Controversy over reform – what’s the deal?

By Sanjay Kishore:

While healthcare has already become a firestorm of controversy for the Obama Administration, the President’s recent reform bill received another blow this past week – once again, from the courts. As reported by the New York Times on January 31st, a federal judge in Florida followed the precedent set by a Virginia court and struck down the constitutionality of the March 2010 Patient Protection and Affordable Care Act (PPACA).

In both court decisions, the issue in contention was the law’s inclusion of an “individual mandate” – a provision that requires all Americans to obtain health insurance or otherwise face a monetary penalty. Essentially, these two justices believe the federal government has overstepped its bounds by pressuring people into purchasing insurance – a sentiment recently echoed by Republican legislators as they passed a symbolic vote to repeal PPACA in the House of Representatives earlier this month.

Obviously, momentum for healthcare reform has shifted in the past year. But, what does all this controversy actually mean – especially in the context of prospective health?

Many advocates of PHC – including students like myself – realize the first step to increasing prediction and prevention in our healthcare system isn’t developing new technologies or utilizing fancy screenings: it’s extending access to what we already have. Before 2010, uninsured Americans had no financial incentive to seek preventive medical treatment – after all, if you’re an individual living on a tight-income, why visit a doctor when you’re healthy? As a result, almost 45 million Americans faced an economic pressure to delay seeking medical assistance until a traumatic incident – say, a heart attack – became too severe to bear.

Though PPACA’s expansion of insurance to 32 million Americans didn’t solve the problem, it was a solid start. If we are serious about halting the spread of chronic disease and promoting wellness in the US, we must extend access to health insurance.

As students interested in preventive healthcare, it’s in our best interests to keep our ears tuned – and our voices loud – for the next few years could be telling for the future of American healthcare!

State of the Union: Health care debate continues

Despite reassurances from the President in Tuesday’s State of the Union Address that the Affordable Care Act will slow rising health care costs, debate on the health care law didn’t skip a beat come Wednesday morning on Capitol Hill. The House Budget Committee is holding hearings this week to evaluate the economic impact of health care reform. On Wednesday the testimony of the CMS Actuary garnered quite a bit of attention when he expressed his doubt that the law will be able to bring down unsustainable health care costs. The White House was quick to respond with a post by Stephanie Cutter pointing out key elements of the law which independent experts have argued will result in cost savings. Notably, Cutter highlights both payment reform and the creation of Accountable Care Organizations to coordinate care as a means to improve health care quality and efficiency. These same sentiments are echoed in a letter released on Wednesday which was signed by over 200 health care leaders stating that the Affordable Care Act contains almost every cost-containment provision that is considered effective at reducing health care costs. The letter counts increased emphasis on wellness and prevention as one of the effective cost containment measures in addition to models of coordinated care and rational reimbursement.
We at the Center believe that providing smarter health care can both improve quality and decrease costs. Although there are a staggering number of variations on the theme of coordinated care, pilot projects in patient populations have shown considerable cost savings in a number of such projects. This is particularly true in populations with heavy burdens of chronic disease, whose inherently high disease costs provide an equally high potential to save costs over conventional approaches to care. My colleagues and I published a piece in Academic Medicine back in November discussing how personalized medicine provides a standardized approach to overcome impediments to both coordination of care and rational reimbursement. As a model of health care which is equally effective at disease prevention and treatment, prospective health care provides an approach on which to base many of these cost containment measures.

Medicare Jumpstarts Wellness and Prevention Efforts

As of January 1st of this year, Medicare must now provide free annual wellness visits and personalized prevention plans to their beneficiaries as stipulated by PPACA. An article by Francine Russo in this month’s Time Magazine discusses what these wellness visits and personalized prevention plans might look like in practice and some of the barriers providers might face in implementing these new measures. The wellness visits and prevention plans described in the article focus exclusively on lifestyle interventions aimed at improving diet, increasing exercise and limiting smoking – a far cry from utilizing an array of risk predictions tools to quantify all of a patient’s individual health and disease risks over time – but an important and critical movement in the right direction. The article points out the difficulty physicians might have in finding the time to fit a comprehensive personalized prevention plan that is thorough enough to be effective, yet compact enough to squeeze into their already packed visits with patients. These types of behavioral modifications are notoriously difficult to initiate and maintain over time. With this new tenet of health care reform going into effect, physicians will now be reimbursed by Medicare for taking the time to work with patients to try and address these lifestyle issues. Such a large undertaking will require the coordination of care between physicians, patients, and nutritionists, lifestyle coaches, etc. in order to be effective. These changes in reimbursement may be just what was needed to kick-start the wellness and prevention movement.

Debating Health Care Reform: more talk, little action

Recently, the Duke University chapter of the Benjamin Rush society held a debate on health care reform.

Moderated by Dr. Christopher J. Conover, the topic was, “How does America achieve affordable, accessible, quality healthcare?” Debate participants included Sally Pipes, Dr. Hal Scherz, Dr. Peter Kussin, and Dr. Gustavo Montana.

The audience was polled just prior to the debate as to whether health care reform would be best addressed by (1) government regulation (2) self-regulation by the private sector or (3) unsure. The same question was asked at the conclusion of the debate. Although no formal statistical analysis was performed, the numbers remained essentially unchanged before and after the debate. One hour of intense discussion among three physicians and a national health care reform expert in the presence of medical students, health care professionals, and members of the public resulted in more of the same – not unlike what we’ve seen in the last two years across both the political and private sectors. . It’s clear people’s opinions on health care reform reflect core moral, political, economic, and philosophical beliefs, and those don’t often shift over the course of an hour-long discussion or a three-minute news splash.

Despite the heated discussion, there were several points that both the “conservative” and “liberal” panelists agreed upon. They agreed that the current system is broken and that PPACA is unlikely to fix it. They agreed that physicians need to be more involved in discussions of health care reform. They agreed that cost-effective care, guided by cost-effectiveness research, is important to improving health care efficiency. They agreed that patient care needs to be coordinated among providers and systems.

Prospective health care provides a solution that cuts across political and personal mores. This approach provides regulation not by government or private companies, but by physicians in partnership with their patients. It provides cost-effective care, not by mandate, but by physician and patient cooperation. It supports rational reimbursement based on documented outcomes. It is a non-partisan, non-government, non-private, but physician and patient based approach that avoids the devastating road-blocks that plague current “debates” on health care reform. Dr. Kussin advocated for an American Solution several times during the debate. If the United States is to find a uniquely American solution to the question of health care reform, it will take all of America, not just one-half. Focusing on the development and implementation of models of reform such as prospective health care provides a real solution for how to provide rationale care, reduce costs, improve outcomes, and increase patient satisfaction. And who can’t agree on that?

Personalized Medicine: A non-partisan solution for health care reform?

Much has been made about the Republicans gaining control of the House in the midterm elections. Potential explanations of why the change in power occurred abound. Conservatives have championed the election as a mandate to reduce health care spending or even scrap the recently passed health care legislation and start over from scratch. On the flip side, others have implied that changing public opinion may be more a function of Americans simply wanting something until they get it. Regardless of political ideology, everyone more or less agrees we’re spending too much money for not enough results.

The focus of controversy in both recent debates and legislation has been largely about insurance reform. What has been absent from these discussions is how health care reform can 1) change how we approach the delivery of health care and 2) support improved health over the life of an individual. Currently, care is sporadic, reactive, uncoordinated, and based on a reimbursement which rewards treatment of disease rather than prevention of disease. If you have any doubt of this just look at any of the highest paid medical specialties – cardiology, radiology, oncology, gastroenterology, and surgery – all procedure based specialties that are well-reimbursed under our current system. We at the Center believe that we can do better than this reactive, procedure-based approach to medicine. Through the use of personalized health plans, providers can quantify patients' health and health risks, identify strategies to mitigate risks and/or treat disease, deliver personalized care, engage patients in their care, and measure outcomes over time. This set of tools can then be used to more effectively implement coordinated care and more accurately measure performance for reimbursement. While PPACA and its attempts to address inadequacies in health insurance and coverage may be stalled by political turmoil for some time, the health care community can use personalized health planning to start to work towards meaningful health delivery reform now. And as we argue in a recent commentary in Academic Medicine, PPACA’s focus on the development of coordinated models of care, provider reimbursement reform, and personalized health planning is a significant opportunity for academic medical centers to lead the way in health care reform.