| 29 December 2017 Dear Interested Readers, Looking Back to Think ForwardIt is not uncommon to see tee-shirts and bumper stickers printed with quotations that begin with “I survived….” If you have ever driven up the steep and narrow road to the summit of Mount Washington you can get an “I survived” bumper sticker for your car as well as a tee-shirt proclaiming your accomplishment. If the ACA could wear a tee-shirt, or had a place for a bumper sticker it could wear the slogan, “I survived the best efforts of Trump and his cronies to repeal and replace me in 2017!” 2017 was a tough year for healthcare and the dream of the Triple Aim, but it turned out to be a little better year than most people were predicting at the end of 2016 while we were steeling ourselves for the events of January 20, 2017. The ACA finishes the year still standing after absorbing the blows of multiple failed attempts by the Republican controlled Congress to repeal and replace it. It survived the appointment of Tom Price as the Secretary of Health and Human Services. The Medicaid extension is still intact even after Seema Verma, who had made a profitable business out of her willingness and her ability to complicate the lives of Medicaid recipients in several states, was named the Administrator of CMS. Who would have anticipated that by year’s end Dr. Price would be gone, but the bill, which he tried every administrative opportunity at his disposal to undermine, would still be the law of the land, having lost only its mandate to tax reform. Price cut the enrollment period for the ACA in half, greatly reduced its budget for advertising, and eliminated most of the funding for counsellors to assist people with their choices. Despite those challenges, 8.8 million people did sign up on the federal government site meaning that the efforts by Price, Verma, and gang only reduced the sign up by 400,000, and in the exchanges run by states like California, New York and Massachusetts, the sign up period extends into January! Two big takeaways for me in regards to the ACA, are that by any name, be it ObamaCare or the ACA, the experience has proven that a majority of people are beginning to understand the principles upon which it is built, and will fight to preserve them. More people now understand that the ACA was designed to free people from the shackles of pre-existing conditions, remove lifetime limits on coverage payments, eliminate substandard policies, and move us closer to universal care while preserving market principles. Parents love the ACA for allowing young adults to remain on family policies until they are twenty six. The ACA has expanded coverage to the working poor through the Medicaid expansion in the states that have allowed it, and has provided subsidies on the exchanges for lower middle class people and families in the individual market. The attempt to abolish the ACA underlined its importance in a way that has educated the public. We don’t have universal coverage yet, but if CHIP is ever permanently renewed, we will have lost less ground to that ideal than we would have ever thought possible after listening to the president’s inaugural address. This time of year there are a lot of “year in review” articles and lists of “The Best___of 2017.” I would suggest that you pay particular attention to the offering from the Commonwealth Fund. I love the stated mission of the Commonwealth Fund: The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.If you follow the link you will get what they believe to be their top ten offerings for the past year. I want to focus on what they think is their number one offering for the year: “Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care.” It is an article from July that compares healthcare data from the top ten performing countries of the world with the performance of the United States. As you probably know, or could guess, we rank behind all of the top ten in most categories and are number eleven overall. If more countries were included, our ranking would be even lower, but these are the ten countries that we consider to be in our economic and intellectual league. They are Australia, Canada, France, Germany, The Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. The article has five sections. - The United States Health System Falls Far Short
- Performance Varies Among Health Systems
- Causes of Poor Performance
- Lessons for the United States
- How We Measured Performance
I have not done an exhausting review of the literature, but I do not ever remember Republicans substantively addressing any of the areas of performance that were reviewed in the article other than the unavoidable issues of healthcare spending and costs. Chief among the concerns that they failed to address and which the ACA did try mightily to improve were the areas of: - Care process
- Access
- Administrative efficiency
- Equity
- Health care outcomes
Accentuating the positive, we did best against the other ten nations in the category of overall “Care Process” where we ranked fifth. As described and measured, Care Process has four subdomains: preventive care, safe care, coordinated care, and engagement and patient preferences. If you are interested, the paper carefully describes what each subcategory includes, and how each one was measured. I think that part of why we scored best in this grouping was because of our collective efforts that were inspired by Don Berwick and the IHI to improve quality and safety through programs of continuous improvement. Despite disparaging slurs such as “Medical Taylorism” I think the spread of Lean, which teaches “management by process” has contributed to improved “Care Process” where it has been given a chance by enlightened leaders. The “government” efforts prior to January 20, 2017 were also success factors that pushed us to number five through the programs supported by the ACA, and administered through Medicare and Medicaid by CMS, and adopted by commercial payers. There was certainly benefit to our score in the “Care Process” category from the 40 billion dollars that the government invested in providing electronic medical records to physicians, and the follow up focus on “Meaningful Use.” Some of our payment innovations such as ACOs, bundled payments, and pay for performance, including payment for measurements of patient satisfaction, and efforts to reduce admissions through better management of CHF, diabetes and asthma, account for why the “Care Process” category is where we score best, although we are still mid pack. This limited success should point the way to how we can further improve, but I do not see Congress, HHS or CMS getting the message. I see Congress and the administration totally neglecting their responsibility to sponsor and encourage improvement. Though limited, the success of these programs has been a good start, but now the government is controlled by those who favor reverting back toward the laissez faire attitudes that will propagate waste, expense, and poor outcomes for a growing number of Americans. The only other category where we are not dead last was “administrative efficiency.” We were tenth, and we beat the French! I love Paris and the French countryside, but “efficient” was never an adjective I would have used to describe my French travel experiences. I would favor “passionately and passive aggressively inefficient” as the descriptors for their approach to American tourists. Apparently that attitude of “you should be happy if we notice you at all” also applies to their healthcare system. The paper describes what is measured in the category of Administrative Efficiency: Administrative Efficiency includes seven measures. Four measures evaluate barriers to care experienced by patients, such as limited availability of the regular doctor, medical records, or test results. Three indicators measure patients’ and primary care clinicians’ reports of time and effort spent dealing with paperwork, as well as disputes related to documentation requirements of insurance plans and government agencies.We love to talk about the deficiencies and delays in the UK, but that is mostly “fake news.” They actually rank number one in Care Process, Equity, and in the overall rankings! They are third best in Administrative Efficiency and Access. The rankings were done rigorously, and every country has room for improvement as demonstrated by the fact even though the UK was the gold medal winner overall, they were number ten in Health Outcomes, beating only us. The paper is quite clear about how Health Outcomes were considered and measured: The Health Care Outcomes domain includes nine measures of the health of populations. Taken together, they are intended to reflect outcomes that are attributable to the performance of the countries’ health care delivery systems. The measures fall into three categories: population health outcomes (i.e., those that reflect the chronic disease and mortality of populations, regardless of whether they have received health care), mortality amenable to health care (i.e., deaths under age 75 from specific causes that are considered preventable in the presence of timely and effective health care), and disease-specific health outcomes measures (i.e., mortality rates following stroke or heart attack and the duration of survival after a cancer diagnosis).
In the population health outcomes category, two measures compare countries on the mortality of populations defined by age (infant mortality and life expectancy after age 60) and one measure focuses on the proportion of surveyed nonelderly adults who report at least two of five common chronic conditions. For each country, mortality amenable to health care includes both the current rate of deaths amenable to care and the 10-year trend. In the disease-specific health outcomes category, two measures focus on 30-day in-hospital mortality following myocardial infarction and stroke, and two measures examine five-year relative survival for breast cancer and colon cancer.Australia was number one in health outcomes when measured as described above. It may interest you that numbers two and three were Sweden and Norway. Working from the bottom up we were 11, the UK was 10, and Canada was 9. I have saved for last the deadly combination of overall cost and access. Since we are the only country of the eleven that has not figured out the importance of covering everyone, it is no surprise that we are dead last in access, but the study was looking at access in a more critical way than just whether or not there was universal coverage. You may remember that in Crossing the Quality Chasm there were six domains of quality: equity, safety, patient centeredness, timeliness, effectiveness, and efficiency. That’s not the order of the six as originally published. It is the order that currently feels most meaningful to me. We all suffer substantially from the lack of equity in our system. Equity is a human rights issue that impacts every aspect of quality and care delivery. We all share the blame and consequences of long ago not more vociferously demanding equity as manifested minimally by universal access. I once thought that the combination of efficiency and effectiveness were the best measures of cost and value, but now I see that as a limited perspective. All six domains are critical to cost and value. The Dutch get the gold medal for affordability and timeliness as described below. Access encompasses two subdomains: affordability and timeliness. The six measures of affordability include patient reports of avoiding medical care or dental care because of cost, having high out-of-pocket expenses, facing insurance shortfalls, or having problems paying medical bills. One measure reflects primary care doctors’ views of the difficulty patients face in paying for care.
Timeliness includes nine measures (three of which are reported by primary care clinicians) summarizing how quickly patients can obtain information, make appointments, and obtain urgent care after hours. It also addresses the length of time needed to obtain specialty and elective nonemergency surgery.One of the things that has irked me most since the inauguration last January has been how the Trump administration and the Republican majority in Congress have used the current costs in the self insured market as a political argument against the ACA. I agree that it is a big issue, especially for members of the middle class who are trapped in the Individual Market and earn too much for the financial support offered through the ACA. The irresponsible aspect of the political discussion is to point to the current situation and not do any analysis for why it exists. Our current health care cost dilemma took us at least 35 years to produce. Prior to 1980 our costs were not much different proportionately to the other ten nations in the Commonwealth Fund analysis. The chart below shows that our costs have accelerated since 1980. [Let me point out that Ronald Reagan was elected in 1980, and that Ted Kennedy gave up his legislative efforts to move us to a “single payer system” at the end of the seventies after a dispute with Jimmy Carter. After 1980 Kennedy’s approach was to work for incremental improvements, although he never gave up the hope for universal coverage.] |
| | This week’s New England Journal of Medicine contains a perspective article, “Evidence-Based Health Policy” by Katherine Baicker, Ph.D., and Amitabh Chandra, Ph.D., two healthcare economists from the University of Chicago and Harvard, respectively. The authors do an excellent job of describing how to responsibly and effectively incorporate the reams of data that are being produced in this digital age into effective policy decisions. Just knowing that costs are high and applying your bias to explain the reasons, and then jumping to a solution defies and desecrates the foundational concepts of continuous improvement.
The authors point to three principles that need attention when trying to implement Evidence-Based Health Policy (EBHP). The bolding is my addition.
- Policies need to be well-specified; a slogan is not sufficient. For example, “expand Medicaid” isn’t a policy. “Expand existing Medicaid benefits to cover all adults below the poverty line” is closer — but, of course, moving to a specific, implementable program requires vastly more detail.
- Implementing EBHP requires us to distinguish between policies and goals. This distinction is important in part because different people may have different goals for a particular policy. Consider the policy of implementing financial incentives for physicians to coordinate care. The evidence that such incentives would reduce health care spending (one potential goal) is quite weak, whereas the evidence that it might improve health outcomes (a different goal) is stronger...
- EBHP requires evidence of the magnitude of the effects of the policy, and obtaining such evidence is an inherently empirical endeavor. Introspection and theory are terrible ways to evaluate policy. In some instances, we have clear conceptual models that suggest the direction of the effect a policy is likely to have, but these models never tell us how big the effect is likely to be...
One statement made by the authors that points out a reality that is obvious, but often lost in many “political discussions” about health care is:
“There is also a key difference between “no evidence of effect” and “evidence of no effect.”
They underline the role of bias in political discussions about healthcare. Their point applies both to passionate seekers of the Triple Aim, like me, and those hoping to undermine and disable many entitlement programs, like Paul Ryan, Mitch McConnell, and Libertarians like Rand Paul.
In addition, just as the distinction between policies and goals is often muddied, interpretations of the evidence are often flavored by the implicit goals of the analyst.
They conclude the article with practical wisdom that could be interpreted as a call for mutual respect, listening to the other side, and attempts to foster bipartisan policy efforts. Any progress is dependent on finding some common ground. Perhaps that common ground could be something as fundamental as accepting evidence-based policy formation as a starting place for an experimental or continuous improvement science approach to our complex problems. I’ve bolded the first “bipartisan step” in the author’s closing comments:,
Finally, even a rich body of evidence cannot guarantee that a policy will achieve its goals, and waiting for that level of certainty would paralyze the policy process. In health policy — as in any other realm — it is often necessary to act on the basis of the best evidence on hand, even when that evidence is not strong. Doing so requires weighing the costs of acting when you shouldn’t against those of not acting when you should — again, a matter of policy priorities.
Just because something sounds true doesn’t mean that it is, and magical thinking won’t improve our health care system. EBHP helps separate facts from aspiration. But as important as evidence is to good policy choices, it can’t tell us what our goals should be — that’s a normative question of values and priorities. Better policy requires being both honest about our goals and clear-eyed about the evidence.
This is where I go back to the issue of cost and the determinants of cost. The ACA is not the root cause of our cost problems. My list and your list of what has created our cost issues would be an exercise in comparing our biases. What is fact is that we have become much more expensive over the last 35 years than other advanced nations with whom we trade and share many other values, as the graph from the Commonwealth Fund shows. This is not new information for any of us. We have different points of view about what has created this reality, just like we have differing opinions about the causes for the weather we jointly experience.
One thing is clear, the ACA, which did not get implemented until 2014, did not cause our current cost problem. Perhaps part of the cause lies in the reverse of Dr. Ebert’s admonition:
“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.”
He was advocating for better outcomes built on the efficient pursuit of programs of preventative care, chronic disease management, and efficiency and effectiveness in the use of resources directed toward what we now call the Triple Aim. We have not been very effective in the application of the implications of his wisdom. My bias is that rather than worrying about the cost of care we have mostly focused on payment. We are driven, not by a desire to improve health, but by the pursuit of better bottom lines for individual practitioners and systems of care through as high a fee for service payment schedule as tolerable.
The Commonwealth Fund article succinctly sums up much of what I have tried to say:
Based on a broadly inclusive set of performance metrics, we find that U.S. health care system performance ranks last among 11 high-income countries. The country’s performance shortcomings cross several domains of care including Access, Administrative Efficiency, Equity, and Health Care Outcomes. Only within the domain of Care Process is U.S. performance close to the 11-country average. These results are troubling because the U.S. has the highest per capita health expenditures of any country and devotes a larger percentage of its GDP to health care than any other country.
Their bottom line:
The U.S. health care system is unique in several respects. Most striking: it is the only high-income country lacking universal health insurance coverage.
That outcome is a choice. Paradoxically, we, the providers of care, and the keepers of policy and the writers of laws, have collectively incurred more expense by focusing on everything related to care except assuring that everyone had access to care. To give care to everyone at a cost we can all afford we must find the operating system and finance mechanism that works for us.
Perhaps the most interesting point that the authors of the Commonwealth Fund paper make is that the ten countries that clean our clock in the healthcare Olympics all have universal access. They get to their better results following different formulas. Analysis demonstrates that there are at least three mechanism of finance that work. The first ranked UK has the most “socialized” system.
...health services are paid for through general tax revenue, as opposed to insurance premiums. Furthermore, the government plays a significant role in organizing and operating the delivery of health care. For example, most hospitals are publicly owned, and the specialists who work in them are often government employees. This is not true of all providers. Most general practitioner practices are privately owned. Health care in the U.K. and other Beveridge [William Beveridge was the designer of the UK’s welfare state and the National Health Service] countries is centrally directed and has more direct management accountability to the government than in other health systems.
Australia, ranked second in overall performance, has a much less socialized system of care than the UK. It operates as a “Medicare for all” system, with the government paying the bill to private providers, but some patients “opt out” for private care. In a way, it is similar to American education with a mix of public and private school options.
In Australia, everyone is covered under the public insurance plan, Medicare. Much like the NHS, Australia’s Medicare is funded through tax revenue. Medicare is distinguished, though, by lesser public involvement in care delivery. Many Australian hospitals are private, and roughly half the population purchases private health insurance to access care outside the public system. To put into an American context, Australia’s Medicare resembles Medicare in the U.S.
Finally, the Dutch who rank third overall but are first in access, and second in equity, have a system that is includes community rated premiums, managed competition with subsidies for the poor, and a mandate that everyone participate. It’s not all that different than the ACA tried to establish for us.
...the Dutch health system relies on private insurers to fund health services for its population. Dutch insurers are mainly financed through community-rated premiums and payroll taxes, which are pooled and then distributed to insurers based on the risk profile of their enrollees. All plans include a standard basic benefit package; subsidies are available for people with low incomes; adults are required to enroll in a plan or must pay a fine. Dutch health care providers are predominantly private. This multipayer system—partly inspired by the managed competition model—shares many similarities with the insurance marketplaces created under the Affordable Care Act.
Looking forward, I do not see much happening in 2018 other than an election. Perhaps the slide toward oblivion of what we did accomplish under Obama with the ACA is over, and we will limp forward toward better understanding of how to effectively achieve the Triple Aim with the hope that someday all the pain and suffering we have now, and will continue to have for a while, will end. Perhaps someday we will have the wisdom and the better experience of the Dutch, the Brits, or the Aussies. Between now and that time I encourage you to continue to work for something better globally, and to ask yourself on a daily basis what you can do locally within the current constraints to make things better. I contend, as I have for sometime, that to be better we need to put our personal and institutional concerns behind those of our patients, and in particular behind the concerns of the underserved who experience both medical neglect and economic inequities.
I do not like the “dog whistle” politics of “Make America Great Again,” but I sure would love it if in a few years the international rankings of healthcare showed us to be number one in all categories. For that dream to come true there is a lot of work to be done.
Stop, Turn Around, and Look
On Christmas day I always like to get in a brisk walk before having a big dinner. The only problem is convincing others to join me. By mid afternoon my family had long finished exchanging gifts and had even had time to get out an old toboggan for a few attempted runs down the slope of the driveway. I had made my traditional biscuits and pancakes, and had cleaned up! We had gotten six inches of fresh snow overnight and during the morning, but the town plows had already been out, and the roads were walkable. The six inches of fresh snow was added to the previous 10-12 inches that were already on the ground. With virtually no cars on the road there was a pristine stillness begging to be interrupted by jolly walkers.
Initially there were six of us. The idea was that we would turn around and head home when anyone felt “half done.” By a mile and a half my two daughters-in-law were ready to “sit by the fire.” After the women departed, those willing to continue on for a while were reduced to a troupe consisting of my oldest and youngest sons, my granddaughter and me.
With renewed determination we headed up Burpee Hill Road hoping to catch a spectacular view of Mount Sunapee in the late afternoon sun. The view was everything that I had hoped it would be, and we were enjoying ourselves so much that we decided to extend the walk to over four miles by doing a loop around Gay Farm Road before heading home. As we walked east on Gay Farm Road a woman approached us in an old Saab convertible. She was waving her arms wildly and pointing to the west behind us. As she passed, we got the message, and turned to see her drive by, but also see what she was trying to get us to see. Sunlight was gloriously shining through the ice and the snow that coated the sugar maples along Burpee Hill Road. You can see what we saw in today’s header.
One of the greatest winter delights is to see the magic of the visual effects created by the last few minutes of light from the sun at its low winter angle in the late afternoon. Summer sunsets are wonderful, but can’t beat the effect of those last rays of cold light on snow and ice. I know that it will be very cold for many of you this weekend. It was “zero” when I took my walk yesterday afternoon. Despite the cold, I hope that you will try to catch some fresh air in the late afternoon sun. It is always good to come up for air after watching a lot of football.
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| Happy New Year! Be well, take good care of yourself in 2018, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
Dr. Gene Lindsey
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| | The Healthcare Musings Archive
Previous editions of the "Healthcare Musings" newsletter, by Dr. Gene Lindsey are now archived and available to you at:
www.getresponse.com/archive/strategy_healthcare
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