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Thursday, July 18, 2013

Health Care Reform Articles - July 18, 2013

The end of Obamacare? Think again

By Dr. Philip Caper, Special to the BDN
Posted July 18, 2013, at 1:49 p.m.
Earlier this month, the Obama administration announced a delay in the the requirement that many employers offer health insurance to their employees or pay a hefty fine, a key part of Obamacare, the federal health care reform legislation. This was greeted (with glee) by many who oppose the law as a sign that it is beginning to unravel.
I disagree. Unless we are able to do something much simpler and more effective sooner, implementation of this incredibly complex and imperfect law will continue, in fits and starts, for many years.
Given the law’s complexity and reliance on so many unpredictable factors, I am not surprised that its implementation is encountering glitches. But I am surprised that there haven’t been more, due both to technical problems and efforts by opponents of universal health care to sabotage it.
The objectives of any effective health care system are to provide access to health care of high quality and reasonable cost to everybody. By international standards, the current U.S. system fails miserably. Even if Obamacare were to work perfectly, it would leave tens of millions of our people uninsured and do little to control overall costs or improve quality, although it does attempt to make some moves in that direction.
Obamacare tinkers with our existing system of private, employment-based, for-profit health insurance, with its thousands of different and unequal programs. Not only is this approach unfair, but it creates almost insurmountable barriers to achieving those three cardinal objectives.
Equality, expressed as equal de jure and de facto rights, is a strong theme in American politics. Since the Civil War, we have seen fitful but unmistakable progression toward a more equal society. Women’s suffrage was passed through a constitutional amendment in 1920, after a 70 year struggle. The Civil Rights and Voting Rights Acts were passed by the Congress in the mid-1960s after a struggle of well over 100 years. The marriage equality movement has made steady progress, initially through the courts and more recently by legislative actions and by popular vote, after many years contentious struggle.
Each of these human rights incubated for a very long time, and were characterized by fitful progress, as last month’s Supreme Court decision gutting an important part of the Voting Rights Act has recently demonstrated.
The Affordable Care Act represents a major lurch (although a belated and imperfect one) toward health care as a human right in the U.S. We still have a long way to go. But as the sea change in attitudes toward gay rights in recent years demonstrates, progress can accelerate when conditions are favorable.
Despite its serious flaws, Obamacare has benefits, some intended and others not. One major barrier to reform of our health care system has been apathy on the part of people who already have good health care coverage (“I’ve got mine”) or who have been lucky enough not to need health care (the young and healthy), and are therefore unaware of our system’s many problems.
That’s about to change. Due to its requirement that as many people as possible have health insurance (the individual and employer mandates) the apathetic population is about to become dramatically reduced. Like it or not, many more people in the U.S. are about to become engaged in the health care system.

A Pillar of Obamacare's Cost-Saving Effort Falls Short
By  on July 16, 2013
It’s no secret that the Obama administration’s effort to roll out health-insurance exchanges in every state is turning out to be more challenging than expected. Its campaign to lower health costs isn’t faring any better. On Tuesday, the Centers for Medicare and Medicare Services announced middling first-year results for the administration’s highest profile cost-control effort: the Pioneer Accountable Care Organization Model.
Obamacare supporters have long promised that Accountable Care Organizations—groups of hospitals and doctors that tend to large flocks of Medicare patients, with an eye toward keeping them out of the hospital—would be integral to bringing down the nation’s health-care costs. ACOs are supposed to come up with innovative ways of keeping patients in better shape by focusing on preventive measures while saving money in the process. Under the plan, the ACOs themselves are to be rewarded with the share of the savings they generate.
Thirty-two health care provider groups signed up for the pioneer program intended to promote the new model, but the Centers for Medicare and Medicare Services said Tuesday that only 13 of them generated enough savings to qualify for a cut. Two participants actually lost money instead.
The news wasn’t all bad. The pioneers produced better-than-average results on cholesterol control for diabetes patients. “Overall, we are very excited about the results,” Patrick Conway, chief medical officer for the Centers for Medicare and Medicare Services, told the Wall Street Journal. But a significant percentage of the pioneers weren’t so thrilled, and nine are slated to exit the program.

Seeking Alternatives for Back Pain Relief

By GRETCHEN REYNOLDS
This column appears in the July 21 issue of The New York Times Magazine.
If you have never suffered from lingering low back pain, you’re lucky or, more likely, young. Up to 80 percent of us will experience low back pain at some point. And for most, there won’t be an identifiable cause.
In the past 10 years, the most popular nonsurgical medical treatment for “chronic, nonspecific” low back pain has been injection therapy, or shots into the lower back of various substances — usually cortisone but also liquid ibuprofen, morphine and vitamin B12. Doctors have been turning to injection therapy at a “disproportionately escalating rate,” according to an overview of back-pain treatments by a team led by Dr. Janna Friedly, a back specialist and an assistant professor of rehabilitation medicine at the University of Washington in Seattle, because it’s relatively easy to administer, less invasive than surgery, can provide some pain relief for a few weeks for some people and is profitable for physicians.
But the benefits do not last, the latest science shows. In a commentary published in May in The Journal of the American Medical Association (JAMA), researchers from the Netherlands point out that there is almost no evidence that the shots ease most people’s pain long term, even after multiple injections. Other recent studies have concluded that injections also do not significantly reduce the likelihood of back surgery later. And in a particularly sobering study published in February, researchers found, to their surprise, that a small group of subjects with pinched nerves in their backs showed less improvement after injection therapy than a control group during a four-year follow-up period. Based on the available data, the JAMA authors conclude, doctors “should not” recommend injection therapy to their patients with chronic low back pain.
The lack of other options that can be administered in a doctor’s office, however, is frustrating to physicians and their patients, says Dr. Friedly. Doctors “want to be able to do something,” she says. But it may be that in their desire to treat back pain, doctors are compounding the problem and creating a disease state where none may exist. “I think we’ve begun pathologizing pain,” she says.

Obama’s last campaign: Inside the White House plan to sell Obamacare

By Ezra Klein and Sarah Kliff, Updated: 

Deep inside the White House, in a bare room that the chief of staff uses for meetings, David Simas is still thinking about turnout.
Turnout has been Simas’s job for years now. As director of public-opinion research and polling for President Obama’s reelection campaign, Simas was at the center of the effort to find and persuade young and minority voters to go to the polls like they did in 2008.
Many doubted the Obama campaign’s contention that it could recapture the 2008 electorate. Simas’s data, however, convinced the campaign that was possible. And when the smoke cleared, young voters and minorities did show up to the polls, and Obama won.
Now Simas, a sad-eyed Massachusetts native with a facility for PowerPoints, needs to reach those same groups again — with a much harder ask. This time, he doesn’t just need them to vote. He needs them to buy health insurance, and, in some cases, spend hundreds of dollars a month for it. If they don’t, the new insurance marketplaces — the absolute core of Obamacare — will be filled with older, sicker people, and premiums will skyrocket. And if that happens, the law will fail.
The debate over Obamacare often focuses on the law’s complexity. Senate Minority Leader Mitch McConnell (R-Ky.) has taken to pushing around a seven-foot stack of paper showing the tens of thousands of pages of regulations it has spawned. Senate Finance Chairman Max Baucus (D-Mont.) has warned that implementing such an intricate statute could be a “train wreck.”
But to the White House, the difference between success and failure is straightforward: They need to entice a sufficient number of young and healthy adults into the new insurance marketplaces that open Oct. 1.
How many younger people are needed each year to hold down premiums depends on how many people sign up for the marketplaces. If the total this year is 7 million people, then about 2.7 million need to be in the 18-to-35 set.
This, then, is the crux of Obamacare’s challenge: Can the federal government persuade young, healthy people to buy health insurance?
Simas is focusing his formidable analytical resources on understanding this group. He begins clicking through a Powerpoint that holds reams of data on these young adults. “What do we know about them?” he says. “They’re overwhelmingly male.” Click. “They’re majority nonwhite.” Click. “One out of every three lives in California, Florida or Texas.” Click. “We have census maps breaking this down into the smallest geographic units.”
A couple more clicks and Simas is showing which television channels they like to watch (Spike TV, among others), which social-media platforms they use (Twitter, Facebook) and who they listen to (“No surprise. It’s mom.”). “We can figure out the message that works best for this group,” Simas says.
The focus on young, minority voters. The heavy reliance on microtargeting. The enthusiasm about nontraditional communications channels. The analytics-rich modeling. It sounds like the Obama campaign. And administration officials don’t shy away from the comparison.
“When I hear the conventional wisdom about Obamacare,” said Jeanne Lambrew, deputy assistant to the president for health policy, “this is the difference between the Karl Roves who put their fingers to the wind and the Nate Silvers of the world who looked at the numbers.”
But the effort will have to go far beyond engineering turnout among key demographics. The administration needs to build more insurance marketplaces than they ever expected, and create an unprecedented IT infrastructure that lets the federal government’s computers seamlessly talk to the (often ancient) systems used in state Medicaid offices. They need to fend off repeal efforts from congressional Republicans — like Wednesday’s vote to delay the individual mandate — and somehow work with red-state bureaucracies that want to see Obamacare fail. And they can’t escape the fact that the law, three years after passage, remains stubbornly unpopular.
Amid these challenges, critics say the administration is simply defining success down. “Their job in 2013 is to declare victory in any way possible,” said Doug Holtz-Eakin, president of the conservative American Action Forum. “They’ll keep moving goal posts until they can declare victory.” Holtz-Eakin noted that the administration has recently delayed significant parts of the bill, like the employer mandate. “It’s an admission that the whole thing can’t be implemented,” he said.
Over the course of three months and in dozens of interviews for this article — with Obama administration officials, state-level implementers, outside experts, steadfast critics and others — two distinct and contradictory views emerged: One, of confident Obama administration officials focused on building its marketplaces and ignoring the naysayers in Washington, who they believe simply don’t understand the law. Another, of Obamacare’s increasingly confident critics, who believe the law is collapsing under its own weight and feel themselves more vindicated by the day.
Caught between those two sides are the state-level bureaucrats and technology consultants who have 76 days left to set up the biggest health-coverage expansion in decades.
“In 2011, there was this ‘we’re going to save the world’ mentality,” said Rebecca Pearce, executive director of the Maryland Health Benefit Exchange. “In 2013, it focuses more on ‘How do we deliver on the requirements of the law?’”

White House says Obamacare changes will keep insurance prices down In 2014

By Phil Galewitz and Julie Appleby, Kaiser Health News
Posted July 18, 2013, at 6:49 a.m.
WASHINGTON — Ratcheting up the campaign to sell the health law, President Barack Obama was expected to deliver a speech Thursday touting how individuals buying insurance in new online marketplaces this fall will pay lower-than-projected premiums on average in at least 10 states and the District of Columbia.
The remarks piggyback on the announcement Wednesday that New York State regulators have approved health insurance rates for individual policies for 2014 that are at least half the cost of current policies on average.
The administration released a fact sheet Thursday showing that average insurance premiums for individuals buying health insurance on their own and small employers will be lower than previously projected not just in New York, but in at least nine other states and the District of Columbia.
Premiums on average will be 18 percent less expensive in those states than projections from the nonpartisan Congressional Budget Office, according to the analysis by the U.S Department of Health and Human Services. Still, some people will pay more than they do now, while others will see greater savings.
Proposed and final premium rates from California, Colorado, New Mexico, New York, Ohio, Oregon, Rhode Island, Vermont, Virginia, Washington and D.C. were included because they have been publicly reported. However, those states are not necessarily representative of the rest of the country, since most , though not all of them, are supportive of the law and are running their own insurance marketplaces.
The analysis comes as the White House pushes back at critics of the health law, who have long said that its fees, broad benefit requirements and other rules will cause rates to skyrocket.On Wednesday, the Republican-led House of Representatives also approved largely symbolic legislation to delay the controversial mandate that most Americans carry health insurance.
Obama is also expected Thursday to say millions of Americans are already benefiting from the law, partly through a provision that requires insurers to pay rebates to consumers if they fail to spend at least 20 percent of their premiums on medical care. Some of the people who have benefited are expected to join the president at the event.
“Anything that is good news for the law is helpful politically,” said Sara Rosenbaum, health policy professor at George Washington University.
Others cautioned that the report averages premium costs and actual premium prices are likely to vary widely. “The impact of the ACA will vary considerably depending on a person’s age, gender, health status, and where they live,” said Robert Zirkelbach, spokesman for the America’s Health Insurance Plans. “Simply looking at averages doesn’t tell you what these reforms are going to mean for a particular person in a particular state.”


In a Culture of Disrespect, Patients Lose Out

By DANIELLE OFRI, M.D.
I’ve always thought about respect as common decency, something we should do because it’s simply the right thing to do. In the medical world, we certainly need to strive for respectful behavior, especially given our historically rigid pecking order, our ingrained traditions of hierarchical bullying and, of course, a primary constituency — patients — who are often on uniquely vulnerable footing.
But then I stumbled across two articles in Academic Medicine that talked about respect as an issue of patient safety. The authors, a group of doctors and researchers at Harvard Medical School, outlined the myriad acts of disrespect that we’ve come to accept as a way of life in medicine, and showed how these can lead to a final pathway of harm to our patients.
This shift in perspective was a shock to the system. When we tolerate a culture of disrespect, we aren’t just being insensitive, or obtuse, or lazy, or enabling. We’re in fact violating the first commandment of medicine. How can we stand idly by when our casual acceptance of disrespect is causing the same harm to our patients as medication errors, surgical mistakes, handoff lapses and missed lab results?
At one end of the spectrum are the examples of disrespectful behavior, like the volatile doctor everyone knows to steer clear of. Then there are the sadly common abuses of hierarchy — the doctor denigrating a nurse, the medical student treated like disposable goods.
Beyond these are the even more widespread passive types of disrespect, the behaviors that don’t ever get reported and are hardly noticed because they are so ingrained in the culture of medicine. Dismissive attitudes — toward other members of the medical team, toward students, toward administrators, toward patients — are as corrosive as outward manifestations of disrespect.
“Lack of respect poisons the well of collegiality and cooperation,” the authors of the articles wrote. The poisoning-of-the-well metaphor is apt. Like pornography, we know it when we see it. Ask a nurse or an intern or a medical student, and they can tell you with pinpoint accuracy which areas of the hospital are toxic to work in, and which are not. Now think of the patients who have the misfortune to be stuck in one of those toxic areas. It’s not just unpalatable; it’s unsafe.
Doctors have to take a good deal of the blame. For better or worse, we often set the tone in a medical enterprise. When we show, or tolerate, even subtle disrespect, it works its way all along the chain.


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