- Monthly Review & Commentary On Health Issues From A Rural Perspective - March 1st, 1998
- The Key American Value of Choice
- From the Consumer Bill of Rights and Responsibilities proposed by the President's Advisory Commission on Consumer Protection & Quality in the Health Care Industry and currently part of the growing debate about how healthcare competition should work:
- "Public and private group purchasers should, wherever feasible, offer consumers a choice of high-quality health insurance products. Small employers should be provided with greater assistance in offering their workers and their families a choice of health plans and products."
- "First, choice is associated with increased consumer satisfaction. In a survey of consumers receiving health care in both indemnity and managed care plans, individuals with a choice of health products report greater satisfaction with their plan and tend to rate both their insurance product and their individual physicians of higher quality."
- "Second, the ability of consumers to choose among competing products is a hallmark of a healthy marketplace. Individual consumers are responsible for 34 percent of all direct expenditures for health care in the United States. As the science of measuring and generating accurate and valid information on the quality of health plans, providers and facilities advances, consumers can wield their purchasing power to create incentives in the marketplace for improvements in health care quality."
- "Third, consumers who have a role in the selection of their caregivers are likely to have greater confidence in those practitioners and are, more likely to seek appropriate care in a more timely fashion and follow agreed-upon care regiments; Fourth, having a choice of providers allows consumers to take action to preserve continuity of care within the health care system by selecting products and providers that allow them to continue provider relationships when continuity of care is especially important (e.g. prenatal care, care of individuals with complex chronic or disabling conditions)."
- Competing by Avoiding Sick People
- From "Showing the Sickest Patients the Door, The current reimbursement system rewards 'medlining' and other ways to avoid high-risk cases" by David Hilzenrath in the Washington Post National Weekly Edition, 2/2/98:
- "Managing a physician network taught Ann Robinow one of the perverse realities of health care economics: Delivering superior service can be the path to ruin. In the 1980s, when rival Minneapolis networks required women to get a referral before seeing an obstetrician, Robinow's group offered unfettered access. as a result, it attracted more than its share of pregnant women--incurring millions of dollars of losses, Robinow says."
- "Though delivering babies was much more expensive than providing routine care, the network was paid the same amount regardless of the patient's needs. So Robinow's group did the only thing that made economic sense: It stopped offering direct access to obstetricians."
- "In the world of prepaid health care, in which health maintenance organizations, physician groups and individual doctors are paid up front to provide whatever services a patient might need, simple economics make healthy patients more desirable than sick ones. Paradoxically, the market can punish health plans that do well for patients who actually need care--by steering more in their direction."
- "As the spread of managed care raises the stakes, analysts, industry executives and government officials say this paradox is among the system's gravest flaws--and they are searching for ways to eliminate it. A movement to overhaul health care reimbursements is gradually gaining momentum, with the goal of rewarding health plans for taking care of sick people rather than avoiding them."
- "If health plans choose the most affluent locales when building clinics or recruiting doctors, they can reduce their exposure to poor populations with disproportionate medical needs. Offering certain relatively inexpensive benefits can pay large dividends. For example, health club memberships appeal to the fitness-conscious. Dental benefits attract young families. and vision coverage can be farsighted: People who would switch health plans for something as modest as a free pair of eyeglasses aren't likely to have the kind of attachment to a physician that develops over the course of a serious illness."
- "Gaps in coverage can be just as meaningful: If a health plan doesn't pay for the devices that diabetes patients use to monitor blood sugar, it might draw fewer diabetics... Left unchecked, market forces could make victims of two groups: the best and most conscientious health care providers, and people who need top-notch care for serious conditions... George Washington University health care economist Warren Greenberg puts it this way: 'I don't see any managed-care firms today advertising, 'Yes, we are the best managed-care firm, especially if you have cancer, if you have AIDS, if you have heart disease.'"
- "Now, as executive director of a Minnesota employers coalition, Robinow is championing an approach through which government programs and large business groups pay health plans based on the medical needs or risks of the people who enroll, instead of compensating all based on the same theoretical average. Thus, health plans with sicker-than-average populations are paid more than the standard rate, and those with disproportionately healthy populations are paid less."
- "Maryland and Colorado recently began using risk adjustment in Medicaid programs for the poor and disabled. In the state of Washington, a health benefits program for public employees implemented it this month. Under legislation enacted last year, Medicare, the federal medical insurance program for the elderly, must begin adjusting reimbursements by the year 2000."
- "Whether the number crunchers have effectively mastered the art of measuring and compensating for medical "risk" is an open question. Health economists say most medical needs are unpredictable. For that reason, risk adjustment systems generally play a game of catch-up--for example changing this year's reimbursement rates based on last year's patient diagnoses."
- But others "balk at risk adjustment...'You're destroying our strategy. We've constructed our provider network to avoid these high-cost risks." With Medicare, Medicaid and commercial insurance we will see the food-fights and politics around setting base managed care payment rates slowly shift to focus on who gets what risk adjustments for whom.
- Secretary Donna Shalala & Rural Health
- Last month, U.S. Department of Health & Human Services (DHHS) Secretary Donna Shalala received one of America's highest accolade's--a nearly life sized picture in USA Today featuring a milk mustache. The same day she spent an unexpected hour and a half talking about the critical importance of rural health with the National Advisory Committee on Rural Health.
- In a wide ranging conversation, the Secretary spoke of her commitment that DHHS has to rural health. (It oversees Medicare, Medicaid and almost every other federal program related to health care, research or education.) She emphasized that she considers rural health to be one of the "cross-cutting" themes that departmental staff are expected to address as they design, implement and manage their complex matrix of programs. In other words, there is a recognition that there are specific "rural programs" such as those encompassed by the federal Office of Rural Health Policy but also that general programs like Medicare need to be routinely evaluated as to their impact on the health of rural communities.
- The link between rural health and rural economic/community development was clear, "We won't have strong rural communities without strong rural health care. Beyond the obvious importance of health care as a source of jobs and as a critical local resource for healthy communities, she cited the President's smoking reduction proposals also including initiatives to help tobacco farmers and their rural communities make the transition away from dependence on tobacco as a major cash crop.
- On the subject of the new federal-state partnerships to dramatically expand insurance coverage for children, the State Children's Health Insurance Program, also known as Title XXI (Wisconsin's version is BadgerCare), she asked for the help of providers in every state to help with identifying and enrolling eligible children. She suggested outreach efforts and workers being based in hospitals, clinics, schools or daycare centers. States have the option to allow for "continuous eligibility," i.e. to give eligibility for 12 months at a time to avoid the administrative costs of monthly putting on and taking off children from eligibility lists as family incomes fluctuate above or below threshold levels. She encouraged states to go to the single page or mail in registration forms similar to those already in use in states like Georgia and South Carolina.
- The Children's Health Initiative will be run by the Health Care Financing Administration (HCFA, responsible for Medicare and Medicaid) but the Secretary is requiring intradepartmental program coordination with the Health Resources and Services Administration (HRSA, responsible for care to vulnerable populations). E.g. both HCFA and HRSA will review and approve state applications. The National Governor's Association has a web site (image intense-slow) tracking implementation issues at:
www.nga.org/CBP/Activities/ChildrenNFamilies.asp
- The President has proposed to expand Medicare for people as young as age 55 (with premiums being charged to cover their costs) ; the Secretary spoke well of the particular need of farmers with whom she has met who currently pay premiums of $1,000 per month; she spoke of the problem of men retired and on Medicare but the problem of their wives, a few years younger, no longer covered by an employer's health plan but not yet eligible for Medicare. She was not asked how this expansion could simultaneously be financed by the new potentially high risk (high need) enrollees while keeping premiums affordable.
- As regards the need for academic centers to better address the need for more community based training, she was unequivocal in her belief that "if you train young people out in rural areas they are more likely to stay there and practice." More pragmatically she spoke of the growing recognition by academic medical centers that unless they develop appropriate ties with rural practitioners they will increasingly see "their referrals dry up." But the bottom line for her was what could be taken as an acknowledgment of the market economy for labor--"we need to pay enough" to practitioners to rural communities and we need to develop better systems to reduce their professional isolation.
- Dr. Earl Fox, HRSA Administrator fielded some questions for the Secretary. He indicated the departments commitment to give increasing weight in their grant funding to those academic centers that are most successful in addressing the nation's need for a better distribution of physicians and other practitioners."
- From her role as co-chair of the President's Advisory Commission on Consumer Protection & Quality in the Health Care Industry, she spoke to the critical importance for rural and urban alike of health care being provided through more "evidence based" systems. While not enthusiastic about the idea of being given by Congress a set of "heavy handed regulations" for DHHS to administer. she declared the need to improve current levels of "over/under and misuse of services." While perhaps not totally consistent with all DHHS activities (such as current Medicare investigations/threats regarding hospital billing errors), she emphasized the need to develop quality improvement systems rather than more penalties--"a blame free environment."
- Her concern for any oversight capacity that is put in place is that it recognize the dynamic nature of current health care trends. "We see now only a snapshot, we need to institute a system nimble enough to adapt over a period of time. What we are experiencing now is very different than what we will experience in ten years."
- As the discussion wound down it turned to administrative issues related to the effectiveness of the relationship between the National Advisory Committee on Rural Health (staffed by the federal Office of Rural Health Policy and advisory to the Secretary.) In recent years, the consensus among committee members is that the Committee had become underutilized and more distant from the Secretary's office. In particular, the need for timely feedback regarding recommendations sent to the Secretary as well as DHHS making better use of the Committee as an expert panel was emphasized. Secretary Shalala pledged a more systemic way for communication with the Committee--that we need to hold both feet (DHHS & NACRH) to the fire."
- Medicare Bankruptcy, a Crisis Only Delayed
- The following is from an open letter by The Concord Coalition in The New York Times, Sunday, January 25, 1998:
- "The Concord Coalition is distressed to hear so many public figures suggesting that, with surpluses now in the forecast, the time for belt-tightening is over. Some are clamoring for across-the board tax cuts. Others want to set the budget table with a smorgasbord of new cash, health and social service entitlements designed to appeal to almost every age group. Apparently, no one has told them we haven't paid for the meal we've already ordered."
- "Let's face the facts: Even the near-term budget outlook remains uncertain. With so much talk about spending the newly projected surpluses, the public might think they're already in the bank. But they're not. If the economy catches the Asian flu, if another bear market chokes off the windfall capital gains revenues filling Treasury's coffers, or if the future spending cuts promised in last year's budget deal aren't enacted in full, the surpluses may never materialize. And even if they do materialize, they will be relatively small and strictly temporary."
- "Beyond Washington's limited ten-year time horizon, the outlook hasn't really improved at all. Now as before, an onrushing age wave is due to push up the number of retirees five times faster than the number of workers--ultimately transforming America into a nation of Floridas. Now as before, Social Security benefits are projected to exceed earmarked tax revenues by ever-widening margins. This shortfall will begin adding to the public debt in 2012 and rise to $615 billion annually by 2029, the last year the program's deceptive trust funds are technically solvent."
- "Now as before, the combined burden of Social Security and Medicare is scheduled to reach 35 to 55 percent of worker payroll by the time today's toddlers are raising their own families. This cost explosion will flatten the very middle class so many of you promise to help with tax cuts. And now as before, every official agency concludes that our long-term future is filled not with surpluses, but with economy-shattering deficits--unless senior entitlements are reformed. As the Congressional Budget Office dryly observes, 'The good news is likely to be fleeting...the outlook for the deficit in the long run is gloomy.' "
- "It's time to stop sending false signals. It's time to acknowledge that cutting taxes today makes no sense if that cut will only necessitate raising taxes even more tomorrow. It's time to drop the pretense that a stack of Treasury IOUs accumulated in a government trust fund adds up to genuine retirement security. It's time to raise savings on all ledgers, public and private. Most important, it's time to focus on long-term entitlement reform, including both Social Security and Medicare, whose spending growth will otherwise overwhelm everything else we do."
- Not Just an HMO Driven World
- The following is from "The Beginning of the End for HMOs, Part 2: Providers Have More Clout Than They Think" by J. Daniel Beckham (Whitefish Bay, Wis.) in the Healthcare Forum Journal, 2/98:
- "A great many organizations are still making decisions based on the belief that they are afloat on the current of one of the stages of the highly promoted 'four-stage model of market penetration.' They believe their market is destined to move in lockstep through each subsequent stage. Although such simple linear logic makes for great conference presentation, linear phenomena tend to have a pretty poor track record when they are confronted with a complex systemic phenomena like the volatile market for healthcare. For providers, relying on the four stage model only ensures that someone else is writing their strategic plan."
- "There are other, more meaningful ways to define a market than just on the basis of managed care penetration. Providers are beginning to shift their focus to these market realities and abandon the notion of an HMO-driven environment:"
- Meaningful linkages among physicians.
- Can they speak with one voice or are they fragmented into impotence in small practices?
- Meaningful linkages among hospitals.
- Are hospitals organized and able (legally) to withhold their capacity from health plans that pressure them for price concessions?
- Meaningful hospital and physician linkages.
- Are doctors and hospitals willing to stand shoulder-to-shoulder in negotiations with health plans?
- Extent of employer activism and clout.
- Are employers educated about healthcare services and have they formed coalitions to negotiate more favorable rates with health plans?
- Extent to which consumer choice is encouraged.
- Are employers and others who buy care on behalf of consumers facilitating choice among enrollees?
- Extent of geographic fragmentation.
- Traffic gridlock and a tendency to identify with a suburb or county tender homogeneous market strategies impotent.
- Doctors Give Mixed Marks to "Gatekeeping"
- From the Journal of the American Medical Association, 11/26/98 as posted on the American Medical Association's web site:
www.ama-assn.org/public/journals/
- "Is Gatekeeping Better Than Traditional Care? A Survey of Physicians' Attitudes " by Ethan A. Halm, MD, MPH; Nancyanne Causino, EdD; David Blumenthal, MD, MPP:
- Context.-Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven.
- Objective.-To assess physicians' attitudes about the effects of gatekeeping compared with traditional care on administrative work, quality of patient care, appropriateness of resource use, and cost.
- Design.-Cross-sectional survey of primary care physicians
- Setting.-Outpatient facilities in metropolitan Boston, Mass.
- Participants.-All physicians who served as both primary care gatekeepers and traditional Blue Cross/Blue Shield providers for the employees of Massachusetts General Hospital, Boston. Of the 330 physicians surveyed, 202 (61%) responded.
- Outcomes Measures.-Physician ratings of the effects of gatekeeping on 21 aspects of care, including administrative work, physician-patient interactions, decision making, appropriateness of resource use, cost, and quality of care.
- Results.-Physicians reported that gatekeeping (compared with traditional care) had a positive effect on control of costs, frequency, and appropriateness of preventive services and knowledge of a patient's overall care (P<.001). They also felt that gatekeeping increased paperwork and telephone calls and negatively affected the overall quality of care, access to specialists, ability to order expensive tests and procedures, freedom in clinical decisions, time spent with patients, physician-patient relationships, and appropriate use of hospitalizations and laboratory tests (P<.001). Overall, 32% of physicians rated gatekeeping as better than traditional care, 40% the same, 21% gatekeeping as worse, and 7% were of mixed opinion. Positive ratings of gatekeeping were associated with fewer years in clinical practice, generalist training, and experience with gatekeeping and health maintenance organization plans.
- Conclusions.-Physicians identified both positive and negative effects of gatekeeping. Overall, 72% of physicians thought gatekeeping was better than or comparable to traditional care arrangements.
- Editor's Note.-The concept of a "physician gatekeeper" who practices comprehensive primary care and determines whether a patient receives additional referral is central to managed care. This study assesses whether physicians who practice both managed care and fee-for-service medicine believe that one system is superior to the other. With statistical significance, physicians reported that "gatekeeping" has a positive effect on controlling costs, improving preventive care, and providing comprehensive overall care. They believe that "gatekeeping" increased paperwork and telephone calls. They believe that traditional medicine provided better overall quality of care and access to specialists and procedures, promoted freedom in clinical decisions, and improved patient-physician relationships. Clearly there are both positive and negative features in both systems. This study provides a head-on comparison that deserves to be repeated. (George D. Lundberg, MD, Editor)
- Web Sites for Rural Minority Health
- Compiled by Roberto Anson, Federal Office of Rural Health Policy:
- Federal:
- Administration for Native Americans
- http://www.acf.dhhs.gov/programs/ana
- Indian Health Service (IHS)
- http://www.ihs.gov
- Rural Information Center Health Services (RICHS)
- http://www.nal.usda.gov/ric/richs
- HRSA Bureau of Primary Health Care
- http://www.bphc.hrsa.dhhs.gov
- Office of Minority Health Resource Center
- http://www.omhrc.gov
- National Center for Health Statistics
- http://www.cdc.gov/nchswww/nchshome/htm
- National:
- American Association of Medical Colleges
- http://www.aamc.org/meded/minority/start.htm
- Latin American Network Information Center
- http://lanic.utexas.edu/
- Inter-University Program for Latino Research
- http://iuplr.utexas.edu/
- National Center for Farmworker Health
- http://www.ncfh.org/
- US Mexico Border Health
- http://ncfh.org/border
- National Rural Health Association
- http://www.NRHArural.org/
- Rural Sociological Society
- http://www.lapop.lsu.edu/rss/
- National Center on Aging
- http://www.ncoa.org
- National Women's Resource Center
- http://www.nwrc.org/
- National Caucus & Center for Black Aging
- http://www.ncba-blackaged.org
- "Mastering the Natural Art of Dying"
- From "Mastering the Natural Art of Dying" by Pythia Peay in Common Boundary as adapted for the Utne Reader, 4/98:
- "Just as we must master childhood, adolescence, and adulthood, dying presents its own challenges. Borrowing from the theories of Jean Piaget, Abraham Maslow and other developmental psychologists, hospice physician Ira Byock--author of Dying Well: The Prospect for Growth at the End of Life and president of the American Academy of Hospice and Palliative Medicine--has conceptualized the landmarks in end-of-life growth: completing our wordly affairs, coming to closure in personal and professional relationships, learning the meaning of one's life, loving oneself and others, accepting the finality of life, sensing a new self beyond personal loss, recognizing a transcendent realm, and surrendering to the unknown. Viewed from this perspective dying becomes another stage that can allow us to conclude our lives well."
- "Yet the vision of 'a good death' in the company of loved ones has been eclipsed by a stormy debate concerning an individual's 'right to die' by euthanasia or physician-assisted suicide. This controversy is one reason for a renewed commitment to "contemplative caregiving' by people who attend not only to the physical but also to the spiritual needs of the dying. Baby boomers transformed the way Americans give birth; Byock hopes they will transform how we die as well."
- The Answer is All in the Question
- The following is from "Turning the Question, Opinions on health care laws shift abruptly when pollsters bring up the issue of cost" by Richard Morin in the Washington Post National Weekly Edition, 1/26/98:
- "Pollsters often are satisfied asking obvious questions that elicit obvious answers. Occasionally we dig little deeper--and learn a whole lot more. Large majorities (in recent polls) have supported laws that would allow patients whose claims had been denied to appeal the decision to an independent reviewer, would make health plans pay for emergency room visits and would allow patients to sue (HMOs) for malpractice."
- However when researchers dug further, "in each instance support for the specified law plummeted. In some instances, the proportion favoring the specific law was cut nearly in half once respondents were forced to confront the consequences of the legislation that proved initially to be so popular."
- "What these researchers essentially found is the 1998 version of those 'Harry and Louise' ads that sank the Clinton health care plan four years ago. Then as now, the core idea of guaranteed health care for all was universally popular... (but) analysts found that 'Americans respond most strongly to the possibility of some employers dropping health care coverage. Hearing that a measure might increase the cost of health insurance or might get the government 'too involved' in health care also results in a drop in support, although majorities still support legislation on four out of six of the proposed requirements for health plans: providing more information, allowing direct access to gynecologists, paying for emergency room visits and allowing independent appeals.'"
- Bull Market Undermines Community Spirit
- From "Whatever Happened to Politics, Washington Is Not Where It's At, For two generations Government elites defined the great issues. Now, a tidal change in culture is sweeping away traditional geopolitics,' by Garry Wills in The New York Times Magazine, 1/25/98:
- "At a basic level, Wall Street is drawing the majority of Americans into a very different idea of citizenship and a very different experience of democracy than the one the country has long been familiar with..."
- "There are superficial similarities between political democracy and shareholder democracy. Shareholders elect management to run a company in their interest. If management fails, the majority of owners can vote them out. But a publicly held company is a democracy without any care for equality. Shareholders have voting rights, but they do not all have the same rights. Voting power is proportional to one's ownership stake. In a corporation, the majority owners owe no special obligation to the minority. To expend resources on the interests of non shareholders--by analogy the nation or society as a whole--would be a breach of fiduciary responsibility..."
- "The shareholder-citizen in whose image politics is being remade is not a new player on the American stage. The new idea of the financially autonomous individual, who manages his own investments so as to not be dependent on government, the community or institutions, embodies the eternal American aspiration to individualism and self-sufficiency. Investing man is a successor to the Jeffersonian ideal of yeoman farmer, whose ability to satisfy his own modest needs was taken as an underpinning of democratic health..."
- "But the contemporary shareholder-citizen is at the same time an impoverished embodiment of that idea, concentrating on material aspects of independence while largely excluding the experience of community and cultivation of civic virtue. Rather than fostering the kind of democratic citizen who can be trusted to govern, as Jefferson's ideal did, the market ideal of citizenship is about developing the means top withdraw from unsatisfactory common institutions--public schools, the Social Security system, even the need to work. The explicit version of this ideology, libertarianism, has been gaining adherents and credibility in recent years. It is the political philosophy fostered by the stock market."
- "The citizen-investor serves his fellow citizens badly by his inclination to withdraw from community. He tends to serve himself badly as well. He does so by focusing his pursuit of happiness on something that very seldom makes people happy in the way they expect it to. In his 1893 Fourth of July proclamation, President Grover Cleveland warned the nation to 'guard against the sordid struggle for unearned wealth' and to 'hold fast to the American ideas that work is honorable and economy a virtue.' He viewed getting rich in the stock market as a dismal aspiration, not just for America but for Americans."
- If Taverns Hosted AA Meetings?
- From "How Much Is Too Much, Addiction or just bad behavior, Internet overuse is a problem" by David Becker in the Wisconsin State Journal, 1/23/98:
- "You may need someone to help you get untangled from the Net if... Think you might have a problem with Internet abuse? Experts say the following could be signs you need to seek help:"
- · "A significant person such as a boss, spouse or parent has complained about your spending too much time on-line."
- · "You cut back on sleep or skip meals so you can spend more time on the internet."
- · "You've skipped classes or appointments, been late for work or called in sick to spend more time on the Internet."
- On-line resources for on-line addiction include:
- · Center for on-line Addiction