- Monthly Review & Commentary On Health Policy Issues From A Rural Perspective - July 1st, 1998
- Question of Patient Choice
- By Robert C. Taylor, Wisconsin Health & Hospital Association President/CEO as it was printed in the WHA News & Views, 5/15/98:
"If there is any single issue that comes to mind most often for health care consumers, it is the critical question of patient choice. When consumers have little information about health care options and are presented a single health plan by their employer, the reality is they either don't have a choice, or at best it is limited."
- "I'm pleased that the Association is taking ever stronger positions in support of maximizing choices for the consumers we serve. At its April meeting, the WHA Board accepted a recommendation that any patient protection legislation should include mandatory point-of-service options. While this affords limited choices, it does offer consumers the ability (at additional cost) to go out of what would otherwise be a closed panel."
- "We are also having some very interesting discussions within the WHA Task Force on Competitive Issues on this question. While that group has yet to finalize its recommendations to the Board, a fundamental question is being raised about whether competition really exists when an employer selects a health plan that is subsequently provided to employees. The question the task force is addressing is whether employers should be required to afford their employees a menu of options, as currently occurs with state employees and the broader federal employee health plan. This approach, if universally accepted, places the key issues of choice not with the employer, but with the employee."
- "Underlying this movement toward choice is the fundamental issue of information consumers need to make intelligent choices. The health care data bill recently signed into law by Governor Thompson should, for the first time, begin to collect and disseminate the type of information that will allow consumers to make informed decisions."
- "I personally believe in a competitive health care environment, but I'm convinced that lack of 'traditional regulation' does not lead to fair competition. As an industry, our challenge will be to fashion the appropriate blend of system requirements and regulations that make the health care system sensitive to the needs of the consumers we serve."
- Congratulations to Bob on his 25th anniversary at WHA.
- Health Marts in Future?
- From an article by Jonathan Gardner in Modern Healthcare, 6/1/98:
- "Managed competition is back, but this time it's Republicans who are pushing it. House GOP leaders are preparing an election-year healthcare bill that could aid the development of 'health marts,' or joint ventures of employers, providers, insurers and consumers."
- "Details are sketchy, but a discussion paper from the House Commerce Committee describes health marts as purchasing pools that would make risk-adjusted healthcare coverage plans available to employer members at group rates, administer the health benefits programs of members and provide information to enrollees on the cost and coverage of the plans available to them."
- "The discussion paper touts health marts as a way to expand choice and coverage while lowering healthcare costs. Health marts are being touted not only for employers, especially small businesses, but also for self-employed people, who have difficulty obtaining affordable insurance coverage."
- "Enrollees could choose from a greater array of health plans, while employers purchasing coverage could take advantage of the lower premiums and reduced administrative costs of the large-group marketplace, the paper said. The health mart proposal may be part of a patient-protection bill emerging from the House Republican leadership's healthcare task force, although some members are said to be raising many questions about the proposal."
"Although health mart advocates bristle at the comparison, observers are noting the similarities between the proposal and the health purchasing alliances included in President Clinton's 1993 healthcare reform proposal. Under that plan, regional alliances would have negotiated with health plans to cover enrollees. Alliances would have covered all employees of firms with fewer than 5,000 employees. Companies with more employees could have formed their own alliances."
- "Although they are making some positive noises about health marts, Democrats also are relishing the irony of the proposal. 'As a means of creating an opportunity for individual choice-which was exactly the goal of the Clinton health plan-they are exactly the same' as Clinton's regional alliances, said Judy Feder, who was the lead HHS official on healthcare reform and now is a professor of public policy at Georgetown University."
- "Feder said opponents of the Clinton plan argued that it would have reduced individuals' choice of providers and health plans. But since its defeat, employers have enrolled their employees in managed-care plans in ever-increasing numbers, narrowing the employees' choice of providers regardless of what the government did, Feder said. 'In response to that narrowing, you're seeing an interest in increasing choice,' she said."
- "Robert Moffit, deputy director of domestic policy with the conservative Heritage Foundation, described health marts as potentially a 'net deregulatory' proposal. They could shield small employers from state health benefits mandates, as the House discussion paper calls for. 'You're not talking about a regulatory regime' as comprehensive as the Clinton plan, Moffit said."
- "Feder, however, also warns that although health marts could make health coverage more affordable for small and medium-sized businesses, they also could contribute to increased costs for people who continue to purchase insurance on their own. If health marts contribute to further fragmentation of the insurance market, risks will be spread among fewer enrollees in the individual market, driving up costs for those who stay in."
- Insurance Reform for Small Business
- RWHC along with a variety of other Wisconsin organizations has formed the Health Insurance Reform Coalition. It has engaged Kevin Haugh from the Institute for Health Policy Solutions based in Washington, D.C. as a technical expert on the operation of health insurance markets. He is acting as a consultant for the Coalition as it prepares to enter into a constructive dialogue with the insurance industry and other key players. Its primary goal is to "provide a means for small businesses and individuals to access health insurance where costs, quality, and stability are not significantly different from larger businesses."
- Key issues raised to date re small businesses and individuals include:
- · poorer access to affordable health insurance.
- · employers forced to offer employees only one HMO
- · instability of insurance rates
- · more limited benefits and higher cost
- For more information about the Coalition, call Kelly Haverkampf at Wisconsin Rural Partners, Inc., 608-265-4525 or email wirural@Madison.tds.net
- HMO Reform & Politics
- From "Running on 'Patients' Rights,' Political Candidates are hustling to respond to public anger over managed health care by Amy Goldstein and Terry Neal in The Washington Post National, 6/8/98:
- "Members of Congress are jockeying over competing bills as they engage in an impassioned debate spurred by public opinion polls suggesting that nearly nine Americans in ten favor candidates willing to tighten the reins on health maintenance organizations (HMOs) and other types of managed care... This issue has acquired momentum even as prospects for other White House initiatives to reshape domestic policies this year appear to be receding. Popular as it may be, the matter of patient rights is producing considerable political angst. Democrats and Republicans alike are wrestling internally over exactly what kind of reins on managed care would be effective--and palatable--and over how best to wield the issue to their advantage."
- "Democrats must decide whether they are better off if Congress adopts a patient-rights law before the elections in November. If Congress fails to act, they can blame the GOP for thwarting what the public wants. Democrats 'have a much bigger political club if health care doesn't pass,' says Dan Danner, chief lobbyist for the National Federation of Independent Business and chairman of a 35-member coalition of business, employer and insurance interests that oppose tighter managed care regulations."
- "The dilemma for Republicans runs deeper. At one level, the very premise of a federal guarantee of patients rights conflicts with the conservative distaste for government bureaucracy as a solution to social problems. At another level, the loudest critics of such a law are traditional GOP constituencies--employer and insurance groups that argue such a measure would increase health costs and thus cause more people to become uninsured."
- "Yet the party cannot afford to cede such a popular issue to Democrats as the GOP fights to retain its slender, 11-seat majority in the House. Democrats are already regarded as more sympathetic on health care issues."
- Competition Requires Risk Adjustment
- The need for "risk adjustment" of HMO payments is one of the most critical unresolved health insurance issues. The following overview relates to the Medicare program but is relevant to all HMOs. It is taken from Chapter 3 of the Medicare Payment Advisory Commission's Report to the Congress, 3/98.
- What is Risk Adjustment?
- "Risk selection occurs when some healthcare plans attract predominantly healthy beneficiaries while others attract those in poorer health. Risk selection can be the result of beneficiaries' preferences; for example, some may be less willing to switch to a new healthcare plan once they become ill. Risk selection may also be affected by plans' decisions about the benefits, premiums, and networks they will offer."
- "Risk adjustment is the process of setting capitation rates that reflect health status, paying plans more to care for ill beneficiaries and less to care for healthy ones. The payment rates might be based on the average cost of caring for patients with specific diagnoses, for example, $10,000 for a beneficiary with congestive heart failure but only $2,500 for one reporting no medical conditions. Plans disproportionately attracting healthy beneficiaries would see payments fall, while plans attracting the less healthy would be paid more."
- Why is Risk Adjustment Important?
- "For managed-care plans, inadequate risk adjustment affects both profits and competition. Ideally, plans that can efficiently deliver high-value care would gain market share at the expense of others. But risk selection causes gains and losses unrelated to a plan's efficiency or value. A plan burdened with costly beneficiaries may not be able to compete, whereas a plan that attracts healthy ones may increase market share."
- "Finally, from the beneficiary's standpoint, the lack of adequate risk adjustment may affect access to and quality of care, particularly for those with high-cost conditions. Plans may be reluctant to develop programs tailored to these vulnerable populations because of the potential for financial losses if the plan attracts a significant number of such individuals. This could result in under-investment in innovative approaches to care for the chronically ill."
- Medicare Mandated to Implement Risk Adjustments
- "The Balanced Budget Act of 1997 provides a clear mandate and a tight timetable to improving risk adjustment in the Medicare program. Additional provisions of the BBA may affect the degree of risk selection, including broadening beneficiaries' choices and restructuring Medicare's enrollment process."
- "HCFA has funded the development of several risk-adjustment models using diagnoses from claims or encounter data. Fundamentally, all the models using diagnosis data work the same way. They try to find diagnoses that identify substantial groups of beneficiaries with above-average costs. For example, since diabetes affects a large proportion of the elderly and tends to drive up medical care costs, all of these risk-adjustment models will set a higher capitation rate if diabetes is diagnosed. The payment weights are determined empirically from Medicare fee-for-service data, so that the higher payment for diabetics reflects their higher average costs under traditional Medicare."
- Medicare Needs to Phase-In Risk Adjusted Rates
- "The introduction of risk-adjusted rates in Medicare involves more uncertainty than any other major payment revision that Medicare has made. This is due to the lack of data and to the unsettled state of risk-adjustment methodology. The potential for substantial changes in payment raises the possibility of disruption for plans and beneficiaries."
- "A significant factor creating uncertainty for the risk-adjustment process is the lack of data. Medicare is only now establishing the data reporting process for plans. Because plans do not currently provide these data, HCFA cannot simulate what any plan's risk-adjusted payment will be. That stands in contrast to Medicare's hospital prospective payment system or the Medicare physician fee schedule, where existing data were used to project how policy changes would affect providers. Finally, without data, there is no way to assess reporting differences among plans or to compare plans' reporting practices with data reporting in the Medicare fee-for-service payment baseline."
- "A second factor is the unsettled state of risk-adjustment methodology. Many options are available that may markedly affect payment rates, with little public discussion of their relative merits."
- "Third, significant changes are occurring in many other aspects of Medicare risk contracting. These include expansion of choices, introduction of an annual enrollment period, removal of teaching-related payments from the Medicare capitation rate, and geographic redistribution of Medicare payments. All of these factors make the Medicare+Choice market more volatile, and argue in favor of moderating payment changes caused by risk adjustment."
- "Plans' practical problems accommodating risk adjustment must also be considered. To arrange for data reporting, some plans may need to rewrite contracts with providers, while others may need to develop entirely new information systems. Plans' accounting systems may need to be modified to conform to Medicare's new payment method. Some plans must consider whether or how to pass through any risk adjustment to their contracting providers. Plans may want to accrue additional reserve (or perhaps reduce reserves) in anticipation of the implementation of risk adjustment. All this must take place against a backdrop where many other Medicare requirements for these plans are also changing."
- "The most reasonable course is to proceed with risk adjustment but to moderate any changes in plans' payments through a reasonable phase-in period. This should be long enough to allow plans to adjust to the payment changes and to allow HCFA to refine its payment models without unduly delaying the intended beneficial effects of risk adjustment."
- "Beneficiaries as well as plans would benefit from moderating any changes in payment. The benefits offered and premiums charged by plans depend critically on the level of Medicare's payment. Sharp swings in payment may, in part, result in large annual changes in those benefits and premiums. Phase-in limits on payment changes would allow plans and the beneficiaries they serve to adjust to the new rates in an orderly fashion."
- Phone Companies Attack Rural Subsidy
- The universal service supporting rural telehealth with $400 in discounts is currently facing the threat of being decreased or completely eliminated by Congress due to a misinformation campaign by the nations large telecommunication companies. Please call your U.S. Senators and member of the House of Representatives and urge them to oppose any efforts to reduce or eliminate universal service for rural health care providers. You can reach them through the Capitol switchboard at 202-224-3121.
- Below is a repeat of a May Eye On Health article that describes the opportunity for rural communities; the program must be protected even as providers begin to apply for the subsidies, a task that the above map shows still has a long way to go.
"The responsible federal agency is the Rural Health Care Corporation which can be found at <www.rhccfund.org/ > but why do you need to know?"
- "It's a corporation established to administer a Universal Service support program authorized by Congress and designed by the Federal Communications Commission (FCC) to make telecommunications services - including the real cutting-edge ones - affordable for rural health care providers.
- "Support applies to monthly telecommunications service charges and installation charges, but not terminal equipment costs. Welcome to the Rural Health Care Corporation's Web Site. The RHCC administers a program making telecommunication services affordable for rural health care providers."
- "This Web Site will be one of the principle ways rural health care providers and telecommunications companies can learn about the program, submit applications, and receive support. We are still completing areas in the web site which will make the application process easier and provide more information to you."
- What does this mean for non-profit rural providers?
- · Support is available for any telecommunications service within maximum bandwidth of 1.544 Mbps.
- · Support is also available for limited long distance charges to an Internet Service Provider (ISP).
- · Your level of support depends on your location and the type of service you choose - it will be calculated individually for you."
- · You can save on a service you already have or upgrade. You can find out what your level of support and total service charge will be before committing.
- Rural Physicians Are Risk-Sharing
- The following is from Rural Physician Risk-Sharing: Insights and Issues, prepared by the Rural Health Research Center at the University of Minnesota; single copies available from Jane Raasch at 612-624-6151 or via:
<www.hsr.umn.edu/centers/rhrc/rhrc.html>.
- "This chartbook summarizes the results of a 1997 survey of rural primary care in nine states that have relatively high statewide managed care penetration rates and large rural populations." (CO, MI, MN, MO, NY, PA, OR, WA & WI)
- "We found relatively high frequencies of risk-sharing arrangements in the rural markets we studied. While the magnitude of the risk-sharing (in terms of percent of practice revenue) is still quite low, the number of practices with active risk contracts was unexpectedly high. These results indicate that managed care and risk-sharing have already spread to rural areas, at least in some states."
- "Rural primary care practices that contract directly with managed care organizations more frequently report risk-sharing arrangements (in the form of capitation, withholds, or bonuses) than do practices that use an intermediary entity."
- Women's Health Fair, August 15th
- Mark your calendar for Wisconsin Public Television's first Women's Health Fair. It takes place at the Dane County Expo Center in Madison, Saturday, August 15th from 9:00 a.m. to 12:30 p.m.; $15 per person including parking.
- The program will present educational, informative and enjoyable event for women, focused on women's health with a theme of stress management. PBS personality Loretta LaRoche will give a keynote presentation based on her new book, Relax, You May Only Have a Few Minutes Left.
- RWHC has joined Dean Medical Center, UW Health and the Wisconsin Women's Health Foundation as a sponsor for the event and related statewide broadcast.
- Ten Ways to Successfully Ruin A Board
- The following is adopted from Fundamentals of Association Management published by the American Society of Association Executives, 1982 (this is not an indirect message to any known boards):
- 1 Pick a poor chair. Make sure he or she doesn't keep discussions on the subject, doesn't keep things moving and doesn't motivate others in the group.
- 2 Muddy your goals. Make sure members are unclear as to what it is they are actually doing.
- 3 Don't take assignments seriously. Approach your task with a lack of enthusiasm.
- 4 Concentrate on the question, "What is it we're supposed to be doing?"
- 5 If by chance a board committee makes specific recommendations, make sure they are ignored.
- 6 Waste as much time as possible on unrelated or unproductive discussions.
- 7 Be sure to have one person to dominate the board or two for sensational arguments.
- 8 Never prepare for board meetings, shunning written agendas and handouts that might actually clarify what is expected.
- 9 Use circular discussion to avoid ever having to take any action.
- 10 Always have a "hidden agenda" or "personal ax to grind." This will assure that you and one or two others can discuss your contribution while the rest of the board goes to sleep.
Collaboration Jazz
- The following description of collaboration was written by Suzanne Morse and presented to the National Advisory Committee on Rural Health at a field visit in Morrisville, Vermont by Scott Johnson, member of the Lamoille Valley Long Term Care Team:
- "When collaborations work, they are a lot like a jazz ensemble."
- "In an interview entitled 'The Musical Democracy" in American Heritage magazine, Wynton Marsalis says jazz contains attributes of music and 'other' things. Among the nonmusical ingredients is the willingness to play with a theme or concept. Jazz invites participation and reaction. It occurs primarily in a social, rather than a solo setting. In Marsalis' words, that means 'learning to make room.' Jazz also represents individuality. "playing jazz means learning how to reconcile differences, even when they're opposites. ...Jazz teaches you how to have dialogue with integrity'--all in all a pretty accurate definition of collaborations"
- "Jazz--and collaborations--must have:"
- "Blues: in Marsalis' words, jazz has an optimism that's not naive. In collaboration, realistic optimism is vital."
- "Swing: this means constant coordination, but in an environment that's difficult enough to challenge equilibrium. Jazz musicians and collaborators are constantly trying to coordinate something with something that's shifting and changing."
- "Collective Improvisation: that's people getting together and making up music as a group. Collaboration, like jazz, requires spontaneity and invention."
- "Syncopation: you're always prepared to do the unexpected. In jazz, the fundamental question is how can we as a group, organize the music? In communities, the question is how can we organize the work to achieve our shared goals?"
- "Working with others in harmony requires dialogue, respect, and most importantly, the ability to deliver a product together."
- Model Long Term Care System
- Also worth sharing from the above noted visit with the Lamoille Valley Long Term Care Team is a copy of one of the most concise and, I believe, on target vision statements I've seen in a long time, laminated and proudly cared by individual team members.
- "Healthy people in a community-owned system of quality care directed by the needs and choices of individuals...
- · easily accessible and affordable
- · effective and efficient
- · home and community based
- · focus on wellness and prevention
- · available to all
- · finances flow to the most appropriate level of service
- · savings flow to meet local community need
- · community resources and talents are coordinated"
- Attitude Matters
- Barbara Elliott, a friend at the University of Minnesota-Duluth School of Medicine sent me this story which she received from another friend, original teller unknown. I don't know if the story is based on an actual incident or not; in either case it is a good reminder of the importance of attitude, whether we are the patient or care giver. At least it passed the "cynic" test of my last remaining live-in teenager.
- "Jerry was the kind of guy you love to hate. He was always in a good mood and always had something positive to say. When someone would ask him how he was doing, he would reply, 'If I were any better, I would be twins!'"
- "He was a unique manager because he had several waiters who had followed him around from restaurant to restaurant. The reason the waiters followed Jerry was because of his attitude. He was a natural motivater. If an employee was having a bad day, Jerry was there telling the employee how to look on the positive side of the situation."
- "Seeing this style really made me curious, so one day I went up to Jerry and asked him, 'I don't get it! You can't be a positive person all of the time. How do you do it?' Jerry replied, 'Each morning I wake up and say to myself, Jerry, you have two choices today. You can choose to be in a good mood or you can choose to be in a bad mood. I choose to be in a good mood.'"
- "'Each time something bad happens, I can choose to be a victim or I can choose to learn from it. I choose to learn from it. Every time someone comes to me complaining, I can choose to accept their complaining or I can point out the positive side of life. I choose the positive side of life.'"
- "'Yeah, right, it's not that easy,' I protested. 'Yes it is,' Jerry said."
- "'Life is all about choices. When you cut away all the junk, every situation is a choice. You choose how you react to situations. You choose how people will affect your mood. You choose to be in a good mood or bad mood."
- "The bottom line: 'It's your choice how you live life.' I reflected on what Jerry said. Soon thereafter, I left the restaurant industry to start my own business. We lost touch, but often thought about him when I made a choice about life instead of reacting to it."
- "Several years later, I heard that Jerry did something you are never supposed to do in a restaurant business: he left the back door open one morning and was held up at gun point by three armed robbers. While trying to open the safe, his hand, shaking from nervousness, slipped off the combination. The robbers panicked and shot him. Luckily, Jerry was found relatively quickly and rushed to the local trauma center. After 18 hours of surgery and weeks of intensive care, Jerry was released from the hospital with fragments of the bullets still in his body."
- "I saw Jerry about six months after the accident. When I asked him how he was, he replied, 'If I were any better, I'd be twins. Wanna see my scars?' I declined to see his wounds, but did ask him what had gone through his mind as the robbery took place. 'The first thing that went through my mind was that I should have locked the back door,' Jerry replied. 'Then, as I lay on the floor, I remembered that I had two choices: I could choose to live, or I could choose to die. I chose to live.'"
- "Weren't you scared? Did you lose consciousness?' I asked. Jerry continued, 'The paramedics were great. They kept telling me I was going to be fine. But when they wheeled me into the emergency room and I saw the expressions on the faces of the doctors and nurses, I got really scared. In their eyes, I read, He's a dead man. I knew I needed to take action.'"
- "'What did you do?' I asked. 'Well, there was a big, burly nurse shouting questions at me,' said Jerry. 'She asked if I was allergic to anything. Yes, I replied. The doctors and nurses stopped working as they waited for my reply. I took a deep breath and yelled, Bullets!' Over their laughter, I told them, 'I am choosing to live. Operate on me as if I am alive, not dead.'"
- "Jerry lived thanks to the skill of his doctors, but also because of his amazing attitude. I learned from him that every day we have the choice to live fully."
- Monato Essay Prize Awarded
- The 1998 Monato Essay Prize, was won by Steve Bartig, a pharmacy student, with his paper, A Proposal to Decrease the Occurrence of Adverse Effects Caused by Medications in the Rural Elderly.
- Steve wrote a proposal for a primary clinic in Rusk County for a central computer system to allow (with a patient's permission) the community pharmacist to access the patient's medical record, medication history, laboratory test results and other pertinent information.
- Recent studies have emphasized the high number of preventable "drug misadventures" ("drug" as in prescribed medicine not illegal drugs) in the United States, particularly among the elderly.
- "One of the most common prescribing errors in the elderly is overdosing. Elderly patients often have decreased kidney and liver function. This becomes a significant problem when drugs requiring dosing modification are administered. By giving the community pharmacist access to the patients laboratory results, the pharmacist is able to estimate the patients renal function. The pharmacist will then be in a position to double check the prescribed dose and make recommendations for dosage adjustments to the provider if needed."
- The Essay Prize was established in honor of the memory of Hermes Monato, Jr., a December 1990 graduate, as well as to highlight the University's growing understanding of the importance of rural health. The writer of the winning essay will receive a check for $1,000 paid from a trust fund established at the University by the RWHC as w ell as family and friends of Hermes.