Monthly Commentary from the Executive Director - January 1st, 1997

Farewell Tour Of A Class Act

Republican Steve Gunderson did something this month that many retiring congressmen probably wouldn't consider, let alone do; he took the time to visit with and say good bye to his district. Ron Kind, his Democratic successor, joined in many of these visits to emphasize the importance of seeking bipartisan solutions to problems faced by the district. At a reception sponsored by the Wisconsin Office of Rural Health and with strong representation from the western district of the hospital association, Steve distributed his office's last congressional white paper on rural health: Rural Health--The Key to Future Stability; a number of his key parting observations are as follows:

"Federal rural health policy has entered a period of dynamic change. In the current balanced budget era, gone are the days of merely propping up under utilized rural hospitals with government subsidies. Future policy changes must ensure that rural hospitals can downsize without losing eligibility for Medicare reimbursement, strengthen incentives for provider networks, including telemedicine, and bolster incentives to keep physicians and other providers in rural areas."

"The future of rural health is dependent largely on redefining Medicare reimbursement to ensure that rural residents have continued access to care... The opportunity to reform federal rural health policy will present itself in the 105th Congress. The key is how well providers from diverse rural areas are able to present a unified front to the key congressional committees."

"Attaining a satisfying solution is challenging because it requires balancing rural interests throughout the nation--which themselves differ--with competing national health priorities. The United States is a leader in medical innovation, but innovation without access is meaningless, whether you are a resident of a small rural town or an inner city neighborhood."

According to SmithKline Beecham's department of Information Resources News, November, 1996:

"Throughout history, the turn of the century, and especially the millennium, has been a popular focal point for profits of doom. Crop failures, pestilence, Armageddon, even the total destruction of the planet--all these predictions have been made and, by and large, laughed off." However ...

"Dealing with Year 2000 date change issue is the biggest challenge Information Resources has ever faced. The problem we face in the second half of the 1990s has its origins in the early days of commercial computing, when processor speed, I/O capacity and disk space were precious commodities. In those days, machine efficiency was the key and, as a result, the use of two digits to indicate the year was considered prudent."

"However, those pioneering programmers and system analysts had no idea that the approach they adopted as a matter of necessity would still be in place decades later; they did not foresee the consequences of adopting conventions that assumed every year must begin with "19". Today the results is all too clear: systems that are unable to 'comprehend' dates beyond 31 December 1999. Left unchecked, most major computer applications are likely to crash or produce erroneous results. Many of these systems will be business critical."

"Riverboat Gambling With Government"

The above named article was in The New York Times Magazine, 12/1/96 by Richard Darman. He was President Bush's director of the office of Management and Budget from 1989 to 1993. A summary follows:

"As a society, we have been guilty of what can fairly be termed policy corruption. In pursuit of bold visions, we have launched one risky scheme after another without anything like responsible evidence. In his 1969 book, Maximum Feasible Misunderstandings, Daniel Patrick Moynihan said of the Great Society's Community Action Program, 'The Government did not know what it was doing.' A major transfer of power was legislated. Yet few officials knew how it would work or what to expect. They bet the system on a hunch and the bet did not pay. Similarly, in 1981, the Senate Republican leaders, Howard Baker, described the bold Reagan tax cut as a 'riverboat gamble.' Fiscal balance was sacrificed to a half-informed hope."

"Combining the Moynihan and Baker characterizations, one gets an image of policy making that amounts to ignorant gambling. Although highly unflattering, it must seem painfully familiar to anyone with experience in the development of bold Federal policy initiatives. When grand domestic visions are in the making, rolling the dice is the norm."

"What, then, might be done by a President interested in boldness but mindful of our ignorance? He could advance a plan to end the era of policy corruption. Instead of trivial tokens or new Federal programs launched at full scale, he could initiate a set of bold research trials. They can focus on alternative major policy initiatives."

"With the governors, the President could take advantage of decentralization and the natural variation offered by 'states as laboratories.' Together, they could foster a constructive excitement about innovation--while setting aside the funds to evaluate trials systematically and honestly. To assure objectivity and accommodate anti-Federal spirit, they might establish a nonpartisan entity-under joint control--to contract with private firms and nonprofit organizations for the necessary evaluation and research. Though large-scale problems would not be solved immediately, pilot tests would proliferate, and through evaluation of them, learning would grow."

A Chilling Post-Mortem Of Health Reform

As we are on the eve of the next great American political fight over health care, this time Medicare, it is a good time to reflect on what we learned with the failed Clinton initiative of 1993-94. Recently published, The System, The American Way of Politics at the Breaking Point by Haynes Johnson and David Broder tells that story as only two top Washington journalists can do it:

"The health care reform fight shows that our mental picture of the lobbying process is badly out-of-date. As Walter Lippmann observed, we are captives of the pictures in our heads. We think the world we know is the world that exists, and the world that will be.. When it comes to the power of special-interest groups, the health care reform struggle requires us to redraw the picture in our heads and see the world as it really is."

"What happened was nothing less than a war, a war without quarter, waged until one side had thoroughly defeated the other. Bill McInturff, one of those who played a key strategic role on the winning side, likened what happened to World War II. McInturff meant that Clinton forces were occupying fixed, static positions like the French in 1940 inside their Maginot Line; there, they were easily bypassed and cut off by Hitler's panzers, leading to France's quick defeat."

"As Paul Starr, the Princeton Scholar and author who played a major part in designing the Clinton health care reform, ruefully said later, 'the collapse of the health care reform in the first two years of the Clinton administration will go down as one of the great lost political opportunities in American history... 'Though many factors contributed to that end, we agree with Paul Starr's retrospective judgment: the lesson for next time in health care reform is faster, smaller. 'We made the error of trying to do too much, took too long and ended up achieving nothing.' "

"A fundamental question that emerges from this story is, why did the anticipated, and needed, great public debate about what kind of health care Americans want never occur? And why did the initially favorable American public become so frightened by the President's reform?'"

"The answer is that 'public opinion' was largely an artifact of the groups that mobilized to defeat reform. They created opinion with their grassroots and media efforts. Then they invoked that public opinion to convince, or provoke a rationale for, the members of Congress, who for reasons of self-interest wanted to vote no."

"In the end, the public got much of information--or misinformation--from partisan or special-interest sources. Those intent on stopping reform were far better organized than its proponents.... More and more journalists and elected officials are coming to realize that public opinion--in the sense of a somewhat informed or reasoned reaction--is more often than not a myth in this democracy. For a nation that rests on the premise that The System helps public opinion become the arbiter of public policy, this can be the most dangerous discovery of all."

Wisconsin Governor's Rural Summit

Wisconsin Rural Partners, Inc. hosted a "Rural Summit" in Stevens Point on December 3rd to identify key issues and concerns facing rural communities as the first step of a longer planning and implementation process. Their mission is to bring "together tribal, federal, state and local public interests, as well as profit and non-profit interest to develop collaborative alliances to advocate for and enhance Wisconsin's rural human, natural and economic interests."

Distributed for the Summit was The Wisconsin Rural Performance Indicator: An Assessment of the Conditions and Needs of Rural Wisconsin. From this white paper, a snap-shot of rural conditions is quickly developed:

"In contrast to the decade of the 1980s, all counties in Wisconsin have grown in population from 1990-1994."

"Wealth continues to be concentrated in urban areas and is growing at a higher rate than in rural areas. Also shown is the widening gap between rural, suburban and urban areas, as well as the wide range of performance among rural counties."

"Rural unemployment increased to a greater degree than urban and suburban areas; (counties in the north experienced a higher increase in unemployment than those in the south.)"

"Poverty rates are consistently higher in rural Wisconsin than in urban or suburban areas -- even than those areas which contain consistently higher rates of welfare payments and other poverty indicators."

"Education is one area to find striking differences between urban and rural settings."

"Rural communities and government agencies are increasingly focusing on preventive health and outreach measures as alternatives to corrective health care. Preventive measures include non-medical as well as medical interventions that will work toward reversing those trends that threaten the quality of rural health."

Mainstream Media & Medicare Equity

A major barrier to achieving more equitable access to and reimbursement for Medicare services is that it has been a technical debate limited to a relatively small set of people interested in the eye glazing details of Medicare financing. But slowly the broader public is being brought into the picture, as this editorial from the Wisconsin State Journal, 12/4/96 demonstrates:

"Be careful what you wish for; you might get it."

"Some members of Wisconsin's congressional delegation think the quickest way to resolve the Medicare budget crisis is to split the difference between the Democratic plan put forth by President Clinton and the Republican plan championed by House Speaker Newt Gingrich. It may be the quickest solution, but it's not necessarily the best."

"Both the Clinton and Gingrich plans to slow growth in Medicare would penalize Wisconsin and other states where "per patient" reimbursement rates are already much lower than the national average."

"Here's why: Workers all across America pay Medicare taxes at the same rate, but actual reimbursement rates to doctors, hospitals and clinics who take care of Medicare patients vary widely. That's because a formula developed in the 1960s has never been adjusted. The national reimbursement average is $440, according to the Coalition for Fairness in Medicare, but payments range from $237 in places such as Vernon County, Wis., to $759 in Richmond, N.Y."

"There are many reasons why Wisconsin doctors, hospitals and clinics get less per Medicare patient than their counterparts in other states, but a major reason is that Wisconsin's medical system is more efficient. Our costs are generally lower, so the Medicare formula payback is less - even though Wisconsin taxpayers pay the same as everyone else."

"If Congress and the President agree to across-the-board cuts in Medicare, the gap in the reimbursement rate will widen and high-cost states won't have an incentive to become efficient. As an executive for Wisconsin's Blue Cross-Blue Shield explained recently, equal cuts between high-cost and low-cost states 'will push Wisconsin providers right to the edge.' "

"Republicans and democrats in Wisconsin's delegation need to work together on this issue. This isn't a matter of partisanship, but getting a fair deal for a state that shouldn't be penalized for doing a better job of controlling its health-care costs."

Managed Care--What About Quality?

The following is from "But What About Quality?" by Lisa Belkin in The New York Times Magazine, 12/8/96:

Paul Ellwood (considered by many to be the father of managed care) says "he set out to create a system of competition between health care providers based on price and quality. What he has seen evolve instead is a system of competition based almost completely on price."
"It is clear that the plans are not making quality their priority. Robert Miller, a health economist at the University of California explains: 'First, they are competing to prove they are the least expensive. Next, that they have a provider within 11 to 15 minutes way from a patient. Last on what we call the 'warm and fuzzies,' to make the patient feel good about the care. But quality, that's the rub. The competition is just not taking place there.' "

"What is less clear is whether this lack of attention to quality results in a decrease in quality. Studies of patient health under managed care show a wide range of results. In general, they seem to indicate that managed care is good at keeping healthy people healthy and not as good at treating people who are seriously ill, but not all the studies agree even on that."

"There are many obstacles... (to judging quality based on outcomes) and the largest--making sure that the data are statistically significant--is the reason that many groups have rejected an emphasis on outcomes measures. A second problem is cost. At what point is the cost of developing this and of carrying it out going to exceed the benefits? Health plans are reluctant not only because they might look bad. Some are reluctant because they might look good."

" 'Can you imagine in practice what would happen if the New York Times printed on its front page that Plan X was the best at treating depression?' says Helen Darling who is manager of health care strategy and programs for Xerox. 'Every depressed indivdiual in New York would flock to that plan. And would anyone who was not depressed want to remain enrolled?' I have been sworn to secrecy by one plan that has the best AIDS program in the world."

"The final obstacle comes not from providers but from the purchasers. Those who buy health insurance have to insist on outcomes measurement, just as they insisted on manged care. They have to be willing to look at quality in addition to price."

Congressional Backlash Against HMOs?

From an article by Sharon McIlrath in American Medical News, 12/2/96:

"With elections barely behind them, lawmakers are gearing up for a replay of last year's political debate over a number of widely criticized HMO practices."
"A proposal to ban the use of so-called gag rules is likely to be introduced by President Clinton and debated early in the new Congress. Some legislators also want to prohibit managed care plans from enforcing practice guidelines that eliminate or shorten hospital stays following a mastectomy. Others will press legislation requiring HMOs to pay for emergency care in non-affiliated facilities for patients with conditions a 'prudent layperson' would view as a serious threat."

"The HMO industry hopes to fend off such actions by exerting more self-discipline. Witnesses at a recent Senate hearing warned Congress not to 'micromanage' the HMO industry. But some physician witnesses, including AMA Trustee John C. Nelson, MD, said such initiatives are 'pro-patient,' not anti-managed-care."

"The Nov. 13 hearing of the Senate Appropriations Subcommittee on Labor, Health and Human Services and Education was only the first in a series of hearings that committee chairman Sen. Arlen Specter (R, Pa.) said he will hold on managed care."

Medicare Prohibits HMO "Gag Rules"

HCFA Press Release, 12/9/96:

"Medicare managed care plans may not prevent physicians from providing information to patients regarding all medically necessary treatment options, the Health Care Financing Administration (HCFA) said today. In a letter to more than 300 managed care plans contracting with Medicare, HCFA said that contract clauses limiting what physicians may tell Medicare beneficiaries violate federal law."

" 'No beneficiary should be denied the information they need to make a sound, informed decision on their treatment,' said HHS Secretary Donna E. Shalala. 'Patients and their doctors must have a free exchange of information.' "

"Many managed care organizations have recently agreed that 'gag clauses' limiting discussion of medically necessary treatments should not exist. President Clinton has endorsed federal legislation that would make such clauses illegal (for all HMOs). Enactment of such legislation is an administration priority."

Clinton Proposes Modest Medicare Reform

The Clinton Administration will propose changes to the Medicare HMO payment methodology according to a December Issue Brief, Rural Healthcare by the Healthcare Financial Management Association. The Administration is proposing that health plans be paid the greater of: "(1) a blend of an area-specific and national rate; (2) a minimum payment amount ($325 per month in 1997); or (3) a minimum percent increase."

The $325 floor is thirty percent below the current national average payment to health plans of $467--41 of 72 Wisconsin counties currently have published rates below this floor but only by an average of $31 per month. The effect of the other proposed changes is not yet known. The bottom line, what payment rate in 1997 will bring Medicare HMOs into which rural areas under what conditions?

Five "Models That Work"

From A Department of Health and Human Services November, 1996 Press Release:

"Health and Human Services Deputy Secretary Kevin L. Thurm today named five innovative local health programs 'Models That Work' for providing better, lower cost health care for people with few options, and for a positive economic and social impact on communities. 'Models That Work offers good sense, big payoff solutions for communities wanting to improve health care services, save dollars and create jobs," Deputy Secretary Thurm said. 'These programs exemplify the best in local problem solving to meet local needs--we want to multiply these successes.' "

" 'These Models That Work break the cycle,' said Ciro Sumaya, M.D., administrator of the Health Resources and Services Administration (HRSA), the agency responsible for putting health care services and professionals in underserved areas and sponsor of the Models That Work campaign. 'Built on the assumption that local health and economic problems are connected, Models That Work attacks both problems at once, and then helps replicate these programs elsewhere,' Sumaya added. The five honored programs are as follows:"

"Tampa, Fla., Hillsborough County Health Care Plan: Has enrolled 27,000 poor and uninsured county residents in its own version of managed care. The plan has seen its members' hospital admissions drop 28 percent, hospital stays decrease 40 percent and per person health care cost plummet 61 percent. Hillsborough County estimates it has saved $6 million by diverting 8,000 emergency room visits to outpatient care."

"El Paso, Texas, Project Vida: Provides primary health care, education and social services to poor, uninsured, predominately Hispanic people and families. Recruits patients to become volunteer or salaried community health workers. Project estimates it saves the local health system $150,000 annually in uncompensated and unnecessary emergency room visits."

"Los Angeles, Calif., Los Angeles Free Clinic Hollywood Center: Reaches out to homeless youth with medical, dental, psychiatric, substance abuse and pregnancy care. Provides HIV testing, job training and placement. Relies on peer counselors to move troubled, vulnerable young people off the streets and into more stable living arrangements."

"Philadelphia, Pa., Resources for Human Development: One of the first nurse-operated managed care programs in the state. Serves two public housing communities. Has dramatically increased child immunization rates, sharply decreased incidence of low birthweight, cut health care costs and created jobs for public housing residents."

"Monroe, Mich., Camp Health Aide Program: Trains migrant and seasonal farm workers as health aides to provide health education, first aid and other health and social services to their peers, and to train health care providers in cultural sensitivity. Encourages and assists aides to complete nursing or medical assistant training programs."

What Is Rural & Who Cares?

What Is "Rural" And How To Measure "Rurality": A Focus On Health Care Delivery And Health Policy has been released by the North Carolina Rural Health Research Center (919-966-5541). Prepared under a grant from the Federal Office of Rural Health, this paper offers:

Health Insurance Or Prison?

From the Raleigh News & Observer, 12/8/96:

"Baltimore--Harriette Matthews was stabbed ten times with a screwdriver by her estranged husband in an attack that left her partially paralyzed. Yet she is asking a judge to spare Damon Matthews a prison term. Instead, Mrs. Matthews wants him ordered to keep his job so his health insurance can pay her medical bills."

Premature Death Rate Higher In Rural Areas

The counties with the highest risk of premature death are more likely to be rural rather than urban according to data now available on the world wide web by the Wisconsin Office of Insurance Commissioner. As communities across Wisconsin work to consider local illness and accident prevention initiatives, it is good that we let die the myth that rural counties are more healthy.

Premature or preventable death is measured in terms of years of potential life lost (YPLL) occurring before the age of 65, calculated as the difference between the age of 65 and the age at death. It is one indicator where community wide health improvement initiatives may make the most difference.

The Wisconsin statewide YPLL average is 392 years per 10,000 population (State of Wisconsin Mortality Information for 1994.) The one quarter of Wisconsin's seventy-two counties with the highest rate of years of potential life lost include sixteen rural counties and only two urban (ranging from 458 to 840 YPLL).

Community-Academic Partnership, For Real

Wisconsin's two medical schools have jointly taken a major step forward in assuring the future of the state's Area Health Education Center (AHEC) System. They have now agreed to create a structure to share with their community partners decision-making on statewide issues and priorities. As observed here in an earlier issue, "a world increasingly characterized by scarce public funds and private managed care competition, will no longer sustain educational systems led by anything short of a full partnership between our communities and our schools."

AHEC's loosely organized Statewide Program Advisory Committee held its last meeting on December 6th; a new Partnership Council will have its first meeting in January to begin finalization of the System's biennial request for Federal funds. The Council will consist of 2 members from each of the four regional AHECs, two statewide community representatives, the two Medical School Deans, the AHEC System Director and seven other representatives of designated academic interests.

Cheryl Maurana, the AHEC System Director has stated that "the Partnership Council will develop policy and provide broad oversight with respect to programmatic direction, long-term financial planning, review and implementation of the strategic plan, system budget development, statewide initiatives, and future directions for the Wisconsin AHEC system."

"The Partnership Council would be built on the foundation of open communication, respect for the strengths that each of the partners bring, and a willingness to understand and incorporate diverse perspectives in finding common ground."

1.3 Million Awarded To AHEC

In large part due to the visionary leadership of Barbara Nichols at the University of Wisconsin and Associate Director of the Wisconsin AHEC System, the Robert Wood Johnson Foundation will be investing 1.3 million dollars in Wisconsin over the next six years for the purpose of recruiting and training health care students with ties to underserved communities.

These students "will be supported in their educational efforts by the AHECs, employers, project staff and the degree granting institution. Distance education courses will allow students to work and learn in their home town. Clinical experiences will include interdisciplinary community-oriented primary care approaches extending the practicum beyond the clinic into the community."

"The proposal builds on existing capacities of employers, academic institutions and communities to collaborate in creating active partnerships and policies fostering NPs, CNMs and PAs."

Internet Grows As Basic Health Care Tool

The following sites on the world wide web are only a few of the growing number of basic resources now available for health care providers on the internet:

"Cooperative Web Site is presented by the National Cooperative Business Association (NCBA). This site presents information about cooperatives to help people understand how they can use the cooperative model to improve their and their lives and communities."

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"Healthcare Financial Management Association is the nation's leading personal membership organization for more than 34,000 financial management professionals employed by integrated delivery systems, long-term and ambulatory care facilities, medical practice groups, hospitals, managed care organizations, public accounting and consulting firms, insurance companies, government agencies and other organizations."

National: < >
Wisconsin: < >

National Committee for Quality Assurance "(NCQA) is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans, including health maintenance organizations (HMOs). NCQA's mission is to provide information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, thereby allowing them to make more informed decisions. Their efforts are organized around two activities, accreditation and performance measurement (report cards), which are complementary strategies for producing information to guide choice."

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"Wisconsin Clearinghouse of Primary Health Care Information and Resources is a project of the Consortium for Primary Care in Wisconsin and its 95 member organizations. Designed for those concerned about primary health care services in Wisconsin, the Clearinghouse provides ready access to aggregated information. The Clearinghouse will be of assistance to students, educators, community leaders, providers, administrators and planners in primary health care."


Greg Nycz Receives Overdue Honor

December has been a good month for Gregg Nycz. After 24 years quietly working as a leading rural health advocate from his base at the Marshfield Medical Foundation and the Family Health Center at Marshfield, Greg is receiving some very well earned recognition.

He has been selected to receive a U.S. Public Health Service Primary Care Policy Fellowship as well as the National Association of Comunity Health Center Congress Advocacy Award. The Advocacy Award is for his "outstanding work to advance the legislative agenda of the health center movement."

The purpose of the intensive three-week Fellowship is to "provide an opportunity for primary care practioners, academicians, researchers aand administrators to better understand the dynamics of primary care policy development, the legislative process, and resource identification."

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