The Names of the Dead

While the political theater slogs towards it’s ‘battle fatigue’ finale in Washington, D.C., and elswhere in the United States of Amnesia, one American, who also happens to be a politician has decided to approach our health care conundrum in the spirit of the Cluetrain Manifesto and from the footprint of the human experience via a story telling process, i.e., the human narrative.

The name is Congressman Alan Grayson, and the site is Names of the Dead (dot) com. While some will immediately look to party affiliation, and standing with respect to the health reform bills before the Congress to position how they’ll ‘receive’ (or discount via an ideological filter) his message, I encourage you to watch some if not all of the videos.

They are personal stories of Americans who died directly as a result of delayed access to medical care. An empirical basis for the claim that lack of health insurance is associated with mortality is provided in the peer reviewed study Health Insurance and Mortality in US Adults.

The publishing of this report is a timely and top of mind topic, since as a male I am one of the 47 million Americans without health insurance, and a boomer in his 50s, who has occasion to think about the 1 in 6 prospects of prostate cancer in my future. Specifically I have pondered, and have avoided to date, submitting to a PSA test. And yesterday via virtual participation in the TEDMED hashtag stream (#tedmed) I came across a prostate CA piece from theVisualMD dot com, which only further affirmed my fear, and stoked a somewhat borderline despair.

Why ‘borderline’ despair? A few illogical and perhaps ‘magical thinking’ reasons come to mind:

• I am avoiding the test since ‘ignorance is bliss, and I am uninsured?’ Ergo, if I or any lab for that matter doesn’t know, then it can’t be confirmed as a pre-existing condition, right?; and
• If I am a positive, then what? I am not insured and can’t afford the treatment. So county here I come? No thanks, I don’t subscribe to the ‘John Goodman theory’ about the mythology of the uninsured in America.

So my choices are to sit with the 1 in 6 odds and continue as I am, pretending not to be concerned. After all, my history is disease free, and as a health care ‘insider’ I avoid interacting with the health care delivery system as a general rule, staying active and eating healthy for the most part.

Yet, I can’t help but think about those stories that Grayson is sharing with America and asking myself, will I be on the list soon?

So while we debate and more accurately obfuscate the nature of the problem we face vis a vis health reform solutions, people die daily. The ‘dead man walking’ queue witnesses some 122 new recruits each and every day.

The health reform imperative is real tweeps. Unfortunately the dividing line all to often seems to be between those who are employed, and have health insurance (aka, the I got mine crowd) and those who do not; many of whom are employed or self employed but none-the-less locked out of the system due to obscene health care costs or opportunistic underwriting and/or retrospective rescission schemes.

So what’s it going to be peeps? As a society, who will we value and install as the ‘anchor’ tenant in medicine? Will it be (generically speaking) a Mayo model, or the status quo, volume incented, quantity driven series of competitive fee-for-service sweat shops, dba ‘McAllen’s’ (generically speaking of course)?

w00t! ‘TEDMED Heads’ 2009 Descend on San Diego

And boldly ask:

Is the end of aging in sight?

The TEDMED conference agenda is jam packed with innovators in technology, education and design all focusing their considerable energies on the applications of genomics to real world problems in medicine including the ‘holy grail’ of extending human life, and reinventing the management, if not elimination, of disease.

TEDMED is an extension of the TED (Technology, Education & Design) Series founded by Richard Saul Wurman. Marc Hodosh is President of TEDMED, a conference he is re-launching right here in San Diego.

Previously Marc led the Archon X PRIZE for Genomics, a $10 million competition to inspire rapid and cost effective genome sequencing technology; which followed the highly successful $10 million Ansari Space X PRIZE.

With the publication of his first book in 1962 at the age of 26, Richard Saul Wurman, began the singular passion of his life: making information understandable. He chaired the International Design in Aspen in 1972, the first Federal Design Assembly in 1973, followed by the National AIA Convention in 1976, before creating and chairing TED conferences from 1984-2002.

Wurman created and chaired the TEDMED and eg2006 conferences. A B.A. and M.A. 1959 graduate with highest honors from the University of Pennsylvania, Mr. Wurman’s nearly half-century of achievements includes the publication of his best-selling book Information Anxiety and his award winning ACCESS Travel Guides.

To contextualize and perhaps frame the conference mindset, a key equation for ‘good health’ was outlined by Bill Davenhall, of ESRI, as follows:

Genetics + lifestyle + environment = risks

According to Alana B. Elias Kornfeld, of the HuffingtonPost: ‘Davenhall spoke about the missing piece to understanding personal health: the environment.’

For a summary of Day One at TEDMED 2009, see Kornfeld’s article TED MED 2009: The Missing Piece In Understanding Our Health.

Note: For the less fortunuate of us unable to attend this conference, you may follow the tweets, aka ‘digital footprint’ via many health tweeps participating in the event using the Twitter hashtag of #TEDMED.

Health Care ‘Texas Style’: A Model for the Nation?

In the aftermath of Atul Gawande’s landmark piece ‘The  Cost Conundrum‘ and the selective emergence of the ‘Mayo v. Mc Allen‘ mantra, I’ve been tweeting of late on the ‘irony’ of certain Texas health markets, particularly given the concentration of hospital assets in non profit health systems, and the timely question of whether such consolidations produce the ‘community benefits’ proffered by their leadership. The recently published Commonwealth Fund study ‘Aiming Higher: Results from a State Scorecard on Health System Performance, 2009‘ has supplied certain metrics to further contextualize the conversation.

First some background: I spent 13 years in the Lone Star state, initially advising a major national proprietary hospital management company’s implementation of its managed care strategy in the Houston market, followed by implementation physician networks for a 140,000 member global risk Medical Group, and finally managing payor and provider contracts for a joint venture ‘Super PHO’ affiliated with a dominant faith based hospital system in Dallas/Fort Worth.

Now mind you, everything in Texas is big – especially its delivery system players who have literally architected quite beautiful (and very expensive)  ’cathedrals of medicine’. Examples include: the Texas Medical Center (an NIH like cluster of some 12+ competing institutions), Memorial Hermann Health System, Baylor Health Care System and Texas Health Resources to name a few of the trophy properties. Yet, years after the roll out of the strategic plans of these health systems, and the fulfillment of their market share objectives, certain of the state’s health care indicators look quite grim when contrasted to other parts of the country.

One might wonder why? Afterall, the typical pre-merger or alliance argument in favor of consolidation, acquisition or market expansion, was typically framed as follows, it will:

· Improve quality

· Improve access

· Increase operating efficiencies; and

· Lower costs

Yet according to the Commonwealth Fund study, and now years after these consolidations, here’s how Texas ranks on key metrics of health status compared to all 50 states, and the District of Columbia.

· Overall: 46

· Access to care: 51

· Prevention & Treatment: 43

· Avoidable Hospital Use & Costs: 42

· Equality between rich and poor: 50

· Equality between non-Hispanic white and minority: 48

· Healthy lives: 21

· Children with medical and dental check-ups in past year: 40

· Adults with a regular doctor: 49

· Medicare reimbursements: 46

· Infant mortality: 19

· Breast-cancer deaths: 18

· Colorectal cancer deaths: 15

· Adults who smoke: 17

· Overweight or obese children: 32

Not exactly ‘best in class’. So why not ask, where is the ostensible and promised ‘community benefits’ and not just those codified in IRS code, to justify the tax exempt status for most of the entities above? How is this ‘return’ (to the community) being measured; (is it via Medicare or Medicaid ‘shortfalls‘, or charity and bad debt write-offs; or some tangible real world contribution); or is it even accurately measured? The IRS 990 filings are somewhat ‘fluid’ on the specific reporting of activities that count towards community benefit.

Most, if not all, of these institutions are primarily ‘non profit’ (with some affiliate JV exceptions) yet they are aggressively managed to generate a surplus of revenue over expenses; after all ‘no margin, no mission’. While they do not have stock holders or investors per se, they do have bonds that require adequate debt service coverage in order to maintain favorable credit ratings and competitive access to capital.

This is where the ’story’ for the consolidations and, for some, the unspoken truth of the matter emerge, IMO. While perhaps stated in the vision for some, most of the benefits of consolidation are to be found in the pricing leverage that comes from asset concentration. Hospitals want higher rates, and payors (health plans and insurance companies) can tell you how difficult it was, and likely remains today, to extract material discounts from these massive institutions given their scale and market dominance.

So the question remains open: have they delivered, or are they just plain ‘doin’ it wrong’? Is the promised value proposition a reality today for the Texas residents they purport to serve? Based on these, and other metrics, many would say no. Rather than more of these Texas sized giants, why not refocus the Lone Star state on their one home grown version of a ‘Mayo Clinic’ model domiciled in Temple, Texas aka ‘Scott and White‘.

In the next blog post, i’ll touch on the physician role in the Texas market, and the historical rise and fall of physician driven integrated delivery systems in particular.

Here’s how Texas ranked in key areas compared to all 50 states and the District of Columbia.

• Overall: 46

• Access to care: 51

• Prevention & Treatment: 43

• Avoidable Hospital Use & Costs: 42

• Equality between rich and poor: 50

• Equality between non-Hispanic white and minority: 48

• Healthy lives: 21

• Children with medical and dental check-ups in past year: 40

• Adults with a regular doctor: 49

• Medicare reimbursements: 46

• Infant mortality: 19

• Breast-cancer deaths: 18

• Colorectal cancer deaths: 15

• Adults who smoke: 17

• Overweight or obese children: 32

Health Care Reform in Perspective

A ‘Post Mortem” in the midst of health reform hysteria courtesy of the New England Journal of Medicine (Note: this is NOT for those craving sound bytes for emotive grand standing at ‘town halls’; will require active cerebral engagement):

President Barack Obama has placed U.S. health care reform at the top of his domestic agenda, and months of legislative work on the issue have resulted in five bills — three in the House of Representatives and two in the Senate — that proponents believe will move the country in the direction of universal coverage, a fairer insurance system, and slower escalation of health care costs. On September 25, in a symposium cosponsored by the Journal and the Harvard School of Public Health, four health policy experts — Henry Aaron, Katherine Baicker, Jacob Hacker, and Mark Pauly — explored the promise and limitations of the bills and the outlook for reform. The discussion was moderated by Arnold Epstein of the Journal and the Department of Health Policy and Management at HSPH.

What follows is a portion of the transcript of the program featuring:  Arnold M. Epstein, M.D., Henry J. Aaron, Ph.D., Katherine Baicker, Ph.D., Jacob S. Hacker, Ph.D., and Mark V. Pauly, Ph.D.

For the complete transcript click here. Page one only is pasted below:

Perspective Roundtable: Health Care Reform in Perspective.

Introduction

DR. ARNOLD EPSTEIN: Past, present, and future. That’s the sequence, that’s how it unfolds. Let’s look back. When President Obama was candidate Obama, just a year ago, when we did our last forum here, he was very clear about his domestic priorities. The economy was number one, and after that was health care and energy. And he has not wavered one bit. And if you look at how health policy has unfurled from the White House, I wouldn’t be the first one to comment that it looks like a redux of reverse Clintonism. For if you go back to 1993, President Clinton wrote the first textbook. He came out in January, and at the end of the month, created a task force of federal bureaucrats, advisors, and counselors to ultimately produce a 1300-page document called the Health Security Act. Enormous in its scope and complexity, and what was remarkable about it is it came totally out of the executive branch. Not a whit out of Congress. It took until September before it was even introduced to the populace, leave alone going through the committees. And the President, to demonstrate his commitment to it, said, with a typical Clintonian gesture, it will be universal coverage and not one bit less. And he appointed his wife to head the task force putting the bill forth as an additional sign of his resolve, not to mention her own formidable ability. And despite that ability, and his resolve, it did not work, and we did not get health reform last time. No legislation.

So this time, we see President Obama really following a totally different script. No executive task force, just the opposite. This is Congress’s job, to propose the laws and make them. And it was the executive’s job, at least until 2 weeks ago, to merely espouse eight very broad principles and to partake in a very modest public relations campaign — getting information, regional forums, things like that. And Mr. Obama made it clear that he wanted something simple, not with labyrinthine complexity. Let’s stick to what we’re familiar with. He made it clear that he was ready to compromise — I have eight principles, but I’m ready to give in. And, oh, yes, please get on it, time is of the essence.

And so now we’ve come full circle towards the endgame. It’s September, and 2 weeks ago today, President Obama took eight principles and started to hone in on some of the things that he thinks are most important. And in Congress, we’ve seen the Congress do its job, still doing its job. Five committees of jurisdiction, three of them in the House, Ways and Means, Labor, and Energy and Commerce, have produced HR 3200, slightly different variants out of each committee, but basically the same bill. The HELP Committee — Health, Education, Labor, and Pensions in the Senate — has produced a bill on the delivery system, but they can’t touch finance. And the Finance Committee is marking up as we speak.   Cont’d

Perspective Roundtable: Health Care Reform in Perspective.

Introduction

DR. ARNOLD EPSTEIN: Past, present, and future. That’s the sequence, that’s how it unfolds. Let’s look back.

When President Obama was candidate Obama, just a year ago, when we did our last forum here, he was very clear

about his domestic priorities. The economy was number one, and after that was health care and energy. And he has

not wavered one bit. And if you look at how health policy has unfurled from the White House, I wouldn’t be the first

one to comment that it looks like a redux of reverse Clintonism. For if you go back to 1993, President Clinton wrote

the first textbook. He came out in January, and at the end of the month, created a task force of federal bureaucrats,

advisors, and counselors to ultimately produce a 1300-page document called the Health Security Act. Enormous in

its scope and complexity, and what was remarkable about it is it came totally out of the executive branch. Not a whit

out of Congress. It took until September before it was even introduced to the populace, leave alone going through

the committees. And the President, to demonstrate his commitment to it, said, with a typical Clintonian gesture, it

will be universal coverage and not one bit less. And he appointed his wife to head the task force putting the bill forth

as an additional sign of his resolve, not to mention her own formidable ability. And despite that ability, and his

resolve, it did not work, and we did not get health reform last time. No legislation.

So this time, we see President Obama really following a totally different script. No executive task force, just the

opposite. This is Congress’s job, to propose the laws and make them. And it was the executive’s job, at least until

2 weeks ago, to merely espouse eight very broad principles and to partake in a very modest public relations

campaign — getting information, regional forums, things like that. And Mr. Obama made it clear that he wanted

something simple, not with labyrinthine complexity. Let’s stick to what we’re familiar with. He made it clear that he

was ready to compromise — I have eight principles, but I’m ready to give in. And, oh, yes, please get on it, time is

of the essence.

And so now we’ve come full circle towards the endgame. It’s September, and 2 weeks ago today, President Obama

took eight principles and started to hone in on some of the things that he thinks are most important. And in

Congress, we’ve seen the Congress do its job, still doing its job. Five committees of jurisdiction, three of them in the

House, Ways and Means, Labor, and Energy and Commerce, have produced HR 3200, slightly different variants out

of each committee, but basically the same bill. The HELP Committee — Health, Education, Labor, and Pensions in

the Senate — has produced a bill on the delivery system, but they can’t touch finance. And the Finance Committee

is marking up as we speakPerspective Roundtable: Health Care Reform in Perspective.

Introduction

DR. ARNOLD EPSTEIN: Past, present, and future. That’s the sequence, that’s how it unfolds. Let’s look back.

When President Obama was candidate Obama, just a year ago, when we did our last forum here, he was very clear

about his domestic priorities. The economy was number one, and after that was health care and energy. And he has

not wavered one bit. And if you look at how health policy has unfurled from the White House, I wouldn’t be the first

one to comment that it looks like a redux of reverse Clintonism. For if you go back to 1993, President Clinton wrote

the first textbook. He came out in January, and at the end of the month, created a task force of federal bureaucrats,

advisors, and counselors to ultimately produce a 1300-page document called the Health Security Act. Enormous in

its scope and complexity, and what was remarkable about it is it came totally out of the executive branch. Not a whit

out of Congress. It took until September before it was even introduced to the populace, leave alone going through

the committees. And the President, to demonstrate his commitment to it, said, with a typical Clintonian gesture, it

will be universal coverage and not one bit less. And he appointed his wife to head the task force putting the bill forth

as an additional sign of his resolve, not to mention her own formidable ability. And despite that ability, and his

resolve, it did not work, and we did not get health reform last time. No legislation.

So this time, we see President Obama really following a totally different script. No executive task force, just the

opposite. This is Congress’s job, to propose the laws and make them. And it was the executive’s job, at least until

2 weeks ago, to merely espouse eight very broad principles and to partake in a very modest public relations

campaign — getting information, regional forums, things like that. And Mr. Obama made it clear that he wanted

something simple, not with labyrinthine complexity. Let’s stick to what we’re familiar with. He made it clear that he

was ready to compromise — I have eight principles, but I’m ready to give in. And, oh, yes, please get on it, time is

of the essence.

And so now we’ve come full circle towards the endgame. It’s September, and 2 weeks ago today, President Obama

took eight principles and started to hone in on some of the things that he thinks are most important. And in

Congress, we’ve seen the Congress do its job, still doing its job. Five committees of jurisdiction, three of them in the

House, Ways and Means, Labor, and Energy and Commerce, have produced HR 3200, slightly different variants out

of each committee, but basically the same bill. The HELP Committee — Health, Education, Labor, and Pensions in

the Senate — has produced a bill on the delivery system, but they can’t touch finance. And the Finance Committee

is marking up as we speak.

Off to HealthCamp SF Bay & Health 2.0

While approaching a one year tenure in the micro-blogging space aka Twittersphere; and a fraction thereof as a periodic health care blogger, I am off to San Francisco with beaucoup energy to link up with like minded Tweeps for face to face conversations.

First stop on Monday is HealthCamp SFBay hosted at the Garfield Center for Innovation (a Kaiser operation), where I expect to see Mark Scrimshire, founder and tireless evangelista for the Healthcamp un-conference series, as well as Cindy Throop, Mike Kirkwood, Maren Connary, and Sherry Reynolds (those that I understand to be attending).

On Tuesday I get to experience my fist ever, aka ‘virginal,’  Health2.0 event at the San Francisco Concourse Design Center. I kinda feel that for someone who’s been on sabbatical for a while, these events will afford me the opportunity to re-engage with my tribe, i.e., a collective of like minded people committed to be the change for better in their lives with a particular passion in the health care space. Almost a coming home experience since my days at UC Berkeley in the 70s; yeah tribe!

But best of all; I get to experience a ‘road trip’ from San Diego to San Francisco accompanied by my youngest son, and Dave Matthews band junkie, Brendon (not too happy with dad here); and that both of us get to stay with my oldest son Anthony in his Ocean Beach flat, with Catherine and “saddie-mo’, a three year old bundle of joy.

Cool deal, out for the week tweeple! I, and many others, will be live tweeting from both venues…

Mayo Clinic ‘Transform’ Healthcare Symposium

The visionaries at Mayo Clinic are at it again.

On September 13-15th, 2009, the Mayo Clinic Center for Innovation is hosting a collaborative symposium entitled ‘Transform‘. This event intends to engage ’stakeholders’ in the timely yet complex conversation of how to reform the health care experience, including its over-engineered, under performing and unsustainable panoply of failed business models.

The net is cast wide to include and crowdsource the entire spectrum of interested parties from physicians, hospitals and health plans to bloggers, ‘twitterers’, scientists, designers, health policy wonks and artists.

The goal is to transform both how health care is experienced, delivered, and lest we forget, financed. The symposium intends to be ‘organic’ and ignite both real time (at conference and via the ‘twittersphere’) and a post event, after market continued engagement in this very timely conversation.

Why Attend?

• To be part of the solution.
• To connect with thoughtful colleagues from inside and outside the health care industry.
• To discover new models of care that will transform the experience and delivery of health care in the 21st century.

Lots of talented and forward thinking tweeple speaking and likley to participate in this event.

So who’s going to be the anchor model in medicine? Will it be Mayo or McAllen? The stakes are high, so why not be the change you want to see Tweeple…. lets get ‘er done!

Health Reform 101 – ‘None of the Ransomed Knew How Deep Were the Waters Crossed!’

Have you ever been sucked into the white waters of the Pacific after falling off your board; only to find yourself gasping for air yet unable to surface? It’s kinda frightening, even for the more accomplished surfers’ amoung us.

Ok you say, I got the visual, but don’t surf and what’s that got to do with health reform? It’s really quite simple. The oxygen (or change imperative ‘momo’) is gone, and the business owner of the reform narrative is desparately flailing for air. What was once seeminbgly brilliant political positioning, i.e., ‘you (the Congress) give me something I can sign into law, now appears to have degraded into a desparate ‘chicken dance’ in search of a tangible face saving political accommodation.

Yet, the war is over and the health insurance industry has already won. They’ve successfully enrolled us in their ‘faux hope’, yet compelling version of ‘The Matrix’. Never mind the 46 million uninsured, or the expanding ranks of the ‘diminishing returns’ under-insured, the dubious and seedy practices of cherry picking or worse yet retrospective recissions, while the relentless and intractable ‘evolution’ of the health insurance industry away from comprehensive (true HMO like) coverage to smartly branded (Edward Bernays could not have offered better ‘reframing’ counsel) ‘consumer directed health plans’, essentially re-defines the industry.

Why United, Aetna, WellPoint, the Blues, or their regional derivative iterations et al, so wholeheartedly embracing this dressed up risk shifting charade is not prima facia evidence that they can’t cut it, have patently failed the American public, and despite their scale, can not manage health risk let alone delivery systems is not front and center in the health reform conversation is beyond me. Where is the primacy of the ‘Mayo (collectively speaking of organically baked, physician group culture based integrated delivery systems) v. McAllen” (as proxy for fee for service sweat shops) debate?

To my great dismay, this tektonic healthplan (health insurance) risk shift is in some measure aided and abetted by well meaning, thoughtful and committed ‘health 2.0 entrepreneuers’ who passionately pursue web based technologies with intent to empower consumers in the crosshairs and rapicious appetite of the ‘resistence is futile’ health care borg.

In the end (and yes, it is over, for now…) that which plays out in Congress will be pure facing saving attempts to ‘put lipstick on a pig with whack a mole DNA’. The byproduct and amalgamation of this output alchemized by the forces of unreasonable change, leveraged by the vocal naysayers relentlessly pursuing their culture war agenda to pierce the veil of what seemed to be a Presidential mandate above reproach, will castrate once hopeful visions of the health reform we so desparately need.

In view of this dumbed down pseudo national conversation, I imagine more slack will be cut for the failed architects of the ‘HillaryCare’ initiative. Apparently, the Millenial answer was not to stay above the fray via Obama’s ‘Eight Principles of Health Reform‘, but perhaps pursue a more managed center absent artificial legistlative deadlines, coupled with enlightened curators of the conversation.

Towards a ‘Preferred Hospitals’ Manifesto

So what’s a ‘preferred hospital’ anyway?  A fair question, since ‘beauty’ is for the most part in the mind of the beholder!

Preferred Hospitals remains a conceptual ‘on the come’ value proposition at this point; but when I first thought of the idea, I had in mind structuring a network of participating hospitals and physicians directed primarily to the 47 million Americans without health insurance. The network’s ’secret sauce’ consisted of providers who contractually committed to a substantially discounted (equivalent to the best or “most favored nation’s”) rates, otherwise extended to ‘wholesale buyers’, i.e., health plans, with the greatest group purchasing leverage.

In the economics of managed care, the more members a health plan trafficked in a specific market, the greater provider discounts they could expect. Most favored nations rates often equated to 50 cents on the dollar (or less!) , i.e., a 50% discount. Thus, the value proposition (to the uninsured) was twofold: (1) the contract rates would be actually honored, and therefore the member would receive a benefit in exchange for the modest dues paid vs. told ‘we don’t participate with that plan’; and (2) the provider’s rates would be adjusted to ‘fair value’ at least as determined by the entities with the greatest purchasing power in that market.

The great irony is hospitals and physicians too often (whether by design or not) reserve their ‘retail book’, i.e., billed charges, for the least able to bear the burden of charge based ’sticker shock’. Many offer cash discounts as a courtesy in the +/- 25% range, but too often fail to present that option upfront before the downstream litany of collection calls.

At the time I originally entertained the idea, the discounted medical plan marketplace (DMPO) was populated with flimsy players, many of whom where exposed by the Georgetown University Study ‘Discount Medical Cards: Innovation or Illusion?‘ So it appeared this idea would have traction in the marketplace. While I enthusiastically jumped in, I found myself banging my head on the wall, over and over again. The value proposition seemed so apparent to me; especially linking the emerging growth of retainer, concierge or micropractices to a targeted and under-served market that contrary to popular wisdom was not a indigent demographic per se. Further, I reasoned (incorrectly I might add) that many of the forward thinking, and compassionate hospital systems (especially the one I worked for in DFW), forged under benefit of tax exemptions would proactively embrace a solution designed to reach an underserved market, and thus make a material deposit into the ‘community benefit’ bank. With IRS and the Congress on the non-profit hospital trail (i.e., Chuck Grassley, et al) looking into the veracity of 990 filiings, certainly these hospitals would see the light and embrace the greater good this model so obviously afforded; not!

None-the-less, I began to negotiate ‘upstream’ with several national PPO network managers, who in search of incremental revenues, and fighting ’silent PPO allegations’, were electing to ‘rent’ and private label their networks in exchange for a per member, per month (PMPM) fee that ranged at that time between $3.50 – $4.00. Yet, as a start up with no membership, it became solely a cat and mouse affair. The PMPM basis was a function of the membership base which at that time was zero. From their perspective, it was a pure play ‘on the come’ business model, and good intentions not withstanding, we could not come to terms.

I also approached several colleagues, and friends in the personalized, retainer model, or concierge medicine market, and attempted to interest them in the business model. Most notably the Society for Innovative Medical Practice Design (SIMPD) was a logical partner or sponsor (I reasoned) to which I ‘pitched’ the idea, though to no avail. They were just not interested in ‘marketing” their nascent member panel at the time, nor reaching out to this underserved market per se.

Thus, no traction developed, and after much time soliticing support, and partner participation, I elected to back off of the business model.

So fast forward a few years and witness the ‘health reform 2.0 moment’ we’re all having. Revived thoughts have surfaced as to what and how a preferred hospitals network might be structured?

Here are a few ‘indicia’ of an emerging preferred hospitals manifesto:

• Commit to pricing, cost and quality transparency
• Adopt social media guidelines to engage and empower patient utilization of the hospital’s services (pre-admission, during and post discharge; especially follow-up concerns)
• Offer ‘members’ most favored nations’ rates via a credible discount medical plan(s)
• Waive where possible, or otherwise, defer collection of all upfront fees, copays, estimated co-insurance, and/or deductibles
• Participate in budget driven and consumer specific time payment programs (as determined by independent financial counselors) via auto-debit direct from the patient’s bank (interest free)

This is only a start. I welcome your thoughts.

Colorado Health Foundation Serves Up Health Reform ‘Home Run’

On the ‘hopium’ of health reform, where do you stand?

“I don’t believe there’s any problem in this country, no matter how tough it is, that Americans when they roll up their sleeves, can’t completely ignore.” ~ George Carlin

“Better brace yourselves for a whole lotta ugly comin’ at you, from a never ending parade of stupid!” ~ Queen Latifah

“Somebody has to do something, and it’s just incredibly pathetic that it has to be us.” ~ The ‘late’ Jerry Garcia (of Deadhead fame)

On July 30 through August 1st the Colorado Health Foundation (CHF)  held a superb conference titled ‘The New  Health Policy Landscape‘. While regrettably I was not able to attend, I followed the ‘tweets’ of @HealthSymposium, and health tweeps using the #09chs hashtag feed. According to their website the conference was ’sold out’, which was not hard to understand considering the event was  hosted at the Keystone Resort in Keystone Colorado. Can you say ‘Rocky Mountain high?’

Major Colbert ‘tip of the hat’ kudos to CHF as the event featured the following health policy wonk industry icons: Susan Dentzer (Health Affairs), Len Nichols, Ph.D. (The New America Foundation), Steffie Woolhandler, MD, MPH (Harvard Medical School) and Uwe E. Reinhardt, PhD (Princeton). For a complete list of the faculty and their presentations, click here.

Three presentations impressed me with their depth, clarity and candor. First up is single payer advocate Steffie Woolhandler, MD, MPH, who confidently presents the data establishing single payer as the sole option that can insure the now 50 million uninsured and not bankrupt the country in the process. Her audio clip is powerful, compelling and difficult to challenge on the merits of her pro single payer thesis. (Note: also on the program was Jeff Lemieux, Senior Vice President for America’s Health Plans aka ‘AHIP’).

Len Nichols, Ph.D., deployed witt and southern charm to address the problems inherent in the public option and chart the argument that viable health reform can only come from the non-ideological center (i.e., not single payor, nor pure ‘market based’ – non government intermediated -solutions). Using MedPAC and other data Nichols highlighted the imperative of reform, while also offering his vision of indicia of an incremental though ‘pluralistic solution’.

Susan Dentzer mastered the challenge of providing a recap and guide to health reform in 37 minutes; she set the tone of what was to come from a stellar cast and well orchestrated series of messages. Her introduction sets the standard for health reform context consideration; listen here.

The quality of the conference was superb and the Colorado Health Foundation’s use of social media and Twitter is to be commended. The one suggestion for enhancement is to consider live streaming the conference via uStream.tv, LiveVideo.com or other video feed server platform (afterall it was sold out). Publishing both the podcasts and the speaker presentations on their site via PDF downloads is also commendable; however, uploading the preso’s to slideshare is an option to consider as well.

The conference boldly models an open approach to sharing vital information that can and should extend beyond the reach of the paid conference attendees in Keystone. Understanding the value proposition of a ‘digital footprint’ (i.e., the deployment of social media tools and it inevitable re-distribution) and openly sharing that content vs. a proprietary content lockdown, is a brave and commendable strategy to support public health.

Thank you Colorado Health Foundation!

A Health Reform “Desiderata” Courtesy of New York Times Op-ed…

Desiderata:

Go placidly amid the noise and the haste, and remember what peace there may be in silence.

As far as possible, without surrender, be on good terms with all persons.

Speak your truth quietly and clearly; and listen to others, even the dull and the ignorant, they have their story.

Avoid loud and aggressive persons; they are vexations to the spirit.

For more…

July 26, 2009

EDITORIAL

Health Care Reform and You

The health care reform bills moving through Congress look as though they would do a good job of providing coverage for millions of uninsured Americans. But what would they do for the far greater number of people who already have insurance? As President Obama noted in his news conference last week, many of them are wondering: “What’s in this for me? How does my family stand to benefit from health insurance reform?”

Many crucial decisions on coverage and financing have yet to be made, but the general direction of the legislation is clear enough to make some educated guesses about the likely winners and losers.

WHAT ARE THE ELEMENTS OF REFORM? The House bill and a similar bill in the Senate would require virtually all Americans to carry health insurance with specified minimum benefits or pay a penalty. They would require all but the smallest businesses to provide and subsidize insurance that meets minimum standards for their workers or pay a fee for failing to do so.

The reforms would help the poorest of the uninsured by expanding Medicaid. Some middle-class Americans — earning up to three or four times the poverty level, or $66,000 to $88,000 for a family of four — would get subsidies to help them buy coverage through new health insurance exchanges, national or state, which would offer a menu of policies from different companies.

IS THERE HELP FOR THE INSURED? Many insured people need help almost as much as the uninsured. Premiums and out-of-pocket spending for health care have been rising far faster than wages. Millions of people are “underinsured” — their policies don’t come close to covering their medical bills. Many postpone medical care or don’t fill prescriptions because they can’t afford to pay their share of the costs. And many declare personal bankruptcy because they are unable to pay big medical debts.

The reform effort should help ease the burdens of many of them, some more quickly than others. The legislation seems almost certain to include a new marketplace, the so-called health insurance exchange. Since there will be tens of millions of new subscribers, virtually all major insurers are expected to offer policies through an exchange. To participate, these companies would have to agree to provide a specified level of benefits, and they would set premiums at rates more comparable to group rates for big employers than to the exorbitant rates typically charged for individual coverage.

Under the House bill, the exchanges would start operating in 2013. They would be open initially to people who lack any insurance; to the 13 million people who have bought individual policies from insurance companies, which often charge them high rates for relatively skimpy coverage; and to employees of small businesses, who often pay high rates for their group policies, especially if a few of their co-workers have run up high medical bills. By the third year, larger businesses might be allowed to shift their workers to an exchange. All told, the Congressional Budget Office estimates that 36 million people would be covered by policies purchased on an exchange by 2019.

IS THERE MORE SECURITY FOR ALL? As part of health reform, all insurance companies would be more tightly regulated. For Americans who are never quite certain that their policies will come through for them when needed, that is very good news.

The House bill, for example, would require that all new policies sold on or off the exchanges must offer yet-to-be-determined “essential benefits.” It would prohibit those policies from excluding or charging higher rates to people with pre-existing conditions and would bar the companies from rescinding policies after people come down with a serious illness. It would also prohibit insurers from setting annual or lifetime limits on what a policy would pay. All this would kick in immediately for all new policies. These rules would start in 2013 for policies purchased on the exchange, and, after a grace period, would apply to employer-provided plans as well.

WHO PAYS? Current estimates suggest that it would cost in the neighborhood of $1 trillion over 10 years to extend coverage to tens of millions of uninsured Americans. Under current plans, half or more of that would be covered by reducing payments to providers within the giant Medicare program, but the rest would require new taxes or revenue sources.

If President Obama and House Democratic leaders have their way, the entire tax burden would be dropped on families earning more than $250,000 or $350,000 or $1 million a year, depending on who’s talking. There is strong opposition in the Senate, and it seems likely that at least some burden would fall on the less wealthy.

Many Americans reflexively reject the idea of any new taxes — especially to pay for others’ health insurance. They should remember that if this reform effort fails, there is little hope of reining in the relentless rise of health care costs. That means their own premiums and out-of-pocket medical expenses will continue to soar faster than their wages. And they will end up paying higher taxes anyway, to cover a swelling federal deficit driven by escalating Medicare and Medicaid costs.

WHO WON’T BE HAPPY? Healthy young people who might prefer not to buy insurance at all will probably be forced to by a federal mandate. That is all to the good. When such people get into a bad accident or contract a serious illness, they often can’t pay the cost of their care, and the rest of us bear their burden. Moreover, conscripting healthy people into the insured pool would help reduce the premiums for sicker people.

Less clear is what financial burden middle-income Americans would bear when forced to buy coverage. There are concerns that the subsidies ultimately approved by Congress might not be generous enough.

WHAT IF I HAVE GOOD GROUP COVERAGE? The main gain for these people is greater security. If they got laid off or chose to leave their jobs, they would no longer be faced with the exorbitant costs of individually bought insurance but could buy new policies through the insurance exchanges at affordable rates.

President Obama has also pledged that if you like your current insurance you can keep it.

Right now employers are free to change or even drop your coverage at any time. Under likely reforms, they would remain free to do so, provided they paid a penalty to help offset the cost for their workers who would then buy coverage through an exchange. Under the House reform bill, all employers would eventually be allowed to enroll their workers in insurance exchanges that would offer an array of policies to choose from, including a public plan whose premiums would almost certainly be lower than those of competing private plans.

Some employers might well conclude that it is a better deal — for them or for you — to subsidize your coverage on the exchange rather than in your current plan. If so, you might end up with better or cheaper coverage. You would probably also have a wider choice of plans, since most employers offer only one or two options.

WILL I PAY LESS? Two factors could help drive down the premiums for those who are insured. In the short-term, if reform manages to cover most of the uninsured, that should greatly reduce the amount of charity care delivered by hospitals and eliminate the need for the hospitals to shift such costs to patients who have private insurance. One oft-cited study estimates that cost-shifting to cover care for the uninsured adds about $1,000 to a family’s annual insurance premiums; other experts think it may be a few hundred dollars. In theory, eliminating most charity care should help hold down or even reduce the premiums charged for private insurance. When, if ever, that might happen is unclear.

In the long run, if reform efforts slow the growth of health care costs, then the increase in insurance costs should ease as well. And if the new health insurance exchanges — and possibly a new public plan — inject more competition into markets that are often dominated by one or two big private insurance companies, that, too, could help bring down premiums. But these are big question marks, and the effects seem distant.

WILL MY CARE SUFFER? Critics have raised the specter that health care will be “rationed” to save money. The truth is that health care is already rationed. No insurance, public or private, covers everything at any cost. That will not change any time soon.

It is true that the long-term goal of health reform is to get rid of the fee-for-service system in which patients often get very expensive care but not necessarily the best care. Virtually all experts blame the system for runaway health care costs because it pays doctors and hospitals for each service they perform, thus providing a financial incentive to order excessive tests or treatments, some of which harm the patients.

An earlier wave of managed care plans concentrated on reining in costs and aroused a backlash among angry beneficiaries who were denied the care they wanted. The most expensive treatment is not always the best treatment. The reform bills call for research and pilot programs to find ways to both control costs and improve patients’ care.

The bills would alter payment incentives in Medicare to reduce needless readmissions to hospitals. They would promote comparative effectiveness research to determine which treatments are best but would not force doctors to use them. And they call for pilot programs in Medicare to test the best ways for doctors to manage and coordinate a patient’s total care.

Any changes in the organization of care would take time to percolate from Medicare throughout the health care system. They are unlikely to affect most people in the immediate future.

WHAT DOES IT MEAN FOR OLDER AMERICANS? People over 65 are already covered by Medicare and would seem to have little to gain. But many of the chronically ill elderly who use lots of drugs could save significant money. The drug industry has already agreed to provide 50 percent discounts on brand-name drugs to Medicare beneficiaries who have reached the so-called “doughnut hole” where they must pay the full cost of their medicines. The House reform bill would gradually phase out the doughnut hole entirely, thus making it less likely that beneficiaries will stop taking their drugs once they have to pay the whole cost.

Not everyone in Medicare will be happy. The prospective losers are likely to include many people enrolled in the private plans that participate in Medicare, known as Medicare Advantage plans. They are heavily subsidized, and to pay for reform, Congress is likely to reduce or do away with those subsidies. If so, many of these plans are apt to charge their clients more for their current policies or offer them fewer benefits. The subsidies are hard to justify when the care could be delivered more cheaply in traditional Medicare, and the subsidies force up the premiums for the beneficiaries in traditional Medicare to cover their cost.

Reformers are planning to finance universal coverage in large part by saving money in the traditional Medicare program, raising the question of whether all beneficiaries will face a reduction in benefits. President Obama insisted that benefits won’t be reduced, they’ll simply be delivered in more efficient ways, like better coordination of care, elimination of duplicate tests and reliance on treatments known to work best.

The AARP, the main lobby for older Americans, has praised the emerging bills and thrown its weight behind the cause. All of this suggests to us that the great majority of Americans — those with insurance and those without — would benefit from health care reform.

http://www.nytimes.com/2009/07/26/opinion/26sun1.html

July 26, 2009

EDITORIAL

Health Care Reform and You

The health care reform bills moving through Congress look as though they would do a good job of providing coverage for millions of uninsured Americans. But what would they do for the far greater number of people who already have insurance? As President Obama noted in his news conference last week, many of them are wondering: “What’s in this for me? How does my family stand to benefit from health insurance reform?”

Many crucial decisions on coverage and financing have yet to be made, but the general direction of the legislation is clear enough to make some educated guesses about the likely winners and losers.

WHAT ARE THE ELEMENTS OF REFORM? The House bill and a similar bill in the Senate would require virtually all Americans to carry health insurance with specified minimum benefits or pay a penalty. They would require all but the smallest businesses to provide and subsidize insurance that meets minimum standards for their workers or pay a fee for failing to do so.

The reforms would help the poorest of the uninsured by expanding Medicaid. Some middle-class Americans — earning up to three or four times the poverty level, or $66,000 to $88,000 for a family of four — would get subsidies to help them buy coverage through new health insurance exchanges, national or state, which would offer a menu of policies from different companies.

IS THERE HELP FOR THE INSURED? Many insured people need help almost as much as the uninsured. Premiums and out-of-pocket spending for health care have been rising far faster than wages. Millions of people are “underinsured” — their policies don’t come close to covering their medical bills. Many postpone medical care or don’t fill prescriptions because they can’t afford to pay their share of the costs. And many declare personal bankruptcy because they are unable to pay big medical debts.

The reform effort should help ease the burdens of many of them, some more quickly than others. The legislation seems almost certain to include a new marketplace, the so-called health insurance exchange. Since there will be tens of millions of new subscribers, virtually all major insurers are expected to offer policies through an exchange. To participate, these companies would have to agree to provide a specified level of benefits, and they would set premiums at rates more comparable to group rates for big employers than to the exorbitant rates typically charged for individual coverage.

Under the House bill, the exchanges would start operating in 2013. They would be open initially to people who lack any insurance; to the 13 million people who have bought individual policies from insurance companies, which often charge them high rates for relatively skimpy coverage; and to employees of small businesses, who often pay high rates for their group policies, especially if a few of their co-workers have run up high medical bills. By the third year, larger businesses might be allowed to shift their workers to an exchange. All told, the Congressional Budget Office estimates that 36 million people would be covered by policies purchased on an exchange by 2019.

IS THERE MORE SECURITY FOR ALL? As part of health reform, all insurance companies would be more tightly regulated. For Americans who are never quite certain that their policies will come through for them when needed, that is very good news.

The House bill, for example, would require that all new policies sold on or off the exchanges must offer yet-to-be-determined “essential benefits.” It would prohibit those policies from excluding or charging higher rates to people with pre-existing conditions and would bar the companies from rescinding policies after people come down with a serious illness. It would also prohibit insurers from setting annual or lifetime limits on what a policy would pay. All this would kick in immediately for all new policies. These rules would start in 2013 for policies purchased on the exchange, and, after a grace period, would apply to employer-provided plans as well.

WHO PAYS? Current estimates suggest that it would cost in the neighborhood of $1 trillion over 10 years to extend coverage to tens of millions of uninsured Americans. Under current plans, half or more of that would be covered by reducing payments to providers within the giant Medicare program, but the rest would require new taxes or revenue sources.

If President Obama and House Democratic leaders have their way, the entire tax burden would be dropped on families earning more than $250,000 or $350,000 or $1 million a year, depending on who’s talking. There is strong opposition in the Senate, and it seems likely that at least some burden would fall on the less wealthy.

Many Americans reflexively reject the idea of any new taxes — especially to pay for others’ health insurance. They should remember that if this reform effort fails, there is little hope of reining in the relentless rise of health care costs. That means their own premiums and out-of-pocket medical expenses will continue to soar faster than their wages. And they will end up paying higher taxes anyway, to cover a swelling federal deficit driven by escalating Medicare and Medicaid costs.

WHO WON’T BE HAPPY? Healthy young people who might prefer not to buy insurance at all will probably be forced to by a federal mandate. That is all to the good. When such people get into a bad accident or contract a serious illness, they often can’t pay the cost of their care, and the rest of us bear their burden. Moreover, conscripting healthy people into the insured pool would help reduce the premiums for sicker people.

Less clear is what financial burden middle-income Americans would bear when forced to buy coverage. There are concerns that the subsidies ultimately approved by Congress might not be generous enough.

WHAT IF I HAVE GOOD GROUP COVERAGE? The main gain for these people is greater security. If they got laid off or chose to leave their jobs, they would no longer be faced with the exorbitant costs of individually bought insurance but could buy new policies through the insurance exchanges at affordable rates.

President Obama has also pledged that if you like your current insurance you can keep it.

Right now employers are free to change or even drop your coverage at any time. Under likely reforms, they would remain free to do so, provided they paid a penalty to help offset the cost for their workers who would then buy coverage through an exchange. Under the House reform bill, all employers would eventually be allowed to enroll their workers in insurance exchanges that would offer an array of policies to choose from, including a public plan whose premiums would almost certainly be lower than those of competing private plans.

Some employers might well conclude that it is a better deal — for them or for you — to subsidize your coverage on the exchange rather than in your current plan. If so, you might end up with better or cheaper coverage. You would probably also have a wider choice of plans, since most employers offer only one or two options.

WILL I PAY LESS? Two factors could help drive down the premiums for those who are insured. In the short-term, if reform manages to cover most of the uninsured, that should greatly reduce the amount of charity care delivered by hospitals and eliminate the need for the hospitals to shift such costs to patients who have private insurance. One oft-cited study estimates that cost-shifting to cover care for the uninsured adds about $1,000 to a family’s annual insurance premiums; other experts think it may be a few hundred dollars. In theory, eliminating most charity care should help hold down or even reduce the premiums charged for private insurance. When, if ever, that might happen is unclear.

In the long run, if reform efforts slow the growth of health care costs, then the increase in insurance costs should ease as well. And if the new health insurance exchanges — and possibly a new public plan — inject more competition into markets that are often dominated by one or two big private insurance companies, that, too, could help bring down premiums. But these are big question marks, and the effects seem distant.

WILL MY CARE SUFFER? Critics have raised the specter that health care will be “rationed” to save money. The truth is that health care is already rationed. No insurance, public or private, covers everything at any cost. That will not change any time soon.

It is true that the long-term goal of health reform is to get rid of the fee-for-service system in which patients often get very expensive care but not necessarily the best care. Virtually all experts blame the system for runaway health care costs because it pays doctors and hospitals for each service they perform, thus providing a financial incentive to order excessive tests or treatments, some of which harm the patients.

An earlier wave of managed care plans concentrated on reining in costs and aroused a backlash among angry beneficiaries who were denied the care they wanted. The most expensive treatment is not always the best treatment. The reform bills call for research and pilot programs to find ways to both control costs and improve patients’ care.

The bills would alter payment incentives in Medicare to reduce needless readmissions to hospitals. They would promote comparative effectiveness research to determine which treatments are best but would not force doctors to use them. And they call for pilot programs in Medicare to test the best ways for doctors to manage and coordinate a patient’s total care.

Any changes in the organization of care would take time to percolate from Medicare throughout the health care system. They are unlikely to affect most people in the immediate future.

WHAT DOES IT MEAN FOR OLDER AMERICANS? People over 65 are already covered by Medicare and would seem to have little to gain. But many of the chronically ill elderly who use lots of drugs could save significant money. The drug industry has already agreed to provide 50 percent discounts on brand-name drugs to Medicare beneficiaries who have reached the so-called “doughnut hole” where they must pay the full cost of their medicines. The House reform bill would gradually phase out the doughnut hole entirely, thus making it less likely that beneficiaries will stop taking their drugs once they have to pay the whole cost.

Not everyone in Medicare will be happy. The prospective losers are likely to include many people enrolled in the private plans that participate in Medicare, known as Medicare Advantage plans. They are heavily subsidized, and to pay for reform, Congress is likely to reduce or do away with those subsidies. If so, many of these plans are apt to charge their clients more for their current policies or offer them fewer benefits. The subsidies are hard to justify when the care could be delivered more cheaply in traditional Medicare, and the subsidies force up the premiums for the beneficiaries in traditional Medicare to cover their cost.

Reformers are planning to finance universal coverage in large part by saving money in the traditional Medicare program, raising the question of whether all beneficiaries will face a reduction in benefits. President Obama insisted that benefits won’t be reduced, they’ll simply be delivered in more efficient ways, like better coordination of care, elimination of duplicate tests and reliance on treatments known to work best.

The AARP, the main lobby for older Americans, has praised the emerging bills and thrown its weight behind the cause. All of this suggests to us that the great majority of Americans — those with insurance and those without — would benefit from health care reform