The pace of healthcare reform appears to be moving quickly on Capitol Hill this week with release Tuesday afternoon of a 615-page draft from the Senate Health, Education, Labor and Pensions Commission, chaired by Sen. Edward Kennedy (D-MA).
The bill, called the "Affordable Health Choices Act," will get its first hearing on Thursday afternoon. But between now and then, there's plenty to review in the bill including proposals calling for:
Requiring all Americans to be insured
Creating new insurance exchanges to provide near universal coverage
Stepping up government oversight of the insurance industry
"We still have a lot of work ahead of us," said Sen. Christopher Dodd (D-CT), in a statement, who has been ushering the bill through while Kennedy recuperates from a brain tumor. However, bipartisanship that was initially anticipated may be somewhat more elusive with this bill.
The committee's ranking minority leader, Sen. Mike Enzi (R-WY), has expressed his displeasure about how quickly the bill has been moving through the committee. "We've been meeting with Democrats for months to discuss healthcare reform, but from what I've seen in this proposal, it doesn't look like they listened at all," he said.
A joint four-page outline was released yesterday as well by the three House committees—Ways and Means, Energy and Commerce, and Education and Labor—on what will be included in their draft bill. The proposal calls for insurance market reforms, such as a health insurance exchange and a public health insurance option, "shared responsibility" or requirements that all get insurance; and rewarding high quality/high efficiency care.
The House proposal also calls for replacing the Sustainable Growth Rate, an arcane formula created in 1997 to calculate Medicare physician payments and limit spending on physician services—but was never successfully applied. However, it is not clear in the outline how it would be replaced.
Work is still continuing on the Senate Finance side as well. Committee Chairman Max Baucus (D-MT) is said to be looking at placing caps on the value of employer based health insurance plans that can be excluded from personal income taxes. But no word yet on the public plan concept, which was severely criticize by most of the panel's Republicans in a letter to the president on Monday.
America's aging and overweight public wants whatever healthcare reforms emerge in the coming months to invest in an ounce of prevention more than a pound of cure, according to a new poll today that ranks disease prevention as the public's top healthcare priority.
The poll of 1,014 registered voters, conducted last month by Trust for America's Health and the Robert Wood Johnson Foundation, found that 70% of Americans gave investing in prevention between an eight and 10 on a scale of zero to 10, with 10 means very important. Of those, 46% gave prevention a10. Prevention was rated higher than all other reform proposals, including tax credits to small businesses and prohibiting health insurers from denying coverage based on health status.
About 76% of Americans support more funding for prevention programs and for policies that help people make healthier choices. Investing in prevention is not a partisan issue: 86% of Democrats, 71% of Republicans, and 70% of independents support it, the poll shows.
"This report shows that the American people believe prevention and wellness are the cornerstones of a high performing healthcare system. And they're right," says Senate Finance Committee Chairman Max Baucus, D-MT. "We spend nearly $800 billion on health problems that are directly linked to lifestyle and poor health habits each year–about one third of our total healthcare spending. Simply put, that's too much. Reforming our system to focus on prevention will drive down costs and produce better health outcomes."
"For too long, healthcare has focused on treating people after they become sick instead of trying to help them stay healthy in the first place," says Jeff Levi, executive director of the nonprofit TFAH. "This poll shows the American public strongly believes it's time we shift from a sick care system to a true healthcare system that stresses disease prevention."
Maybe.
While Americans talk up the idea of disease prevention, it's not clear if they'd actually practice what they preach. The Centers for Disease Control and Prevention reports that 27% of Americans are obese, and there is no sign that that trend is slowing. The value of McDonald's restaurant stock has tripled since 2003 and that's not because people are eating more McSalad.
The advocacy group Partners for Prevention estimates that more than 117,000 lives could be saved each year if Americans would follow basic prevention steps, such as cancer screenings, quit smoking, or even take one aspirin daily to prevent heart disease.
"Tens of thousands of Americans die needlessly every year because they don't do something as simple as taking an aspirin a day or getting a flu shot," says Robert Gould, president of the nonprofit advocacy group Partnership for Prevention. "It's time for Congress to remove the barriers that hinder people from getting such services. In many cases, their lives may depend upon it."
"A number of obstacles–including lack of coverage as well as co-pay and deductible requirements–currently discourage doctors from providing these services and also discourage many patients from obtaining them," Gould says.
Partnership wants Congress to provide coverage for high-value preventive services in all federal health plans, to encourage it in all private plans, and to remove deductibles and copays. Gould says that three of the five basic prevention services–aspirin counseling, tobacco cessation counseling, and adult flu immunization–save money, while breast and colorectal cancer screenings are cost-effective.
The poll also found that:
77% believe prevention will save money, and 72% say investing in prevention is worth it even if it doesn't save money because it will prevent disease and save lives. 57% say they support prevention programs for health and quality-of-life reasons while 21% say they support prevention to lower costs.
59% believe the nation needs to put more emphasis on prevention and 15% think there should be more emphasis on treatment. This represents a significant shift toward prevention over the last two decades–in 1987, 45% thought there should be greater emphasis on prevention.
The poll was conducted by Greenberg Quinlan Rosner Research and Public Opinion Strategies from May 7-12, and is available at www.healthyamericans.org. The margin of error was +/- 3.1%.
In its ongoing effort to improve communication and quality of care, The Joint Commission released proposed requirements for field review in the areas of advancing effective communication, cultural competence, and patient-centered care. These proposed requirements will be open for comment for six weeks beginning this Monday.
The Effective Communication, Cultural Competence, and Patient-Centered Care (ECCCPC) concept acknowledges that effective communication is needed to ensure patient safety, but can often be hampered by barriers of language and culture, as well as physical impairments like sight and hearing, and other causes—a lack of health literacy, cognitive impairments, disease, disability.
"We do need to advance communication and cultural competence," says Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor. "This is nothing new in concept. The Joint Commission has always been involved in this. And this is what nurses do—patient center care."
The program also targets racial and ethnic health disparities, which have been linked to poorer health outcomes—and lower quality of care.
"We have a mosaic entering both coasts of cultural diversity. We need to tune in to cultural competencies," says Di Giacomo-Geffers.
It is not clear yet if it will be implemented for all programs though it most likely, says Di Giacomo-Geffers.
"My first reaction is that this is excellent," says Di Giacomo-Geffers. "We'll need time to digest the standard. They're identifying 17 chapters."
Di Giacomo-Geffers recommends reviewing what is effective communication and what are patient-specific needs.
"Hospitals need to take a look at this, review them, and I encourage everybody to make their comments to The Joint Commission about those issues they feel are opportunities for improvement as well as opportunities that may be difficult or challenging or them to implement," Di Giacomo-Geffers.
At the earliest, The Joint Commission hopes to have proposed requirements implemented by January 2011.
"I think a lot of this we have in place," Di Giacomo-Geffers. "There are some things that are going to take a little work on our part. It's important to identify those parts that are going to take a while to implement. I applaud them. This is a much needed part of care."
Two new federal reports highlight the extent to which health disparities exist across the country between racial and ethnic minorities and whites, as well as between the rich and the poor.
"Minorities and low-income Americans are more likely to be sick and less likely to get the care they need," said Health and Human Services Secretary Kathleen Sebelius, who on Tuesday released one of the reports on health disparities in America. "These disparities have plagued our health system and our country for too long. Now it’s time for Democrats and Republicans to come together to pass reforms this year that help reduce disparities and give all Americans the care they need and deserve."
In that report, entitled "Health Disparities: A Case for Closing the Gap," researchers discovered higher rates of obesity, cancer, diabetes, and AIDS among racial and ethnic minorities than among whites. "One of the most glaring disparities is apparent in the African-American community, where 48% of adults suffer from a chronic disease compared to 39% of the general population," the report said.
The report added that 48% of all African-American adults suffer from a chronic disease, compared with 39% of the general population. And 15% of African-Americans develop diabetes, compared with 8% of white Americans, 14% of Hispanics, and 18% of American Indians. Hispanics were one-third less likely to receive counseling on the dangers of being obese compared to whites.
The study was compiled from statistics from numerous agencies, including The Commonwealth Fund, the Centers for Medicare and Medicaid Services, the American Cancer Society, the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality.
The second report, from the Healthcare Cost and Utilization Project, a division of the AHRQ, found major gaps between care of people in rural versus urban areas, and between poor families (those in communities whose annual median household income is less than $38,000) versus those in other income brackets. The report was based on data gathered in 2006.
For example, the rate of hospitalization among people in poor areas was 22% higher compared to people in wealthier communities.
And people in poor communities were more likely to be admitted to a hospital for preventable conditions, such as asthma–87% more likely to be admitted to a hospital; diabetes complications–77%; chronic obstructive pulmonary disease–69%; congestive heart failure–51%; skin infections–49%; pneumonia–42%; dehydration–38%; urinary tract infections–37% and nonspecific chest pain–32%.
The rate of hospital stays among those ages 45-64 was nearly 50% higher for people in the lowest income communities versus wealthier areas.
"Low socio-economic status is associated with higher hospital admission rates, possibly due to lower utilization of routine and preventive health care services among poorer individuals that could prevent the need for hospitalization," according to the report.
Perhaps surprisingly, poor people admitted to the hospital received services that cost $700 less ($7,800) than for wealthier inpatients ($8,500), although their five-day lengths of stay was the same as for wealthier patients. The report did not suggest a reason why the poor incurred lower costs.
However, the report noted, people who live in poorer communities were 8% more likely to be admitted through the emergency department, compared to patients living in more affluent communities, and were 63% more likely to leave against medical advice.
One disparity that is often overlooked involves the difference in care between people residing in poor rural versus wealthier rural or urban areas. According to the report, "the rural poor had the highest rate of hospitalization, (1,597 stays per 10,000 population), which was 22% higher than in wealthier rural areas."
But the largest disparity in hospitalization rates occurred in large urban areas, where the poor were admitted 27% more often than people in wealthier large urban areas.
The report offered insight on the reasons for the different admission numbers for poor versus wealthier residents. For example, chronic obstructive pulmonary disease was the sixth most common reason for poor patients, but the 16th most common reason for wealthier patients.
Osteoarthritis was the seventh most common reason wealthier patients were admitted, but the 19th most common for poorer patients.
Faced with shrinking bottomlines, many hospitals have recently been paring back their infection prevention programs. However, these short-term solutions may be costing them more in terms of costly hospitalizations related to infections, according to a survey by the Association for Professionals in Infection Control and Epidemiology released this week during its annual conference.
Of the nearly 2,000 APIC members responding to a survey in late March, 41% reported cuts in their budgets related to the economic downturn in the past 18 months. These cutbacks have come in the form of reduced staffing (39%); hiring freezes (35%), reduced education funding (74%), and reduced infection prevention budget (53%).
"Cuts have made it harder to do the work that protects patients," said APIC President Christy Nutty, who is an infection control consultant in Metropolis, IL. In particular, about 44% attend fewer meetings at their hospitals; 45% said they received less support for attending educational meetings; 42% have fewer walking rounds; and 38% have cut educational activities for families, staff, and patients.
One of the problems is that in recent years, the amount of work for infection prevention has increased, Nutty said. While staffing and related resources have decreased, new reporting requirements have risen—which can take time away from the infection prevention work.
While transparency—in the form of public reporting—could lead to better outcomes, fewer institutions have received additional resources to compensate for these added regulations, Nutty said. "This leaves infection prevention struggling to do much more with much less."
Deaths are still occurring from infections: for instance, about 30,000 hospital deaths annually are from blood stream infections; 36,000 cases are related to ventilator-associated pneumonia, Nutty stated.
For surgical site infections, costs can run as high as $25,000 in excess of what it would cost; bloodstream infections, $36,400 more; VAP, about $10,000 more; and urinary track infections, $1,000.
"Remember, these are excess costs"—above and beyond what is now paid with Medicare money, said Denise Murphy, vice president for quality, Main Line Health System, and a former AHIC proposal.
Eliminating extra days in hospitals by preventing infections can save those hospitals money—especially when Medicare is declining now to pay for those hospital-acquired infection cases requiring longer hospitalizations, Murphy said.
For instance, preventing just 10 surgical site infections would open up about 260 bed days—plus increase income, Murphy said. If 10 bloodstream infections are eliminated, that would pay for an "effective program" that includes two executive infection preventionists, clerical support, and half a medical director, Murphy added.
The great unknown of the healthcare debate is whether the current political landscape will prove more hospitable to mandates, cost controls, and tax increases—all measures now on the table that helped doom President Clinton's plan. But Obama enjoys some key advantages the last Democratic president did not. The economic crisis has made healthcare stakeholders more receptive to change, and unlike Clinton, this White House is allowing House and Senate committee chairmen to design the legislation with a heavy dose of administration input.
A Senate plan to overhaul the nation's health system is likely to include a new tax on some employer-provided health benefits that exceed the value of the basic plan offered to federal employees, Senate Finance Committee Chairman Max Baucus said. Baucus is drafting the health reform measure, and told reporters reporters that taxing employer-provided benefits is "perhaps the best way to raise money for an overhaul of the healthcare system" and offered details about the form that tax is likely to take.
A broad consensus on the nation's healthcare system overhaul appeared to be developing among Democratic leaders as three House committee chairmen outlined a bill generally similar to one being written in the Senate. Democratic leaders in both houses said they would require individuals to carry insurance and employers to help pay for it, but they have yet to decide how to raise the necessary tax revenue.
House leaders outlined a healthcare overhaul plan that would create a national health-insurance "exchange" for consumers and include a government-run plan as one option, while Sen. Edward Kennedy introduced a similar bill in the Senate. The draft House plan would require almost all Americans to have health insurance and provide subsidies to those with annual incomes as high as four times the poverty level. People without insurance could find a plan on an insurance exchange that would be set up by the government.
Deadly hospital infections cause almost 10,000 deaths a year and add more than $20 billion to the nations healthcare costs, but infection-control professionals say their ranks are being thinned and they are losing the resources they need to fight infections as part of cutbacks linked to the economic downturn. In a survey, the Association for Professionals in Infection Control says that 41% of nearly 2,000 respondents reported cuts in their budgets, including money for technology, staff, education, products, and equipment.
