Kansas Health Institute

Blogs from here and there

New Dates: 2010 National Symposium

Aug. 4, 2010

Join the conversation and help define the next steps to advance high-value health care delivery in America by attending the 2010 Mayo Clinic Health Policy Center Symposium, “Achieving the Vision: Advancing High-Value Health Care.” The event is being held December 5-7, 2010 at the Bethesda North Marriott Hotel & Conference Center in Bethesda, MD. With [...]

Secretary Sebelius Visits Mayo Clinic

June 2, 2010

Secretary of Health and Human Services Kathleen Sebelius is visiting the Mayo Clinic campus in Rochester, MN tomorrow to learn more about Mayo’s patient centered model of care and to discuss implementation of the recently passed Patient Protection and Affordable Care Act (PPACA). The Secretary will be joined by U.S. Senators Amy Klobuchar and Al [...]

A Perspective on Current Health Reform Issues from Mayo Clinic

March 26, 2010

With the President’s signature this week on the Patient Protection and Affordable Care Act, Mayo Clinic is committed to assist in anyway we can with the effective implementation of the new law as well as the development of future patient-centered health care reform efforts. Even though Mayo Clinic did not take a position of support [...]

Effects of Health Care Legislation

March 26, 2010

The Mayo Clinic offers a 1-page summary concerning the impact of the Patient Protection and Affordable Care Act for individuals and patients who have questions. Filed under: Uncategorized Tagged: Health Care Reform, Mayo Clinic

Former Mayo Clinic CEO Denis Cortese, M.D. on CNN with Sanjay Gupta, M.D.

March 25, 2010

Dr. Sanjay Gupta visited with former Mayo Clinic CEO, Denis Cortese, M.D. on March 20, 2010 to discuss a variety of topics about health care in America. To watch the interview, mouse over the video window to activate the video controls and fast-forward to 8:40. Filed under: Uncategorized Tagged: Denis Cortese, Mayo Clinic, Quality

FSB: Best Lawyers in America 2011

Aug. 20, 2010

This past week I received notice that I was again selected by my peers for inclusion in The Best Lawyers in America® 2011 in the field of "Health Care Law". In all, nine lawyers from Flaherty Sensabaugh Bonasso PLLC were selected for inclusion in The Best Lawyers in America® 2011. Congratulations to my partners, David Givens and Mark Robinson, who were selected for the first time this year in the category of "Medical Malpractice".Below is a list of all the 2011 FSB honorees: Mike Bonasso - Commercial LitigationStephen Brooks - Medical Malpractice Law and Personal Injury LitigationBob Coffield - Health Care LawTom Flaherty - Personal Injury Litigation David Givens - Medical Malpractice Law Ted Martin - Medical Malpractice Law Mark Robinson - Medical Malpractice Law Don Sensabaugh - Medical Malpractice Law and Personal Injury LitigationJeff Wakefield - Bet-the-Company Litigation, Commercial Litigation, Medical Malpractice Best Lawyers is based on an exhaustive peer-review survey in which more than 39,000 leading attorneys cast almost 3.1 million votes on the legal abilities of other lawyers in their practice areas. Corporate Counsel magazine has called Best Lawyers "the most respected referral list of attorneys in practice."

CMS Awards WV Medicaid $945K Federal Matching Funds for EHR Incentive Programs

Aug. 4, 2010

iHealthBeat reports that West Virginia Medicaid along with five other states will receive federal matching funds from the Centers for Medicare and Medicaid (CMS)to help implement electronic health record (EHR) incentive programs.West Virginia Medicaid will receive $945,000 in federal matching funds. The CMS press release indicates that West Virginia will use the funds for planning activities that include conducting a comprehensive analysis to determine the current status of HIT activities in the state. The funds will be used to gather information on issues such as existing barriers to its use of EHRs, provider eligibility for EHR incentive payments, and the creation of a State Medicaid HIT Plan.The CMS press release states:WEST VIRGINIA TO RECEIVE FEDERAL MATCHING FUNDS FOR ELECTRONIC HEALTH RECORD INCENTIVES PROGRAMIn another key step to further states’ role in developing a robust U.S. health information technology (HIT) infrastructure, the Centers for Medicare & Medicaid Services (CMS) announced today that West Virginia’s Medicaid program will receive federal matching funds for state planning activities necessary to implement the electronic health record (EHR) incentive program established by the American Recovery and Reinvestment Act of 2009 (Recovery Act). West Virginia will receive approximately $945,000 in federal matching funds. EHRs will improve the quality of health care for the citizens of West Virginia and make their care more efficient. The records make it easier for the many providers who may be treating a Medicaid patient to coordinate care. Additionally, EHRs make it easier for patients to access the information they need to make decisions about their health care. The Recovery Act provides a 90 percent federal match for state planning activities to administer the incentive payments to Medicaid providers, to ensure their proper payments through audits and to participate in statewide efforts to promote interoperability and meaningful use of EHR technology statewide and, eventually, across the nation. “We congratulate West Virginia for qualifying for these federal matching funds to assist its plan for implementing the Recovery Act’s EHR incentive program,” said Cindy Mann, director of the Center for Medicaid and State Operations at CMS. “Meaningful and interoperable use of EHRs in Medicaid will increase health care efficiency, reduce medical errors and improve quality-outcomes and patient satisfaction within and across the states.” West Virginia will use its federal matching funds for planning activities that include conducting a comprehensive analysis to determine the current status of HIT activities in the state. As part of that process, West Virginia will gather information on issues such as existing barriers to its use of EHRs, provider eligibility for EHR incentive payments, and the creation of a State Medicaid HIT Plan, which will define the state’s vision for its long-term HIT use.

WVHCA: Proposed CON Standards for Megavoltage Radiation Therapy Services/Units

July 21, 2010

The West Virginia Health Care Authority has issued a Notice of Public Comment Period on a new Proposed Certificate of Need Standard for Megavoltage Radiation Therapy Services/Unit.Written comments on the proposed Certificate of Need Standard must be filed with the Authority on or before July 30, 2010. Written comments should be directed to Timothy E. Adkins, Director of Certificate of Need Division.

WVHCA: Proposed Amendment to West Virginia CON Law Defintion of "Private Office Practice"

June 28, 2010

On June 15, 2010, the West Virginia Health Care Authority filed a Notice of a Comment Period on a Proposed Rule with the West Virginia Secretary of State amending West Virginia CSR 65-7, Certificate of Need Rule.According to the Summary and Statement of Circumstances filed with the Proposed Rule the "amendment clarifies the definition of "private office practice" for purposes of administering the Certificate of Need Program. Those entities meeting this criteria may be eligible for an exemption from Certificate of Need review pursuant to West Virginia Code 16-2D-R(a)."Written comments on the Proposed Rule are due on or before July 16, 2010.

What Health Care Employers Need to Know about the West Virginia Patient Safety Act

June 25, 2010

Ryan Brown, a health care attorney at Flaherty Sensabaugh Bonasso PLLC who specializes in medical malpractice defense, health care regulatory work and health care related employment issues wrote this summary of the West Virginia Patient Safety Act. In 2001, the West Virginia Legislature passed the Patient Safety Act (“PSA”), W.Va. Code § 16-39-1 et seq. The purpose of the PSA was to provide an avenue for health care workers to report instances of waste or wrongdoing without the fear of retaliatory or discriminatory treatment by their employers through termination, demotion, reduction of time, lost wage, or lost benefits. The PSA requires the identity of a health care worker who reports waste or wrongdoing to a health care entity (e.g., hospital, clinic, nursing facility, etc.) or appropriate governmental authority to remain confidential. Health care entities are also required to post a summary of the important provisions of the PSA on the premises for its employees.It is important for health care entities to understand that the PSA prohibits retaliation or discrimination against a health care worker who made a good faith report; advocated on behalf of patients, services or conditions of a health care entity; or cooperated in any investigation relating to the care, services or conditions of the health care entity. A health care worker who has been retaliated or discriminated against by his or her employer in violation of the PSA may file a civil suit and recover payment of back wages, costs of the litigation, reasonable attorney fees, and even reinstatement.Many employers in West Virginia have had experience with the West Virginia Human Rights Act (“WVHRA”), W.Va. Code § 5-11-1 et seq, and its exception to the “at-will” employment doctrine. The WVHRA prohibits discrimination on the basis of race, religion, color, national origin, ancestry, sex, age, disability, and familial status. The WVHRA has been used by former employees as a way to defeat “at-will” employment by alleging that they were wrongfully terminated based on a protected status, rather than for unsatisfactory job performance. Although initially designed to improve the quality of patient care, the PSA has also been used by some former health care employees as a way to get around the concept of “at-will” employment. For example, a discharged health care worker could potentially sue his former employer using the PSA to allege that he was discriminated against after he reported instances of the employer’s waste and wrongdoing. Health care entities must take special care not only to document the unsatisfactory performance of its employees, but also document and investigate complaints of waste or wrongdoing to shield itself from such PSA lawsuits. These lawsuits can be quite complicated as they encompass elements of both employment litigation and medical professional liability litigation.

Insurance Companies Cancelling Health Insurance of Sick Patients

Sept. 15, 2009

With President Obama’s speech to Congress last night outlining the details of his overhaul of healthcare in the United States, one interesting point popped up - the fact that Obama would guarantee that insurers could not reject people because of preexisting conditions. Health insurance companies are increasingly citing the failure to disclose preexisting conditions as a means to cancel policies and deny benefits to people in need of care. The term for this is "Post Claims Underwriting". What this means is that the insurance companies will not investigate someone for verification of entitlement to coverage until after they are sick and need the insurance. Of course, if they then determine the person is sick but not qualified they cancel the coverage and the sick consumer is left with no insurance. Insurance companies are using the term "rescission" to refer to the cancellation of insurance coverage due to a company being misled. Rather than trying to mislead companies, omissions of preexisting conditions seem to be honest mistakes by people filing out increasingly complex forms. There have been countless stories about how people have signed up for health insurance, only to have their policies later cancelled when they need care. No one knows how often policies are cancelled because of a variety of different state laws and policies in place, however, the practice has become rampant enough to result in numerous lawsuits and new regulations put in by states throughout the country. In the past year and a half, California has fined the five largest insurers in its state almost $19 million for cancelling the policies of individuals who became sick. One insurance company even admitted offering bonuses to employees who were able to find reasons to cancel policies. President Obama has been trying to gain support for his healthcare overhaul in part tapping into consumer dissatisfaction with the insurance industry, an industry that has never been popular among the American people. His plan for healthcare overhaul includes restricting insurance companies from screening for preexisting conditions, however, this still might not save people from having their policies cancelled. With new regulations, insurance companies might not necessarily cancel the policies of those individuals with undisclosed preexisting conditions, however, a company might institute further preauthorization requirements on services for certain patients, which might discourage such patients from renewing their policies. Lawsuits continue to be instituted against insurance companies who have cancelled policies. Rather than fight fraud, rescission has devolved into a backdoor route for insurance companies to stop paying the medical bills of people in their time of greatest need.

Coverage at the county level...

Aug. 19, 2009

Plenty has changed since 2006, the latest year that the uninsured of California was counted by the U.S. Census. But even then, many months before the current recession hit, the percentage of people living without health insurance in our state was startling. This week, the Sacramento Bee laid out the statistics, finding quite a disparity between those with health insurance and those without. Just in the five-county region The Bee covers, Yolo County posted an uninsured rate of 22 percent of people under 65, while the more prosperous Placer County -- with more employment-based coverage -- posted a 13.7 percent rate. That's quite a disparity, and the article by Phillip Reese and Anna Tong is worth reading. But the Bee doesn't limit information to its circulation area, it also posts online a comprehensive rundown of each of California's 58 counties' uninsured rate, along with an interactive map of the state and rollover charts. Here's a sampling of what the authors wrote: "The uninsured present an immense fiscal and public health challenge: 18,000 Americans die each year because they aren't covered, according to the Institute of Medicine, a nonprofit research organization. This is because having insurance is closely tied to health outcomes: The uninsured won't see a doctor regularly, and if they seek care it is likely to be inadequate or too late. Moreover, the uninsured are a cost for society: One economist recently estimated the tab at $56 billion per year, 75 percent of which is paid by governments. In cash-strapped California, that cost is critical: 6.6 million residents went uninsured in 2007, more than in any other state, according to the California Healthcare Foundation." You can bet that, with massive layoffs and small businesses closing since that Census count, the number of those among us -- members of our communities -- who are going without health insurance is a great deal larger. Factor in the Governor and Legislature's cuts in health and insurance programs for lower-income Californians, their children and the elderly, and you get an unimaginable sum of fellow Californians without access to affordable, quality health care -- notably, preventative health care, with better outcomes. This is what the conversation about health care reform boils down to, not pumped-up talking points and hyper-emotive protests based on misinformation. This is not a partisan issue. It is a people issue. And the bottom line is that the majority of Americans have already voted -- for substantive change for a better future for our country.

California Offers Lessons on Insurance Exchanges

Aug. 6, 2009

As Congress debates creating insurance "exchanges" as part of a health-care overhaul, the failure of a similar effort in California may offer important insights, former participants in the program say. From 1993 to 2006, small businesses in California could buy health insurance through an exchange run initially by the government, and later by a nonprofit group. The plan was undermined when some businesses with relatively healthy workers bought policies more cheaply directly from insurers, bypassing the exchange. That left the exchange with a shrinking pool of less-healthy workers, forcing rates higher and prompting many insurers to withdraw. Managers chose to shut the program in 2006 when one of three remaining insurers withdrew. "There are definite lessons to be learned," said John Ramey, who as former head of the Managed Risk Medical Insurance Board helped implement California's exchange. "We learned them the hard way out here." Among those lessons, he and others said: Employers and individuals who qualify must be required to obtain health insurance through the exchange. Failing that, John Grgurina, who ran California's exchange from 2002 until it ended, said government must impose rules governing rates and eligibility to protect the exchange from attracting a disproportionate share of high-risk people. An exchange aims to get better prices for coverage by banding together businesses and individuals. Insurers would have an incentive to join an exchange because they would gain access to more potential customers. Individuals and employees of businesses that participate in an exchange would be able to chose from the available plans and pay the same rate. Exchanges, either on a regional basis or a single national one, are likely to be a part of any final health-care legislation. Late Friday, the House Energy and Commerce Committee approved its health-care bill, though a full House vote won't come until the fall. President Barack Obama on Saturday praised the House committee's action and urged lawmakers to "build upon the historic consensus." The compromise proposal agreed to in the House Friday exempted more businesses from the mandate to provide coverage to their employees and offered subsidies to fewer individuals to buy insurance through an exchange, which would shrink the number of potential participants. Each of the three major bills -- one in the House and two in the Senate -- would create one or more exchanges. The specifics vary, but most of the proposals would impose more regulations than the failed California program, which analysts say would help the exchanges compete. Despite California's struggles, insurance exchanges are still the most effective way to expand coverage, said Elliot Wicks, a health-care consultant who wrote a report on the California program. The report, released last month, was commissioned by the California HealthCare Foundation, a private independent nonprofit. Veterans of the California effort said the ultimate effectiveness of any exchange would rest on details that have yet to be worked out. They said the pool of people in an exchange should be as broad as possible, to spread both risk and administrative costs. Click here for your free California health insurance now!

Public Health Insurance Would Be Too Good and We'd Like It Too Much

Dec. 17, 2008

A common thread is emerging in the right wing response to healthcare reform. Its opponents aren't claiming that public healthcare will be bad. Rather, they are terrified that the new system will be so good that no citizen would buy expensive private insurance--or vote for politicians who wanted to take public insurance away. The Obama team is sending clear signals that healthcare reform is a core economic issue, and the health insurance industry is becoming increasingly anxious by the future administration's determination to bring healthcare costs under control. Some Americans are seeing their healthcare premiums rising at four times the rate of inflation, if they have insurance at all. Healthcare reform is a pocketbook issue for all of us, according to the Obama team. In tough economic times it might be tempting to postpone healthcare reforms, but Obama is adamant that delay would be a false economy. In the American Prospect, Joanne Kenen and Sarah Axeen support claims about the high cost of doing nothing: A recent report by the New America Foundation's health-policy program estimates that the cost of doing nothing about health care, including poor health and shorter lifespan of the uninsured, is well above $200 billion a year and rising. That's enough to cover the uninsured and still have some left over for other public-health needs. If healthcare costs continue to rise at their current rates, it will cost $24,000/yr to insure a family of four by 2016, an 84% increase from today. At these rates, half of American households would have to spend at least 45% percent of their income to be insured. In the Nation, Willa Thompson describes how a bicycle crash made her appreciate the connection between healthcare and politics. Thompson was 21 years old when she suffered major injuries after a collision with a truck. Luckily, she was covered by her parents' medical insurance until she turned 22. She later realized that if she had been just a few months older when the accident happened, she wouldn't have been able to pay for her medical care. We all agree that something needs to be done. Let's briefly review the options that have been proposed so far. Obama wants to provide healthcare for all by requiring private insurance companies to cover everyone and creating a public health insurance plan to compete with private insurers. The second part of his plan is the public option that Republican opponents are so scared of. Click here for your free California health care quote now!

Why is single-payer health reform not viable?

Dec. 2, 2008

When it comes to health care reform in America, there is a relatively simple solution that will cover everyone's basic health care, control costs and save businesses, most people and the country a lot of money. It's called a single-payer health plan, where the government collects taxes to finance national health insurance. The government, which is the "single payer," covers all citizens and pays the bills when they visit private (or public) doctors, hospitals and other facilities for medical care. All would have basic coverage, regardless of whether they have a job, or where they work. Nobody gets billed for basic care. No-body goes broke because of medical bills. Yet this option has been declared "off the table" by Sen. Max Baucus, D-Mont., who's among those leading the charge for health care reform in America. Top Democrats who will be deciding policy in America in 2009, including Baucus and President-elect Barack Obama, say single-payer is "not politically feasible," because the public won't strongly support it. What they really mean is that when it comes to health care reform, they don't want a political fight with some of the nation's most powerful financial interests, which have the resources and the motivation to turn public opinion against meaningful reforms. These interests include the health insurance industry, pharmaceutical drug companies, some hospitals, highly paid medical specialists, medical suppliers and others who now profit handsomely from our current system - and who could no longer command those profits under a single-payer system or an alternative form of a national health plan. Californians, click here for your free health insurance quote now!

New Ideas In Medicaid Financing

Sept. 1, 2010

The Medicaid program is facing major new challenges. The new health care law puts both significant new responsibilities and financial burdens on the program. At the same time, Medicaid, as one of the three major federal entitlement programs, is a top priority for policy makers trying to address the federal government’s staggering budget deficits. Unfortunately, [...]

Health Affairs Briefing: Medical Liability And ER Use

Aug. 31, 2010

The September 2010 issue of Health Affairs is devoted to two issues that arguably were insufficiently addressed by the Affordable Care Act: medical liability and patient safety; and the growing nonemergency use of the nation’s hospital emergency rooms. The issue contains new estimates of how much medical liability costs the health care system overall; of [...]

Robert Butler’s Legacy

Aug. 30, 2010

Editor’s note: Earlier this summer, on July 7, Robert Butler died of leukemia. Butler was the founding director of the National Institute on Aging, a Pulitzer Prize-winning author, and one of the nation’s leading authorities on aging and geriatrics. With the essay below by Christine Cassel, president and CEO of the American Board of Internal Medicine, Health [...]

Revisiting ‘Witness To Disaster’: First-Person Accounts Of Katrina’s Aftermath

Aug. 27, 2010

Gulf Coast residents have only recently been able to mark, in Churchill’s words, “the end of the beginning” of the Deepwater Horizon oil spill. This week, these Americans and the entire nation also mark the fifth anniversary of another disaster: Hurricanes Katrina and Rita. Several months after these devastating storms, in its March/April 2006 edition, [...]

Berwick To Speak AT AHIP Conference

Aug. 27, 2010

Don Berwick, the Administrator of the Centers for Medicare & Medicaid Services, will address Implementing Health Care Reform: The Administration’s Priorities, at AHIP’s 2010 Medicare Conference, September 12-14, in Washington, D.C. Health Affairs is a media partner for the conference. Berwick will highlight the Administration’s health reform priorities, including changes under the Medicare program and [...]

IN THE NEWS: Health Wonk Review -- The Hills Are Alive (With the Sound of Wonking)

Sept. 2, 2010

The latest Health Wonk Review is up over at the InsureBlog, and features Henry Stern channeling Julie Andrews, pleased to find that even though the passage of the ACA led many wonks to move on to new issues, a few of his favorite... bloggers are still hard at work.He's got... [cue the music]...Econ from Shafrin and Mahar on Florida"Smackdown" from Vineyard and ADA vs. OSHAElmore on privacy, tied up in HIT These are a few of his favorite things.Blogging doctorsState exchanges When you're feelin' sad Just simply remember Stern's favorite wonks And the you won't feel, sooooo bad.I'd keep going, but then I'd derive you of the pleasure of the review itself. It's a good one, check it out! Health Policy Program

COST: Three Looks at the Economic Aspects of Health Reform

Aug. 30, 2010

The Robert Wood Johnson Foundation and the Urban Institute’s John Holahan and Linda Blumberg have published a set of three short (and informative) briefs on health care and the economy. Takeaway points included the fact that although health care is a big part of the economy, the changes we’re making in health care aren't all that big in the context of the overall economy. And much of the talk about the economic impact of health care is focused on tax and spending changes to the status quo -- not how the tax and spending changes may interact (albeit in hard to forecast ways) with a health care delivery system that will change and evolve as new models and incentives unfold.Here are some of the bottom line conclusions from the three papers (any emphasis added is ours):1) Will Health Care Reform Hurt the Economy and Increase Unemployment?The authors write:Despite fears expressed by some in the political arena, health reform is not likely to have a significant direct effect on the U.S. economy or on employment. The changes in spending and taxes in health reform generally have offsetting effects and are simply too small relative to the overall size of the economy, to have much of an impact2) How Will the Patient Protection and Affordable Care Act Affect Small, Medium, and Large Businesses?Blumberg's analysis suggests that small businesses probably have the most to gain. There’s no mandate, they can get tax credits, and they will be able to get better coverage options in the exchange than they currently can in the small group market. The exchanges will be better regulated, more transparent, and will distribute risk better among the healthy and the not-so-healthy.Medium-sized businesses, with 50 to 100 workers, should also benefit from using the exchange -- but they could also face penalties "if their modest income, full-time workers obtain federal subsidies due to a lack of affordable coverage available through the workplace."Generally speaking, big businesses won’t see much change although there is the possibility of higher costs if more workers (or their dependents) take up employer-sponsored insurance. They too could face penalties if lower income workers go through exchanges and get subsidies.3) Will Health Care Reform Increase the Deficit and National Debt?Holahan writes:The CBO has estimated that health reform will reduce the deficit primarily because cuts in Medicare combined with new revenues will more than offset new spending, and that the deficit reduction effects will increase over time. The CBO projections may have underestimated spending growth but probably not in any significant way. There is some chance that the cost of Medicaid expansion and subsidies to individuals and families could be higher than expected. Some of the indexing provisions that begin in 2019 may be difficult to sustain. [ie: Congress may not stick to its guns on those payment trends.] Similarly, the cuts in Medicare also may be difficult to sustain over the long-term.On the other hand, the CBO may have underestimated the effectiveness of the many cost-containment provisions in the bill -- the increased competition within exchanges, the taxes on high-cost health plans, and such cost-containment initiatives as accountable health organizations, medical homes for the chronically ill, comparative effectiveness research, and many prevention measures. There will also be a major new effort to improve the management of care for dual eligibles. There are many other ways the government could strengthen cost-containment provisions if CBO estimates prove too optimistic. Health Policy Program

QUALITY: Innovating in Oregon

Aug. 20, 2010

Here is my latest contribution to the Altarum Institute's Health Policy Forum, another in my series of "what works" posts. This one is about an innovative Medicaid Managed Care plan in Oregon.Care Oregon, the state’s main Medicaid managed care plan, had two choices a few years ago, after many commercial partners in the Oregon Health Plan decided to get out of the money-draining business.It could go broke. Or it could change its world.It opted for the latter. Today, the Portland-based nonprofit CareOregon is a bit savvier about the business end of its mission. And it’s still trying to change its world.I started hearing about CareOregon here and there over the last year, and I heard several of its leaders -- including CEO Dave Ford -- speak at IHI events, both about population health (the “Triple Aim” in IHI lingo) and about specific attempts to better serve complex patients with multiple chronic conditions. Medical director David Labby, MD, Ph.D., and I chatted this spring, and he’s updated me recently to refresh my memory. CareOregon’s leaders are quite frank about being a work in progress. But some progress can be discerned.One question I’m always asking as I write about innovators in health care is about what’s come to be known as “spread.” There are good ideas out there, and good results, but it’s often very isolated. Good news doesn’t always travel. In this case, the folks at CareOregon traveled to the good news. They had heard Doug Eby, vice president of medical services for Southcentral Foundation in Anchorage (I’ve written about Southcentral here and here) and were intrigued. “Doug is an inspiring speaker. But is it real,” Labby wondered. Thirty people from CareOregon went to Alaska to see for themselves.It was real. Even if the Southcentral model couldn’t be exported to Oregon wholesale, many of its features, systems, and values could be adapted. Labby came back determined to create a “customer” (aka patient) driven system; proactive, team-based care; greater cultural sensitivity, barrier-free access to care, and a greater integration of behavioral health into primary care. Southcentral, however, is part of an integrated system. CareOregon is the payer working with various providers, large and small, urban and rural, across the state.CareOregon launched several new programs (including centralized care management, drawing on the Eric Coleman model -- more spread). But we spoke mostly about the reinvented -- and reincentivized -- primary care teams. They call it “Primary Care Renewal” and it’s basically a drive to create patient-centered medical homes within safety-net clinics.In 2007, CareOregon asked its five largest providers, community health centers that serve about 40 percent of its beneficiaries, to each create one integrated primary care team. CareOregon helped finance the start-up. Every six weeks or so, the various teams got together to learn with and from one another. The idea was to have the teams run for a year, in a sense doubling as an ongoing experiment and a proof of concept.It spread faster than expected; other providers demanded to be part of similar teams. “They were asking, hey why can’t I do that. They are having more fun,” recalled Labby. By fall of 2009, 63 primary care renewal teams were operating in 15 clinics, covering about a third of CareOregon’s membership. (It’s still hard to spread the model to smaller and/or more isolated practices, a certain volume is required.)By 2009, CareOregon was shifting the payment model away from pure traditional fee for service to rewards for meeting goals of access, satisfaction, quality, and utilization, a process that was deepened in 2010. Outcomes were measures for such things as well-controlled diabetes and immunization rates.It was a very different approach than providers were accustomed to, both because they were more anchored in their teams, and because they had to change how they approached care -- and bring their patients along with them.“Usually, if you want a pill or a test or a diagnosis -- medical services -- you go to the doctor, ask him or her to help you, and you leave. That’s the classic model. It’s acute care. You go away and you are on your own,” he said.In contrast, said Labby, “We ask, ‘How can I help you between visits to have the best possible health?” Maybe that means a telephone follow-up to touch base and make sure a patient understands what he needs to do, and has the means to do it -- or identifying and removing barriers. Maybe it means a class or a group visit. Maybe help with transportation, or other ways of helping to link medical and social services. It is a shift from what Labby calls the “visit-based economy” to an outcome-one.If a patient ends up in the ER, because he couldn’t get an appointment with the PCR team fast enough, the team has to take responsibility. Ditto when a patient is admitted to the hospital, for instance, because they aren’t getting or using their medications. (CareOregon hasn’t yet seen a significant drop-off in ER and hospitalization utilization).“We don’t believe just being more efficient or even creating better access in and of itself will reduce the waste in the health care system. It will reduce some of it…But we need to put new resources into primary care, to develop new resources to address the needs of the chronically ill and complex patients. Primary care practices will have to support them between visits and they are going to need staff and training and information systems. It’s complicated. We believe this is a new clinical practice.”One goal is to start shifting some of the big chronic disease management from the Portland-based central teams into the primary care teams. Labby recently emailed that they are introducing depression and diabetes management programs (with the depression one drawing on a successful program at the University of Washington. More spread.)Health reform will help in some ways -- including by simply reducing the number of uninsured patients the clinics see. There will be lots of pilots and demonstrations, although Labby isn’t sure how and when those will roll out in ways that address CareOregon’s specific trajectory. But he knows that if he wants to stay on the road to improvement -- not the road to bankruptcy -- changing the delivery system and the business model is essential“We started with primary care. Now we are starting to think about specialists, about partnering with hospitals. We believe some of the same lessons we’ve learned in primary care apply throughout the health care system.”But he doesn’t see health reform as merely a change in finance or structure or practice. It requires a change in culture. How doctors and nurses and social workers and care managers and primary care teams and specialists learn to think about their own interactions, and their relationships with their patients.“Basically, it comes down to how do we engage in a useful way? How do we join with them in making their health better. Even a person with chronic illness is going to want to have the best possible health. Nobody wants to have the worst possible health.”(After I met and interviewed David Labby, the Commonwealth Fund also published a 36-page case study. CareOregon: Transforming the Role of a Medicaid Health Plan from Payer to Partner, which I recommend if you want greater detail). Health Policy Program

HEALTH REFORM: The Tax Man Cometh

Aug. 18, 2010

This continues our series of posts on the various constitutional challenges to the individual mandate, by Tony Cardona, an attorney who is doing some work with New America's health policy program. Read his post about the Commerce Clause here.The President stares out the windows of the Oval Office into a cold January. He can do nothing but wait; it’s now up to the courts. Overwhelmed by a divided Congress and high unemployment, the President looks on as the agenda he muscled through Congress with political savvy is debated and challenged. Meanwhile, the economy washes slowly and tepidly forward, seemingly on the verge of receding back into the deep, dark water. The law suits begin to surface and the President’s agenda is attacked with concern at best and contempt at worst. Ultimately, it is brought before the Nine. These represent the final judgment not only for the law, but also, possibly, for the President. Everybody waits, not knowing whether Congress has exceeded its powers. Justice Roberts sits in his chamber and drafts his opinion, joined by six other justices. His decision rejects the new Act, declares it invasive of State sovereignty, and finds that Congress has no Constitutional authority to impose such a mandate on the populace. The law is a failure. The President sits down, wondering whether his moment has passed.Such was the scene in 1936, when Justice Owen Roberts struck down President Roosevelt’s Agricultural Adjustment Act (AAA) in the case United States v. Butler, dealing a blow to the New Deal farm policy. Justice Roberts argued that Congress cannot use its taxing and spending powers to “purchase compliance” from farmers for a regulatory purpose, where that regulation was the sole jurisdiction of the states. Although the Court established the precedent that the taxing power is valid under the general welfare clause, its regulatory effect in Butler removed it from Congress’ constitutional control. Relying on the Child Labor Tax Case, the Court decided that the AAA was an improper exercise of the federal taxing power since it was designed as a statutory plan to regulate and control agricultural production.United States v. Butler was decided in the final years of what is now referred to as the Lochner Era, when courts severely constrained federal regulation. However, following the 1937 decision of West Coast Hotel v. Parrish and Justice Robert's infamous switch, the Court shifted to a less restrictive view of economic regulation and FDR’s New Deal moved forward. The Court’s decisions in Steward Machine Co. v. Davis and Wickard v. Filburn (which I explained in Part 1 on the commerce clause) made Butler nearly irrelevant and the new Agricultural Adjustment Act of 1938 was found valid under the commerce clause. FDR’s policies shaped a nation emerging from an economic collapse and established a structure still relied upon today. Butler, once vibrant on a cold January day, faded.Butler is back. In a previous post I noted that the White House changed course slightly and argued that the individual mandate was constitutional, pursuant to the power to tax. Though most legal scholars agree that the commerce clause is a sufficient source of power for the mandate, the taxing power introduces new challenges on both sides. Congressional power “to lay and collect taxes . . . for the general welfare” under Article 1 section 8 is broad, but not entire. Despite a “presumption of constitutionality,” Congress is subject to some limitations. In the current challenges to the individual mandate, the Commonwealth of Virginia has resurrected Butler to claim that these limitations, though rare, are alive and controlling.Under current case law, the power to tax is upheld under an analysis of two factors: (1) the tax must be a genuine revenue-raising device, and (2) any regulatory effects must have a reasonable relation to the statute’s taxing purpose. For example, the government could not tax machine guns if they had already made it illegal to possess them since the regulatory purpose would be essentially irrelevant and no tax nexus would remain. Additionally, if the tax infringes on a fundamental right or is not for the general welfare it may be struck down as unconstitutional. Regardless, Courts will generally not look “into the hidden motives which may move Congress” to exercise a tax, so long as the tax, on its face is constitutional. This idea that a tax can still be legitimate despite having a regulatory effect or penalizing behavior argued in Sonzinsky v. United States (1937) and heavily relied upon by the President Obama’s lawyers, is symbolic of the post Lochner Era. However, Congress cannot regulate through taxation that which it has no power to otherwise regulate. This is Butler and this is the current tax power debate for the individual mandate.In Commonwealth of Virginia v. Sebelius (the current lawsuit by Virginia Attorney General Cuccinelli against the individual mandate), the administration’s lawyers maintain that the Minimum Essential Coverage Provision (sec. 5000A) is a genuine revenue-raising device that is directly related to “the goal of requiring every individual to pay for the medical services they receive.” However, Virginia argues that the tax (referred to as a “penalty” in sec. 5000A) is intended not to generate revenue but to regulate conduct. Since it would generate little if any revenue and is a penalty rather than a tax, Virginia argues, Congressional authority must be from an enumerated power -- otherwise, the provision interferes with state regulation.The fight over the Minimum Essential Coverage Provision thus largely depends on the resolution of two crucial decisions: (1) whether the “penalty” can stand alone as a genuine tax, and (2) if not, whether Congress has the authority under the Commerce Clause to regulate economic inactivity through a tax. The government has a much tougher challenge in arguing that the penalty is a tax. In addition to President Obama’s repeated statements that the penalty is not a tax, the deliberate use of the word penalty in sec. 5000A rather than tax (tax is used in other areas of the bill to mean tax) gives the Commonwealth’s argument more credibility. Recently, Judge Hudson determined that in Commonwealth of Virginia v. Sebelius, the question whether “Congress has the power to regulate—and tax—a citizen’s decision not to participate in interstate commerce” is novel and merits a further hearing. The law is still on the side of reform. Courts have permitted taxes that raise only ‘negligible’ revenue. Additionally, the courts have permitted a tax even though it discourages or deters activities and thus has regulatory purpose. Taxes must only raise some revenue and be for the general welfare of the nation. If that is met, the federal government and not the individual states maintains the power. Decided five months after Butler and two months after Sonzinsky, Judge Cardozo explains in Helvering v. Davis:“One might ask . . . whether the system of protective tariffs is to be set aside at will in one state or another whenever local policy prefers the rules of laissez faire. The issue is a closed one. It was fought long ago. When money is spent to promote the general welfare, the concept of welfare or the opposite is shaped by Congress, not the states. So the concept be not arbitrary, the locality must yield.” Health Policy Program

HEALTH CARE: Prescription for the "Farmacy"

Aug. 17, 2010

Watch out strip mall drugstore. You may have some competition. Natasha Singer reported recently in the New York Times, “The farm stand is becoming the new apothecary, dispensing apples—not to mention artichokes, asparagus and arugula—to fill a novel kind of prescription.”Wholesome Wave, a nonprofit dedicated to increasing access to healthy foods, announced its “Fruit and Veggie Prescription Program" pilot program where physicians at community clinics can prescribe vouchers for local farmers markets and then monitor the impact of increased fruit and vegetable consumption on a patients’ health. (Watch Dr. Shikha Anand on CNN talk about the program here.) It's being tested in Holyoke, Lawrence and Boston, Mass., and in Portland, Maine.The food scrips contribute to an ongoing effort in Boston to subsidize fresh fruits and vegetables and bring healthier foods to “food deserts." The Boston Bounty Bucks initiative, for instance, matches farmers’ market purchases made using SNAP (Supplemental Nutrition Assistance Program) benefits for up to $10, writes Patrick G. Lee of the Boston Globe. Moving forward, food policy will play an increasing role in health policy, as we institute programs and policies to curtail the obesity epidemic. According to John Cawley, associate professor in the Department of Policy Analysis and Management at Cornell University, incentives, including food prices, agricultural policies, income, maternal employment and technology, all contribute to the spike in childhood obesity. One study, for example, found that the increase in a mother’s average weekly work hours explains 11.8-34.6 percent of the rise in childhood obesity in high socioeconomic-status families, as children spend more time watching television and eat fewer home cooked, nutritious meals.Cawley pointed out that while the real price of food fell significantly between 1990 an 2007 (the McDonald’s quarter-pounder with cheese fell 5.44 percent and the two-liter bottle of Coca-Cola fell 34.98 percent), the real price of fruit and veggies rose 17 percent between 1997 and 2003. Fast cheap burgers and pizza versus labor-intensive and more costly home-cooked veggie-rich meals contribute to childhood obesity, which in turn has significant health and economic consequences, which compound throughout a person’s lifetime.Reading these articles, we started wondering just how common farmer's markets have become. We've started to see them more and more -- but we live in a city. Turns out, it's not just us. There are more farmers markets, everywhere. The U.S. Department of Agriculture (USDA) has kept a tally of farmers markets operating throughout the country since 1994, and, since then, the number has jumped from 1,755 to  6,132 -- with a 16 percent increase between 2009 and 2010 alone. The U.S. Census of Agriculture of 2007 shows that the value of agricultural products sold directly to individuals for human consumption (roadside stands, farmers’ markets, pick-your-own sites, etc.) was 6.2 percent in 2007, up from 5.5 percent in 2002, and we'll bet it's on its way up more. (A farm, by the way, is defined as "any place from which $1,000 or more of agricultural products were produced and sold, or normally would have been sold, during the census year," and, since 1850, this definition has changed nine times.)The growth in farmers markets is driven by an interest in food safety, nutrition and "eating local" --  preserving local flavors, economics, culture, and farmers. Here, the USDA points out all the benefits of farmers markets -- for the community, small and medium size producers and, of course, for you and me. Use this tool to find one. We found 28 in our own city, Washington D.C. The states with the most farmers markets include: California 580, New York 461, Illinois 286, Michigan 271, Iowa 229, Massachusetts 227, Ohio 213, Wisconsin 204, Pennsylvania 203 and North Carolina 182."Seeing such continued strong growth in the number of U.S. farmers markets indicates that regional food systems can provide great economic, social and health benefits to communities across the country," Agriculture Secretary Tom Vilsack said in a statement. "Farmers markets provide fresh, local products to communities across the country while offering economic opportunities for producers of all sizes.How to connect these markets -- which are still outnumbered of course by fast food outlets and convenience stores -- to better health? We'll be interested in seeing what happens with the New England test project. This country, and its children, can use a "wholesome wave." Health Policy Program

A Longer-Term Fix For Medicaid?

Sept. 1, 2010

The news on Monday that one in six Americans are now enrolled in government poverty programs (Medicaid, food stamps, unemployment insurance and welfare) was an unsettling reminder of the economic fix we currently are in. Medicaid, as I’ve written before...

Rick Scott: A Great Makeover, But Still the Same Guy – Part 2

Sept. 1, 2010

Summary: Rick Scott, the former hospital executive who is now a candidate to become Governor of Florida epitomizes the power that concentrated wealth now has to influence American politics—and, perhaps, buy elections. As Jane Mayer explains in her superb New...

Implementing Health Care Reform: The Health Wonk Review Highlights Posts that Raise Questions

Aug. 29, 2010

The most recent Health Wonk Review, hosted by Joe Paduda at Managed Care Matters, raises provocative questions about making health care reform a reality. You’ll find Paduda’s round-up of some of the meatiest health care posts that have appeared on...

I Remember Rick Scott: A Great Makeover, but Still the Same Guy Part-1

Aug. 26, 2010

Summary: When I wrote Money-Driven Medicine, the Real Reason Health Care Costs So Much (Harper Collins, 2006), Rick Scott stood out as one of the more memorable characters in a rogues’ gallery of CEOs who helped create the stock market...

Rick Scott’s “Inner Voice”

Aug. 26, 2010

Below, an excerpt from an imaginary dialogue between Rick Scott and Rick Scott’s “inner voice” from Warren Langer’s blog “Still liberal at 83” http://stillliberalat83.net/2010/06/28/rick-scott-republican-candidate-for-florida-governor-talks-to-rick-scott/ It seems, to me, to capture Scott’s inner spirit in an important way. Rick Scott, Republican...

The Obesity Paradox, MIT Scientists Beaming, and New York’s Life Expectancy Gap

Sept. 2, 2010

The Obesity Paradox: While overweight people are more prone to heart failure, patients with heart failure have lower mortality rates if they are obese. MIT scientists are trying to enable Type I diabetes patients to test their blood sugar levels with light. It beats using a needle. New York female/male life expectancy gap is wider than in [...]

But Senator Baucus, Did the “Experts” Read the Bill?

Sept. 2, 2010

I doubt that it surprises anyone that Senator Max Baucus did not read the ObamaCare bill that he navigated through the Senate, but we should all be surprised that he has no shame in admitting it in a town hall meeting that he hosted last week with the U.S. Secretary of Health and Human Services [...]

We-Have-to-Pass-It-to-See-What’s-In-It Fact of the Day

Sept. 2, 2010

Faced with mounting debt and looming costs from the new federal health-care law, many local governments are leaving the hospital business, shedding public facilities that can be the caregiver of last resort… More than a fifth of the nation’s 5,000 hospitals are owned by governments and many are drowning in debt caused by rising health-care [...]

Is the Federal Government Broke?

Sept. 1, 2010

We previously reported on Larry Kotlikoff’s assessment. The first issue of a new publication by Morgan Stanley called Sovereign Subjects is captioned “Ask Not Whether Governments Will Default, but How.” Here is Richard Posner’s comment at his blog: Morgan Stanley’s report estimates that the ratio of current U.S. public debt to realistically realizable tax revenues is [...]

Why Is the Economy Not Recovering?

Sept. 1, 2010

Disastrous economic policy is almost certainly the reason. And number one on my list of disasters is the new health reform law. Did you know that the Patient Protection and Affordable Care Act (PPACA) uses the term “the Secretary shall” 1,075 times? That means enormous discretionary power to make decisions about the fate of a sector [...]

Secretary Clinton on the Global Health Initiative: More on the WHAT and the WHO, but Not the HOW

Aug. 17, 2010

By Nandini Oomman - Secretary Hilary R. Clinton spoke yesterday at SAIS on the objectives of the Global Health Initiative (GHI). The webcast of the event provided a forum for an interesting and interested set of tweeters (I participated) to point out what we heard and did not hear during the talk. My overall impression, echoed by several others [...]

A Refreshingly Open Debate on the Value of Universal Access to AIDS Treatment for U.S. Foreign Policy

Aug. 9, 2010

By Mead Over - The Center for Strategic and International Studies (CSIS) hosted a debate last Friday with the provocative title “Resolved: That the US commitment to universal HIV/AIDS treatment is unsustainable and decreases US leverage in the nations’ foreign policy.” (Note: This resolution which you will hear debated is edgier and has more foreign policy content than the [...]

Right Hearing, Wrong Message on Neglected Pediatric Diseases

July 29, 2010

By Tom Bollyky - Last week, the U.S. Senate Health, Education, Labor, & Pensions (HELP) Committee held a hearing that had all the elements of an important event for global health. It was the right topic – the lack of effective treatments for rare and neglected pediatric diseases. It was the right venue – particularly in an environment of tightening [...]

Microbicide Study: Important for Science and Global Development Partnerships (Postcard from Vienna)

July 26, 2010

By Nandini Oomman - The biggest news from the 2010 AIDS Conference was no doubt the encouraging results from the Centre for the AIDS Programme of Research in South Africa’s (CAPRISA) trial of a female microbicide gel to block the transmission of HIV. As my colleague Mead Over describes, this possible prevention technology offers us new hope after a [...]

Does the Global Fund Reach the Most Marginalized and At-Risk Populations? (Postcard from Vienna)

July 22, 2010

By Christina Droggitis - Under the banner “Rights Here, Right Now,” the International AIDS Conference currently taking place in Vienna is committed to translating funding for human rights-based programming for HIV to address the stigma and discrimination that often impede an effective response. On Wednesday, Global Fund executive director Michel Kazatchkine and others participated in a session titled “The Global Fund: Proving Impact, Promoting [...]

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