Books by doctors on health reform and beyond

As a freelancer, I’ve been known to grumble about doctors who write. After all, why should they hog the Pulitzers and the pages of The New Yorker when they have perfectly good day jobs? On the other hand, doctors in print often offer us an alternative to the mass-marketed Dr. Oz or the perky, laminated docs on daytime TV’s “The Doctors.”

So put down that Parade magazine. (We’ll admit that  Dr. O has some good advice about sleeping problems.) Instead, check out the always rich “Ideas” section of The Boston Globe, where you’ll find a column by MGH doc Suzanne Koven on doctors who write.

Perhaps so many doctors are writing literature today as an antidote to our increasingly rushed and technological medical practice. There’s less time or incentive to include, in the modern case history, vivid descriptions of a patient’s appearance, details about his occupation and family life, or musings about what might ail him, than there were 100 years ago. When Oliver Sacks showed his friend, W.H. Auden, film clips of the stiff and mute patients about whom he wrote in “Awakenings,’’ he asked the poet “What do you think they lack?’’ “Music,’’ Auden replied. Doctors who write literature supply the grace notes missing from today’s medical records, recapturing the music of the human condition.

Maybe.  The column arrives in anticipation of the release of an anthology “Writer, M.D.: The Best Contemporary Fiction and Nonfiction by Doctors,’’ edited by Leah Kaminsky . And the story includes a list of other works by doctor-writers.

Writing about patients can generate compelling narratives.  Try pitching a story on health reform.  So, we are surprised to see that you need to buy a ticket for the Cambridge reading Jonathan Gruber’s Health Care Reform: What It Is, Why It’s Necessary, and How It Works. Maybe we should learn to draw: it’s a comic book.

 

For a more text-based, deeply informed view of politics and health reform, check out the free discussion by Stuart Altman and David Shactman of  “Power, Politics, and Universal Health Care’’ on Monday  at 7 p.m. at Brookline Booksmith. Altman, a Brandeis professor, has been bouncing back and forth between Waltham and Washington for years. He knows his stuff.

 

 

New fitness and exercise blog on the Globe web site

The Globe has added another health blog — this one on fitness:

Elizabeth Comeau is the senior health & wellness producer at Boston.com. She will be blogging about her personal fitness journey and using a device called a FitBit to track her weekly goals and progress (see below). Follow her journey and share your own. Read more about Elizabeth and this blog.  

Bring on the user-generated content. Pairs up nicely with CommonHealth’s “Why to Exercises Today” series.

We’ve added it as a link, along with another for  WBUR’s Healthcare Savvy:

What is Healthcare Savvy?

We are a community of patients who are starting to shop for health care based on quality and cost.        Have you thought about whether you are getting the best care for the best price?        Share your experiences. Read about ours. Post a tip or a resource. Ask questions! Browse at your leisure. Join anytime by registering.

Harvard video: The Supercommittee Collapse and America’s Healthcare Future

Harvard School of Public Health Panel

Mass. single-payer advocates take on limits of state health reform

Before you write off these folks, note that a recent survey of doctors by the Massachusetts Medical Society found that a growing number of doctors support the idea of a single-payer system. More than 40 percent, up from  34 percent last year. So do a lot of folks at Occupy Boston.

Massachusetts Health Reform in Practice and The Future of National Health Reform

OVERVIEW: While the Massachusetts health reform law of 2006, widely regarded as the model for the new federal health law, reduced the uninsured population in the state, it did so at the cost of rapidly rising underinsurance, increased health care premiums, and a financial crisis among the state’s safety-net hospitals and community health centers. And the financial burden of the reform has fallen disproportionately on lower-middle-class families.

Those are some of the findings in a new, exhaustively documented report on the outcomes of the Massachusetts reform law released by Mass-Care and Massachusetts Physicians for a National Health Program. The report draws on hundreds of sources, including academic studies, government statistics and scientific surveys, in the first compilation of its kind.

EXECUTIVE SUMMARY

The Massachusetts Health Reform Law of 2006 expanded Medicaid coverage for the poor and made available publicly subsidized private health insurance for additional low-income residents of the state. It also mandated that all but the poorest uninsured residents either purchase private health insurance or pay a substantial fine (up to $1,212 in 2011). Smaller fines (up to $295 per employee) were also levied on employers who fail to offer insurance.

Four years after full implementation of the law, Massachusetts has not achieved universal coverage, although one-half to two-thirds of the previously uninsured now have some type of insurance policy. Most of the gains in coverage have come from expansions in publicly subsidized insurance. This largely represented a shift of patients from the state’s former Free Care Pool, which compensated hospitals and community health centers directly for care of the uninsured, to private insurance plans, which is a more costly way to provide care. The reform did not lead to a sustained increase in employer-sponsored coverage, but did slow declining employer coverage. Instead of dropping coverage, employers in Massachusetts have increased cost sharing, shifting costs on to employees, leading to rapidly rising underinsurance after health reform. The use of high-deductible plans more than tripled for residents with private insurance, and good insurance coverage at small businesses all but disappeared over a few short years after reform.

Reform has had a positive impact on access to care in the state, but this impact has affected a modest share of residents, and for some patients has been negative. For example, some low-income patients who previously received completely free care under the state’s prior free care program faced new co-payments and premiums after becoming insured, which impeded their access to care. Reform has not reduced the burden of medical bills and medical bankruptcy on Massachusetts’ families.

The growth of residents with insurance coverage has exacerbated a primary care shortage in Massachusetts by increasing wait times for appointments and decreasing the portion of physicians accepting new patients, creating access problems even for those with coverage. Reform did not reverse growing use of the state’s emergency departments for care, despite expectations that expanding insurance coverage would reroute patients through primary care offices. There is no evidence as of yet that expanding insurance coverage has had an impact on health outcomes or disparities in health outcomes. Reform has also created a financial crisis for safety net providers that specialize in care for low-income communities and the uninsured, by shifting resources away from safety net providers while patient demand for safety net care has actually increased.

The public cost of reform has been high, exceeding $800 million in fiscal 2009 for a state with a total budget of $32.5 billion.  However, federal taxpayers paid for the bulk of the law’s public expenses. The state has made a broad range of cuts to the original law in order to its keep costs down, cutting back coverage for over 30,000 documented immigrants, curtailing some benefits, increasing cost sharing, and increasing the share of enrollees required to pay premiums. Substantial funds from the federal stimulus bill were also used to sustain the reform law, but this was a short-term fix only.

Public payments account for only a portion of the reform law’s costs. A central premise of the law was that the state, employers, and individuals would all have to sacrifice financially to approach the goal of universal coverage. This premise of “shared responsibility” for the costs of the reform was in many ways disingenuous. Although employers, individuals, state and federal government have shared the burden of increased costs roughly equally, this overlooks the fact that governments pass on their spending to taxpayers, and employers pass on their costs to employees.  The actual burden of health reform was regressive, with increased spending after health reform falling disproportionately on lower-middle income residents.

The reform failed to “bend the cost curve” in Massachusetts because it contained no significant cost-control provisions. Health care costs in Massachusetts are higher than in any other state in the nation, and reform has been found to accelerate the rising costs of employer-sponsored health care. There is general agreement that the Massachusetts reform is itself not sustainable without effective cost control.

Massachusetts enjoyed favorable circumstances at the outset of reform, such as previously high levels of spending on health care for the poor, high personal incomes, and relatively low rates of uninsurance. Without controlling costs, national reform will run up against the same difficulties as Massachusetts: growth in public insurance coverage will prove unsustainable and will accompany the rapid erosion of private insurance benefits, while modest gains in access to care will be threatened in the short term by unsustainably high costs that are increasingly shifted on to patients.

While Massachusetts health reform has enjoyed support from a majority of residents in the state, that support has declined since national health reform instigated a broader debate over alternatives to the Massachusetts plan. Moreover, while residents support the Massachusetts reform law over no change at all, they have expressed increasing skepticism that the law is working for vulnerable communities, and more residents report that the law is hurting them than helping them.

We believe that the data in this report should give pause to those concerned with national health care reform. Although not without its successes, the Massachusetts reform has not addressed the fundamental deficiencies in the health care system – treating symptoms rather than causes – and even its modest successes are unsustainable for the state and Massachusetts residents.

Health policy digest takes on reform loopholes and clueless reporters

The latest edition of the roaming digest of health policy blogs;

Health Wonks – the SuperHero Edition!!!

The deficit battle is on and politicians are in full voice – both in Washington and out on the hustings, where GOP candidates are loudly denouncing health reform as unAmerican and a job killer.  Hipsters and greying hippies are occupying Wall Street and Main Street, while Tea Partiers are claiming they hold the title of most outraged.  The one percent is wondering what the 99 percenters are so upset about, while the 99 percenters are after their well-coiffed scalps.

Into the bloody fray, with nary a fear for life or health, reputation or career, plummet our worthies, those denizens of the blog-o-sphere that specialize in separating the non- from the -sense, the BS from the fertilizer, the ill-formed opinion from the logically-based interpretation!

Join us as we follow their heroic deeds, gasp as you read their trenchant and timely missives, awed by their grasp of the incredibly-esoteric and yet critically important.

Occupy Health Care: Boston protesters say Wall Street makes them sick

While health reform may not be at the top of their agenda, some of the Occupy Boston protesters down at Dewey Square had no problem linking the high cost of medical care to their complaints about Wall Street.  Some support Obama’s reforms; others called for a single payer system. But, nearly everyone interviewed had universal health care on his or her list of demands.

Even MIT professor Noam Chomsky said  the health care system is tainted by what he described as a government dominated by private corporations. Speaking on Saturday night, he told the crowd that the  federal budget deficit could be eliminated if the US had a health care system like other countries in the developed world — presumably single payer.

Medicare itself is not the problem, he said.

“It’s a problem because it goes through the privatized, unregulated system,” he said. “It is totally dysfunctional. You can’t talk about this in Washington because of the power of the financial institutions. “

More from the rank and file below.

Occupy Boston and Health Care

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Vermonters on how to improve access to primary care

As far as health delivery and payment goes, there’s much innovation to be found north of here. Craig Jones of the Vermont BluePrint for Health was among the speakers at a recent Alliance for Health Reform panel on primary care in DC.

Here’s a summary of his presentation. You can find more and a full transcript on the AllHealth website. 

Dr. Craig Jones, director of Vermont Blueprint for Health, followed with another example of a state health care reform program that is increasing control of quality and cost by advancing a primary care foundation for the health care system.  Like Minnesota, Vermont is instituting payment system reforms to promote quality and outcome reporting to validate the effects of reform.  Dr. Jones also spoke about Community Health Teams, which are unique to Vermont and include social workers, nutrition specialists, and community health workers.  Vermont expects the services provided by Community Health Teams to strengthen the primary care foundation of their health care system and be very cost-effective by preventing hospitalizations and chronic conditions.  Dr. Jones closed by assuring the audience that the ACA was essential for state-led health care reform.  He listed several sections of guidelines, research and evaluation systems, and innovation grants that will facilitate states making the investments necessary to transform into high-performing, primary care-based systems.

From the program’s web site:

Vermonters learning to live healthier.

The Blueprint works to help Vermonters who have chronic conditions stay as healthy as possible – improving their quality and enjoyment of life and avoiding the need for complex care later when illness is harder to treat. Hundreds of Vermonters have attended Healthier Living workshops sponsored by the Blueprint. These self-help workshops teach individuals to manage their chronic conditions and improve their health.

Communities taking action for health.

Communities all over the state are joining the Blueprint to become healthier places to live, work, learn and play. The Blueprint guides and funds hospital service areas and communities to assess local infrastructure, start coalitions, recruit health care providers, host Fit & Healthy Vermonters events and Healthier Living workshops – encouraging everyone to take charge of their health.

A new medical information system.

Having the right information at the right time is essential for providing the best possible care for patients. The Blueprint is developing a web-based chronic care patient information system that is free to health care providers and requires only Internet access.

Consultant: Consumers feel powerless over health care costs

You need to register to get this report from a Boston research company. This from the press release:

Most Consumers Feel Helpless in Lowering Healthcare Costs 
Chadwick Martin Bailey study finds 67% of consumers believe they have little or no impact when it comes to lowering their healthcare costs

Boston, MA September 16, 2010- A new study of over 1500 consumers looks at how Americans feel about Healthcare Reform and how it will impact them. The key findings show that while most consumers do not fully understand Healthcare Reform, they do anticipate it will have an impact on their lives.  When it comes to lowering their own healthcare costs, however, most consider themselves helpless. The findings have been released in a free Healthcare Reform report available from Chadwick Martin Bailey and South Street Strategy Group.

With much of the coverage of Health Reform focused on increased costs to businesses and subsequently to their employees, the majority (67%) of consumers believe that they have little to no impact on reducing their own healthcare costs.  While consumers feel that they do not have a major impact, 75% of consumers see health insurance companies as responsible for lowering health costs, significantly more than those pointing the finger at government agencies (46%). 

Consumers’ Understanding of Reform and the Impact
The study found while 30% consider themselves knowledgeable about Health Reform, half only consider themselves somewhat knowledgeable and 19% fully admit they don’t know much at all when it comes to Healthcare Reform. Much of this confusion or partial understanding may be due to the perception that the media does not present the issues in an unbiased way (only 18% said that it is presented without bias).

Even with the confusion surrounding Health Reform, most people believe that reform will have an impact on their lives with 35% expecting a major impact on them or their family, 39% expecting a small impact, and 18% unsure of the impact they should expect.  In fact, only 9% of those included in our research thought it would have no impact on them or their family.

About This Research
An executive summary report with additional findings from this study is available as a free download from Chadwick Martin Bailey and South Street Strategy Group. Data was collected from 1,504 adults (aged 18 and over) via a nationally representative online survey questionnaire within the United States by Chadwick Martin Bailey the week of August 23rd. 

Opinions: One on Medicare, one on investor-owned hospitals in Mass

Three items of note in the morning papers:

• A staff editorial in this morning’s NY Times charges says the Republicans are dangerously clueless about how to preserve Medicare.

Republicans claim to be deeply worried about the deficit — their favorite political target, followed closely by President Obama’s relentlessly demonized health care reform. So why are they so determined to overturn one of the central cost-control mechanisms of the new reform law?

Republicans in both the Senate and the House have introduced bills that would eliminate the new Independent Payment Advisory Board, which is supposed to come up with ways to rein in excessive Medicare spending — and stiffen Congress’s spine.

More fodder to demonize now CMS head Donald Berwick, the NYT says: Republicans are also eagerly, and shamefully, pillorying Dr. Donald Berwick, the new head of the Centers for Medicare and Medicaid Services. There are few figures who command greater respect for uniting health professionals and institutions to improve the quality of medical care while reducing costs. That is not stopping these critics from implying — baselessly — that he will introduce socialized medicine and death panels in this country.

  The truth is that Dr. Berwick has praised the socialized British health care system, especially for  its emphasis on primary care. This country certainly needs to do more to develop its primary care system. And he has, rightly, called for an open discussion of the health care rationing that is already widespread in our system. When insurers decline to cover procedures, or high prices screen out low-income people, that is rationing.

Dr. Berwick has endorsed the use of “comparative effectiveness” research to determine which treatments work best. He would use such research to judge whether a new drug or procedure is worth the cost of coverage, a step the reform law shies away from. He does not have the power to change that law. But the issue will have to be addressed at some point if there is to be any hope of restraining medical spending.

Democrats have to counter the Republicans’ demagoguery with facts. Americans need to understand that if Senator (John) Cornyn (of Texas) and others get their way, runaway health care costs will only get worse.

• And an editorial in the Globe says the state needs to scrutinize the sale of the Caritas hospitals to a group of investors to make sure it’s a good deal for everyone:

 THERE ARE good reasons to support the proposed sale of Boston-based Caritas Christi Health Care to New York private equity firm Cerberus Capital Management. In addition to protecting over 12,000 in-state jobs, Cerberus has promised to pay off the non-profit hospital chain’s debt, permanently secure employees’ pensions, earmark $100 million for hospital renovations and expansions, create up to 4,300 new jobs, and increase the system’s footprint by 117,000 square feet. With promises like that, it’s no wonder elected officials including Senators John Kerry and Scott Brown are urging Attorney General Martha Coakley to approve the deal. But before Coakley signs off, she must obtain from Cerberus a clearer sense of how it plans to achieve these goals, and a new commitment of a longer time period before the firm can back out by selling the hospitals.

•  WIth that — and Partners — in mind, check out this story from The Washington Post on the pros and cons of large health care systems, including one in with Roanoke, Virginia. 

ROANOKE — Railroads put this city on the map, but the king of the domain is now health care — or rather, the Carilion Clinic.

Carilion owns the two hospitals in town and six others in the region, employs 550 doctors and has set off a bitter local debate: Is its dominance a new model for health care or a blatant attempt to corner the market?

Carilion says it represents an ideal envisioned by the nation’s new health-care law: a network that increases efficiency by bringing more doctors and hospitals onto one team, integrating care from the doctor’s office to the operating room. The name for such networks, which the new law strongly promotes with pilot programs, is accountable care organizations, or ACOs — providers joining together to be “accountable” for the total care of patients, with incentives from insurers to keep people healthy and costs down.

“We need to fundamentally get off a transaction system where you’re paid for what you do to patients to being paid to care for them,” says Carilion chief executive Edward Murphy.

But skeptics apply a more old-fashioned term to networks like Carilion: monopolies, which they say will make health care even more expensive.

“The only way to decrease costs that truly works is increasing competition, but for some reason in health care, we’re supposed to believe that competition drives up costs,” said ophthalmologist Frank Cotter.

The gap between those two views is at the heart of whether the law succeeds in controlling costs. Meanwhile, the question is creating a schism in the Roanoke Valley, a region of more than 250,000 people that depends on Carilion’s 12,300 jobs but also worries about health-care costs out of proportion to the area’s cost of living.

BHN Reports: Gawande on reform — “All health care is local.”

The notion that “all health care is local” may sound odd coming from someone who has been deeply involved in health reform at the national level.

But Boston surgeon and New Yorker writer Atul Gawande made the case for locally driven reform this morning at a health care quality colloquium at Harvard.  Communities, he said, need to find ways to create working systems out of the complex, fragmented elements of medicine.  

 “Our deepest struggle in medicine in this wake of health reform –we can imagine that it is money or the rules and regulations that exist or yet to come down,” he said. “But if you watch the day to day experience of what it is to take care of people, you realize that the deepest root of our struggle is the complexity of what we are trying to pull off. “

Health care workers are surrounded by tests of their ability to handle the complexity that comes in the form of 13,600 diagnoses, 6,000 drugs and 4,000 procedures.  And, he said, they are trying to do it within a system that was built for a world that had fewer, simpler solutions.

The system evolved in another era when medicine was “small, fragmented and artisanal in nature,” he said. “But the volume and complexity of our discoveries has now reached  a point where it has exceeded our ability as individual artisans to deliver optimal care reliably, safely and without the waste of resources.”

He used the advent of penicillin to make his point. Penicillin seemed like a miracle, he said. It could cure diseases that seemed incurable.

“It was so simple,” he said. “It was just an injection. And it made us imagine that this would be the future of medicine. We were fooled. It made us think that discovery was the hard part and execution would be easy.”

He compared the current execution to a poorly built machine with great parts. The fee for service system has “made us almost giddy in our use of high tech services” at the expense of low profit services like geriatrics, mental health and preventive health.

But, Gawande said that he sees solutions in his reporting on cost and practice pattern variations. The highest costs systems don’t always provide the best care, he said.

“That means there is hope,” he said. “It means that there is something to be learned from what we are doing to make quality and safety better in ways that actually reduce costs.”

 Gwande spoke at the National Quality Colloquium,  which is being sponsored by the Jefferson School of Population Health at  Thomas Jefferson University in Phildelphia.