Wednesday, December 30, 2009
JAMA -- Improving the Delivery of Preventive Services to Medicare Beneficiaries, December 23/30, 2009, Lesser and Bazemore 302 (24): 2699
Sunday, December 20, 2009
Manager’s Amendment to the Patient Protection and Affordable Care Act
Providing More Competition & Affordable Choices for Americans
The Manager’s Amendment to the Patient Protection and Affordable Care Act builds upon the strong bill we already have. It demands greater accountability from health insurance companies while creating more choice and competition for consumers. It implements new programs to further rein in health costs and makes health insurance policies more affordable; and it improves access to quality, affordable health care for children and vulnerable populations.
Tougher Accountability Policies for Health Insurance Companies
- Stronger medical loss ratios. Health insurers will be required to spend more of their premium revenues on clinical services and quality activities, with less going to administrative costs and profits – or else pay rebates to policyholders. These stricter limits will continue even after the Exchanges begin in 2011, and apply to all plans, including grandfathered plans.
- Accountability for excessive rate increases. A health insurer’s participation in the Exchanges will depend on its performance. Insurers that jack up their premiums before the Exchanges begin will be excluded – a powerful incentive to keep premiums affordable.
- Immediate ban on pre-existing condition exclusions for children. Health insurers will be immediately prohibited from excluding coverage of pre-existing conditions for children.
- Patient protections. Health insurers will have to abide by a set of patient protections that, for example, protect choice of doctors and ensure access to emergency care.
- Ensuring access to needed care. The use of annual limits on benefits will be tightly restricted to ensure access to needed care immediately, and will be prohibited completely beginning in 2014.
- Guaranteed opportunity to appeal coverage denials. All health insurers will be required to implement an internal appeals process for coverage denials, and states will ensure the availability of an external appeals process that is independent and holds insurance companies accountable.
Stronger Policies to Make Health Care Affordable
- Innovation. Medicare will be able to test new models and, if successful, implement them via a stronger Innovation Center, Independent Payment Advisory Board, and other authorities.
- Transparency. New requirements will ensure that insurers and health care providers report on their performance, empowering patients to make the best possible decisions.
- Small businesses. A package of improvements include starting the health insurance tax credit in 2010, expanding eligibility for the credit, and improving the purchasing power of small businesses.
More Health Insurance Choices
- Multi-state option. Health insurance carriers will offer plans under the supervision of the Office of Personnel Management, the same entity that oversees health plans for Members of Congress. At least one plan must be non-profit, and the plans will be available nationwide. This will promote competition and choice.
- Free choice vouchers. Workers who qualify for an affordability exemption to the individual responsibility policy but do not qualify for tax credits can take their employer contribution and join an exchange plan.
Improved Access to Quality Health Care for Seniors, Children, and Vulnerable Populations
- Quality of care in Medicare. Seniors will benefit when additional health care providers are reimbursed by Medicare for the quality of care they deliver, not the quantity of services they provide.
- Children’s health. Support will be extended for the Children’s Health Insurance Program and the adoption tax credit. Foster care children aging out of Medicaid will be able to retain its comprehensive coverage.
- Community Health Centers. A substantial investment in Community Health Centers will provide funding to expand access to health care in communities where it is most needed
- Rural and underserved communities. Access will be expanded through funding for rural health care providers and training programs for physician and other types of health care providers.
- Vulnerable populations. A range of new programs will tackle diseases such as cancer, diabetes, and children’s congenital heart disease, will improve the Indian Health System, and will provide support for pregnant teens and victims of domestic violence.
Identifying Alternatives to Litigation
- Testing new models. States will be eligible for grants to test alternatives to civil tort litigation that emphasize patient safety, disclosure of health care errors, and early resolution of disputes, with a provision for patients to opt-out of these alternatives at any time. Alternatives will be evaluated to determine their effectiveness.
Sunday, December 06, 2009
Here's where we are:
The House of Representatives passed their bill last month. The Senate is aiming to pass its version before Christmas.
Overall, both pieces of legislation would do four major things:
- Create a "Health Insurance Exchange." The bills create a one-stop marketplace where people can choose from various insurance plans, including the public option. The details aren't set yet, but initially the Exchange would likely be open to the self-employed, people without insurance at work, and small businesses.1 The key with the Exchange is that it brings "the bargaining power and scale that's generally accessible only to large employers" to individuals—and with that, lower costs and better options.2
- Provide insurance to over 30 million more people. The House bill would expand coverage to 36 million people by 2019. The Senate bill extends coverage to 31 million.3
- Outlaw discrimination based on pre-existing conditions and gender. Insurance companies will have to stop denying coverage to people with "pre-existing conditions." And they won't be allowed to charge women more than men for the same coverage.4
- Eliminate coverage limits and price-gouging. The bills differ on some details, but in general would place limits on how much people have to pay for health care beyond their premiums. They both cap out-of-pocket costs and ban insurance companies from setting limits on how much health care they'll cover for a person each year.5
Here's what still needs to be fixed:
- Both bills leave millions uninsured. The House bill leaves 18 million without insurance in 2019; the Senate bill, 24 million. Neither comes close to the vision for universal coverage so many of us fought for for years. We'll all need to fight to continue to expand coverage in the bills this year, and in the years to come.6
- The Senate public option is weak, and conservatives are pushing to make it weaker. The public option is a core piece of reform that will create real accountability and competition for private insurance—and that's why it's at the center of such a huge fight. While the House bill creates a national public option, the Senate lets states opt out, denying their residents access to it. Plus, conservatives are working to weaken it even more. We're all going to have to fight hard for the strongest version possible.7
- Many reforms don't start quickly enough. While some pieces of reform go into effect right away, the larger structural changes are not scheduled to go into effect until 2013 (House bill) or 2014 (Senate bill). This includes the Exchange, the public option, and subsidies—the major ways coverage will be expanded.8
- Required insurance could still be too expensive for many. Both bills require virtually all Americans to have insurance. But the caps on how much we're expected to pay are way too high, and the subsidies are way too low. Many progressives are working to fix this, but it's going to be a significant fight.9
- Reproductive rights are severely restricted in the House bill. An egregious anti-choice amendment in the bill virtually prohibits anyone purchasing insurance in the Exchange from buying a plan that covers abortion—even if paid for with their own money. We need to make sure the final bill doesn't include this rollback of reproductive rights.10
- The Senate bill could discriminate against lower income workers. The current Senate legislation retains a version of what's called the "free rider" provision, which essentially penalizes employers for hiring lower income workers. This provision needs to be fixed before the bill is finalized.11
Check out more about the House bill here and the Senate bill here or here, and see what the impact of reform would be in your state here. If you want to read the full bills, for the House, click here or here (PDF), and for the Senate, here or here (PDF).
Thursday, November 19, 2009
I really do not understand all the controversy about the new USPSTF recommendation on breast screening. Actually, I do. I just read an article by Gerd Gigerenzer of the Harding Center for Risk Literacy and colleagues who document the statistical illiteracy of patients and doctors. People in around the world (not just Americans) do not seem to have knowledge of basic statistics and math. We do not understand risk, and what the purpose of screening for disease is. It starts very young, as we do not teach our children the basics of statistics in school.
This combines with a medical-industrial complex that makes us believe that everything modern medicine has to offer is good. Doctors are as guilty as anyone else. We have all come to believe that tests, medicine, and procedures are good. The problem is that modern medicine rests on science, something the previous witchdoctors did not do. If we are going to continue to practice modern medicine, that is based on the science of medicine, then we have to start accepting that all tests and medicines are not always good.
Combine this with the fact that our medical costs are skyrocketing to a level we cannot afford. Indeed the problem with the current health care reform (which I support) is that no one wants to ration care. But, we already ration care. Rationing is not a bad thing: it protects us from unneeded, expensive, and possibly harmful tests and treatments. We have to start realizing that we cannot expect to get every test under the sun whenever we want it. It costs too much, and it probably causes more harm than good.
Let’s all start to educate ourselves on the basics of risk and modern medicine:
- The biggest risk factor for death is being born.
- There are treatments and tests that can harm us.
- Let’s start talking about effective care that acknowledges the limits to medicine.
Sunday, November 08, 2009
RAND: Health COMPARE: Analysis of Options: Policy Options Dashboard
Sunday, October 25, 2009
Thursday, October 08, 2009
"We've made a conscious effort to diversify our sources of revenue," Heim said. "This is the first of what we hope will be many Consumer Alliance agreements. We're looking across a broad spectrum. This is just our initial partnership."
"Consumer alliance agreements." What kind of stupid term is that? This an "industry" alliance. How dare you call it a "consumer" alliance?
A few years ago the AAFP partnered with McDonald's on its obesity project. Now Coca Cola. Who's next? Frito Lay? So we can have education program on picking which chips are best for you? Mars? So we can educate you on which candy bars to buy?
The AAFP should take the advice of someone Micheal Pollan posted on his NY Times website:
"Eat foods in inverse proportion to how much it's lobby spends to push it." -Krik Westphal
Friday, September 11, 2009
"One of the leading products of the American food industry has become patients for the American health care industry." Doctors promote this by believing that drugs are better than vegetables.
"There’s more money in amputating the limbs of diabetics than in counseling them on diet and exercise." I would say A LOT more...
"Terms like “pre-existing conditions” and “underwriting” would vanish from the health insurance rulebook — and, when they do, the relationship between the health insurance industry and the food industry will undergo a sea change."
On his major thesis- that the health industry will force the food industry to change- I'm not so sure I agree. The private health sector is too fragmented. They don't know whether a person on their plan will still be their in a year when the employer or employee changes jobs. I don't think they have enough steak in the game to force big changes in the food industry. They may start offering more exercise and nutrition counseling, but I don't see them going further.
To reform the food system, we would need to take on the food system. This is a good job for the HHS secretary, the Surgeon General, and the rest of us.
The gatekeeper and the wizard, redux -- Kamerow 339: b3624 -- BMJ
Thursday, September 10, 2009
He had many excellent frames. I've been advocating for him to use George Lakoff's frame's of health care and he did just that.
A classic frame was talking about the public option like public colleges: "But by avoiding some of the overhead that gets eaten up at private companies by profits and excessive administrative costs and executive salaries, it could provide a good deal for consumers, and would also keep pressure on private insurers to keep their policies affordable and treat their customers better, the same way public colleges and universities provide additional choice and competition to students without in any way inhibiting a vibrant system of private colleges and universities. "
Most importantly he brought health care from a policy issue to a moral issue. He first brought up stories of people who can't pay for their health care. You can see another example, of a boy's family who can't pay for his cancer care here:
He then brought up Teddy's letter on why a fellow American thought that his fellow Americans should have the same access to care that he did.
"On issues like these, Ted Kennedy's passion was born not of some rigid ideology, but of his own experience. It was the experience of having two children stricken with cancer. He never forgot the sheer terror and helplessness that any parent feels when a child is badly sick. And he was able to imagine what it must be like for those without insurance, what it would be like to have to say to a wife or a child or an aging parent, there is something that could make you better, but I just can't afford it. "
Continuing he puts health care in the frame of the Family of Americans:
"That large-heartedness -- that concern and regard for the plight of others -- is not a partisan feeling. It's not a Republican or a Democratic feeling. It, too, is part of the American character -- our ability to stand in other people's shoes; a recognition that we are all in this together, and when fortune turns against one of us, others are there to lend a helping hand; a belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgment that sometimes government has to step in to help deliver on that promise."
Keep talking about health care as a moral issue. It IS in our country's character to get everyone health care. Keep telling the stories of friends and family who were denied by insurance companies for life saving care. We are here to end that, because that is not the way we live in America.
"We did not come to fear the future. We came here to shape it. I still believe we can act even when it's hard. ... I still believe we can do great things, and that here and now we will meet history's test. Because that's who we are. That is our calling. That is our character."
Thank you President Obama, for speaking to our hearts.
Tuesday, September 08, 2009
When you speak tomorrow night, speak of all the people in this country who have an illness and cannot get care because they cannot pay for it. This is not right in our country. We need to pass your American Health Care Plan to insure everyone of our siblings, friends, parents, and children. Every day from now until health insurance reform passes, you should read a letter from someone suffering because of lack of health insurance. The people will win over the insurance companies. Our country is great and we can achieve the right of quality, affordable healthcare for ALL.
Thursday, August 20, 2009
In the above article I point out the fault in previously published guidelines on nutrition industry - research interactions. Instead of the industry policing themselves with guidelines, I argue that the journal editors should make and enforce policies on industry collaboration in nutrition research.
I cite several policies by other medical journals that the nutrition journals could adopt to increase the integrity of nutrition research.
The response to my letter was from Mr. Hentges. He side stepped most of the issues I brought up. He could not defend his group's initial argument that industry is more likely to have better results in their research. He also did not respond to my idea of stricter journal editorial policies.
However, he did agree with me that increased full disclosure of conflicts of interest would benefit research. But, he did not further back up this claim with action. His own conflict of interest statement states that he is the director of ILSI supported by North America "industry membership." Full disclosure would mean stating all the food industries that ILSI is funded by. Surely readers might want to know if he is funded by Coca Cola, Kraft, and the other food giants. These details used to be on their website, but I could no longer find it.
I will continue to view industry-funded nutrition research skeptically. You should to. Now it is time for journal editors to reform their policies.
Sunday, August 16, 2009
YouTube - How Dems Are Failing to Sell Health Care Reform - George Lakoff
We need to start talking about how insurance companies and HMOs have harmed the care of many of our family members and friends. The American Plan, proposed by Obama and the Democrats will guarantee every American the right to see their doctor. It will put health back in the hands of Americans and their doctors and nurses. Are you for or against the American Plan? If you are for it, you better call your representative and Senator. If not, the evil insurance companies will win again.
We need to start talking differently about health care. NOW.
Monday, August 10, 2009
I'm following this debate about end-of-life care in the news. Basically, there is a provision in the House bill that adds Medicare coverage for you if you want to go to your doctor and discuss end-of-life care. My research shows it's a good idea to talk to your doctor while you are healthy, to discuss what types of medical interventions you would want if you became seriously ill.
Great idea! Right? Except it is blown into a conservative message of "the government is trying to kill you." The problem is the Democrats do not know how to defend it because they do not really understand the issue. Even Obama fumbled with it.
As physicians, we care about choice and honoring patients personal wishes. Often what happens is that people end up attached to tubes, never having the discussion with their doctor. The default is to keep them attached to tubes and sedated. Then the decision is put on the family to decide what to do with their elderly parent.
The idea of this provision is to have the doctor know ahead of time what the patient would want, so the decision is easier later on.
Honestly, it is discussion that should happen more. Maybe it doesn't happen because Medicare does not pay for that type of discussion. Thus, paying for these sessions is a good idea.
This exemplifies why doctor's need to be in this debate: to give the real story of what is happening every day. Obama should find doctor's and have them out on the road speaking for this reform. I'm not sure he is capable of it himself. So get involved doctors: www.npalliance.org
Debate Continues Around End-Of-Life Care - Kaiser Health News
Thursday, July 16, 2009
So this begs the question, do al these hospitals overall increase health at a reasonable cost?
There are probably great differences in this group. For instance, Mayo is known to try to provide cost effective care.
What I really want is for US News to rank hospitals on the cost effectiveness for their care. If they did, hospitals with a large amount of primary care outreach would be high.
Best health care should be defined as what a hospital system does for the health of their community, not how highly rated their sub-specialties are.
America's Best Hospitals: the 2009–10 Honor Roll - US News and World Report
Monday, July 13, 2009
This is very exciting.
Obama Names Dr. Regina Benjamin New Surgeon General - ABC News
Wednesday, July 08, 2009
"When you tell a patient he can't eat a hamburger and fries, and he walks out of your office and sees hamburgers and fries, what message are you sending?" he added. "
Hospitals give healthy food more operating room - MarketWatch
Posted using ShareThis
Sunday, July 05, 2009
In this great article in the New Yorker, Dr. Gawande shows how we need to come together and provide high quality care. This usually means less tests, consultants, and procedures.
Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker
The best idea I have heard on organizing physicians around quality care is from Brownlee and Fine (excerpted by Dr. Colin Kopes-Kerr, MD, JD:
"Primary Care for All will require new infrastructure at the regional, state, and federal levels to support universal access to primary care health centers... Each community or region will need a Primary Care Board, which can contract with primary care practices to provide effective, efficient care... Each state will also need a Primary Care Trust to plan and oversee the functions of primary care practices. The Federal Government will need an Assistant Secretary for Primary Care in the Department of Health and Human Services to bring focus and direction to the many agencies inside the Department that are concerned with primary care."
"Primary Care for All is not a proposal to change what most Americans have now. Instead, it brings together three existing systems that currently provide primary care, and out of them creates a primary health care infrastructure that cares for all citizens"--existing private primary care practices, community health centers, and vertically integrated accountable health care organizations like Kaiser Permanente. They see the continuation of a healthy tradition of private practice is "necessary for critical check and balance on the integrity of a more public system."
There are two possible methods that could be used to finance Primary Care for All. "The simplest method is for all payers (including Medicare and Medicaid) to put $400-500 per beneficiary per year into a Primary Care Trust--a state-based, non-profit, private public partnership, responsible for paying all primary care practices on a risk-adjusted, capitated basis. These funds would pay for the primary care of all Americans, not just the uninsured...People without health insurance would also be required to pay into the Primary Care Trust, but would receive tax credits for doing so. Those living in poverty would receive public subsidies for primary care, to be funded either by tobacco and alcohol taxes, or taxing employee health benefits."
The alternative payment mechanism would involve the use of Community Health Savings Accounts. "Like HSAs, Community health Savings Accounts are high deductible health insurance policies linked to tax advantaged savings accounts owned by the individual. Where they differ from HSAs is that policy holders would be required to make monthly payments out of their savings account to a certified primary care practice chosen by the individual."
"Why pay primary care practices through the Primary Care Trust? The Primary Care Trust approach is intended to produce an equitable and effective infrastructure, and reduce or eliminate regional disparities in the type and amount of care people receive." In addition there is a need for a single set of quality and service delivery measures, and population-based outcomes measures selected by the wisest among us. The important characteristic of this system is that physician reimbursement will no longer be on a fee-for-service basis. Like original sin, this single flaw at creation doomed us to the health care we have now.
As do most analysts of health reform, Brownlee and Fine expect to encounter work force issues--like a need for 25,000-50,000 more primary care physicians. They accurately comment, "The optimal supply of primary care physicians and practices for a given population, and the ideal composition of the primary are team is not known at present." They go on to speculate that "[S]ome of the immediate need for more primary care physicians will be relieved by improved organization or primary care practices, and by increased use of physicians assistants, nurse practitioners, case managers, and my favorite alternative, Community Health Workers.
Brownlee and Fine conclude, "Financing health care system reform can succeed best if it is accompanied by focused improvement in primary care delivery and organization. The development of Primary Care for All presents an essential and affordable first step toward an effective and efficient health care delivery system, and sustainable health care reform.
Saturday, June 20, 2009
In Poll, Wide Support for Government-Run Health - NYTimes.com
Monday, June 08, 2009
Making smaller portions and substituting apples for fries.
But, Burger King won't really be healthy until they take the burger off the main course.
What about offering beans and kale? That would be having it my way.
Burger King crafts three more better-for-you kids' meals | Healthy Food Options | QSR Web
Sunday, May 31, 2009
It was everything I wanted... great cinematography, acting, and writing. About a couple just trying to find out how to do the right thing. I think the answer is that you just do what you think is best at that moment, and as long as love is there, that's the best you can do.
John Krasinski, Maya Rudolph, and Dave Eggers answered questions afterwards. A great event.
Dave Eggers signed my book before the movie. He wrote, "Lenny-
My apologies in Advance
Your true friend,
Away We Go | Film Overview | Focus Features Movies |
Friday, May 29, 2009
Friday, May 01, 2009
Nutrition Experts Propose New Class of Low-Sugar Beverages to Reduce Role of Sugary Drink Consumption In Obesity and Diabetes Epidemics - April 20, 2009 -2009 Releases - Press Releases - Harvard School of Public Health
Monday, March 16, 2009
We have now had a bunch of trials that show that many different diets "work", but only modestly. If we try and take these interventions into the clinical (i.e. non-research) world, we will likely have even less success.
So what do we take out of this? The editorial by Martijn Katan (linked to below) says it best:
"We do not need another diet trial; we need a change of paradigm."
He goes on to talk about how behavior change is hard, and we will only be effective if we work at a community level:
"Like cholera, obesity may be a problem that cannot be solved by individual persons but that requires community action. ...the apparent success of such community interventions suggests that we may need a new approach to preventing and to treating obesity and that it must be a total-environment approach that involves and activates entire neighborhoods and communities."
I have been advocating for this for some time. Obesity treatment (via dieting) is not the answer to this large public health problem. Obesity prevention through large scale public health research and interventions is the answer. Let's start taking responsibility for our laws, policies, and community designs that contribute to obesity. Let's all work together to make our communities healthy places for our children, spouses, friends, and parents to live in.
NEJM -- Weight-Loss Diets for the Prevention and Treatment of Obesity