No Good Fixing Just One Tire
A good quote from the recent NRHA annual conference in Atlanta: "We need to fix both tires to get anywhere - personal health care and community health." (attributed to Bill Roper, Center for Disease Control, 1992)
"The Debate That Wasn't"
The following is taken from the lead article, "The Debate That Wasn't" in the Spring 1995 issue of Health Affairs by well known public opinion researcher Daniel Yankelovich:
"The nation's leadership and public are carrying out a bizarre dialogue of the deaf. The nation's elites have little trouble conversing with one another, but when it comes to engaging the public, there is an astonishing lack of dialogue. Public relations, punditry, advertising, speechifying, spin doctoring, and so-called public education - these mechanisms of top-down communication abound. The absence of plain give-and-take between leaders and public is striking."
"In the 1960s the level of confidence in the medical profession (including hospitals) was almost twice that of all other institutions (73 percent versus 40 percent). By 1993 American's confidence in all institutions had dropped, but medicine's fall was far more precipitous: to an astonishingly low 22 percent, falling for the first time below other institutions."
"... Given this perception, it is not surprising that most Americans resist making sacrifices to correct a problem they think the doctors and lawyers have caused. The vast majority rejects the idea that the explosion of health costs must lead sooner or later to 'limits on what is available to the average person," 77 percent insist the cure is to 'cut the waste, high profits, and fraud."
"Since the public blames the system, not itself, it understandably rejects calls for sacrifice and behavior change, on the assumption that if the system is to blame, then the system should take the hit, not the innocent victims and bystanders who constitute the public."
"The Public Agenda (Yankelovich is President) and Kettering Foundations research has led them to conclude that the public has yet to confront three major dilemmas of health care reform :"
"Only Bread, Circus Games Needed"
Uwe Reinhardt, Professor of Political Economy at Princeton, expressed a contrary perspective to that of Daniel Yankelovich in the same issue of Health Affairs, a brief excerpt follows:
"Indeed, Yankelovich's paper leads one to wonder whether the American public is either intellectually or temperamentally inclined ever to engage in the protracted, sincere, public deliberation of complex public policies called for by the optimistic author. If successful health care reform must await the day when the public musters the patience to deliberate carefully on the hard choices before us, then we may have to wait a long time."
"Given the general public's age-old preoccupation with panem et circenses, it will generally go along passively with its leadership, unless that leadership makes evidently egregious mistakes or is evidently divided. ...thus we allow leadership (along with leaders of sundry special interests) to regulate and sometimes deregulate the conduct of the plebes, and thus, perhaps one day, we shall undertake a major reform of our health insurance system. Perhaps."
WI High Priority Areas Identified
The Wisconsin Primary Health Care Association has submitted its preliminary report, State of Wisconsin Primary Health Care Access Data, Resource Analysis and Recommendations to the Division of Health. "The intent of the project, referred to as the state primary care access plan, from a federal perspective, is to identify high priority areas for the purposes of targeting federal resources, such as community health center funding and National Health Service Corps personnel."
A second phase of the analysis and report is expected to be completed shortly. Among other additions, it makes more extensive use of an analysis that examines other groupings of the data beside the traditional county listings. I understand that there are some interesting differences in the results when one considers county-wide aggregates verses primary care markets.
Initial results are shown below. Note that while all of Rock county is shaded, the ranking applies only to an area designated as "Beloit City." A Level One Rank indicates those areas of relative highest priority. Non-shaded counties received a ranking below Two. The rank is based on data related to: percent below 100% poverty, percent over age 65, infant mortality rates and the area's physician population ratio.
Private Sector Pays 29% Tax
Non-HMO payers in the private sector pay on average a tax equivalent to 29% of what they would otherwise pay Wisconsin hospitals in 1994 if the costs had been equally shared ($135/$105). What is scary for so many of us is that while Government talks about significantly reducing the amount they pay for Medicare and Medicaid, but they rarely talk about the large discounts that they have already awarded themselves:
Data Source: Wisconsin Hospital Association, News and Views, 4/28/95
New Technology, It And We Adapt
As we try to understand and prepare for the use of telecommunication in rural health, it is helpful to consider what we know about technological change and its assimilation. One source, Made In America, An Informal History of the English Language in the United States. talks about the process of assimilating a previous set of inter-connected boxed wires and monitors - early network television:
"On July 1, 1941, the New York television station WNBT-TV interrupted its normal viewing to show, without comment, a Bulova watch ticking. For sixty seconds the watch ticked away mysteriously, then the picture faded and normal programming resumed. It wasn't much, but it was the first television commercial."
"Many people got their first glimpse of television at the New York World's Fair in 1939. The New York Times forecast that it'd never be a serious competitor for radio because 'people must sit and keep their eyes glued on a screen, the average American family hasn't the time for it.'"
"It is curious that from its inception, people instinctively grasped that this was a medium built for trivializing, when color transmission was first demonstrated in London in 1928 - yes, 1928 - viewers were treated to the sight of a man repeatedly sticking out his tongue."
Urban Split On Payment Localities
As part of HCFA's reconsideration of the State Medical Society's application for Wisconsin to become a single payment locality, physicians in the seven counties that would have a lower geographic factor were asked whether they supported the move. Those in favor (of returned surveys) were as follows:
Dane County 71%
Kenosha County 50%
Racine County 61%
Waukesha County 39%
Washington County 36%
Ozaukee County 28%
Milwaukee County 16%
Applying the above percentages to all physicians in the noted counties and adding that support to the rest of the state which is assumed to be 100% supportive, two-thirds of the state's physicians support the proposal. HCFA's decision whether or not to proceed is expected shortly.
RWHC Asks For Federal Ruling
Pursuant to the Department of Justice's Expedited Business Review Procedure, the Cooperative has asked for approval to assist smaller, rural hospitals to contract fairly with insurance companies, employers and other groups for the furnishing of hospital health services. This venture will not require exclusivity and at this point does not include physician services. An initial response is expected within 60 days.
Medicare HMO-PPO-POS Challenge
We often note that rural providers are paid less than their urban counterparts but we neglect the larger picture that a combination of lower utilization and lower rural reimbursement rates translate into even lower Medicare Payments on behalf of each Medicare enrollee. This is particularly significant as the trend towards expanding the use of HMO, PPO and POS finance-delivery models may continue or worsen the historical lower Medicare program payments for rural enrollees.
The Feb. 1995 Health Care Financing Review, Medicare and Medicaid Statistical Supplement (page 171) presents the national average program payment per enrollee in 1992 as $3,391. Compared to the national average, payments for services received by rural residents in Wisconsin (at both urban and rural sites) averaged $2,636 (78%) and for services received by urban residents in Wisconsin, $3,033 (89%).
On a separate issue from the rural/urban differential but highly critical to the development of Medicare HMOs is the fact that 9.8% of all Medicare enrollees account for 68.4% of all Medicare payments. The following table (developed from data shown on page 32 of the Medicare and Medicaid Statistical Supplement) hopefully makes crystal clear the perverse incentives for systems to attract or avoid particular Medicare enrollees.