If you've not heard the buzz surrounding Atul Gawande's recent New Yorker article, "The Cost Conundrum," you've either been out of the country or you've been following the Michael Jackson death soap opera too closely.
Let's just say that the good doctor's efforts have struck a chord. Even the president has mentioned the article in his efforts to get Congress to pass a healthcare reform bill.
Gawande's work to present the healthcare cost disparity in narrative form has caught the attention of many who believe healthcare's costs are out of control and that its growth profile is completely unsustainable. He found that tiny McAllen, TX, boasts higher healthcare costs than any other statistical area in the country, save Miami, which has much higher staffing and living costs. And the outcomes aren't any better.
Not one, not two, but three influential people gave speeches last week at the American Hospital Association's annual Leadership Summit in which they prominently referenced the article as a window into the problem with healthcare costs. I've been to other conferences around the country too this summer, and if the article is not the first topic people bring up in casual conversation about healthcare, it's the second.
But so what?
What amazes me about these speeches and conversations is not the fact that the article has received so much acclaim. It is well-written, and Gawande, a physician himself, does an admirable job of searching for other possible explanations to McAllen's cost problem than the conclusion to which he's ultimately drawn:
Are people there are unhealthier than those in other areas of the country? No.
Do hospitals and physicians in McAllen provide exceptionally better healthcare than anywhere else? No.
Is it malpractice insurance costs? No.
Is there overutilization of medical services? Absolutely.
People are waving this article around like it's some revelation. They're rightly using it as a call to action for healthcare providers, government, and payers to coordinate care and use evidence-based protocols to prevent so many unnecessary tests and surgeries. But where have they been for 20 years?
The Dartmouth Atlas of Health Care has been around for more than that long. It says the essentially same thing as Gawande's article, except it's much more detailed, depending on reams of Medicare cost data to tell essentially the same truth.
Gawande concludes that local variability is rooted in the overuse of services. But it can be easier to make fun of McAllen than it is to turn the mirror on yourself. You don't have to wait for healthcare reform to take action. Here are a few ideas:
Do you know where your community stands in the Dartmouth Atlas or other global efficiency metrics?
Within your hospital or medical group, have you done an analysis of key diagnostic procedures and orders, particularly to identify gross outliers of overuse by procedure or by provider/group?
Have you fixed those outliers within your control?
Have you collaborated with other providers in the community to analyze any troubling patterns?
If there are community health issues (high rate of diabetes, obesity, smoking, etc.) that contribute to overuse of services, have you initiated a critical review of current community wellness programs and explored ideas for future interventions?
Coordinating care is hard. Developing evidence-based medicine protocols is hard. Ordering tests and surgeries is relatively easy, and it pays a heckuva lot better.
It's no surprise that healthcare costs so much. Outside of some commercial plans that pay close attention to such things, what incentive do doctors and hospitals have not to over-test or over-cut their patients? What incentive do they have to tell their patients "no" when "yes" is so much easier, not to mention more lucrative?
Meanwhile, many folks who are against evidence-based medicine or comparative effectiveness research want to raid the national healthcare cash register with one hand while they use the word "rationing" as an obscenity to belittle those who want to do something to fill in the bottomless pit that healthcare spending has become.
We've known about vast waste in healthcare spending for more than 20 years now.
When are we going to actually do something about it?
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Although the majority of Americans support healthcare reform, more people are changing their minds as the healthcare debate heats up, according to a new study conducted by the Kaiser Family Foundation, a health issues research foundation.
More than half (56%) of Americans believe health reform is more important than ever, even in today's economy. The public (two to one) thinks that the country as a whole would be better off if Congress enacts reform now, according to the July Kaiser Health Tracking Poll of more than 1,200 English- and/or Spanish-speaking Americans. Nevertheless, the tide of public opinion is swaying.
"The public wants help with their health care bills and supports health reform, but the hotter the debate and the longer it lasts, the more anxious the public will become," said Kaiser President and CEO Drew Altman in a Kaiser press release last week.
Shifting tide of public opinion
The study indicates that Americans are changing which box they mentally check: "for" or "nay" on the big "R" word—reform. Public support for health reform is down 5 percentage points from last month, falling from 61% to 56%.
Why the change of minds?
One reason is expenses. Initial reports estimate the healthcare overhaul will costs $1 trillion over the next 10 years. The public splits on the whether the United States can actually afford to pay that price tag for health coverage. Fifty-one percent are willing to open their wallets to pay higher insurance premiums or taxes, while another 44% are not.
Another reason why the public is reconsidering reform may be that they are influenced by advertisements. People report seeing more healthcare reform-related ads now, up 10 percentage points this month, rising from 21% to 31%, and most of the ads are negative.
Americans may also be changing their minds about healthcare reform because they believe such a national change will affect their family. More than half (54%) of Americans have doubts and worries that congressional intervention will be bad for their family. The study indicates that the public's concern about the effects on families is driven by Republican voices, according to the study.
In fact, when asked, "Which worries you more: the government or insurance companies," more people (45%) answered "the government." Another 36% said insurance companies are scarier, and 12% are equally concerned about both types of institutional intervention.
Crossing party lines
But it seems most Americans, regardless of party affiliation, can change their minds on a dime. As demonstrated by congressional voices on Capitol Hill, the hot button issue of healthcare reform crosses party lines. Both sides split on support and opposition. Seven in 10 Democratic Americans back reform now. Six in 10 Republicans do not.
"Public support for health reform will depend on which arguments get through to the American people and, ultimately, how they answer the question of how will health reform affect their family," said Kaiser Vice President and Director of Public Opinion and Survey Research Mollyann Brodie in the Kaiser press release.
The House Energy and Commerce Committee will again hold hearings on Friday—after meeting throughout Thursday—with the goal of completing the markup of the Tri-Committee healthcare reform bill before the House's recess officially begins on today. But on the House side of the Hill, reform has been—and is likely to be throughout August—anything but quiet.
The House leadership has agreed to hold off a full-floor vote on the bill (H.R. 3200) until at least the legislators return in September, but new challenges are arising over the bill.
While the Energy and Commerce hearings were delayed for more than a week while discussions proceeded with members of the fiscally conservative Blue Dog Democrats (which has seven members on the committee), new voices rose up Wednesday from the another sizable group in the House that led to the cancellation of a mark-up session.
Members of the liberal Congressional Progressive Caucus, along with members of the Congressional TriCaucus—comprised of the Congressional Black Caucus, the Congressional Hispanic Caucus, and the Congressional Asian Pacific American Caucus—met in front of the Capitol on Thursday to warn against any further "weakening" of sections of the bill.
"We want a plan with a meaningful public option," said Rep. Lynn Woolsey (D-CA), who is co chair of the Congressional Progressive Caucus. "When leaders of the House meet in August to consider the three bills and produce a final one, we expect that it will retain a robust public option. If it doesn't, we will vote against it."
Nearly half of the 120 members of the groups signed a letter sent to House Speaker Nancy Pelosi (D-CA) on Thursday that called for a public plan that "must be available immediately." In addition, they are requesting that the public plan must receive "at least the same consumer subsidies as private plans."
On the other side of the aisle, the GOP has released its own $700 billion healthcare reform measure that calls for tax credits to help people buy insurance. However, unlike Democratic proposals, the measure does not call for individual or employer mandates to obtain coverage.
The Republican plan was drafted by Rep. Tom Price (R GA), a physician, who President Obama invited to the White House to further discuss the measure.
Unlike Democratic proposals, it does not call for creating a federally regulated insurance exchange. Instead, it permits individuals to shop for health insurance across state lines and "allows for patients to control their own healthcare coverage" by allowing for a defined contribution in employer sponsored plans.
Senate Finance Chairman Max Baucus (D-MT) said Thursday that his panel will not mark up a bipartisan healthcare reform bill before August 7, which is the beginning of the Senate's summer recess.
The panel of senators will continue to meet during the recess—and through the summer, if necessary, by videoconference, they said.
While Baucus and Finance ranking member Sen. Chuck Grassley (R-IA) appeared together on Thursday to dispel talk that negotiations had broken down, some committee members are showing frustrations.
The panel still had "a number of remaining issues to resolve before they will be able to reach a bipartisan agreement," said Sen. Michael Enzi (R-WY), who is also the ranking member of the Senate Health, Education, Labor and Pensions Committee, which passed its healthcare reform bill earlier this month. "We still have several areas where we haven't been able to come to a consensus. No deal is at hand and substantive issues, big and small, remain under discussion and need to be resolved. We need to keep working together," he said.
Meanwhile, in a prepared comment, Grassley said, "It'll be a lost opportunity if Democratic leaders in Congress and the administration force action on healthcare legislation that's not ready because of the complexity of the issue and the high stakes in getting it right."
"Republicans have been negotiating for a bipartisan bill that improves the health care system for everyone who relies on it," he added. "The bipartisan discussions that Chairman Baucus has led in the Senate Finance Committee have made very good progress because of his long term commitment to bipartisanship, and could lead to a bill that makes things better, not worse, but that'll never happen if Democrat leaders tell Republicans to take a hike by forcing the committee to move on an all Democrat bill."
Meanwhile, Senate Majority Leader Harry Reid (D-NV) and several other Democratic senators joined with representatives of provider groups on Capitol Hill Thursday to urge completion of a healthcare reform measure.
"Our doctors' orders are very, very clear," Reid said. "If we don't start taking better care of our healthcare system, it's only going to get worse."
Joe Stubbs, MD, president of the American College of Physicians, said his patients "will experience irreparable harm if we leave it to a future Congress to pick up the pieces of our currently broken healthcare system. We can and should debate how to achieve these goals, but debate must not be an excuse for delay."
Meanwhile, Jim King, MD, American Academy of Family Physicians board chairman, said, "We have a rare opportunity to reshape healthcare in this country by providing primary care that prevents costly illnesses and coordinated care for different specialists and settings."
Other groups joining Reid in the briefing were the American Academy of Pediatrics, American Medical Student Association, American Osteopathic Association, Doctors for America, and the National Physicians Alliance.
Nearly half of 24 recommendations from the General Accounting Office last year to prepare for a flu pandemic have not been implemented by the responsible agencies, the GAO said in a report yesterday.
"Much more needs to be done, and many gaps in planning and preparedness still remain," which have "become even more pressing in light of the very real possibility of the return of a more severe form of the H1N1 virus later this year," the GAO's report said. "As the current H1N1 outbreak underscores, an influenza pandemic remains a real threat to our nation."
Gaps exist in leadership, authority, and coordination, which cause issues with detecting threats and managing risks, planning proper training, and exercising possible responses. It also raises concerns about assuring capacity to respond and recover, and share information, according to the GAO.
Of particular concern, the report noted, is the lack of guidance sought by many state and local health agencies and hospitals on how to manage scarce resources in a way that saves the maximum number of lives. The difficulty of addressing ethical, legal, and medical issues involved had delayed drafting such proposals, and they looked to the federal government for help.
For example, among the most important concerns is the need for the U.S. to plan for assisting other countries, especially developing nations, with their surveillance and detection efforts so the U.S. can take relevant actions involving its transportation system and border crossings.
The Centers for Disease Control and Prevention has recorded 44,000 Novel H1N1 illnesses and 302 deaths as of this week, and more are anticipated this fall.
The report synthesizes recommendations in three prior reports in the last three years whose recommendations were based on experiences in prior disasters such as hurricanes Andrew and Katrina, 9/11, threats of bioterrorism, and emerging infections like Severe Acute Respiratory Syndrome (SARS).
"Unlike incidents that are discretely bounded in space or time (e.g., most natural or an-made disasters), an influenza pandemic is not a singular event, but is likely to come in waves, each lasting weeks or months, and pass through communities of all sizes across the nation and world simultaneously," the GAO said.
It added that while the current H1N1 pandemic seems relatively mild, it is widespread, and its history "suggests it could return in a second wave this fall or winter in a more virulent form."
While H1N1 won’t directly damage the nation’s physical infrastructure, such as power lines or computer systems, it could disable "the essential personnel needed to operate them" for weeks or months. Absences due to illness, fear, or the need to care for family members may reach 40% during peak weeks of an outbreak. Additionally, such a pandemic could result in 200,000 to 2 million deaths in the U.S., according to the report.
These deficiencies remain among the 10 highlighted recommendations:
As the U.S. saw so tragically with the Katrina disaster, federal coordination is key. But "it is not clear how (existing agencies) would work in practice," the report said. Relationships and roles of the Departments of Health and Human Services, Homeland Security, the Homeland Security Council, the Federal Emergency Management Agency, and principal federal official for influenza pandemic are "unclear," the report said. While several exercises had been conducted since 2007, "it is unclear whether these exercises rigorously tested federal leadership roles in a pandemic." Roles of federal versus state officials also remain unclear, especially as they relate to border closures and vaccine distribution.
Better coordination and collaboration between federal and state governments and the private sector are needed to assure adequate supplies of energy, food and agriculture, telecommunications, transportation, and water.
Crucial documents, such as the National Pandemic Strategy and National Pandemic Implementation Plan, do not address five of six crucial characteristics of an effective strategy, and contain "no discussion of what it will cost, where resources will be targeted to achieve the maximum benefits and how it will balance benefits, risks and costs. Moreover the documents do not provide a picture of priorities or how adjustments might be made in view of resource constraints."
Several agencies are "still in the early stage of developing their . . . measures to protect their workforce."
While the federal government has provided some guidance and funding to help states plan for additional capacity, "some states' officials reported, however, that they had not begun work on altered standards of care guidelines, that is, for providing care while allocating scarce equipment, supplies, and personnel in a way that saves the largest number of lives in mass casualty event."
Or, they "had not completed drafting guidelines, because of the difficult of addressing the medical, ethical and legal issues involved." The GAO recommended that HHS serve as a clearinghouse for sharing such standards, but "HHS did not comment on the recommendation, and it has not indicated if it plans to implement it."
The House Energy and Commerce Committee resumed work on major healthcare legislation, voting to establish a government-run health insurance plan. By a vote of 35 to 24, Democrats defeated a Republican effort to eliminate a section of the bill that would create the public health insurance option. President Obama supports a public plan, saying it would foster competition and keep private insurers honest.
President Obama has pledged that a revamped healthcare system would hold down exploding costs. But efforts to control medical practices that have driven up expenses, including physician "self-referrals," underscore how difficult it is to alter entrenched patterns. A host of studies and reports by academics and the federal government shows that physicians who own scanners order many more scans than those who do not. As a result, Americans pay billions of dollars in extra taxes and insurance premiums.
Senate GOP negotiators are trying to slow down healthcare talks, likely delaying a long-awaited bipartisan deal until after the August recess. Three Democratic and three Republican negotiators on the Senate Finance Committee continued to insist that they were making significant progress in crafting a $900 billion bill that would provide coverage to 95% of Americans, but they acknowledged for the first time that they will not have a full-committee legislative markup until after Labor Day.
Liberal lawmakers from solidly Democratic districts are threatening a revolt that could doom President Obama's bid to sign a major healthcare bill this year. In the House, liberals are furious at their leaders for striking a deal with conservative Democrats that would weaken the proposal to create a government insurance program. On July 30, 57 of these liberals sent a letter to Speaker Nancy Pelosi warning that they would vote against any bill that contained the terms of the deal.
A new study shows that Americans spend roughly $34 billion a year out-of-pocket on alternative therapies that aren't covered by insurance. That's a growth of more than 25% in the past decade, says an in-person survey of 23,000 Americans from the Centers for Disease Control and Prevention and National Institutes of Health. Alternative therapies now account for 11% of the total amount that Americans spend out-of-pocket on all healthcare.
