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.

The ghost of past, present, and future health care – cost.

On Christmas Eve, Uwe Reinhardt posted a piece which raised a familiar ghost of healthcare past, present, and future: cost. The post reminds us that between 2000 and 2009, Medicare spending on physician services per beneficiary rose a whopping 61 percent, even though physician fee rates only increased by 7 percent. Reinhardt argues that he culprit behind this pattern of cost increases is increased utilization, with the fastest growing sectors of health care utilization (imaging and diagnostic testing) increasing by 80% between 2000 and 2009. Increased use of health care resources is not necessarily a sign of bad healthcare, but it is a sign of expensive healthcare. If we knew what was driving increasing utilization and how to control it, we would be able to largely rein in skyrocketing health care costs. Although a portion of these increases may reflect new, valuable health care technology and improvements, a larger portion likely just reflects more health care. The underlying etiology of this latter type of health care spending includes self-referral, a misaligned fee for service reimbursement model, and patient demand. A prospective model of health care would address all of these issues by coordinating patient care and removing duplication of diagnostic testing, providing rational reimbursement to discourage unneeded and self-referral driven testing, and engaging the patient in the decision making process so that they might be less likely to demand costly services that often lead to little, no, or potentially negative health benefit.

PPCA Uncertainty but the Central Issue Remains

Earlier this week, a Virginia judge ruled a key provision of PPACA to be unconstitutional. The individual mandate, requiring the purchase of health insurance by all is a key requirement within PPACA that provides the financial resources to support other benefits. Without this provision,the viability of the law is in doubt. This issue will certainly come to the Supreme Court for resolution, but the resulting decision and it's impact on the legislation will not be known for some time. In my view, this uncertainty about PPACA should focus us even more sharply on the importance of addressing the most fundamental need for health care, how care is delivered and the role people can play in improving their health. Health is an individual resource and value and personalized health planning can be accomplished without legislation. Innovation in care to make it coordinated and personalized can be created without legislation and it is hoped that insurers, CMS and private enterprises will develop capabilities to accomplish these goals for their own merits. Improving the approach to enhancing health and care delivery is essential to the success of PPACA and the legislation does have features to facilitate such approaches but needed change can and should occur regardless of that law. Such changes make good sense and good business as they will be very cost effective.
While we wait to see what the impact of legal challenges to PPACA do to the law, I suggest concerted Government and private sector initiatives to spur better models of care delivery.

To fix our economy, we must reform health care delivery

The dominant political debate of the day regards the form of tax legislation needed to prevent major tax increases beginning in January 2011. Underlying this debate is the weakness of our economy and the loss of employment for so many Americans. There were many drivers of the economic "melt down" in 2008 but one that has gone out of focus recently is the tremendous burden of health care costs. And with the passage of last year's health care reform legislation (PPACA), costs will increase even more. Regardless of the outcome of new tax legislation and potential stimulus spending, deficit reduction remains a necessary yet menacing challenge. What needs to be discussed more rationally and addressed quickly is how we stem the continued escalation of health care expenditures, particularly with the passage of PPACA and the increased coverage of many more Americans.

In an editorial in this Sunday's New York Times, this issue is discussed with a primary focus on reducing costs by cutting Medicare expenditures and increasing the costs borne by individuals. Neither of these approaches gets to the root of the problem. Lowering overall expenditures for
health care must be addressed as our current weakened economy is straining under this burden. Importantly, it is feasible to both lower costs and improve care! PPACA, while monumental in its scope, focuses largely on insurance coverage but deals lightly, and in my view ineffectively, with the root problem of health care delivery in the US. Our health care delivery "system" is uncoordinated, reactive, and focused on the expensive treatment of disease events associated with late-stage preventable chronic illness. Physicians and providers are currently rewarded economically for interventions, particularly invasive ones. It is recognized that coordinated care which emphasizes prevention and, when needed, interventions over time, and is focused on a motivated and involved patient, provides the most cost effective outcomes. Reimbursement for prevention and coordinated care to minimize disease is insufficient to cover costs. Yet reimbursement must be structured to reward such care. PPACA addresses these issues, but the solutions require the establishment of new bureaucracies, many years, and changes that will be subject to intense political debate. The type of care needed to improve health, outcomes and decrease costs is well understood today, but little is being done to foster its adoption. Care must be coordinated, personalized, preventative, and involve an engaged patient. Unfortunately, current incentives work against such models of care being established. I don't see a timely solution, given the current approaches.

To foster change, I propose highlighting the imperative to do so along with the establishment of a bipartisan Presidentially-appointed committee charged to recommend new models of coordinated care delivery and reimbursement strategies. The Bowles-Simpson Committee is an example of a bipartisan approach to recommend solutions to knotty problems. The report of a Health Delivery Improvement Committee could be expected within six months. Both private insurance and CMS could provide reimbursement incentives to foster recommended changes rapidly. The answer to our current wasteful approach to health care will be far easier to find than overall solutions to a tepid economy, but the former will provide strong support to make the latter solution easier.

All the tests in the world don’t mean much without a plan

I recently spoke to a representative from the Indian Health Service about “personalized medicine” in federal initiatives. Of particular note, I mentioned during the course of our conversation that the Patient Protection and Affordable Care Act includes two stipulations for personalized health planning. Under the new law, Medicare will pay for one personalized health planning visit annually. Additionally, personalized health planning was a key initiative for demonstration projects through community health centers. Interestingly, despite the IHS’ focus on personalized approaches to care, this individual knew nothing about personalized health planning within the law. So I decided to see what the federal government actually says about personalized health care. Here’s what I found.

The government has great hopes for personalized approaches to care. In fact, “personalized health care will improve the safety, quality, and effectiveness of healthcare for every patient in the US.” The government also has a very limited definition of personalized health care, which is “using ‘genomics’, or the identification of genes and how they relate to drug treatment” as the means to “enable medicine to be tailored to each person’s needs.” But how could this be? What about Sec. 4206 of PL 111-148, “Demonstration Project Concerning Individualized Wellness Plans.” Or Sec. 4103, “Medicare Coverage of Annual Wellness Visit Providing a Personalized Prevention Plan?”

The omission may in part be due to the fact that personalized health planning hasn’t caught on as a concept yet, despite its arguable potential to change the way health care is delivered – and perhaps more importantly, to improve health outcomes, as we’ve seen with coronary heart disease and type 2 diabetes here at Duke.  Instead, many people are wide eyed by the concept of fancy tests and SNPs and the prospect that if we decode a patient’s genetics we will have found the silver bullet and not only cure patients of disease, but prevent disease altogether.

Except we won’t.  At least not in the foreseeable future for the health problems that are currently costing us the most money.  Because science tells us that our genes are only one part of the story. Our environment is another – in many cases more important – contributor to our health. In fact, our environment can actually change the way in which our genes are expressed. We’ve see this phenomenon in nature. We’ve seen it in people.  And in both cases, we’ve found that there’s no way to predict exactly how the environment will change the phenotype.

But there is something we can do successfully for patients at risk for chronic disease. We can track those environmental factors known to affect gene expression – like nutrition and stress and environmental exposures to name a few. It’s called personalized health planning, a strategic approach to care that identifies all a patient’s risk factors for disease (genetic, environmental, behavioral, psychosocial) and very importantly tracks those factors that the patient  can do something about – either themselves or with the help of modern medicine.  Three quarters of national health care expenditures are for chronic diseases due to health behaviors, namely smoking and obesity. If we really want to improve the health of the nation while reducing health care costs, expensive genetic tests cannot be synonymous with, or the primary road to, personalized health care. We can run all the tests available in modern medicine. (Some might argue we already do.) But if we don’t help patients to plan for their good health in the context of their known risks from all those tests, we’ve failed them.    

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?