  The program would be optional for states for the first six years then federal compliance would prevail.  Organizations such as Kaiser Family Foundation have already established online “gateways” (www.healthreform.kff.org) to inform consumers wanting to know more.

Health reform is coming fast and furious.  On Monday, June, 15, the Congressional Budget Office is expected to release their projections on what it will take to pay for such massive reforms.  Hospitals and physician groups are deeply concerned about cuts in Medicare payments – estimated by the President on his weekend radio chat as an additional $313M on top of the $309M included in the Administration’s FY2010 budget.

Further legislation will be released this week; keep an eye on the Senate HELP Committee, Senate Finance Committee, House Energy & Commerce, House Ways & Means, and House Education and Labor.

There’s much more to health reform than covered here.  I encourage you to find a passion point of entry and share your insights.

And get ready to swallow a very big pill.

Here’s a quick list of what’s hot in health care reform:

  • Public Option
  • Electronic Medical Records
  • Elimination of pre-existing exclusion
  • Patient-Centered Care
  • Accountable Care Organizations
  • Payment based on value not volume
  • Integrated health delivery systems
  • Federal Health Board
  • Transparency in data, costs and outcomes
  • Personalized health care/personalized information
  • Chronic care models/Transitional Care Models
  • Prevention and wellness programs
  • Comparative Effectiveness
  • Payment reform/Medicare cuts
  • Shared decision making

You may also like these posts

Read comments »


One Response to “Hot Topics In Healthcare Reform: A Primer”

  1. Becky says:

    Your list of what's hot in health care reform is missing its foundation for implementation: Single payer.

    Everyone knows about this option and the fact that it's being kept off the table by vested interests, hoping it will just go away.

    Keeping hundreds (thousands?) of private health insurance companies, and their profits, intact is why startup costs for reform will be so huge. We could do it for less if the public good was really a consideration here.

Return to article »

Latest Interviews

Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

Read more »

How Do Hospital Executives Feel About Locum Tenens Agencies And Traveling Physicians?

I recently wrote about my experiences as a traveling physician and how to navigate locum tenens work. Today I want to talk about the client in this case hospital side of the equation. I ve had the chance to speak with several executives some were physicians themselves about the overall…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »