Check out a great new resource on the Massachusetts health care system from the Blue Cross Blue Shield Foundation of Massachusetts: the Massachusetts Health Care Delivery System Map. As the state's new Health Policy Commission seeks to get its mind and arms around the issue of market concentration, the Foundation's new site boils the issue down to the key factors in an impressively accessible and compelling way.
For example, if you want to begin to understand why Partners Healthcare is so dominant in the state's healthcare market, don't go to this page, Hospital Systems by Size, on which Partners is #2 after Steward Health Care System. Go this this page: Physician Networks and Major Medical Groups, where the size of Partners' physician network (called Partners Community Healthcare Inc., PCHI, or "peachy") is larger than #2 (Steward) or #3 (Atrius), combined.
Or look at hospitals by Net Patient Service Revenue, and see that Partners total NPSR in 2010 ($4.2 billion) was the same as #s 2 (UMass Memorial), 3 (Steward), and 4 (Beth Israel Deaconess) combined.
Don't forget this helpful page of Recent Changes in the Massachusetts health care market.
I found the page on Inpatient Capacity helpful as well. Yes, Partners dominates the Boston market, but no other, not even in the Greater Boston market. Pretty much every region (except for Northeast Mass.) has a single dominant player. The biggest is UMass Memorial which owns 54% of the inpatient capacity in Central Mass. If anything, this page helps to understand why inpatient hospital capacity is no longer the essential feature of market dominance that it used to be. It's about the docs.
So much more to explore in this highly useful and accessible tool as the state debate over cost and market dominance continues. Kudos to Massachusetts Health Quality Partners which did the legwork on this terrific resource.
And congratulations to the Foundation on choosing a new Executive Director to succeed Sarah Iselin. Their choice is Audrey Shelto who has been a highly respected professional in government and non-profit health care in Massachusetts for three decades. An excellent choice to ensure that the Foundation continues its useful and important work for the Massachusetts health system.
Is Medicaid worth it? More specifically, is being on Medicaid better than being uninsured?
This past week, we witnessed a surprising and heated argument over these questions. On Thursday, the New England Journal of Medicine published "The Oregon Experiment -- Effects of Medicaid on Clinical Outcomes." The results are already being used by folks trying to influence state decisions on whether or not to expand Medicaid eligibility as authorized under the Affordable Care Act.
In short, it's a study with impact. First, let's back up.
Today, President Obama addressed the controversies over implementation of the Affordable Care Act. You can read his complete remarks here, and here is his summation:
"And -- and the last point I'll make, even if we do everything perfectly, there'll still be, you know, glitches and bumps, and there'll be stories that can be written that says, oh, look, this thing's, you know, not working the way it's supposed to, and this happened and that happened. And that's pretty much true of every government program that's ever been set up.
"But if we stay with it and we understand what our long-term objective is, which is making sure that in a country as wealthy as ours, nobody should go bankrupt if they get sick and that we would rather have people getting regular checkups than going to the emergency room because they don't have health care -- if -- if we keep that in mind, then we're going to be able to drive down costs, we're going to be able to improve efficiencies in the system, we're going to be able to see people benefit from better health care, and that will save the country money as a whole over the long term."
Two articles this past week, each written in whole or part by Harvard's Atul Gawande, put our health care and hospital dilemma into exquisite perspective.
First, one can only feel admiration and respect for the incredible job done by Greater Boston hospitals and hospital personnel in the wake of the Marathon bombing. Our hospital system, our physicians and nurses and emergency personnel from across the City and beyond rose to the challenge in a deeply impressive way. If there was ever a moment to take collective pride in the world's most concentrated academic teaching hospital environment, this was it.
Here's a good account from USA Today highlighting the extraordinary efforts of our local and regional medical system in the wake of the terror.
As usual, Atul Gawande, the prize winning author, surgeon, and Harvard faculty member, put a special spin on it in a brief report for The New Yorker explaining Why Boston Hospitals Were Ready:
A new report on state-by-state trends in employer-sponsored health insurance (ESI) caught my eye both for the national and Massachusetts trends, comparing 1999/2000 with 2010/2011. Bottom line from the Robert Wood Johnson Foundation-funded State Health Access Data Assistance Center: big changes nationally and in most states, and not so in Massachusetts. Some key findings:
The percent of non-elderly who obtain health insurance from their employers declined from 69.7 to 59.5 percent over the decade, a stunning 10.2% drop -- public coverage increased by 3.1% in the same period.
The share of private firms offering health insurance dropped from 58.9 to 52.4%, and the "take up rate" (the percent of workers accepting employer offers) fell from 81.8 to 76.3%.FULL ENTRY
Here's an info-graphic designed by a team from the George Washington University School of Public Health as part of National Public Health Week (last week). It's pretty smart and worth a look:
OK, you probably haven't noticed, but April 1-7 2013 is National Public Health Week. The American Public Health Association is leading this week's recognition and has created the above-linked spiffy website. Lots of Schools and some cities and towns are noting and doing something special this week. Though the Massachusetts Public Health Association seems not to have gotten the memo. And ditto for my own institution, the Harvard School of Public Health.
It's always been true that public health is not good at celebrating itself and APHA is to be congratulated for giving it a push. And it's too bad because public health in the U.S. deserves more attention, resources, and credit than it gets.
So let's review a little.
If Maryland health officials have their way, their state's health care financing system is going to resemble key elements of the Massachusetts health care financing system as adopted by our Legislature and Governor Patrick last August. Click here to read Maryland's 136-page proposal to the federal Centers for Medicare & Medicaid Services (CMS). If adopted, Maryland will be the second state, after Massachusetts, to establish a framework to keep health care costs rising no faster than the growth of the state economy.
What's that saying? One is an accident, two is a trend, and three is a movement. But I'm getting ahead of myself. Let's review some history:
This weekend marks the third anniversary of the signing of the Patient Protection and Affordable Care Act (PPACA) by President Obama on March 23 2010. One week later, the President signed a companion act, the Healthcare Education and Reconciliation Act of 2010 (HCERA), consisting mostly of changes to the PPACA necessary to secure that Act's passage in the House of Representatives. The combined two laws are collectively referred to as the Affordable Care Act, or ACA, or Obamacare.
It was a wild legislative ride to passage and it's been a wild implementation ride for the three years since then. By my count, the ACA has survived three near-death experiences. The first occurred in utero with the January 19 2010 election of Republican Scott Brown to the US Senate seat from Massachusetts, depriving Democrats of a vital 60-seat majority, and convincing many that health reform was dead; the second was the US Supreme Court decision on June 28 2012 when complete repeal of the entire law was averted by a late change of mind/heart by Chief Justice John Roberts; the third was on November 6 2012 when a Republican victory for White House and Senate control would have led to certain repeal.
While the brushes with death are over, huge challenges remain -- especially leading up to those coming on January 1 2014 when these enormous reforms all take place on the same day:FULL ENTRY
I have a new article just made available on the website of the New England Journal of Medicine on budget sequestration and the U.S. health sector, available here. I explain the sequestration process, how key federal health-related functions will be affected, and why this is happening. One quote:
The Food and Drug Administration projects that it will conduct 2100 fewer inspections at domestic and foreign food manufacturers (down from just over 20,000 in 2012). The Substance Abuse and Mental Health Services Administration plans to cut the Mental Health Block Grant program, eliminating services for 373,000 (of about 6.9 million) adults and children and cutting inpatient admissions for addiction by 109,000 (from about 1.8 million). The Indian Health Service, which normally covers about 48,000 inpatient admissions and 12.8 million outpatient visits per year, expects to cover 3000 and 804,000 fewer, respectively. The Health Resources and Services Administration anticipates cuts to AIDS drug-assistance programs, with 7400 fewer patients' receiving HIV medications as a result (about 209,000 received treatment in 2010).
A lot of damage, and none of it needs to happen.
Oftentimes, it seems to me that tobacco and smoking prevention are yesterday's issues. Been there, done that. Sure, six million persons die every year globally due to smoking and secondhand smoke (about 440,000 in the U.S., according to the Centers for Disease Control & Prevention). Sure, when tobacco is used as intended, about half of smokers will die from causes directly related to its use.
But, so few folks I see still smoke. It must be disappearing.
Or so I thought.FULL ENTRY
Way back in 1993, I met Dr. C. Everett Koop MD, the nation's most recognized and respected Surgeon General (he served in the 1980s under President Reagan). We met at an event at the Federal Reserve Bank in Boston where he and I both received awards from Health Care for All.
Reading about me in the event program, he noticed that I was the product of a Jesuit education (B.C. High and Boston College). With that knowledge, he felt safe tossing me a phrase in Latin: "Illegitimi non carborundum." I didn't have the nerve to tell him I didn't have a clue what the phrase meant, so I just shook his hand and said: "Thank you, sir!"
In 1993 there was no Web to find out translations instantly, so it took a little time for me to find out what it meant. I finally did: "Don't let the bastards grind you down."
I thought of that encounter last week at the sad moment of learning of Dr. Koop's passing. But I had also thought of it a few days before when I read a New York Times column by Mark Bittman raking our current Surgeon General, Dr. Regina Benjamin, over the coals for her near-invisible public profile and other sins:
"No one I asked (including a member of Congress) could name the current one. She’s Regina Benjamin — and no, I didn’t know, either. In theory, the surgeon general is the nation’s doctor, an independent practitioner whose major concern is our health. In reality, the position has been eviscerated..."
Way before the fight over creating the Affordable Care Act, broad agreement existed on one vital national health reform issue: the nation's health care workforce shortages. Even without the ACA, America faced serious problems with deficits of physicians, dentists, pharmacists, mental health professionals, and many more. With passage of the ACA, these issues assumed more urgency because of the pending expansion of health insurance to 30+ million formerly uninsured Americans.
The ACA sought to address these needs. Title V of the law is devoted entirely to measures to address America's health care workforce needs. No other title of the law received such broad support and so little controversy as did Title V. During the legislative debate on the ACA, I heard condemnation of nearly every part -- except for Title V. Here's the description of the Title from healthcare.gov:
The widely shared wisdom about Medicare and Medicaid is that the programs are in crisis because of rapid and uncontrollable spending increases. Many say the only solutions are to raise the Medicare eligibility age to 67 from 65, block grant and cut Medicaid payments to states, and undertake other draconian steps to reduce eligibility, benefits, and cost protections from the programs' 112+ million enrollees.
The conventional wisdom is wrong, and the evidence keeps getting stronger. See this chart below from a new report by the Center on Budget and Policy Priorities:
And change is affecting prospects for the Affordable Care Act/ObamaCare as well. In the past two days, we have seen developments inconceivable before November 6th.
First, yesterday, Florida Governor Rick Scott became the 7th Republican chief executive to endorse the ACA's Medicaid expansion for his state. More than Arizona's Jan Brewer and Ohio's John Kasich, Scott has been the most virulent opponent of the ACA before nearly anyone else. Back in 2008, even before Obama took the oath of office, Scott was using part of his large fortune to finance TV ads opposing health reform. Though Scott repeatedly denounced the ACA's Medicaid expansion, yesterday he said:
"While the federal government is committed to pay 100 percent of the cost, I cannot, in good conscience, deny Floridians the needed access to health care."
Scott only endorsed the expansion through 2016, the first three years when the federal government pays 100% of the cost. After that, the federal share gradually declines over three years to 90%. And there is no guarantee that the Republican controlled Senate and House will go along with Scott's recommendation. Scott is already facing a vigorous 2014 re-election challenge from former Republican Governor Charlie Crist (who turned Democrat last year). This recognition of reality by one of the nation's fiercest ObamaCare critics is an important political signals of the changing landscape for the ACA.
Second, yesterday Douglas Holtz-Eakin, president of the American Action Forum, who served as director of the Congressional Budget Office from 2003 to 2005 and Avik Roy, a senior fellow at the Manhattan Institute, and a 2012 healthcare adviser to Republican nominee Mitt Romney, published a Reuters column calling on conservatives to now focus on modifying rather than repealing the ACA:
"For far too long, conservatives have failed to coalesce around a long-term vision of what a free-market healthcare system should look like. Republican attention to healthcare, in turn, has only arisen sporadically, in response to Democratic initiatives.
"Obamacare is the logical byproduct of this conservative policy neglect. President Barack Obama’s re-election was a strategic victory for his signature healthcare law. Once the bulk of the program begins to be implemented in 2014 — especially its trillions of dollars in new health-insurance subsidies — it will become politically impossible to repeal. And as the baby boomers retire and Obamacare is fully operational, government health spending will reach unsustainable levels.
"The great irony of Obama’s triumph, however, is that it can pave the way for Republicans to adopt a comprehensive, market-oriented healthcare agenda. The market-oriented prescription drug program in Medicare has controlled the growth of government health spending. Similarly, conservatives can use Obamacare’s important concession to the private sector — its establishment of subsidized insurance marketplaces — as a vehicle for broader entitlement reforms."
In other words, rather than a socialist takeover the U.S. health care system, the ACA is actually a concession to a private market vision of how the system can reflect conservative principles. This from one of the nation's leading conservative policy critics of ObamaCare for the past three years.
From me, no gloating, no "I told you so," no smugness. Instead, I feel appreciation for common sense overtaking extremism and myopia. Thanks to Gov. Rick Scott, Douglas Holtz-Eakin, Avik Roy, and others, we are reaching the point where Congress can consider how to improve and enhance the ACA.
Better times ahead, just in time.
This past week, I had the opportunity to interview Dr. Donald Berwick at a Harvard School of Public Health forum. We talked about his early days in the 1980s when he started the now-world famous Institute for Healthcare Improvement, based in Cambridge. We discussed his movement in the 1990s into health policy that led to the ground-breaking Institute of Medicine reports: To Err Is Human and Crossing the Quality Chasm. He reflected on his 17 months running the U.S. Centers for Medicare & Medicaid Services (CMS). And he looked ahead to his nascent campaign for Governor of Massachusetts in 2014.
Regular Health Stew readers already know I am a huge fan -- see this post from when he left CMS, Why Berwick Matters.
On a lighter note, I had the chance to ask him what it is like to get knighted by the Queen of England -- this happened because of IHI's quality improvement consulting with the British National Health Service (NHS). Here's what he told me:
"They called, the Consulate General in Boston. They don't just 'knight' you. They ask you -- here's how it goes. 'Dr. Berwick, if the Queen were to offer you a knighthood, would you accept it?' Because they want to kind of clear the way, and it could be insulting. So I said, 'Yes I would.' So that was the beginning. And for non-British citizens the actual procedure is not done by the Queen, it's done by the Ambassador of the country you're in. So I went to the British embassy in DC and there's a signed parchment thing and a seal, and these guys in uniforms walk out and hand it to you.
"And then you get the 'Knight Manual' -- there's a manual. And I don't remember what's on the first page, but at one place it says: 'Privileges of Knighthood.' One is: If you commit a capital crime, unlike commoners who are always hanged, you can get to choose. You can be hanged or beheaded.
"Actually it was an amazing experience, and I feel so grateful for it and so honored by it. And I know what happened -- IHI got invited to go to the U.K. in the late '90s to try and change care there, and it was a whole team. And it was a little embarrassing because there were about ten people who worked in the U.K. in that decade helping to make the changes."
Last evening, we had two remarkably divergent views on health care cost increases and the Affordable Care Act. First, here's President Barack Obama in his State of the Union speech:
"Already, the Affordable Care Act is helping to slow the growth of health care costs."
Pretty clear. Then we have these comments from House Speaker John Boehner:
"Obamacare is driving up costs, jeopardizing coverage, and making it harder for small businesses to hire."
So who is right?
On Monday, Ohio's John Kasich became the fifth Republican Governor to embrace the expansion of Medicaid, as permitted by the Affordable Care Act (ACA, Obamacare). "I think that this makes great sense for the state of Ohio," he said.
Of course, until last June 28, expanding Medicaid was not an option for states, and was included in ACA as a mandate. U.S. Supreme Court Justice John Roberts convinced a majority of his colleagues to make Medicaid expansion optional, the major change in the ACA from the Court's ruling, one I like to call the "Roberts Rule."
Last week, I was in Washington DC at the annual conference of Families USA, the national consumer health advocacy organization. In talking with folks from states now grappling with how to convince Republican governors and state legislators to expand Medicaid, I have developed a counterintuitive hypothesis for your consideration:
The June 2012 Supreme Court decision making the Medicaid expansion a state option will turn out, politically, to be enormously positive, perhaps even a game changer, for the future of the Medicaid expansion in particular and the ACA in general.
A major new public opinion survey on the Affordable Care Act, Medicare, Medicaid, and other key health issues (done by the Kaiser Family Foundation, the Robert Wood Johnson Foundation, and the Harvard School of Public Health -- including my colleague Robert Blendon) is chock full of important and compelling findings. Let's look at some:
1. Though Americans continue to have mixed feelings about the ACA, they increasingly support implementation of the law's primary pillars. For example:
-- On the ACA, while 52% agree that opponents of the ACA should continue trying to change the law or stop it, with strong differences between Democrats and Republicans, fully 86% of Americans say that "creating a health insurance exchange or marketplace" is an important or top priority.
-- 65% say that "expanding Medicaid" is a top or important priority.
I appreciate and patronize Whole Foods (and Stop & Shop) and had no knee-jerk reaction when I heard its CEO John Mackey refer to the Affordable Care Act (ACA/Obamacare) as "fascist." Eye-rolling, perhaps, at another example of over-the-top ACA hyperbole. Mackey quickly apologized for his "poor word choice" and added the below comment:
"I believe that, if the goal is universal health care, our country would be far better served by combining free enterprise capitalism with a strong governmental safety net for our poorest citizens and those with preexisting conditions, helping everyone to be able to buy insurance. This is what Switzerland does and I think we would be much better off copying that system than where we are currently headed in the United States."
So let's talk Switzerland. It is true -- the Swiss system is 100% private with no public health insurance like Medicare or Medicaid at all. But that's not all. Swiss health insurers, by law, are 100% non-profit -- no profit-making plans at all. (Not quite "free market", huh?) More than that, Swiss plans are even more tightly regulated than are health insurers in Massachusetts, one of the most heavily regulated health insurance markets in the nation. I used to joke, post MA-health reform and pre-ACA that Massachusetts has drifted out into the Atlantic and was heading toward ... Switzerland!
And how is the Swiss system doing? Here's a recent summary slide from the Commonwealth Fund:
In my experience and memory, just about any major complex law, federal or state, gets revisited and revised repeatedly by the legislative body that created it, especially when that law is health-related. The adjustments may be large, small or in-between; substantive or technical; most often they get noticed by the tiny "attentive publics" and ignored by 99.99% of everyone else.
And so it is with the Affordable Care Act (aka: ACA, Obamacare). Many assume that partisan gridlock on Capitol Hill has blocked Congress from altering the ACA, and they are mistaken. The repeal of the CLASS Act in the new year's "fiscal cliff" tax law, (the ACA's entire Title VIII) led me to consider: how much alteration has already occurred, and how much real damage has been done? I knew there were more than a few items, and I had never seen a list of all of them.
By my count, (and please let me know what I have missed) there have been eight consequential, substantive changes to the ACA since its signing in March 2010. Seven were done by Congress and one by the U.S. Supreme Court (SCOTUS). I list them in order of consequence, recognizing that many will disagree with my rankings:FULL ENTRY
In the new law to avoid the so-called fiscal cliff (the American Taxpayer Relief Act of 2012, ATRA), approved last week, Congress and the President repealed the entire Title VIII of the Affordable Care Act (ACA, Obamacare), arguably the largest change in the national health reform law since it was signed nearly 34 months ago in March 2010. One might assume this repeal involved lots of budget savings -- that would be untrue. Savings = $0.00. So what happened?
Title VIII is called CLASS: Community Living Assistance Services and Supports, and was the personal cause of my Senate boss, the late Senator Edward M. Kennedy, who advocated for its inclusion in the ACA until his very last days in August 2009. What was CLASS?
In news accounts of yesterday's new tax law approved by Congress to avoid the "fiscal cliff," health care barely got a mention. One might think that the law had nothing to do with health care. Nothing could be further from the truth.
The big issue was Medicare physician payment, and preventing a nearly 30% drop in physician fees because of the 1997 law called the Balanced Budget Act which included a flawed provision called the Sustainable Growth Rate (SGR) that has been causing havoc with Medicare physician payments since 2002. Congress and the President prefer to repeal the whole thing, but can't figure out how to find the $300 billion to do so, so they keep approving short term, one-year "patches."
So the SGR's impact is again delayed for another year, at a cost of $25.2 billion. [Click here to go to the CBO report on the cost of health provisions included in the new law.] There are other provisions that increase spending by small amounts, though most of the other provisions are "pay-fors" to finance the cost of the one-year physician payment fix. There are 29 Medicare and other health related sections in all. Here are some of the big ones:
At this special time of the year, I offer a message of Christmas cheer to nine of our nation's Governors. This is not random pick. These are the nine who have declared they will not allow their respective states to participate in the expansion of Medicaid to all their states' uninsured residents with incomes below 133% of the federal poverty line, beginning on January 1, 2014. Merry Christmas!
Under the Affordable Care Act/Obamacare, all states were required to participate in this expansion. The U.S. Supreme Court ruling, this past June 28, made the Medicaid expansion an option for states to decide. According to the survey conveyed in the map below, 9 Governors have decided no, 5 are leaning no, 5 are leaning yes, 14 are definite yes, and 17 are still undecided. Here I want to focus on the 9 definite nos.
In the wake of the shootings in Newtown Connecticut, it has been encouraging to hear so many calls for attention to improving mental health services in the U.S. Like oral health, mental health is a poor step-sister in our nation's behemoth health care system, mostly on the outside, shouting for attention, and having to settle for second class.
So it's good to hear voices saying we have to do better.
Here's a question: regarding U.S. mental health policy, what's the most important and consequential federal legislation ever signed into law?
Answer: the Affordable Care Act, also known as the ACA and Obamacare. Hardly anyone appreciates the enormous advance in mental health policy created by the ACA, and it's true.
Really. Permit to me to explain.FULL ENTRY