Hard at Work
|Section members hard at work at morning/evening (how can you tell?) business meeting. |
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Message from the Chair
Happy New Year!
[For a long time it has been posited that the Chinese ideogram for crisis is made up of two symbols, one meaning danger and one meaning opportunity. I understand this may be a fallacy, however, that misunderstanding meets my needs for this letter, so read on.]
It is 2009, a year that starts with the world in crisis. Crisis as written by the Chinese is danger plus opportunity. 2009 is indeed a time of danger, given the state of the world’s economy and the state of international tensions around the world; it is also a time of opportunity, with a new administration entering the White House.
2009 is also the Chinese year of the ox. I think the ox is a good sign for the times. According to lore, those born in ox years tend to be painters, engineers and architects. 2009 will need all of our creative thinkers, builders and inventors to facilitate our getting through these challenging times.
I am optimistic, and I don’t believe that I am alone.
I can’t attribute all of my good feelings to a new administration, although some of the things may be related. Some of the good feeling has to do with having enjoyed a great annual conference. We had some truly wonderful events including the “Evening with…Steffie Woolhandler and David Himmelstein” and our Donabedian Award Winner, Robert Brooks. Our Student Award presentations were outstanding. New members joined us at 7 a.m. business meetings, and inactive members have re-engaged. Health Reform is back on the nation’s agenda, and the Medical Care Section is ready to jump into the fray. The Obama transition team is asking for input, and our members are weighing in. Single payer was not mentioned in the moderator’s packet for the house health forums, but it was included in the reports coming out of those forums. Our voices will be heard.
Optimism makes us believe that things are possible and that things can change. Optimism gives us the energy to try again.
By the time you are reading this we will have held our annual mid-year meeting at APHA headquarters. I know some of you will attend for the first time. Thank you. We will, hopefully, have submitted 1-2 (or more?) policy papers for consideration by the JPC; we will have identified roles the Section will play in APHAs health reform efforts; formalized our slate of candidates for Section and APHA offices; identified new ways in which Section membership can benefit our members, and….
I am optimistic about our potential for growth and our ability to influence the health reform debate both within and outside the Association.
I am optimistic, and I don’t believe that I am alone.
I invite you all, as I do each time, to get involved with the Section, and with APHA, as much as is feasible given your time and monetary constraints, in whatever ways best suit your needs and your strengths. I invite you to reach out to other colleagues and invite them to join us, to join APHA. We benefit through the sharing of ideas and the forming of new friendships and new collaborations, through our increased voice within the Association, and through the Association’s increased voice within the national dialogue.
It’s a New Year, a new beginning -- crisis that includes opportunity. I am optimistic.
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Patient Centered Medical Home
The Rise of the Patient Centered Medical Home: What is it? What does it mean?
By Mona Sarfaty, MD
The previously unfamiliar term “Patient Centered Medical Home” (PCMH) made its way into conversations about the health care system over the course of the last year. Since January 2008, the National Committee on Quality Assurance (NCQA), one of the nation’s arbiters of health care quality, has certified primary care practices that seek to be designated as a PCMH. The total number to apply for or receive the designation is still small, but the number of applications is growing. In some states, including the state of Pennsylvania, the PCMH designation translates into higher reimbursement rates for primary care services. The link between designation and reimbursement has led to a rush of education offerings by medical societies and the continuing medical education industry to clinicians and practices that may wish to apply for NCQA designation.
There are numerous indicators of widespread interest and activity. Legislation is under consideration in 20 states to stimulate the establishment of patient centered medical homes. The Center for Medicare and Medicaid Services (CMS) has made available a demonstration program funded through federally qualified community health centers. Think tanks, policy groups, and business trade organizations have published histories, analyses, and interpretations on PCMH for their constituents. The New England Journal of Medicine and Health Affairs, both journals with a wide reach, have recently published thoughtful commentaries on this subject.
A bit of history is helpful. The concept of the patient centered medical home was first utilized in the 1980s by academic pediatricians who focused on building a “medical home” for children with special needs. A decade later, the Future of Family Medicine project was organized by the American Academy of Family Practice (AAFP) to rejuvenate family medicine at a time when managed care was the cause of rising fragmentation and disruption of established networks of care. The AAFP project focused on the “personal medical home,” which was intended to reflect the key principles of primary care such as point of first contact, comprehensive care, continuity and coordination. The new term implied a reincarnation of these well-established principles that were defined in the 1960s and '70s but were not accompanied by a solid evidence base until later and perhaps never had sufficient public relations to be heard over the blare of excitement about specialty medicine. A few years later, the American College of Physicians brought elements of Ed Wagner’s chronic care model into its parallel formulation called the “advanced” medical home.
The “patient centered” half of the new term emerged onto the landscape when the Institute of Medicine, in its popular publication Crossing the Quality Chasm (IOM), held that “the system of care should revolve around the patient, respect patient preference and put the patient in control.” The patient centered focus has been growing in prominence ever since, associated with research on self management to address chronic disease and the growing awareness of the need for “practice re-engineering” of the health delivery system to achieve a more efficient and less fragmented system that is better at generating meaningful health care outcomes.
The Commonwealth Fund together with the American College of Physicians co-sponsored a project to evaluate the cost of building the medical home. Subsequently, health systems began to sponsor demonstration programs. Examples include the Emblem Health project, the Mid-Hudson Valley pilot, and the Improving Performance in Practice (IPIP) initiative developed and initiated in several states funded by the Robert Wood Johnson and American Board of Medical Specialty Society Foundations
The PCMH morphed from a theoretical idea to a reality with the establishment of a primary care collaborative of the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association. These primary care professional organizations with heightened awareness of the importance of primary care services assembled for the purpose of building consensus among payers and reformers of the health system about the importance of primary care services and the pivotal significance of reimbursement rates that actually pay for those services. The organizations aimed to ensure that payers provide payment for the functions that are integral to the success of primary care.
Two factors added a sense of urgency to this work. The first is the “crisis” in primary care services that was declared by the American College of Physicians a couple of years ago when it was noted that there was a dramatic fall-off in the choice of a primary care careers by graduating medical students and medical residents. The fall-off was a present-day indicator of a dramatic change in the future landscape. The second factor was the snag that developed in the efforts to achieve universal access to care at the state level through state health reform efforts. Experiences like that of the state of Massachusetts pointed up with startling clarity that even access through insurance coverage could not guarantee medical care if there were no clinicians to provide it. A shortage of primary care providers in Massachusetts hampered efforts to get newly insured individuals the care they anticipated.
Decades of development and the urgency produced by the brewing crisis led to consensus of the four prominent primary care societies. A collaborative of these societies issued a statement that defined the essential characteristics of a patient centered primary care medical home. The definition included: 1. a personal physician; 2. a whole person orientation; 3. coordinated and integrated care; 4. safe and high-quality care (evidence-based, appropriate use of health information technology, continuous quality improvement); 5. enhanced access to care; and 6. payment that recognizes the added value that is provided to patients who have a patient-centered medical home. The American Medical Association and 11 other major medical societies or associations formally endorsed these concepts. The NCQA criteria involves measurement of these characteristics and adds a few others. Specifically, NCQA adds requirements for measurement of population based characteristics and use of strategies demonstrated by the chronic care model like care management and self management.
Activity over the last year occurring around the PCMH concept such as meetings, publications, demonstration programs and certifying agencies, etc. typically reflects lasting change. However, it is hard to predict the future of the patient centered medical home concept, especially its impact on the delivery of primary care services or the health delivery system in general. For many years, the health care system has only grown in complexity and fragmentation. Whether the patient centered medical home will strengthen primary care services or reimbursement on a grand scale or have any larger impact on the delivery system remains to be seen. Stay tuned.
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In the Exhibit Hall
Arlene Ash, Section Councilor, and colleague in front of our new exhibit!
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We Have Money for Health Care, but Need Courage
Opinion – Santa Fe New Mexican
Sunday, January 11, 2009:
Once again the Legislature is talking about increasing the number of people who have health insurance in New Mexico. The lobbyists will be out in force, money will flow and votes will be cast. There are several things to consider as this annual theater begins:
In 1992, after years of studying the health care system and considering various reforms, the Legislature passed a law calling for universal health care. The studies done in the 1990s, just like the study repeated last year, showed that the state could cover everyone and save money with a universal health care program that is publicly funded and administered (so-called "single payer" financing). Care would continue to be provided by both private fee-for-service and public providers, exactly as it is now.
In 1993, Bill Clinton became president and the Legislature decided to wait for national health reform and not act first. By October 1994, Congress gave up on national health reform and the Legislature let their mandate die. Instead of demonstrating courage, leadership on the national stage and doing the right thing for the people of New Mexico, the Legislature continued to choose the private for-profit insurance industry over the needs of the people of the state.
Using a formula developed by the Institute of Medicine at the National Academy of Sciences adjusted for our state, five New Mexicans a week die from lack of health insurance, 40 during each 60 day Legislative session and 3,584 since the Legislature chose incremental reform over universal health care.
Using this same formula, the national total is 252,000 Americans dead, from the lack of health insurance, since Congress gave up on universal health care in 1994.
The actual numbers would be even greater if they included people who died from bad insurance. Others call this underinsurance; you pay your premium and still can't get care because of unaffordable co-pays, deductibles, insurance denials and delays caused by the business of insurance.
It is impossible to get to universal access to health care through private for-profit health insurance. The United States has been trying to do this for more than 60 years and the dangerous experiment not only kills people, it wastes money. The purpose of private insurance is to collect more money than is spent and keep the money left over as profit. The U.S. spends more per person on health care than any country in the world, leaves nearly 50 million people uninsured, and our health status is not even in the Top 10.
The administrative burdens of private health insurance would take a whole page to list, but here are some as examples:
. The enrollment/agent/employer bureaucracy
. Billings for premiums
. The nightmares related to billing for services delivered
. Advertising and marketing
. Tracking deductibles and co-pays
. Receiving fair and timely payment,
. Provider credentialing
. Pre-existing condition exclusions
. Pre-approval and referral systems that waste time and drive providers crazy.
The administrative waste of private health insurance adds up to 1 of every 3 health care dollars or about $350 billion a year in the United States, or a $1 trillion every three years. New Mexico health spending is approaching $9 billion a year. Using the national estimate of 31 percent for administration, the cost in New Mexico is $2.6 Billion for administration every year. Public financing and administration could cut this overhead in half, freeing up more than enough money to cover every resident.
Most of the uninsured in New Mexico are hardworking, taxpaying workers and their families. Most New Mexicans with health insurance have their insurance paid for by taxpayers. New Mexico has one of the highest rates of people insured by the public; Medicare, Medicaid, SCHIP, SCI, Indian Health Service, VA, uniformed services, public employees, educators, government-funded programs, grants and contracts, with the largest being Los Alamos and Sandia national labs.
The majority of the health care in New Mexico is already paid for by taxpayers. This makes the hassles and extra costs of private health insurance even more tragic. You are using public money to fund private, mostly for-profit, corporations, that drain money from the health care system while needlessly killing five New Mexicans a week just because they can't afford medical care.
This is the unacknowledged corporate bailout of a non-essential industry, and it has been going on for decades. If Medicare, our national single-payer insurance program, can run the most-popular government program with a 5 percent administrative cost; how can we justify paying the private insurers an extra 25 cents of every health care dollar?
The 2009 Legislature has enough money to cover everyone in New Mexico with a publicly financed and administered system. Money for health care is not the issue. Courage to take on a powerful special interest is the issue.
Carol Miller is a public-health activist and acequia commissioner in Ojo Sarco.
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Creating a Single-Payer Plan
Atlanta Journal Constitution
Sunday, December 14, 2008
Creating a Single-Payer Plan is the Best Solution to our Health Care Crisis
The report last week that the U.S. economy lost nearly 2 million jobs this year, and 533,000 jobs in November alone, sent shudders through our nation’s households. That’s the biggest one-month plunge in jobs in 34 years. “Horrendous” was how one economist put it, while others said the number of unemployed, and underemployed, could easily double over the next year.
These job losses spell disaster for our health. Millions of people are losing their employer-sponsored health insurance, joining the 46 million who already lack coverage. Millions more are finding it harder to pay their co-pays and deductibles and are scrimping on their medications and doctor visits. Many go without care, risking their health and often their very lives.
In short, affordable health care has never been more urgently needed. Yet most of the health reform proposals coming out of Washington these days won’t get us there.
Sen. Max Baucus (D-Mont.) recently unveiled his proposals for incremental health reform, which largely mirror the ideas of President-elect Barack Obama and Sen. Edward Kennedy (D-Mass.).
However well-intentioned, the Obama/Baucus/Kennedy approaches share a fatal flaw: they preserve a central role for the private health insurance industry.
To varying degrees, they would mandate that everyone buy private health insurance – the private insurance that is failing us today. Some of these plans offer a Medicare-like, public option that people could buy into, but experience with Medicare shows that the private plans refuse to compete on a level playing field. They cherry-pick healthier patients and insist on more than their share of payment.
Experience with mandate-based plans in Washington state (1993), Oregon (1992) and Massachusetts (1988 and today) shows that they simply don’t work, achieving neither universal health care nor cost containment.
As long as we rely on private health insurers, universal coverage will be unaffordable. These companies generate immense overhead costs and force doctors and hospitals to spend heavily on billing and paperwork.
Administration consumes about one-third of every health care dollar in the U.S. By contrast, in countries with nonprofit national health insurance, administrative costs consume only half that amount.
There is a cure, however. Eliminating the private insurance industry would save $400 billion annually in administrative costs, enough to ensure that everyone is covered and to eliminate all co-pays and deductibles.
At this critical juncture, a single-payer plan is the only medically, morally and fiscally responsible path to take.
We already have an example of an American single-payer system that works— traditional Medicare. It’s not perfect, but people with Medicare are far happier than those with private insurance. Doctors face fewer hassles in getting paid, and Medicare has been a leader in keeping costs down, at least until Washington politicians decided to pay private insurance plans to enroll seniors at a cost 12- to 19-percent higher than traditional Medicare.
Single-payer systems give patients complete freedom to choose their doctor and hospital. They also enhance cost containment through global budgeting, the bargaining power of being the sole buyer, and an emphasis on primary care and prevention.
With a universal plan of this type, doctors and other health professionals could return to their main task: caring for their patients.
Single payer, or an improved Medicare for All, is embodied in the U.S. National Health Insurance Act, H.R. 676, sponsored by Rep. John Conyers (D-Mich.) and 92 other members of Congress.
Opponents of single payer often admit it’s the best, most efficient and equitable way to provide quality care, but say it’s not politically feasible and is therefore off the table in this round of the debate. How so? A solid majority of physicians, 59 percent, and an even higher percentage of the public, 62 percent or more, support national health insurance, recent surveys show. Single payer should be front and center.
Medicare for All is within reach, but only if we are prepared to take on the private health insurance industry. The time is now. It requires only the political will.
• Dr. Oliver Fein is associate dean and professor of clinical medicine and public health, Weill Cornell Medical College in New York and president of Physicians for a National Health Program.
Note: This article was originally published in the AJC under the title "There is a cure for our current plan."
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Moving Forward or Backward?
Sonny Patel, MPH candidate
Amid the ongoing dramatic and varied problems in the Middle East, the issue of health care in the region is often largely ignored. However, two students are seeking to blaze the trail in this vital, yet woefully underrepresented, area.
Luke Manley and I recently spent a month in Istanbul intensively researching the current transition of the Turkish health care system from one that is mainly public, community-based, socialized medicine to a more private scheme, reminiscent of the health care “system” in the United States. During our stay, Luke and I conducted 12 official interviews with health practitioners from across the range of occupations (e.g., health officers, medical directors, pharmacists, clinical psychologists, and herbal practitioners) working in each of the major divisions of health care provision (private, public, public-private). Such an immersion in the culture left both of us with an even greater respect for the immense complexity of balancing all of the different aspects of health care development and provision, especially in such a distinctive and complicated society. Further reflecting on our journey, it is apparent that modern Turkey presents a wonderful challenge for research, especially in health care, as its culture, geographical location, and uniquely secular political society highlight the current struggle to simultaneously “Westernize” without losing the old Ottoman values of community and cooperation.
Our preliminary data indicate that this current transition marks an intense period of change for the government, business, and the people of the country. Strong and informed opinions seem to dominate all sides of the evolution of health care in Turkey, and both of us hope to be able to conduct further research in Istanbul, as well as the other major regions of Turkey in the near future. Currently we are in the process of analyzing and organizing our data for a number of presentations with the intent of publishing a paper on the subject later this year.
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First 100 Days Health Agenda
First 100 Days Health Agenda:
Building Momentum for Reform
The First 100 Days Health Agenda is building momentum for quality, affordable and accessible health care for all, and to improve the nation’s health. It responds immediately to the deepening economic crisis by shoring up and expanding existing public health insurance programs. And it makes a down payment on eliminating the social and economic inequalities that make people sick.
When enacted, the provisions of the Agenda will themselves provide a substantial financial stimulus and relieve serious financial pressures facing individual and families as well as businesses, unions and state and local governments. They strengthen existing public sector social insurance programs, which are uniquely equipped to extend coverage to everyone while controlling costs.
The Agenda consists of two parts. The first comprises measures that can be enacted in the First 100 Days. They expand health coverage and access through public sector programs, halt the erosion of traditional Medicare and improve access to affordable medicine. The Agenda alleviates the economic crisis by extending health coverage through Medicaid to all who receive unemployment insurance, and increases federal matching funds to states. It protects Medicare by eliminating excess payments to private Medicare Advantage plans, and ends the prohibition on government negotiating for lower drug prices. It supports the extension of coverage for children through SCHIP, and increased funding for safety net institutions.
The second part identifies policy and program initiatives that we should launch now even though they won’t be finished in 100 days. These aim to ensure greater health justice for veterans, improve the health of the nation by tackling social and economic conditions that create preventable inequities in health, and build the basis for effective, efficient financing and delivery of health care.
We believe that these actions will forcefully address the crushing immediate needs of our country for continuity and expansion of health care coverage during the economic crisis. Taken together, they will set the stage for the more far reaching reforms that must be enacted to achieve health security for all residents of the United States.
We encourage organizations and individuals to endorse this Agenda, and to contact members of Congress and the Administration in support of these proposals.
A First 100 Days Health Agenda
We ask Congress and President to act in the First 100 Days to expand health care and improve the public’s health: [a]
Extend and expand health coverage and access.
■ Children – Expand SCHIP to cover ages 0 – 25 by enacting the CHAMP Act of 2007.[b]
■ Medicare – Extend coverage and access:
· Lower the eligibility age to 50.
· Eliminate the 24-month wait for Medicare benefits for persons with qualifying disabilities.
■ Medicaid – Increase enrollment and access:
· Increase the federal match in Medicaid funding and minimize cost shifting to patients.
· End the categorical nature of Medicaid eligibility and extend eligibility to everyone living in poverty (proposed by Sen. Baucus), and to all recipients of unemployment compensation.
· Simplify the documentation and application requirements.
· Increase transparency of the state waiver process that is eroding federal standards for Medicaid.
■ Safety-net institutions: Increase funding for public hospitals, and for community and migrant health centers.
Halt erosion of traditional, public Medicare.
■ Stop the excess payments to Medicare Advantage plans. (President Obama favors this.)
■ Cancel the 2010 Medicare Comparative Cost Adjustment demonstration. (Speaker Pelosi favors this.)
■ Eliminate the arbitrary 45 percent cap on general revenue funding for Medicare. (The House refuses to implement it).
■ Eliminate means-tested (income-based) premiums for Medicare Part B.
Improve access to affordable medicines.
■ Create a public prescription drug benefit within traditional Medicare, requiring CMS to negotiate drug prices.
■ Allow re-importation of prescription drugs.
Policy and Program Initiatives for the First Year
Ensure health justice for veterans.
■ Eliminate the barriers (financial, administrative and gender) to timely health care for veterans.
Improve the health of the nation.
■ Take steps now to link action across government sectors (employment, housing, education, environment, commerce and trade, health) to address the social and economic conditions and policies that make people sick and produce health inequities: economic deprivation, discrimination, and adverse conditions at work, in the environment, and in the neighborhood.[c] Make improving health and reducing health inequities a criterion for all government initiatives.
Build a basis for effective, efficient financing and delivery of health care.
■ Speed up the development of an adequate primary care workforce.
■ Investigate the effectiveness, efficiency, and discriminatory practices in the health insurance industry.
■ Compare effectiveness of medical treatments and implement best practices.
■ Propose adequate, stable Medicare financing with cost-growth containment to ensure Medicare’s continued ability to meet beneficiary needs without being burdensome financially.
■ Enact universal coverage for quality, affordable, publicly accountable health care.
Ellen Shaffer, MPH, PhD, APHA Executive Board
[a] Our nation’s hard-won commitment to parity for mental health coverage must be implemented throughout.
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Julie M. Zito, PhD, past chair of Medical Care Section, was given a five-year appointment to the FDA Panel on Drug Safety and Risk Management.
Courtney Queen, PhD, previously the Student Assembly liaison to Medical Care, was awarded her doctorate and is a Research Assistant Professor at the Abramson Center for the Future of Health, University of Houston
Amy Fendrich, MD, primary care physician in South Florida, participated on a clinical panel that evaluated AHRQ's preventive health indicators.
Ollie Fein, MD, past Chair of Medical Care Section, began his term as president of the Physicians for National Health Care on Jan. 1, 2009.
Martha Hargraves, PhD, Section Governing Councilor, was one of the thousands of people whose life was turned around when Hurricane Ike hit Galveston, Texas. We wish her well.
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Medical Care Newsletter Archives