10 March 2017

Dear Interested Readers,


What’s Inside This Letter

I hope that you have looked at the most recent posting on strategyhealthcare.com. If you have read the posting entitled “Looking Underneath the President’s Comments About ‘Repeal and Replace,’” and if you have examined Paul Ryan’s bill, you were able to see that what President Trump had promised in his address to Congress last week was an accurate preview of the Republican bill that was introduced in the House of Representatives on Monday. The only thing missing is selling insurance across state lines.

In my posting you would have read a repetition of the point that I tried to make in last Friday’s letter that the root cause problem is not high insurance costs caused by Obamacare, but rather the high cost of care with subsequently expensive insurance. I believe that the causes of the high cost of care which drive expensive insurance lie within our practices and our industry and are not an outcome of the ACA.

...the cost of care is high because of the waste, poorly organized processes of care, and perhaps the business practices of institutions and suppliers including insurance companies and big pharma.

The first section of this week’s letter is an updated review of the Republican bill which is now being considered in the House of Representatives. By now you may have read several reviews and opinion pieces on your own. I will try to offer some synthesis of what I have read and season the section with my own take. It is a mixture of reality and worry.

The second section of the letter could be considered an explanation of what the ACA was trying to do or an outline of the considerations that I think would be the framework of a plausible system of care. Over the last forty plus years I have given a lot of thought to the theoretical world where I would have enjoyed practicing. Over the last nine years I have been trying to describe that world in bits and pieces. I think that anyone who tries to think or write about what would be a better process of healthcare has shared the President’s epiphany, “Nobody [who?] knew that healthcare could be so complicated.” Writing about healthcare is also complicated and difficult for me. A detailed presentation of “what should be” can’t be summed up in five simple points as the president tried to do. The Triple Aim as articulated in 2007 was the brilliant distillation of decades of effort to articulate the objectives of healthcare reform, and the recent twenty-five word presentation of the “Quadruple Aim” is a the current best effort to describe the vision of an “ideal” state that we can all share.

Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.

The letter concludes with some words about a seasonal celebration, the joy of rising sap. Rising sap is the most positive environmental activity in my neighborhood. The weather is sketchy. It is not really winter and not spring. Where I live we are moving toward “mud season” and that means that there are buckets hanging from the maple trees. I write about how I am carried forward through difficult times by my admiration of one man who lives to serve others and boil sap. Watching him and having expectations of fishing and watching baseball in a few weeks will get me through the end of winter.

I hope something in the letter will speak to you.

An Initial Reaction to “Ryancare”

Paul Ryan has finally presented his “repeal and replace” bill, now identified as the American Health Care Act (AHCA) to the House. It does not take much effort to find intelligent articles in responsible journalism outlets and healthcare publications that identify what a terrible and dangerous bill it is. Over the last few days the AARP, the AMA, American Hospital Association, the American Nurses Association and many other organizations have expressed their objections to the AHCA and concerns about the damage it will do.

Within Congress there is the potential of a strange coalition of objectors. Members of the “Freedom Caucus” in the House and very conservative and libertarian senators object to the bill as “Obamacare Lite,” or a Republican expansion of entitlements. Democrats object because it will lead to many millions of recently covered insurance recipients losing coverage as it shifts significant monetary gains to upper income Americans. Together they could defeat the bill. Ryan seems confident of quickly pushing his bill through the House and Mitch McConnell promises swift action in the senate. One goal of Ryan and McConnell seems to be to get the AHCA to President Trump for signing before the CBO can estimate its impact or comment on its funding. In his ubiquitous tweets, the president seems delighted with the prospects of passage, although the outcome will be far less than his expansive description of how wonderful the replacement plan would be that would accompany repeal of the ACA.

I have downloaded the bill and given it a perusal. It is easy for you to do the same thing. It is not a big bill, but reading it is not a very satisfactory exercise. The download is 123 pages (25 lines to most pages with less than 10 words per line) and is probably less than 20,000 words. Its readability is reduced by endless legalese and references to sections of the ACA and other regulations. Curiously, there are several pages that seem written to prevent lottery winners of significant amounts of money from being on Medicaid. I saw no language about benefits or any evidence that improving healthcare was even a remote concern. The prohibitions against using federal funds for abortion were very easy to understand. The primary goal seems to be to reduce the federal responsibilities to states for Medicaid by setting limits on federal funding through block grants and reducing the number of people on the Medicaid rolls while being able to argue to their conservative base that the bill honors states’ rights and individual freedom.

The bill definitely does away with the mandate to buy insurance, but not really, because a patient must pay a 30% of premium surcharge as a backend surrogate mandate when or if they decide to buy insurance after being uninsured. That surcharge could potentially be more than the mandate penalty would have been. In a very informative piece in the New York Times entitled “Follow the Healthcare Money” David Leonhardt writes:

Many Americans over the age of 60 would have to pay more for health insurance under the Republican health care plan. Many low-income families would lose their insurance. Many disabled people, hepatitis patients and opioid addicts, among others, would no longer receive treatments that they do now.

They would go largely to the richest 1 percent of households, those earning at least $700,000 a year, according to the Tax Policy Center. A disproportionate amount of the savings would go to the richest of the rich — those earning in the millions.

I apologize for the continuing cynicism that I attach to any pronouncements of the president or his Republican colleagues in Congress. Perhaps I hear deception, outright dishonesty, and deceit in their every attempt to communicate their plans to make America great. Since the bill is difficult to understand it is published with a FAQ sheet (frequently asked questions) which you may want to read. If the “web of your beliefs” or your personally evolved reality and biases has at its core a set of values that makes you a person who highly prizes self reliance, favors a small central government, hopes to see a reduction of entitlements, does not like to pay taxes, and believes that the free market and competition can solve all problems, then you will find the Q and A quite reassuring. If your reality is built on ideals of community, the belief in the ability of responsible government to improve the lives of people, have a desire to see a reduction in the social determinants of disease, and if you have concerns for the underserved and marginalized members of our society, then the Q and A will enrage you.

Below I offer some examples from the FAQ sheet and then give my answer after the “official answer”

What does your legislation do?

Our plan delivers relief from the taxes and mandates that have hurt job creators, increased premiums, and limited options for patients and health care providers.

It returns control of health care from Washington back to the states and restores the free market so Americans can access the quality, affordable health care options that are tailored to their needs.

As I have noted above, the bill definitely reduces taxes and ends the government mandate to consumers and employers. What it also does is to allow the insurance companies to introduce penalties up to 30% to those who attempt to buy insurance after a period when they are not covered. As the Commonwealth Fund has suggested it offers a way to substantially reduce the number of people who have access to Medicaid. By introducing grants to states rather than payment for the individuals on Medicaid, it will reduce the overall federal support individual states receive for Medicaid. The Boston Globe discussed how this will likely play out in Massachusetts.

Across the country you can expect to see as many as 10 million Medicaid recipients lose coverage and the benefits provided reduced for those who are still covered. Many believe that the number will be 20 million. David Blumenthal and Sarah Collins writing for the Commonwealth Fund say that 1 in 10 Americans or 30 million will lose coverage. I think Blumenthal’s and Collins’ projections are closer to what will happen. People who have not gotten subsidies through the ACA may get some money or benefit from expanded health savings accounts or their ability to buy cheaper insurance that covers less. The wealthy, big pharma, and medical device manufacturers will see their taxes go down.

How will this improve my health care?

What we’re proposing will decrease premiums and expand and enhance health care options so Americans can find a plan that’s right for them.

This answer makes me choke with disbelief. It is a perfect example of a statement that is essentially false but has small elements of fact that are expanded by a person of authority for a political advantage. The majority of Americans had pretty good coverage before the ACA but forget that their costs were going up annually by some multiple of the GDP and overall cost of living. The focus of the ACA for them was to bend the cost curve while offering a better product that could not be denied when they became ill or had a preexisting condition. For the minority of Americans who had no coverage the goal was to give them care through the expansion of Medicaid or allow them to buy insurance through the exchanges with financial support if their income was low. Ryan ignores and denies the progress that the ACA has made progress toward both goals. With the AHCA some employers and some individuals will have the option of buying coverage that is inferior to the standards established by the ACA. Insurers will be able to charge older Americans up to five times more than younger consumers. Many believe that the costs of care will take off again and the number of uninsured will rise dramatically. It is ironic that the Freedom Caucus is afraid that the government will still spend too much if the AHCA is passed.

Are you repealing patient protections, including for people with pre-existing conditions?

No. Americans should never be denied coverage or charged more because of a pre-existing condition.

 
Some of this is true, but Ryan fails to completely reveal what will happen when a person has a “gap” in coverage or how the bill will finance the coverage of preexisting conditions minus the mandate and the taxes that will be repealed. 

There are several more good examples of half truths and deceptions as you read through the FAQs. I will leave them to you to read after concluding this section of the letter with what I consider to be his most dishonest assertion. 

I assume that he is hoping that his answer is true between now and the end of 2019 when the Medicaid expansion ends and the switch to a new funding mechanism is complete. According to numerous economists and healthcare experts, whose opinions he must be aware of, this statement is false. Do not forget that the AMA, the AHA, the ANA, and the AARP along with numerous others have protested that his plan will damage the lives of millions. That leaves me with the conclusion that he is being dishonest with us or he is naive. I think that he is a focused politician who is willing to distort the truth to achieve an end that is consistent with his personal philosophy. Ironically, the Freedom Caucus and libertarians are more straightforward and truthful than Paul Ryan, Mitch McConnell, their colleagues, and the president. What makes this conclusion very likely is that Ryan, McConnell and the president do not want to wait until the Congressional Budget Office evaluates the economic impact of the legislation. 

I shake my head in disbelief when I think back on the debates and speeches during the run up to the election. During three debates between Clinton and Trump there was less than twenty minutes of superficial discussion of healthcare. The press may have failed to push the right questions. I remember all the discussions of walls, emails, Benghazi, marginal observance of social norms, and inferences about body parts, and virtually nothing about what voters might expect if the ACA were repealed without a better replacement.

A Different Reality and Vision

For almost a decade I have frequently included in my writing and speaking the vision and wisdom of Robert Ebert. Perhaps you have read before or heard me describe my amazement when while searching through his papers in the Countway Library archives, I discovered an incredible passage in a letter that he had written in 1965 while requesting financial support from the Commonwealth Fund for his grand experiment which became Harvard Community Health Plan. In 1965 Lyndon Johnson had just pushed Medicare and Medicaid through Congress. At the time I doubt that there were many people who imagined that it would be forty five years before there would be another broad expansion of coverage for the uninsured. The issues and concerns for Dr. Ebert in 1965 were a combination of his realization that the rural and urban poor were still inadequately covered, and his conviction that we did not have sustainable processes of medical education and care delivery.

He summed up his concerns by saying something that still describes the realities that we face today.

The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.


I like to think that the wisdom of that statement evolved into the Triple Aim and that the expression of the Triple Aim has evolved into what some call the Quadruple Aim

Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.

Dr. Ebert did more than pontificate. He proposed a hypothesis. He believed that fee for service payment for care in a system where there was no shared accountability for outcomes could never be the answer to the search for a conceptual framework and operating system that will provide optimally for the health needs of the population. He was interested in the advantages that prepaid healthcare offered to clinicians who were organized to improve health through a greater understanding of how to promote health, prevent disease, and efficiently respond to disease through the development of group practice that appropriately avoided the hospital.

I think that the thinkers who helped create Medicare and Medicaid, and the AMA that so vigorously tried to resist its passage, realized the power that the government would have through finance to direct the evolution of our delivery system. I also believe that most physicians were too busy with business to think positively about how new payment methodologies and centrally developed expectations could affect the evolution of care. What we witnessed after the huge achievements of 1965 was a forty five year plateau during which potentially beneficial ideas like managed care were introduced and undermined as physicians and the public resisted change. Despite the failures of that forty five years we learned a lot. The ACA was an attempt to apply some of those learnings toward a leap forward like the effort in 1965. President Obama was a student of previous failures. Unlike President Trump, he knew healthcare was complicated and that progress would require accepting something that was not an ideal outcome but an improvement.

Bernie Sanders was absolutely right that the most efficient set of solutions that would give us a conceptual framework and operating system that will provide optimally for the health needs of the population would begin with the acceptance that healthcare was a universal entitlement that required a single payer. Perhaps long after there is moss on my tombstone that wisdom will be accepted. Obama knew that capitalism, a belief in markets, privately owned resources, and the illusion of progress through competition were national preferences. No one between Kennedy in 1978 and Don Berwick in 2014 really tried to push a single payer. President Obama accepted exchanges without a public option to gain the support of the insurance industry. Contrary to common misconception President Obama tried to have a bipartisan process. Many concessions were made to Republicans when the bill was in committee in the House and Senate. After modifying the product, as Charles Grassley of Iowa did in the Senate Finance committee, they refused to vote for it and have continuously attacked it and President Obama while denying the advances that it has produced.

Perhaps the most onerous of the provisions of the ACA are its mandates to individuals and employers and the taxes on suppliers of care and employers that fund it. During the election primaries Bernie Sanders honestly reported that a single payer system would require an increase in taxes, but that it would result in an overall savings when the cost of care and insurance was considered. Without a single payer to finance care for everyone out of tax dollars we must have a mandate.

The optimal insurance product in lieu of a single payer would be built on the old concept of “community rating” where everyone pays the same no matter how sick or how old they are. The well subsidize the ill. The young subsidize the old. The concept is built on the reality that most of us will at some time in our lives require care. Preventative care and early access to interventional care for everyone when needed lowers the ultimate cost and complexity of care by improving many problems before they become hopeless or more expensive.

The ACA is not a perfect example of community rating but it is a movement in that direction. Value based reimbursement is a movement toward prepayment or capitation. The ACA is built on all of these principles. To improve the ACA and to lower the cost of care and make the expense of universal healthcare sustainable, we need to go further toward the opportunities that community rating and value based reimbursement offer, and not run away from them toward systems of care that will be perpetuated by the AHCA and have already proven that they are inadequate.

The fabrications of the moment are numerous and built on partial truths. What we hear is that the ACA is failing. It is not. We hear there are no doctors that accept Medicaid. Many do not, but access to care is better for the underserved with Medicaid than with no insurance. We hear that costs are going through the ceiling and that financial failure is eminent. That is not true. The annual increases in costs are less than they were before the ACA, by a lot. The greatest untruth is that things will be better if the ACA goes away. Better for whom? Certainly not for the underserved and probably not for almost everyone since the ACA not only expanded coverage it improved the quality of the insurance products that could be offered. It also controlled to a small extent the large profit margins that insurers could demand.

Crossing the Quality Chasm was published by the Institute of Medicine in 2001. The ACA conforms to the templates for quality and optimal care delivery that were proposed in that document. Crossing the Quality Chasm taught us that quality medical care was

• Patient centric
  
• Safe
  
• Timely
  
• Efficient
  
• Effective
  
• Equitable
  

It also suggested that optimal care came from systems management and that good systems of care would be described by:

• Care based on continuous healing relationships: Care should be given in many forms not just face to face encounters. The system should be responsive 24 hours a day.
  
• Customization based on patient’s needs and values.
  
• The patient as the source of control. Encourage shared decision making.
  
• Shared knowledge and the free flow of information: Unfettered access to medical records with effective communication between patients and clinicians
  
• Evidence based decision making. Practice should not vary illogically from clinician to clinician.
  
• Safety as a system property.
  
• The need for transparency.
  
• Anticipation of need. [For me this is an exciting challenge. We say that we practice preventative medicine but is that the same as anticipatory medicine?]
  
• Continuous decrease in waste.
  
• Cooperation among clinicians. “I to we” within practices, across practices, across systems and throughout the community.
  

The primary reason that Paul Ryan, the president, Mitch McConnell and others give us for needing to repeal and replace the ACA is that health insurance is to expensive. They do not connect the dots between the high cost of insurance and how care is delivered. The ACA did make that connection. It’s many regulations and requirements as well as its innovation arm, CMMI within CMS, were designed to move us toward the vision of the Triple Aim based on the principles articulated in Crossing the Quality Chasm. The AHCA, the anemic offering before Congress, is built on nothing substantial. It’s primary goal is to reduce federal spending on entitlements, and it is a legislative lie that will be supported and signed, if passed, by a president who virtually admitted within the last month that he knows nothing about healthcare when he said with astonishment, “Nobody knew healthcare was so complicated.”

A Spring Ritual

My friend Steve is an enthusiastic participant in the life of our community. He is a leader in numerous acts of community service. I have joked (to myself) that he does more community service than the average crook whose debt to society includes x number of hours of community service. I doubt that there is ever a day that goes by that Steve does not ask himself what he could be doing to help someone.

Through many activities around our community and our church Steve and his wife are the spark plugs that start the projects that touch people in need for miles around. If you are broke and you are trying to heat your house with wood, call Steve. You will suddenly have a cord of seasoned wood neatly stacked near your back door. If you must move to a new house or apartment and do not know how you can ever do it because you are broke and disabled, call Steve and he will show up quarterbacking a crew of able bodied men and women who will do the job. If you are a young adult and are confused about how to get started in life give or have a substance abuse problem, give Steve a call and he will take you to lunch and listen to your problems and then help you get started on a road to success and or recovery.

Steve and his wife lead a youth group that brings middle school children into direct contact with the concerns of the homeless and immigrants. He is actively involved with a group from Colby-Sawyer College in a community development activity in one of New Hampshire’s poorest towns. When Steve is not directly helping people in a hands on way, he is chairing a committee or serving on a board.

For fun Steve loves to watch basketball, snowshoe through the woods and up a mountain, and boil maple sap to make maple syrup. As you might guess, Steve makes maple syrup to give it away. This time of year when we have cold nights and warm days Steve gets to enjoy the combined reality of rising sap and March Madness basketball.

I think the part of maple syrup production that Steve enjoys most is boiling down the sap. This year the sap is weak so it will take about fifty gallons of sap to make one gallon of syrup. The part I enjoy the most is watching Steve holding court around the boiling sap. It is a social activity. The conversation is usually about reaching for a better world.

One picture can’t capture the whole process of syrup production but today’s header does give you a picture of the first step. If you drop by Steve’s place, you can watch the next step and enjoy the conversation that goes along with watching the sap boil. Watching the sap boil is a good time to collectively imagine a better world which on the personal side might include fishing and baseball in the not too distant future.

Whatever you like to do this time of year, I hope that you will get a little exercise and enjoy the company of friends and family this weekend. You need to recharge yourself because there is much work to do to keep the faith of a better world as others focus on what we should fear and how we can keep more for ourselves living in a world where many of our neighbors nearby and around the world have less.