1. Decision Makers Differ on How to Mend Broken Health System, Washington Post -- 6/9/09
2. House Democrats Considering Tax on Employer Health Care, Baltimore Sun -- 6/9/09
3. Health Care Spending Disparities Stir a Fight, New York Times -- 6/9/09
4. Health Bill Highlighted as Vehicle for Long-Term Care, Boston Globe -- 6/9/09
1. Decision Makers Differ on How to Mend Broken Health System
Washington Post --- 6/9/09
By Ceci Connolley
Nowhere else in the world is so much money spent with such poor results. On that point there is rare unanimity among Washington decision makers: The U.S. health system needs a major overhaul.
For more than a decade, researchers have documented the inequities, shortcomings, waste and even dangers in the hodgepodge of uncoordinated medical services that consume nearly one-fifth of the nation's economy. Exorbitant medical bills thrust too many families into bankruptcy, hinder the global competitiveness of U.S. companies and threaten the government's long-term solvency.
But the consensus breaks down on the question of how best to create a coordinated, high-performing, evidence-based system that provides the right care at the right time to the right people.
During eight years in office, President George W. Bush took an incremental approach, adding prescription drug benefits to the Medicare program for seniors and the disabled and expanding the number of community clinics nationwide. President Obama, like the last Democrat to occupy the White House, contends that was insufficient and is pushing for an ambitious reworking of the entire $2.3 trillion system.
Framed by President Bill Clinton 16 years ago as a moral imperative to deliver health care to all, this summer's historic debate comes against a more urgent backdrop. As the national unemployment rate nears 10 percent and giants such as General Motors crumble, the expensive, inefficient health system has deepened the country's economic woes.
By virtually every measure, the situation has worsened.
Today, about 46 million Americans have no health insurance, so they go without or wait in emergency rooms for expensive, belated care. Everyone else helps pay for that Band-Aid fix in the form of higher taxes and an extra $1,000 a year in insurance premiums.
Pockets of medical excellence dot the landscape, but at least 100,000 people die each year from infections they acquired in the hospital, while 1.5 million are harmed by medication errors. Of 37 industrialized nations, the United States ranks 29th in infant mortality and among the world's worst on measures such as obesity, heart disease and preventable deaths.
Bright young physicians trained at prestigious and expensive universities enter a profession built on perverse financial rewards. They, like assembly-line workers of the past, are paid on a piecemeal basis, earning more money not by doing better but simply by doing more.
Yet more care rarely translates into better health. Extensive research by Dartmouth College has found the exact opposite: Health outcomes are often best in communities that spend less compared with cities such as Boston and Miami where the medical arms race of specialists and high-tech gadgets often leads to greater risks and injuries.
The Institute of Medicine estimates that one-third of all medical care is pure waste, such as duplicate X-rays, repeat lab tests and procedures to fix mistakes.
"Most Americans don't understand how bad health care in the United States is," said Michael F. Cannon, head of health policy at the libertarian Cato Institute. "We need big reforms."
Across the ideological spectrum, the diagnosis is remarkably consistent. "Sure, some people here have the best health care in the world, but the average American is paying too much and not getting enough in return," said John D. Podesta, who led Obama's transition team and heads the
Center for American Progress, a think tank.
Said Sen. Judd Gregg <http://projects.washingtonpost.com/congress/members/g000445/%5Ct>
(links to outside webpage) (R-N.H.): "What's tragic is that so much of this spending is on duplicative or unnecessary care that doesn't improve health outcomes."
Simply put, the goal of health reform is to finally get our money's worth, say industry leaders, policymakers, consumers and business executives.
They envision a health-care system that guarantees a basic level of care for everyone, shifts the emphasis to wellness and prevention, minimizes errors, and reduces unnecessary and unproved treatment. Such a system would coordinate care, track patients and doctor performance electronically, and reward good results. The high-value system of the future would be organized "so that people get the care they need and need the care they get," said Elizabeth A. McGlynn, associate director of the health research division of Rand Corp.
Nowadays, that is often not the case.
On average, Americans receive the recommended, proven care 55 percent of the time, according to Rand studies. Sometimes, doctors or nurses overlook a basic but critical step, such as prescribing a beta blocker medication to patients after a heart attack, a therapy shown to significantly reduce the risk of a fatal attack. At other times, patients undergo procedures when there is no evidence that they are any better than a simpler, cheaper alternative.
Ten years ago, in its landmark report "To Err is Human," the Institute of Medicine estimated that 44,000 to 98,000 people die each year from medical mistakes, highlighting the need for improvement. Since then, the tally has risen, said Janet Corrigan, president of the National Quality Forum, a nonprofit membership organization that promotes quality standards.
"We now know estimates of those who die from hospital-acquired infections is upwards of 100,000," she said. "Many of those, if not most, are avoidable and preventable."
Sen. Robert C. Byrd's <http://projects.washingtonpost.com/congress/members/b001210/%5Ct> (links to outside webpage) recent hospital stay, for example, has been extended because the West
Virginia Democrat developed a staph infection.
"Everyone agrees that hospitals are hazardous to your health," said Mitchell Seltzer, a consultant who advises large medical institutions. "For every day a patient is in a bed, they are subjected to a higher probability of medical errors, hospital-acquired infections, inappropriate tests that do not have a direct bearing on the medical condition being treated."
Part of the problem is cultural, said Rand's McGlynn.
"People tend to demand the new thing even if there's not much evidence it will make a difference in the length or quality of life," she said.
Few patients or physicians have any idea who delivers good, or bad, care, because few organizations track results. Consumers have more information to evaluate their cars than they do their surgeons.
"It's like a doctor flying the plane without instruments," said James N. Weinstein, a spine surgeon who directs the Dartmouth Institute for Health Policy and Clinical Practice.
Obama set aside $19 billion in his economic stimulus package to promote the use of digital records, on the belief that they reduce duplication, produce more consistent care and cut down on errors.
Because the fee-for-service payment system rewards quantity over quality, there is little incentive -- and there are even disincentives -- for doctors, nurses and hospitals to improve, Corrigan said.
"Is it a surprise we have lots of extra imaging tests and lab tests?" she said. "Not at all."
The consequences are especially glaring in regions with larger numbers of specialists and pricey technology, the Dartmouth data show.
Take the case of Miami vs. La Crosse, Wis. In 2006, using inflation-adjusted figures, Medicare spent $5,812 on the average beneficiary in La Crosse, compared with $16,351 in Miami. Yet an examination of health status in both places, adjusted for age, finds no evidence that the extra spending resulted in better care, Weinstein said.
"That's the enigma here," he said. "Less is more, and more isn't better."
Physician behavior and spending patterns in Medicare have been good indicators of broader trends across the nation, Dartmouth has found.
Even the best physicians cannot stay current with all of the drugs, tests and treatments available today -- another reason to digitize modern medicine, Corrigan said.
Many fear that the push to contain costs will result in rationing.
In today's system, "we don't ration care, we ration people," said Donald M. Berwick, president of the independent Massachusetts-based Institute for Healthcare Improvement. "We know that if you are black and poor or a woman, there are all sorts of effective interventions you are not going
to get."
Though the transition would be painful and the politics treacherous, Berwick said it is possible to spend less on medical care and have a healthier nation.
"If we could just become La Crosse, think of how much better off we would be," he said.
2. House Democrats Considering Tax on Employer Health Benefits
Baltimore Sun --- 6/9/09
By David Espo (AP)
Despite a less-than-rousing reaction from the Obama administration, House Democrats are considering a new tax on employer-provided health benefits to help pay for expanding coverage to the uninsured.
Several officials also said an outline of emerging legislation envisions a requirement for all individuals to purchase affordable coverage, with an unspecified penalty for those who refuse and a waiver for those who cannot cover the cost.
"There's no sense having a mandate unless you have a contribution," Rep. Charles Rangel, D-N.Y., chairman of the House Ways and Means Committee, said Monday. He referred to the suggestion as "play or pay."
Rangel and other senior Democrats arranged to bring members of the party's rank and file up to date at a midday session Tuesday on the effort to draft health care legislation at the top of President Barack Obama's agenda.
No details were available on the possible tax on health benefits, and several officials stressed that no final decisions would be made for several days.
The idea has been gaining currency in recent weeks as Congress intensifies its search for more than $1 trillion to help pay for a health care overhaul.
Sen. Max Baucus, D-Mont., first floated the idea several weeks ago, and emerged from a White House meeting last week saying Obama was open to it.
Obama's top aides did not disagree, even though the president attacked the idea lustily last year when campaign rival John McCain proposed it. Instead, White House officials say Obama prefers his own suggestions: cuts in projected Medicare spending and tax increases on the wealthy that thus far have gained little favor among Democrats in Congress.
Several officials said the House legislation will include a government-run insurance option as well as plans offered by private companies. The government option draws near-unanimous opposition from Republicans and provokes concerns among many Democrats as well, although Obama has spoken out in favor of it.
The officials spoke on condition of anonymity, saying they did not want to pre-empt the presentation to rank-and-file Democrats on Tuesday.
Under the House Democratic plan, individuals and small businesses would be able to purchase coverage from a "health exchange" and the government would require all plans to contain a minimum benefit, these officials added. No applicant could be rejected for pre-existing conditions, nor could one be charged a higher premium, they said.
House Democrats also are considering a wide-ranging change for Medicaid that would provide a uniform benefit across all 50 states and increase payments to providers, according to several officials. Medicaid is a joint state-federal program of health coverage for the poor.
The disclosures came as the pace of activity quickened in both the House and Senate on health insurance legislation. Obama scheduled a meeting Tuesday at the White House with several Democrats.
Party leaders hope to pass legislation in both houses by early August and complete work on a compromise measure in the fall for Obama's signature.
The president has stepped up his own involvement in the issue in recent days, and there has been a flurry of negotiations involving outside interest groups who have pledged to take steps to achieve savings within the private insurance market.
Alongside those efforts, financing Obama's plan to spread coverage more widely carries a price tag estimated at more than $1 trillion over a decade. House Democrats are considering cutting projected Medicare payments to home health care, pharmaceutical companies, insurance companies, hospitals and others to cover costs, but not on the scale that the president proposed last winter.
The option for taxing insurance benefits is also under consideration as part of legislation taking shape across the Capitol in the Senate Finance Committee.
Numerous options are possible, many of which involve either a tax levied according to the value of an individual's employer-provided health plan or on the benefits received by upper-income taxpayers.
The issue poses multiple potential problems for Obama, who has pledged not to raise taxes on individuals making less than $250,000 and also ran commercials criticizing McCain's call for a tax on health benefits in last fall's campaign.
In recent weeks, the president and his aides have sought to straddle the issue, neither accepting it nor ruling it out.
3. Health Care Spending Disparities Stir a Fight
New York Times --- 6/9/09
By Robert Pear
President Obama <http://topics.nytimes.com/top/reference/timestopics/people/o/barack_obama
/index.html?inline=nyt-per\oMorearticlesaboutBarackObama> (links to outside webpage) recently summoned aides to the Oval Office to discuss a magazine article investigating why the border town of McAllen, Tex., was the country’s most expensive place for health care. The article became required reading in the White House, with Mr. Obama even citing it at a meeting last week with two dozen Democratic senators.
“He came into the meeting with that article having affected his thinking dramatically,” said Senator Ron Wyden <http://topics.nytimes.com/top/reference/timestopics/people/w/ron_wyden/
index.html?inline=nyt-per%5CoMorearticlesaboutRonWyden> (links to outside webpage) Democrat of
Oregon. “He, in effect, took that article and put it in front of a big group of senators and said, ‘This is what we’ve got to fix.’ ”
As part of the larger effort to overhaul health care, lawmakers are trying to address the problem that intrigues Mr. Obama so much — the huge geographic variations in Medicare
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicare/index.
html?inline=nyt-classifier%5CoRecentandarchivalhealthnewsaboutMedicare> (links to outside webpage) spending per beneficiary. Two decades of research suggests that the higher spending does not produce better results for patients but may be evidence of inefficiency.
Members of Congress are seriously considering proposals to rein in the growth of health spending by taking tens of billions of dollars of Medicare money away from doctors and hospitals in high-cost areas and using it to help cover the uninsured or treat patients in lower-cost regions.
Those proposals have alarmed lawmakers from higher-cost states like Florida, Massachusetts, New Jersey and New York. But they have won tentative support among some lawmakers from Iowa, Minnesota, Montana, North Dakota, Oregon and Washington, who say their states have long been shortchanged by Medicare.
Nationally, according to the Dartmouth Atlas of Health Care, Medicare spent an average of $8,304 per beneficiary in 2006. Among states, New York was tops, at $9,564, and Hawaii was lowest, at $5,311.
Researchers at Dartmouth Medical School have also found wide variations within states and among cities. Medicare spent $16,351 per beneficiary in Miami in 2006, almost twice the average of $8,331 in San Francisco, they said.
The Senate Finance Committee recently suggested that one way to pay for health care overhaul would be to reduce geographic variations by cutting or capping Medicare payments in “areas where per-beneficiary spending is above a certain threshold, compared with the national average.”
Another proposal would spare health care providers in low-spending, efficient areas from across-the-board cuts in Medicare payments.
The committee chairman, Senator Max Baucus <http://topics.nytimes.com/top/reference/
timestopics/people/b/max_baucus/index.html?inline=nyt-per%5CoMorearticlesabout
MaxBaucus> (links to outside webpage) Democrat of Montana, and the panel’s senior Republican, Senator Charles E. Grassley <http://topics.nytimes.com/top/reference/timestopics/
people/g/charles_e_grassley/index.html?inline=nyt-per5CoMorearticlesabout
CharlesE.Grassley> (links to outside webpage) of Iowa, are from lower-spending states.
But the proposals are not just pork-barrel politics. They are based on the research by Dartmouth experts who have documented wide geographic variations in health spending. The research has become phenomenally influential on Capitol Hill since it was popularized by Peter R. Orszag
<http://topics.nytimes.com/top/reference/timestopics/people/o/peter_orszag/index.html?
inline=nyt-per%5CoMorearticlesaboutPeterOrszag> (links to outside webpage) as director of the Congressional Budget Office <http://topics.nytimes.com/top/reference/timestopics/organizations
/c/congressional_budget_office/index.html?inline=nyt-org%5CoMorearticlesaboutCongressional
BudgetOffice,U.S.> (links to outside webpage) and then as President Obama’s budget director.
Aides said Mr. Obama had been intrigued by regional variations in health spending since before his inauguration. The topic came up at a meeting with Mr. Orszag in Chicago late last year.
The magazine article, by Dr. Atul Gawande in the June 1 issue of The New Yorker <http://topics.
nytimes.com/top/reference/timestopics/organizations/n/the_new_yorker/index.html?inline=nyt-org%5CoMorearticlesaboutTheNewYorker> (links to outside webpage) said a major cause of the high costs in McAllen was “overuse of medical care.”
Dr. Elliott S. Fisher, one of the Dartmouth researchers, diagnosed the problem this way: “Medicare beneficiaries in higher spending regions are hospitalized more frequently, are referred to specialists more often and have a much smaller proportion of their visits to primary care
physicians.”
In his blog last month, Mr. Orszag wrote, “The higher-cost areas and hospitals don’t generate better outcomes than the lower-cost ones.”
But other researchers and politicians are not so sure. They say it would be a mistake to cut or cap Medicare payments without knowing why spending in some places far exceeds the national average.
“There is too much uncertainty about the Dartmouth study to use it as a basis for public policy,” said Senator John Kerry <http://topics.nytimes.com/top/reference/timestopics/people/
k/john_kerry/index.html?inline=nyt-per%5CoMorearticlesaboutJohnKerry> (links to outside webpage) Democrat of Massachusetts. “Researchers can’t explain why some areas of the country spend more on health care than others. There are many reasons spending could vary: higher costs of living, sicker people or more teaching hospitals.”
“States like Massachusetts are concentrated centers of medical innovation where cutting-edge treatments are tested and some of the nation’s finest doctors are trained,” Mr. Kerry added. “This work might cost a little more, but it benefits the entire country.”
Madeline H. Otto, an aide to Senator Bill Nelson, Democrat of Florida, said he was “adamantly opposed” to the proposed cuts in higher-spending areas because the cuts did not distinguish between necessary and unnecessary care.
Mr. Orszag says health spending could be reduced by as much as 30 percent, or $700 billion a year, without compromising the quality of care, if more doctors and hospitals practiced like those in low-cost areas. The supply of hospitals, medical specialists and high-tech equipment “appears to generate its own demand,” Mr. Orszag has said.
A Democrat from a low-spending state said critics were trying to “blow holes in the Dartmouth analysis.”
Dr. Michael L. Langberg, senior vice president of Cedars-Sinai Medical Center in Los Angeles, is among the critics.
“The statement that Medicare costs can be cut by 30 percent has been repeated so many times that it has come to be viewed as a proven fact by some,” Dr. Langberg said in a recent letter to the Senate Finance Committee. “It is not a fact. It is a gross oversimplification of an
untested theory.”
Dr. Langberg endorsed the goal of covering the uninsured, but said, “We do not believe that rushing to make large cuts in Medicare payments tohospitals is the right way to fund that coverage.” The Dartmouth team has cited Cedars-Sinai as having very high Medicare spending per beneficiary.
Research by Dr. Robert A. Berenson and Jack Hadley of the Urban Institute suggests that much of the geographic variation in health spending can be explained by differences in “individual characteristics, especially patients’ underlying health status and a range of socio-economic factors, including income.”
“Some patients may benefit from higher spending,” said Mr. Hadley, wh is also a professor at George Mason University in Virginia. “They could be adversely affected if they live in geographic areas where payments are cut.”
Dr. Berenson, who was a Medicare official in the Clinton administration, said, “There remains too much uncertainty about the Dartmouth findings to ground public policy on them.”
4. Health Bill Highlighted as Vehicle for Long-Term Care
Boston Globe --- 6/9/09
By Lisa Wandness
It was the room where both John and Robert Kennedy announced they planned to run for president. The room where the Senate held hearings on Watergate and the Titanic disaster.
The Caucus Room of the Russell Senate Office Building, with its carved marble walls and heavy chandeliers, is where historic things happen, an aide to Senator Edward M. Kennedy explained to some 250 people. That, she said, is why his health committee decided to host a briefing there
yesterday on how its health-reform bill could transform life for people with disabilities and create a new national long-term care insurance plan.
But the 77-year-old Kennedy, who is battling brain cancer, did not attend the briefing. He wasn't on Capitol Hill last week, either, when Democrats on his committee began preparing to unveil their draft healthcare legislation. Senator Chris Dodd, a Connecticut Democrat and Kennedy's top deputy, has been filling in.
Kennedy spokesman Anthony Coley said Kennedy has been working on the healthcare bill while receiving his cancer treatments, but he did not expect him back in Washington this week.
"As Senator Kennedy has said many times, guaranteeing that all Americans have access to affordable and quality healthcare is the cause of his life," Coley said in an e-mail, noting that Kennedy had "a very productive meeting" over the weekend with Dodd.
"He's been a leader on this issue for 40 years, and he continues to lead," Coley wrote. "That doesn't depend on location."
Last week, Dodd had choked up when he was asked how Kennedy was doing.
"I'm getting indications every day that the senator will get back here as quickly as he can," Dodd said last Wednesday. "He's fighting hard. . . . He's doing OK. Look, this is tough."
Senator Orrin Hatch, a Utah Republican who has sometimes worked closely with Kennedy over the years but has expressed disappointment about the extent of government spending and regulation in Kennedy's draft healthcare bill, said yesterday he has not spoken directly with Kennedy about his concerns.
"If he wants to chat with me, I'll chat with him anytime, but I want to see him get through this as much as he can," he said.
Still, committee Democrats yesterday highlighted two more potential components of the healthcare bill.
Senator Tom Harkin said he is going to push to wrap into the healthcare package a bill known as the Community Choice Act, which would let people who qualify for long-term care services - either medical or personal assistance - decide whether to receive them at home or in an institutional setting.
Harkin said the legislation would cost billions, but in a healthcare bill that will cost $1 trillion to $1.5 trillion over a decade, "I'm here to tell you that $2 billion, $3 billion, $4 billion is not much to
ask."
The committee hopes to include a new national long-term insurance program that would provide basic help for people as they age or if they become disabled. Under current law, people who want long-term home or community-based care find it difficult to get into the popular Medicaid "waiver" programs offering home health services. Many elders who need assistance wind up spending their savings in order to be poor enough to qualify for Medicaid, so they can enter a nursing home, when they might just need regular help around the house and regular home nurse visits.
All working Americans would automatically be enrolled in the plan unless they choose to opt out. Students and poor people would pay only $5 a month, others would pay not more than an average of $65 a month. After being enrolled for five years, members could receive limited home
services once they need them.
Republicans have expressed distaste at the cost of the Democratic proposals being floated so far - particularly those from Kennedy's committee. Yesterday a Republican aide who was not authorized to speak for the record said the long-term care proposals could be very expensive, though the Congressional Budget Office has not finished reviewing the proposals yet.
"If they are aiming very high and willing to negotiate, that's our hope," the GOP aide said. "If that's not the case, and this is just a hard-and-fast marker, take it or leave it, there's going to be a real
problem from our side."
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