We Have The Month of August To Think About Healthcare Reform: Let's Not Waste It With Choice A or Choice B

Whew! That pressure cooker known as Congressional health reform has taken a one month break. During this legislative downtime, our elected representatives will have a month to hear what their constituents think. If they’re smart, they’ll also check in with the health policy bloggers from time to time for insights unavailable anywhere else. Readers just need to watch out for all those preconceived non-transparent and recycled notions based on inflexible ideology.

Speaking of which, the Disease Management Care Blog distrusts anything that offers BIG solutions in the health reform. That includes big health care insurers, big government solutions, big power held by a single group of insulated experts or big piles of regulations. The DMCB likes small overlapping regional insurers that are tightly regulated by State governments. It’s a messy patchwork but the DMCB thinks it works pretty well for most people most of the time.

What isn’t working for the small insurers is the battle against health care inflation: as costs spiral up, the patchwork is raising prices. It doesn’t have Medicare’s advantage of being able to print money or Medicaid’s ability to pay pennies on the dollar. The DMCB also doubts the huge multi-state commercial insurers are all that effective in controlling costs either. Ultimately, because health care costs are so expensive, everyone’s ability to pay for hospital and physician services is being frayed and getting more ragged. This is effectively shutting millions out of affordable coverage.

No wonder vituperative critics to point to the ‘immoral’ and ‘villainous’ business logic of insurers diverting some of the premium dollar to administrative costs or shareholders. They have a point. Yet, the contrarian DMCB wonders why more of our leaders aren't visibly shocked by the absolute amount of premium dollar that is going to health care costs in the first place. It asks if pumping even more money toward the medical-industrial complex will only feed the beast. Which is truly better: a) insurers returning income to their investors that can be used to support other productive areas of the economy, or b) insurers spending premium in their networks that is used to build another hospital wing the size of an ocean liner (with a fountain in the lobby tossed in for good measure), buy more magnetic resonance imaging scanners so we can scan even more patients more often, pay for stratospherically expensive chemotherapy that adds weeks to cancer patients’ life expectancy or open more bariatric weight loss surgi-centers?

The DMCB thinks the real answer to the question is ‘c).’ The answer is complicated, multi-faceted and some of it is scattered in prior posts.

So far, it seems to the DMCB that the current batch of reform proposals before Congress favors making things bigger without really addressing the underlying inflation problem. No coherent ‘c)’ option from inside the beltway is in sight yet.

That’s the DCMB’s preconceived notion during the August recess, but unlike other bloggers, it is a) alerting readers to its biases ahead of time and b) is more than willing to change its mind over the next month.

An Examination of the Public Plan Option

The Disease Management Care Blog really liked this efficiently written Wall Street Journal piece on healthcare reform. While it didn't agree with everything, the inspiration led this humble blogger to review the main arguments in favor of the public plan, which are paraphrased below.

A public plan will keep the private insurers honest.

Given the prior Administration’s failures, it seems comforting to believe that a change in leadership means the Federal government’s track record in healthcare is destined for change. Yet, Veterans and American Indians have been disappointed by broken promises from both sides of the aisle for decades. Alternatively, if we agree that the D.C. mandarins are imperfect, it’s hard to understand how they are necessarily less so than many smaller and honorable not-for profit plans that remain largely unmentioned by the national media.

Private insurers have broken the public trust

While we can thank some incredibly tone-deaf plans for introducing the word ‘rescission’ into the popular vocabulary, buying insurance only when its needed and driving up premium rates for those of us who play by the rules has a more familiar word to describe it: fraud. The specter of coverage denials is also understandably frightening to healthcare consumers/voters, but the other side of the story is our collective sense of boundless entitlement and unwillingness to read and grasp the small print in a binding contract, especially when it's too good to be true. Yet somehow, we’ve been led to decide between these two extremes by abdicating a huge slice of our economy to a dysfunctional political club that relies on bombast, political expediency and unread legislation to govern.

Public insurance has a lower overhead, which means savings for consumers

The notion that government can do anything more efficiently strains credulity. What’s more, comparing Medicare and commercial insurance is like comparing the alternative universes of Nancy Pelosi and Sarah Palin. While commercial insurance has its own set of issues, the truth is that government-run programs like Medicare rely on an arcane thicket of Federal regulations subject to desultory retroactive IRS-like enforcement by the underfunded Office of the Inspector General, which is only spurred to action when the problem becomes ‘staggering.’ Add this 10% waste factor to CMS' considerable hidden overhead and the transfer of many expenses to the providers and the government doesn't look like such a good deal anymore.

The public option will control costs

The logic here is that the Federal government will be able to use its purchasing power to force a better deal for healthcare consumers. A better possibility is that the long-standing pattern of underpayment to hospitals and physicians by Medicare and Medicaid will spread to new sector of the healthcare market, leaving hospitals and doctors with nowhere else to go to recoup their costs. The end result will be price controls, which are economically indistinguishable from queues and rationing.

If you have insurance you like, you can keep it.

The insurance you like now won’t disappear overnight, but its demise in the coming years, thanks to inevitable crowd-out, hostile tax policies, clumsy regulations, Congressional meddling and unintended consequences will likely lead to a three tier system: underfunded Medicaid at the bottom, the one-size-fits-all middle public plan and the gold plated plans only available to our highest paid elites with the best benefits. Care to guess which one will be used by our political leaders?

Cost vs. Benefit in the Healthcare Reform Debate: More on Pacemakers in Centenarians

In its Obama Pacemaker post, the Disease Management Care Blog pointed out that critics would use the President’s convoluted response about the merits of a $30,000 device in a 100-year-old against him. As if on cue, the Wall Street Journal (WSJ) editorial pages mined Mr. Obama’s answer and came up with an interpretation that predicts that government rationing is around the corner.

The WSJ’s clairvoyance aside, the DMCB has some Peggy Noonan- inspired (and unsolicited) advice for reform-minded policymakers who are struggling to answer questions about cost and value: we need to reduce our wonky paragraphs down to sentences. There is a time for careful reasoning and then there is a time for conviction. If meaningful reform is to occur, now is the time for the latter.

Take disease management, for example. While it can be thought of as ‘evidence-based population-based care management initiatives that seek to achieve maximum health care value for persons with chronic illness,’ another way to explain it is ‘your nurse that’s there to help you.’ The medical home is supposed to be a ‘team-based patient centered primary care system of care that offers comprehensive personalized care coordination,’ what it really is ‘your own family doctor on steroids.’

And what was the issue that the President was trying to communicate with the pacemaker question? That we are reaching the point where we can no longer support modest individual health gains at huge taxpayer expense. No wonder he dropped his usual laser-sharp eloquence.

Consider the following graph: as health care spending for any group or population or country increases (from low to high on the horizontal axis), the overall benefit as first increases sharply (‘A,’). Then – as more money is pumped in – the incremental additional benefit begins to slow down (‘B’), stop (‘C’) and then actually declines (‘D’).

All those darlings of the health care economists – the Mayos, the Kaisers – apparently inhabit the A and B parts of the curve, while McAllen Texas has been accused of being on the C part of the curve. Open ended health insurers that pay for everything and anything are responsible for the ‘D’ part of the curve. That’s where infections happen among hospitalized patients, where mammograms in low risk women cause more biopsies than save lives, where unnecessary colonoscopies cause more bowel perforations than detect cancer and the where invasive placement of cardiac stents cause more damage than just taking pills.

The D part of the curve accounts for Medicare’s interest in stopping payment for services such as readmissions to the hospital for avoidable complications. Easy.

The DMCB thinks one attraction of comparative effectiveness research is that it can address the C part of the curve – if it is allowed to assess cost. Less easy.

The top part of the B curve is far trickier because that is where pacemakers in centenarians comes in. Very hard. There is cost (in this case, $30,000) that results in real incremental benefit (5 years of quality life and a daughter that can visit her in the home), but it’s not as much as the same pacemaker in a 60 year old (who would get 40 years of benefit, including years of taxable income and trips with grandkids to Disney World). The DMCB thinks the 100 year old got a worthwhile use of healthcare dollars. However, there are more difficult examples of higher cost with lower levels of benefit: one example includes cancer treatments that cost 6 figures and lead to an increased life-expectancy that is measure in months. Another may include the notion that everyone should have a regular physical examination, which rarely detects a problem.

Five other points while we grapple with this:

a) many policy makers think solving the C and D parts of the curve are enough to solve the health care budget crisis. The DMCB isn’t too sure about that.

b) don’t believe that money saved on the B, C and D parts of the curve necessarily means more money will be available for A. The money isn't necessarily wired that way.

c) don’t expect an individual physicians dealing with individual patients to solve this curve on a day to day basis no matter how you pay or decision support them.

d) the DMCB believes disease management and the patient centered medical home - which typically charge less than $100 per patient per month - occupy the steeper part of the B curve: the investment results in considerable increases in benefit.

e) while Mr. Obama ducked the pacemaker question with a paragraph, the day of reckoning is coming: sooner or later, we'll need to use sentences to decide what life-prolonging therapies we can afford and how we intend to afford them.

Blogs vs. Traditional Journals in Health Care Policy Making: McAllen Texas as an Example (and the possibility that it's not an outlier)

Atul Gawande’s New Yorker McAllen Texas article is the policy zombie that refuses to die. The big news is that while this still-walking undead has generated some vigorous debate, it's prompted a fascinating insight about the growing role of non-traditional media in driving health reform.

First off, there’s a lengthy Health Affairs academic, contrasting policy and business-oriented roundabout on McAllen from the learned Elliott Fisher, Gail Wilensky, Robert Berenson and Robert Galvin. Don’t want to read all 16 pages? Neither did the Disease Management Care Blog, who was reminded of an exchange by its spawn years back. The daughter was talking about something extremely remarkable to the utter boredom of her brother. Seeing her enthusiasm wasn’t being shared by the lout, she stopped and asked him what was wrong. He laconically replied the topic was interesting enough, but she was ‘using too many words.’

Thanks to some Argentinean Torrentes and grilled salmon, the wordiness became tolerable and can be summarized for your quoting pleasure as follows:

Fisher: Being from the outfit that brought out the Dartmouth Atlas, he finds Gawande’s lay person style to be an accurate portrayal of the science of variation. Given the public’s interest in health reform, the article's timing was perfect. Dr. Fisher is against slashing prices in an effort to cap McAllen’s expenses and prefers the use of positive incentives, bundled payments and better integration of primary care and specialist physicians.

Wilensky: This former Medicare and Medicaid administrator is concerned that the article may have been too simplistic and missed some other explanations, other than dysfunctional incentives, for McAllen’s outlier status. That being said, she thinks the phenomenon is real and physicians need to be better aware of it. It’d be nice to fashion some turbocharged demos to attack variation, but in the meantime, she doubts physicians are ready to walk away from old fashioned fee-for-service (FFS).

Berenson: He spotted McAllen back in 2003 but no one paid attention. Medicare might want to investigate for fraud and abuse and, if none is present, he’ll chalk it up to the community’s practice style. Speaking of which, Boston, Chicago and Atlanta have much to be desired in their practice styles also. He likes accountable care organizations (ACOs) because they don’t have to take on insurance risk and accurate risk adjusted payments are within reach. If it’s done right, physicians might even be willing to give up on FFS. He also warns that bundled payments don’t necessarily mean that a population will have better outcomes or that hospitals won’t come to dominate the health care scene.

Galvin: This General Electric medical director was also struck by how unaware the McAllen physicians were about their outlier status. He isn’t sure that (ACOs) are a proven answer to the problem of variation and, what’s more, they could become local monopolies. He prefers comparative effectiveness research linked to yet-to-be-developed payment models.

As pointed out in another post, the DMCB agrees there is variation but points out that outliers are a) randomly inevitable in any large market and b) don’t necessarily hold any lessons that can’t be learned by studying the average. The trick is to tell the difference between randomness and causality, which was conspicuously absent in Gawande's article.

But hold on. Maybe McAllen isn’t even an outlier if Medicare enrollment, socioeconomic status and disease burden are properly accounted for. Check out this very important analysis that was posted by health services researcher Daniel Gilden on the Health Care Blog. He concludes that McAllen’s utilization patterns are high, but if careful and standard statistical methods are used to neutralize the cost drivers outside of the physicians’ control, McAllen is decidedly close to the average. In contrast to the Health Affairs posting, every word on this very important article has huge implications for the argument that physicians have run amok with unwarranted practice styles.

So here’s the real lesson: Classic journals like Health Affairs and the New England Journal and their go-to authors still have a role to play in policy discussions but alternative media, like the blogs, are becoming remarkably nimble in ‘posting’ insights that seem to be out of reach of these traditional information venues. While policy giants went on and on and on in the staid Health Affairs, Mr. Gilden chose the non-traditional but widely read THCB to post an important and provocative analysis that will undoubtedly garner significant attention. It's deja vu all over again for the DMCB and its spawn.

That’s why the DMCB hasn’t submitted many manuscripts lately to any journals. Sure, keeping a blog is fun and just as remunerative as assigning eternal copyright to the publisher for free, but the emerging potential of the web as the most important source of health policy information is truly remarkable.

A Peek at the U.S. Senate Committee's Health Reform Proposal

An expository (and exclusive) on-line summary of the U.S. Senate’s Finance Committee’s health reform proposal is available via the levorotatory Ezra Klein’s Washington Post column that the Disease Management Care Blog discovered thanks to the mulish Matthew Holt over at the hortatory Health Care Blog. The fact that he is accusing the Dems of pusillanimity suggests the proposal is practicable. But, we share an admiration for HotForWords, which makes Matthew’s point of view exculpable. But don’t take the DMCB’s 'word' for it, check it out the summary for yourself.

Hope vs. Optimism for Healthcare Reform

Today, the Disease Management Care Blog listened in on Michel Martin's Tell Me More, which featured an interview with three physicians (Dr. David Ellington of Lexington VA, Dr. Hector Flores of Los Angeles and Dr. Carolyn Barley Britton of the National Medical Association) who have special expertise in the care of low income patients. None of their points of view over the public option, payment reform and the role of primary care were particularly suprising. Toward the end of the interview, each were asked about their level of optimism over the prospects for health reform. 'Very optimistic,' said one, for at least incremental reform, 'stars are aligned,' said another, while the third said the ball 'will move down the field... we're going to do it.'

The DMCB hopes there is health reform if it's done right. As for being optimistic, well.........



Hatp tip: HealthHombre

So, What Is a Health Insurance 'Cooperative?' and Five Reasons Why Senator Conrad's Idea is a Realistic Option for Health Care Reform

If you've been following developments in Washington's attempts at health care reform, you may have read how the concept of an 'insurance co-op' was "pitched" by Senator Conrad (D - N.D.). See him describe it here. It's a compromise offered to bridge the disagreement over just how the Feds should sponsor a public option.

Senator Baucus (D-Mont.): “I am inclined, and I think the committee is inclined, toward a co-op”

Senator Grassley (R - Iowa): "there was a thing suggested that would be kind of a private-sector option along the lines of co-ops."

Senator Rockefeller (D - W. Va) is "dubious."

Senator Hatch (R - Utah) "I'm totally opposed"

When the Disease Management Care saw the term 'insurance cooperative' bubble up in its news feeds, it was confused but, unlike our Senators, didn't offer up any snap judgments. Instead, it did its homework. At first, it thought a 'co-op' was a large carbon footprint air-conditioned store filled with baguette-laden wicker baskets where boomer earth mothers and natural-foodies drive their hybrids to buy over-priced asparagus. That plus high end Chardonnay. Thanks to some web-enabled detective work, the DMCB found out they don't necessarily involve hybrid automobiles and that the concept of a co-op can be applied to the purchase of health insurance.

So, exactly what is this thingie called an 'insurance cooperative' and what is its potential for meaningful health reform? Because you regularly read the DMCB, you'll find the answer to this question well before you can finish that lunch you've been eating at your desk.

According to this Commonwealth Fund Issue Brief, an insurance co-op exists when small employers 'band together' on a regional basis to form a purchasing block that can negotiate better deals with the local commerical health insurers. This efficiently consolidates the decision making, billing and servicing under one roof and often allows for choice among several competing plans. It also allows all the participants to 'pool' their insurance risk, which, in turn, should lead to lower and more predictable premiums. Unfortunately, the track record of co-ops has been spotty, apparently because member businesses are constantly on the look-out for better deals and may exit the co-op, leaving the higher-health risk businesses behind in the equivalent of a death spiral. If they don't keep and maintain a large market share, they can't go toe-to-toe with the commerical insurers.

For a more complete review, this paper from Health Affairs teaches us about a number of pooled purchasing arrangments including the 'co-op.' It seems this has been around for a long time. They typically operate at the state- level, are not for profit, are run by employers, don't have to accept all insurers, carve out the administrative/back office functions to an insurer for an administrative fee, leave it to employees to choose the insurance they want from a list, and, thanks to ERISA, may not be subject to all State regulations.

And if you're wondering if the famous Group Health Cooperative has anything to do with this, the answer is yes. Back in 1947, a multi-member community-based group decided to buy its own clinic to offer health care for its employees. The rest is history.

How would the co-op fit in healthcare reform? According to this link, the legislative outline currently under consideration would require them to be State-by-State or regional, non-profit, provide a coverage option for individuals and small businesses with as few as 2 employees, be subject to State laws and have 'governance standards' that would presumably trump a consumer focus in the Boards of Directors.

The naive DMCB thinks the co-op idea may develop legs:

1. As noted previously on the DMCB, as debate on the public plan option matures and stakeholders realize it's not synonymous with 'Medicare for All,' the focus will shift toward other more politically nimble options that also offer credible health insurance. The co-op is such an option.

2. According to the Commonwealth Brief and Health Affairs articles described above, commercial health insurers don't like co-ops because they force them to compete on price instead of benefit design. The fact that insurers have historically been hostile to the co-ops is telling and could be reason enough for many Democrats to support the idea.

3. Without a government-run public plan, employers will have less of an incentive to drop health insurance for their employees.

4. The very term 'co-op' has the kind of fuzzy appeal - like ''pesticide-free' or 'consumer directed' - that the Democratic majority can spin while it seeks to counter partisan Republican attacks.

5. While the the DMCB has seen little evidence of input from the NAIC anywhere in the healthcare reform debate, it suspects the nation's insurance commisioners would support the co-op as a reasonable compromise between the State and Federal governments over what is a looming intrusion by Washington DC into their space - which, by the way, they think they've done a good job regulating. Recall that Ms. Sebelius is a Past President of the NAIC, so she'd probably understand how her fellow Commisioners could shepherd the State by State co-ops into position.

The articles above are somewhat skeptical about the ability of co-ops' to control costs. While that is a fair assessment of their track records, some of the examples cited occurred during the 1990s, when health care costs were on their way down and employers were disinterested. That's not the case now, so the DMCB thinks their prospects are better. That being said, If the co-op idea moves forward, look to Congress ponder regulations that keep (as in 'mandate') small employers and individuals in the co-op risk pool and keep insurers from poaching away low risk business with side deals.

McAllen Texas and Healthcare Utilization: A Function of Statistical Variation, Not Poor Policy

How about McAllen Texas? Readers may recall that locale* was the topic of an essay in The New Yorker magazine by the impressive surgeon-essayist and Democratic advisor Atul Gawande. The McAllen 'hospital referral region' has the dubious distinction of having been identified by the Dartmouth Atlas as being close to the top nationwide (pretty cool graphic) for the amount of total fee-for-service Medicare dollars spent per beneficiary in 2006.

The DMCB’s first reaction was “so what?”

It took a second look when that hapless locale was seized upon by Peter Orszag of the Office of Management and Budget (OMB), Consumer Reports and some notable blogs as the symbol for all that ails American healthcare. Commentators are accusing the ‘McAllens of this country’ of consciously and unconsciously economically ripping off the system with precious little quality to show for it.

Yet, the dubious DMCB remains unexcited about Dr. Gawande’s faux discovery and disappointed that others haven’t considered the most likely cause of McAllen’s outlier status. Is there something really special about McAllen or is something else going on?

To illustrate the point, conduct a thought experiment by imaging many bags of pennies (to pay the primary care providers), quarters (for the rest of the physicians) and dollars (yes, they are available as metal coin) for the hospitals suspended above a huge map of the United States. Mentally open the bags, releasing coins that fall, clatter and roll across the map. Since the distribution of the coins is random, some areas of the U.S map will have no coins, others might have just pennies, others may have dollars and pennies, some will have all three and a few will have lots of all three. Somewhere on that map, however, there will be a pile of coins that is bigger than the rest. Perform the same experiment using Monopoly style plastic clinics and hospitals across a board-map and the same thing will happen. In these thought experiments, the area of the map with the extreme outlier status happens to be McAllen*.

It’s hard for non-statisticians/non-economists to think of human behavior in markets as being ‘randomly’ distributed around an average, but it’s true. The best (painfully so) examples of this are the performance of mutual funds, as well as what happens to losing vs. winning teams and their professional sports coaches . The same is true in healthcare: given the overall upward growth in the number of hospitals, specialists and clinics with an inevitable distribution (both high and low) around that trajectory, it is statistically inevitable that there will be a McAllen somewhere in the United States.

It is the nature of our minds to believe there must be something “causing” outliers. In other words, there must be something about McAllen that attracted all those coins, right? The DMCB, in reading Dr. Gawande’s article, thinks that may be true in Miami (which is number 1 in the U.S), but it doesn’t think that's the case for McAllen as described in the New Yorker magazine article. The gumshoe M.D. reporting clearly shows the McAllen providers are mystified by their status. It’s not as though they planned to take advantage of the system. In fact, they didn’t. That’s because it’s all random.

This is important because most healthcare providers involved in quality improvement learned long ago that ‘identifying’ and then ‘managing’ outliers with targeted interventions is a poor way to promote overall system improvement. Outliers naturally regress to the mean over time and they're not the problem anyway. Rather, the trick is to reduce overall variation around the mean (reducing the standard deviation) and to move all providers toward a better average level of behavior. That’s a lot of complicated work that, frankly, isn’t as enthralling to editors or the readers of The New Yorker. It's too much work.

While popular media can be forgiven for using simplistic descriptions of extreme outlier anedotes to pander to a political agenda, the DMCB isn’t too sure about Dr. Gawande. However, the DMCB is most frightened by potential reaction of the OMB. Short of complete central planning for the entire health care system, random distributions of performance, expense, quality, claims, satisfaction and countless other measures around a mean will be unavoidable. Of all persons, Dr. Orszag should understand that outliers are an ironic certainty, not evidence of malfeasance. Most are anomalies, not proof of anything. They are, in short, interesting, but not lessons and certainly not the stuff of policy making.

*correction: McAllen is not a county in Texas.

Is 'Patient Centered Care' the Jordan River for Health Reform? Thoughts on Dr. Berwick's Piece in Health Affairs & Implications for Disease Management

Ever hear of 'patient centered care?' You might think those are just the standard buzzwords applied to any healthcare initiative that means well. Like.... reducing rehospitalizations, promoting access to primary care, increasing immunization rates and expanding coverage to the uninsured. They’re all ‘patient centered,” right?

Wrong.

The ever insightful and occasionally contrarian Don Berwick of the famous Insitute of Healthcare Improvement takes up the topic in a Health Affairs 'web exclusive.' It's worth a look for anyone interested in treading on the less traveled paths of health reform. While there is a surprising amount of policy history behind the idea, patient centeredness ultimately means that the patient is in charge. Period. That means it's the responsibility of the health care system to meet the patient's needs as defined by the patient - not the professionals, not HIPAA weenies, not pencil headed administrators and certainly not picayune insurers hiding behind reductionist definitions of medical necessity.

Wow.

Before you snort derisively at such a naïve notion and decide to surf on over to the Health Care Blog for more tiresome reruns on the virtues of single payer systems, the wonderfulness of EHRs and the evils of AHIP, pause and think about walking on this wild-side. Then realize Dr. Berwick has already anticipated the three biggest objections from us know-it-alls in the healthcare expert class:

1) Patients may override evidence-based medicine. Dr. Berwick thinks that is a small price pay in exchange for responding to a population of patients that are far better informed than we give them credit for. It is very possible to rely on education coupled with lots of provider dialogue to help patients choose wisely. While some may make unwise decisions, that’s more likely a function of the quality of the education and the dialogue. Last but not least, a few crazy and demanding patients should not hold the rest of the medical world hostage.

2) Patients may use up precious resources. Dr. Berwick asks 'as defined by who,' especially when you consider that demand for health care services doesn't drive supply, rather it's vice versa. Paradoxically, if persons were truly allowed to make their own decisions, the overall demand for health care services could go down.

3) Patients may lose out on the two-way doctor-patient relationship. Dr. Berwick points out that it is far more common for docs’ to tell patients what they can’t have, coupled with emotional distancing. This is a way out of the ‘no, because…’ Desert to the Promised Land of 'yes, if....' Patient Centeredness is our way of getting over the Jordan River.

And he has some simple suggestions. For patients, care needs to be customized, transparent and fully under their control. The training of young physicians needs to be retooled. Older physicians need to be reassured. Finally, providers of health care services can measure performance on patient centeredness using long established and validated surveys created for that very purpose.

The DMCB is intrigued. While Dr. Berwick can be forgiven for restricting his perspective to the patient-physician axis, that doesn’t mean those of us in the population-based care business can’t go further in thinking about this outside the box:

First off, disease management organizations need to approach the topic with cautious optimism. Veterans will recall that the earliest underpinnings of the industry was "patient empowerment." It sounded good at the time, but we were accused of undercutting the physicians' authority. The DMCB appreciates the irony, but doubts a word switch from 'empowerment' to 'centeredness' - even if embraced by Dr. Berwick - will make it any more palatable. That doesn't mean our colleagues in the population-care business shouldn't be prepared to speak to the topic. After all, we are experts.

A small minority of self insured employers and their broker-consultants would be the most likely to embrace a yet-to-be developed 'patient-centered health benefit.' If they can be found (and if the Obamacare blob doesn't impede innovation in commerical employer-based settings), these brave souls could end up being the vanguard of a new chapter in health care reform. An innovative disease management organization could help. Medicare will be struggling on how to sponsor a demo on the topic years from now.

The DMCB thinks the industry-wide focus on ‘evidence-based’ discreet HEDIS measures is a barrier to patient centered care. One way to dispatch this is for insurers to think about a) waiving any and all utilization review and b) pay full P4P to any provider group that convincingly demonstrates they adhere to patient centeredness. Why not? If a patient doesn’t get a mammogram, it’s because the educated patient chose not to. If a high dollar MRI is ordered, it’s because the educated patient wanted it. To go even further, insurers could offer up their own X-Prize to any physician group that develops the criteria and delivers on the promises of the patient centered care approach. Disease management organizations could provide the necessary support for a patient centeredness initiative and help sponsor the Prize.

Why not?

The Healthcare Reform Circus

The Disease Management Care Blog spouse doesn’t understand why her husband likes to go to the circus. Well, it’s the Technicolor noisy 3-D spectacle of it all: the elephants, trapeze artists, the ringmaster’s bombast, the army of silly clowns, grimacing tigers, brazen horse-riding Cossacks plus the children of all ages whooping it up while they wave their overpriced battery-powered blinking plastic batons.

Plus, as an added bonus, who else but the DMCB would use this year’s version of The Greatest Show On Earth as a link-laden metaphor for the Big Top of healthcare reform?

In General: compared to previous years, this show was skinnied down: the arena seemed cavernous compared what was happening on the floor: fewer acts with fewer actors. It seemed the economy was sucking some of the air out of the theatrics. It reminded the DMCB of $1.5 trillion worth of air.

The Clowns: the DMCB may have been touchy thanks to the sugar-based caloric density in the surrounding miasma, but it thinks the jesters sported a rather snooty European French-accented persona. This is what we aspire to? What's more, the clowns were clearly responsible for filling the ‘empty’ parts of the show with distracting feel-good silliness while the real work went on outside of the spotlight.

The Elephants: good grief, they are huge. There may have only been ten of them but when they appeared, there was no looking away. Like the uninsured. And one of them, well, did what elephants are known to do while they’re stomping about. A warning perhaps?

The Trapeze Artists: success of Le Cirque du Soleil has clearly prompted a disruptively innovative change from the old fashioned airborne aerial acrobatics to a more flowing crowd-pleasing style of eye candy. Behold the new style of policy making.

The Guy Being Shot Out of the Canon: Absent. Just like the Republicans. ‘Nuff said.

Dogs Chasing Frisbees: quick, nimble, never giving up and often unwilling to let it go. Reminds the DMCB of the healthcare blogs.

Motorcycles: that’s right, a metal caged sphere of death filled with up to seven (seven!) noisy high-speed choppers that miraculously failed to crash into each other. The DMCB doesn’t know how they did it, but it has come to appreciate the how the physics of centripetal force can be altered to make things go up when they common sense says they should go down.

The Tigers: what magnificent beasts. It was quite the sight to see them slinking meekly into position, either sitting, laying down, rolling over or leaning back with claws up on command from the trainer. The DMCB, however, remembers the days when a rifle toting guard was discreetly posted just outside the ring. That may not be such a bad idea even today.

The Horses: and at full gallop too. When they and their riders were stampeding across the floor, it seemed there was no stopping them. But, as persons in the front rows quickly discerned, the horses’ trajectory was not inevitable.

The Ringmaster: The appearance and style were eerily similar.

The $16 Dollar Seats: Considerably cheaper than the seats down below and probably far less than the ‘celebrity’ guests who got to ride around in festooned carts right in the middle of the show. While the righteous DMCB is thinks it’s a crime to deny equal access to first-dollar coverage of the best circus view available for everyone, the DMCB is sad to report that the likelihood of getting the spouse into clown wagon next year is remote. In the coming year, the DMCB will seek movement across the stages of change and aggressively attempt to modify her noncompliance.

The Rumor Mill About the Medical Home Demo (and good news about today's meeting at the White House on health reform)

The Rumor Mill:

The Disease Management Care Blog has heard a completely unconfirmed report that CMS will delay until 2010 the announcement about which States will be chosen to participate in the Medicare Medical Home Demonstration.

It would make sense. The Medical Home may well be a component of major healthcare reform and it wouldn't make sense to have a concurrently running demo. What's more, my primary care colleagues are concerned that participation by smaller primary care sites may be put out of reach by imposing a Tier 3 requirement. Perhaps the whole thing is so star crossed, it should be scuttled.

Let The Horse Trading Begin

Nothing like being invited to the White House for a friendly chat. The DMCB would have liked to been in on some of the background conversations leading up to today's meeting on healthcare reform. If the details about simplification, efficiency, coordination and improvement seem vague, it's because they are. Think of this as a warm up to the painful details that will be discussed at the May 12 U.S. Senate Finance Committee.

Unlike the Bank CEOs, however, everyone hopes they have a chance getting something in return. DMCB readers are already aware of AHIP's posture toward the public insurance option. Kaiser's excellent Health Policy Daily Report points out pharma is holding out to keep cost-benefit analyses out of comparative effectiveness research while providers want to avoid onerous take it or leave it fee schedules. Care to guess what the physicians would like?

However, the disease management community doesn't need to necessarily 'trade' anything. Today's White House meeting affirmed that billions in healthcare costs can be achieved via

'Encouraging coordinated care, both in the public and private sectors, and adherence to evidence-based best practices and therapies that reduce hospitalization, manage chronic disease more efficiently and effectively, and implement proven clinical prevention strategies.'

The DMAA has it right. If there is any hope of intelligently reducing healthcare costs in the coming years, we have to address the burden of chronic illness. Let the details begin.

Snatching Humiliation From the Jaws of Compromise

Much is being made of the apparent ‘concession’ from America’s Health Insurance Plans (AHIP) to drop gender as part of underwriting.

You can read Karen Ignagni’s statement here. On first read, the Disease Management Care Blog wouldn’t have caught the its significance, but on page 4, it says ‘We envision a rating system based on the following demographic factors: geography, age and [insurance] product type.’

That’s right, the word ‘gender’ as an underwriting factor is absent.

Massachusetts’ Senator John Kerry’s staff certainly picked up on it, which enabled some public puffery over the issue of gender discrimination in the follow-up Q&A. This in turn flushed Ms. Ignagni ‘s page 4 insurance industry ‘setback’ out into the open.

What has been absent from the press reports about this is how the commercial insurers are hanging tough over the linkage of an individual mandate to guaranteed issue and community rating as well as the non-necessity of the public plan option. It may be paying off. Senator Charles Schumer of New York is working hard to find a compromise that will allay the concerns of enough conservative democrats who are apparently willing to break ranks and vote ‘no’ against what could be shaping up to be a public-option poison pill. The optimistic and naïve DMCB believes compromise is in reach and will ultimately depend on how a ‘public’ plan is defined. A very regulated plan administered by a private insurer of last resort could fit the bill.

But how about that gender issue? As a physician, the DMCB is well aware that women are, well, built differently. That translates into different healthcare needs. To further research the issue, the DMCB went to many interesting web sites but ultimately headed on over the USPSF’s Guide to Clinical Preventive Services and searched on the word ‘women.’ It found things have not changed much since Senator Kerry’s wisdom was given such public display: women have considerable healthcare needs. What’s more, they deserve to access to the full range of services that will address them. It could be argued that insurers agree and charge women more in their premiums so that they can be assured that those services will be available to them.

Readers need to decide for themselves if the insurers are guilty of clandestine conscious and unconscious sexism or enlightened business practices aimed at doing the right thing for an important market segment. As for Senator Kerry’s comment about ‘the disparity between women and men in the individual marketplace is just plain wrong and it has to change,’ the DMCB is having trouble between the choosing between a) grandstanding for political advantage and b) showboating by beating up on a favorite whipping boy, er sorry, person. Compromise is one thing. Making it appear as if it's humilation is another.

Post script: By allowing rating based on age and geography, is the US Congress going to permit ageism and geographism? Don’t the elderly deserve the same consideration? Shouldn’t persons living in New York have the same low insurance costs available in Minnesota? Tsk tsk.

Would You Want To Do Business With Medicare Under These Two Scenarios?

The Disease Management Care Blog doesn't think so. It may be dating itself, but it recalls an original Star Trek episode that featured Harcourt Fenton Mudd. His shady promises proved to be part of a grand design concoted to serve Mudd's devious interests, and Mudd's interests alone.

So with that introduction, the DMCB found two other scenarios within the U.S. Senate Finance Committees' “policy options” that are under consideration as part of its healthcare reform efforts. Based on rosy interpretations of some existing science that are really tilted toward to the government’s advantage, they aren’t win-win, or even win-lose. They’re simply Mudd-like win.

‘Payment for Transitional Care Activities’ (page 10)

This would pay for ‘transitional care management’ for recently discharged beneficiaries with a chronic illness DRG, based on interventions that have ‘proven successful’ in the Medicare Coordinated Care Demonstration Program, the Medical Home and ‘other care management models.’ Physicians would be reimbursed for ‘in person’ activities performed by non-physician professionals within 30 days of discharge. Payment would be contingent on not being readmitted.

That may sound good except for one small problem: the Medicare Coordinated Care Demonstration hasn’t really proven to be successful. In addition, the reason the Medical Home has been slated for a demo is because we don’t know if that’s going to be successful either, especially when it comes to readmissions. Limiting payment to ‘in person’ activities is not only Neo-Luddite, it’s an example of there-you-go-again, here comes one-approach-fits-all Medicare. What, Medical Homes will not get credit for telephoning patients? Can they count on Medicare alerting them in a timely manner when a patient is discharged from the hospital? Since re-hospitalizations will never get to zero despite the best of care, the DMCB suspects the only winner in this payment methodology would be Harcourt Fenton Medicare.

‘Accountable Care Organizations (ACOs)’ (page 17)

Since the Physician Group Practice (PGP)Demo ‘showed promise,’ the option here would be to set up a mechanism in which groups of providers would aggregate into business units that would exist to a) meet quality thresholds and b) benefit from a 50% gainshare once savings get beyond a 2% baseline.

Recall, based this DMCB post about the PGP, that a grand total of two out of ten organizations received any money in the gainshare, though the Senate Finance policy paper says there were four. Hmmm, doing the math, that means the odds are against the average ACO provider group ever making any money on this. However, assuming that a 40% chance of payment from Medicare is an accepted business practice, keep in mind that the types of physician groups that participated in the PGP demo in the first place provide less than 1% of the entire healthcare in the U.S. But the lack of generalizability to the other 99% is not all: what is missing from this policy option is any mention of how the PGP groups relied on old-fashioned disease management. As the DMCB recalls, the groups in this demo were also stymied by the lack of data support from Medicare. Based on what the DMCB is reading, this is also very tilted toward Uncle Sam-Mudd.

(There's lots more on Accountable Care Organizations here)

Governor's Sebelius' Nomination, Delay and the Art of War

Not too long ago, the Disease Management Care Blog read Sun Tzu’s classic, The Art of War. Given the news of the delay in Ms. Sebelius’ nomination as Secretary of HHS, believes the Congressional Republicans have also.

While the DMCB read it years ago, it recalls Sun Tzu had a dim view of obvious frontal attacks. Rather, his was a game of strategy, flexibility, deception, deflection, feinting, leverage and delaying until the time was right. General Tzu’s opponents knew an apparent lack of activity by his army did not mean all was well. Quite the opposite: more likely, disaster was on the way.

Ms. Sebelius’ Congressional confirmation as the Secretary of Health and Human Services (HHS) has been delayed. Republicans have asked that further action be put off until answers to ‘additional written questions’ can be reviewed. That will push the nomination back two weeks. While two weeks may not seem like a long time, the DMCB is vaguely aware that Congress has a very proscribed legislative calendar and that getting a major health bill to the President by September involves a lot of moving pieces – including a number of deadlines and a visible and supportive HHS Secretary. Quietly depriving HHS of a leader of Ms. Sebelius’ caliber for even a short time would be approved of by General Tzu.

As those days pass and other delays add up, the minority opposition’s disadvantage may lessen even further, thanks to the 1) eventual evaporation of the ‘Blame Bush’ marketing strategy, 2) the likely intrusion of other newsworthy distractions, 3) inevitable decline in the President’s approval ratings, 4) more bad economic news (unemployment is bound to rise further, tax receipts are likely to be lower than anticipated and other shoes are getting ready to fall) and 5) the natural second thoughts that arise once the details of Any Big Plan become apparent.

This isn’t enough to derail the ObamaExpress entirely, but the momentum has been slightly slowed. The DMCB suspects that Dr. Tzu would calculate the likelihood of large scale reform this fall decreased by one notch. Disease management organizations may want to plan accordingly.

While the Federales continue to tie themselves up in knots, check out this report from Hewitt. Employer-sponsored population care programs are continuing their torrid growth. The challenge, as always, is to engage more enrollees, even if it means developing performance guarantees, value-based benefit designs, financial incentives and sophisticated and industrial strength employee communication, outreach and marketing strategies. Growth opportunities in the non-government commercial health insurance sector continue to increase by additional notches.

General Tzu knows the DMOs are already planning accordingly.

Last Minute Thoughts.....

According to the President's remarks at yesterday's Summit (they're here, fast forward to 6:20), healthcare costs lead to a bankruptcy 'every thirty seconds.' Is that so?

The Disease Management Care Blog invites the White House staff to follow its playbook: take the effort to read the underlying science for yourself and measure twice and cut once when it comes to making public conclusions.

And for those who feel left out: the DMCB feels your pain. It wasn't there either.

An Anything-You-Please, Not Thelma and Louse White House Health Care Summit

The Disease Management Care Blog sat through the C-SPAN health policy video of one of today’s White House Health Care Summit ‘conversation’ break out sessions. There was something for everyone here, and everyone certainly had something to say. The session heard about planned parenthood, low income women, cancer prevention, nurse-patient staffing ratios, the public plan option, research, hospitals, obesity, bankruptcy, coverage doesn’t equal access, shortage of providers in rural settings, food safety, nurse workforce issues, centers of excellence, drug reimportation, interoperable health information systems, end of life care, obstetrical units, pre-exisiting conditions, single payer system, public reporting, Medicare Part D, mandatory coverage, malpractice reform, long-term disabilities, community-based services, the Latino community, immigration reform, stem cell research and comparative effectiveness.

The healthcare reform quote of the day was that things are so dire, it’s not a Harry and Louise moment, but a Thelma and Louise we're gonna drive-off-the-cliff moment. The DMCB thinks it was more like a narrow interest, soapboxy never waste a crisis, anything you please moment.

But it was a comment about employer-based insurance that caught the DMCB’s ear.

General Mills, the maker of Cheerios, Green Giant veggies, Progresso soups, Pillsbury bakery products and Yoplait yogurt has 18,000 U.S. employees in multiple States. Its CEO, Ken Powell, was at the Summit and pointed out that his company and the rest of the Business Roundtable wants to preserve the ability of employers like General Mills to offer health insurance for two reasons: 1) it helps them recruit and retain skilled employees and 2) they’re really good at it.

In addition to a highly competitive health insurance plan with a manageable cost trend, Mr. Powell pointed out General Mills has tobacco cessation and weight loss programs, diabetes coaching programs, pharmacists to help persons understand their medications and access to other venture-capitalist funded, multi-employer supported chronic condition care programs. He hopes healthcare reform allows his and other companies to continue to leverage this strategic advantage when it comes to maximizing its human capital.

The DMCB hopes so too. In a prior post, the DMCB reviewed a highly informative report that pointed out that the distribution of ‘best practices’ from high performing systems, 7-day-a-week hospitals, the right kind of health information technology, controlling admissions, optimizing discharges and other proven strategies across the United States can save billions of dollars. The additional General Mills option, unlike the swirl of other narrow interest group issues listed above, is in the mainstream of health care, it deals with the twin challenges of cost and quality and is within legislative reach this year

The DMCB recommends the reformists listen closely to employers like General Mills. Promotion of their approach nationwide is a key consideration in wellness, prevention and care of populations with chronic conditions.

Reform Health Care? Let's Eat!

The Office of the President Elect is recommending that the American body politic assemble in holiday gatherings to discuss health care reform. The Disease Management Care Blog heartily endorses this grand idea: it's one thing to write about this stuff, but the prospect of a festive gab-fest is irresistible. The DMCB wants this class to start so it can sit in the back of the room and raise its hand ooo…oooo like a kid with a full bladder.

The DMCB regrets to report, however, that the spouse disagrees. It turns out that she has other reasons for family and neighbors this season. She suggests if the DMCB wants to host a policy party, it do so off-site and pay for the expenses using the income from this blog.

While rebuffed, that doesn't mean the DMCB can't help. It calculates that there are vast numbers of engaged citizens who are planning to do their duty, but are struggling with a critically important issue. No, it’s not whether to include the role of ICD-10 in risk adjustment of Medicare payment rates on the discussion agenda. It’s what to serve the guests, especially if one of them might be Maximum Czar-To-Be Daschle himself.

The DMCB to your rescue with a recommended menu. Serve up this mix of celebratory cerebral treats and watch the ideas flow faster than you can say 'NAIC guidelines on the use of investment income to support health insurance premiums!'

Champain: no, it’s not misspelled, it’s shared.

Egg-Head Nog: blended n’ smooth, but be careful not to choke on all the economists’ and actuarial assumptions!

Double Smoked Ham: this tasty entrée claims to reduce costs by increasing spending. Eat up before the logic disappears!

Creamed Corniness: that’s right, this is for the children. Every time an opponent says otherwise, God makes a baby cry.

Hot potatoes: pass it to the left, or better yet, to tomorrow.

Republican mashed turnips: ‘Nuff said

Turnkey Turkey: if it’s tasty in Sonoma Country, California, it’s sure to be just as savory in Dade Country Florida and just as yummy in Clinton Country, Pennsylvania.

Gravy Train: a tasty high fat mix of entitlements, tax credits, grants, spending and mandates. Watch your guests jostle for the ladle.

Cramberry Sauce: more covered benefits per spoonful.

Health Fed Bread: put this basket in the middle of the table and wait for it to tell you and your guests when it’s OK to start eating. And when a fork is best. And whether three chews are enough.

Comparative Effectiveness Cookies: mmm! Sugar coated and they sure look good. But just wait until you eat one and find out what “it shouldn’t be covered” tastes like. This treat bites back!

Hostage Soup: serve this to your physician guests while you ask them if they know when the next ‘SGR’ fee schedule adjustment will occur.

Didn’t Mean It Soufflé: all those campaign promises? It’s the hot air used to raise this delicate fluffy dough.

After We Talk, We’re Doing It Our Way Anyway Pie: the recipe for this tasty treat has already been written and isn’t going to change.

The DMCB's Principles for Healthcare Reform

Exciting times indeed. The new President is setting up his cabinet while the Congress is readying itself for the new legislative session. The economy is job one, but a majority of those who elected Obama expect something big from our new President in the health care arena. Is the time right for a complete overhaul of the healthcare system, or should we pursue incremental reform?

Either way, change is in the air. One symptom of this is the number of organizations that are offering up recommendations or principles for reform.

The DMCB has been thinking about this for several days. After seeing the band 'Yes' in concert and seeing how Steve Howe's still got the chops tonight, it decided to post some of its own principles. It thinks they're best read by clicking below on the 2nd part of Starship Trooper and letting it play in the background. Hope your speakers have sufficient bass:

The rising cost of health care is our most pressing challenge. Failure to control costs will inevitably lead to rationing. Imperfect but useful options to slow the rate of cost increases include, but are not limited to, prior authorization, value-based purchasing, increased consumer participation in the purchase of transparently priced health care services and bundled payment arrangements.

Chronic illness is a significant source of health care's cost increases. Imperfect options to slow the rate of increase and achieve greater value include, but are not limited to, disease management, the chronic care model, pay for performance, consumer incentives, decision support, patient registries and electronic records. Combinations work better than any single option.

Health insurance is necessary but not sufficient to assure adequate access to health care. Options to increase participation in health insurance include requiring coverage (play or pay), lowering premium expense by control of cost (see above) plus, over the short term, value-based insurance designs and plans that trade lower premiums for increased out of pocket expenses. Serious consideration should be given to insurance options that protect against financial ruin, not meeting mandates. Increased participation in health insurance is likely to increase utilization of health care.

Stop talking waste, start talking value. Start with assessing how to maximize the effectiveness of studying comparative effectiveness. Assessment of technologies will need to consider their potential of additive growth vs. substitutive value.

Primary care is of sufficient value by itself to warrant increased payment without any need to concoct rationales such as pay for performance or extra payment for patient centered medical homes.

Research funding must be focused on improving systems of care outside Academic Medical Centers or Integrated Delivery Systems. Some funding should be discarded in favor of Prizes. Registries of data from publically funded research should be deidentified and open sourced on-line for data analysis.

The worksite and community are the better locations to provide wellness and prevention programs, not the health care system.

The public schools and community are a better location to provide obesity prevention and management, not the health care system.

One Way to Obtain Less Wasteful Test Ordering Behavior: Recognize that Physicians Also Need to Manage Uncertainty

The Disease Management Care Blog delighted in reading Dr. Lisa Rosenbaum’s personal essay that appeared in the October 16 New England Journal of Medicine. It was the high point of the weekly “Perspective” section of the Journal that was otherwise abysmally hijacked by a pair competing partisan pseudo-evaluations of the McCain and Obama health care plans. The DMCB has decided that it’s going to stop paying attention to the two candidates’ health care proposals until after the election, especially when they're reported in the Journal. It's not until after January 2009 when the real swordsmanship begins.

Dr. Rosenbaum is a 2nd year internal medicine resident in training in Boston. She wryly describes in wonderful narrative the struggles of a young physician in dealing with patient symptoms for which there is no explanation. Caring for such individuals is a struggle, she writes because 1) the culture of modern medicine has little patience for the unknown, 2) patient-consumers want answers and 3) it’s practically impossible to submit a bill without a diagnosis code. An EHResque ‘Rise of Machines’ is only adding fuel to this fire, since electronic formatting of patient encounters makes it impossible complete them without a diagnosis. As a result, physicians are being cornered into diagnoses of pseudo-certainty like “Lupus” or “prostatitis” that take on a zombie electronic life of their own. These faux diseases work their way into patient problem lists, past medical history records and care plans not only long as these patients live, but well beyond.

In the DMCB’s former life as a primary care physician, symptoms of lingering numbness, unsteadiness, fatigue, aching, poor memory, vision changes and the like were quite common. Docs deal with it, usually with some combination of intuitive understanding of what could be serious versus what isn’t, providing comfort with assurances of what isn’t wrong and using the most important test of all: time backed by a confident caring demeanor, ready availability if things change and firm plans for a follow-up appointment.

Note that the DMCB did not indicate that it routinely ordered many blood or imaging tests or referred patients to many specialists to help sort out the known from the unknown. That’s because it quickly discovered that tests commonly ‘lie’ thanks to ‘sensitivities’ and ‘specificities’ that are commonly south of 100%.

That’s right. Stress tests, CAT scans and blood tests can be remarkably imperfect, with falsely positive (positive tests in persons without any disease) and falsely negative (normal tests in persons with disease) test rates that can approach 30%. It’s the job of smart docs to weigh the probability that ‘positive’ test result is a lie and if the likelihood of a lie is greater than the possibility of real disease.

The DMCB also got used to many of his specialist colleagues’ inability to grasp that fundamental truth. The DMCB is not surprised that electronic records (and their evil twin, our latest generation billing systems) are also unable to accommodate this.

To Dr. Rosenbaum, the DMCB says hang in there. The system needs good docs like you to rescue us from ourselves.

The Big Bailout, Obamaite David Cutler vs. McCainiac Gail Wilensky and the New England Journal of Medicine Roundtable on Health Care Reform

Take a diazepam, don your dark sunglasses, apply those ear plugs, don’t look at your 401K and disregard the Feds’ looming commitment of $2300 dollars per person to The Big Bailout. Imagine the US Congress will not be distracted by the wars in Afghanistan and Iraq, the growing militancy of Iran or the volatility of energy prices. You’re now ready to view the remarkably civil and educational 56 minute on-line video that pits the earnest optimist Obamaite David Cutler against the experienced technocrat McCainiac Gail Wilensky in an “Election 2008” roundtable on health care reform. Q&A were from Karen Davis of the Commonwealth Fund, Jon Kingsdale of the Massachusett's Health Insurance Connector Authority and Thomas Lee of Partners HealthCare.

No time? No problem. The Disease Management Care Blog had a glass of Sauvignon Blanc (the best is still Cloudy Bay 2005), donned the high mag spectacles, turned the volume up, accepted its financial advisor’s advice to not cash out (now is the buying opportunity!) and wrote up this summary for your reading pleasure.

David Cutler of Harvard says Obama has 3 goals:

1) Access to quality and affordable care. This should “not very hard” if waste and redundancy are reduced and if we have the will to spend money in the short term. Spending can be partially funded by rolling back the Bush tax breaks and using that to fund tax credits. Lower prices plus insurance reforms that encourage more participation in risk pools will lead to even lower costs.

2) Modernizing the costly wasteful and doctor-unfriendly system. This will happen thanks to “investment” in state-of-the-art prevention, comparative effective analyses, quality measurement and reporting, electronic records, paying for quality and achieving tort reform by preventing errors with health information technology HIT and settling disputes outside of courts.

3) mainstreaming non-politicized public health principles to address tobacco, obesity global epidemics and other issues. Emphasis on non-politicized.

The DMCB take away: even with the fiscal room to maneuver, it was unlikely that Congress would go along with “short term” spending increases. In the Q&A, Dr. Wilensky correctly pointed out that true “waste” is rare. What is far more common is health care that is high cost, low value and high demand. There is little proof that the modernization items listed above will reduce cost individually or in combination. And while the present administration elevated this to an art form, when hasn’t public health been vulnerable to political interference?

Gail Wilensky of Project Hope reports McCains’s emphasis is on controlling costs. To do that, he proposes harnessing the purchasing power of an increasingly mobile job-changing workforce. Giving these individuals tax credits for insurance purchases and letting insurers openly and transparently compete across State lines will not only reduce the number of uninsured in the short term but force the market to control costs over the long term.

Yes, there are predictably high spenders who will be unable to buy insurance at any price. For those who can’t access employer-based coverage under COBRA, the Feds can kick in new dollars for “high risk” insurance pools.

There was little disagreement over the need for the modernization ideas listed above.

Dr. Wilensky reminded the audience that the admittedly imperfect Medicare Modernization Act taught us that passage of a health care bill is possible when Congress’ preeminent role is respected and Presidential leadership is deployed to achieve the best compromise. Contrast that with the Clinton reform debacle. Ms. Wilensky asked which candidate has the best track record of working with a Senate in which 60 votes are never a sure thing.

The DMCB take away: Dr. Wilensky believes individuals spending their own cash can deputize health insurers to do something about runaway cost inflation. Health insurers are already doing their darndest to do that within State lines, so it’s hard to see how that will happen in a cross state market unless they’re willing to risk another backlash. The more likely result is that persons will buy inadequate coverage. McCain is also counting on a precarious pre-bail-out pot of money. Finally the MMA was an example of what happens when a single political party uncompromisingly dominates the national discourse.

Is the DMCB being a morose, cynical nattering nabob of negativity? While both sets of proposals have their problems, they offer a real contrast between government involvement in a failing market versus using government to rehabilitate that market. In the end, however, their reliance on new spending, other national security distractions, recent news that the number of unsinsured dropped and the willingness of States to promote their own reforms makes the DMCB believe that the likelihood that either candidate’s proposals will succeed in the next year or two is very unlikely. Anything meaningful happening after the Big Bailout will require a miracle.