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The run up to the midterm elections says a lot about American ambivalence about reforming the health care system. The rhetoric about health reform – and the public’s reaction to that rhetoric – underlines why it has been so difficult to reform the health care system for the past 100 years– and, why it still might fail.

In general, whenever opinion polls are done about the health care system, people say two things: they think we should have universal coverage in this country and health care spending is too high. But, those are all positions taken in the abstract and reflect a theoretical view with no depth of understanding of the specifics that need to go along with implementing those goals. Those responses are kind of like a poll when a particular candidate is compared to “any Democrat” or “any Republican.” This kind of polling is not very enlightening about how people react when confronted with the reality of what those kinds of choices mean.

So, let’s take a look at the two things people say they want in a “reformed” health care system: universal coverage and cost control.

There are really only two fundamental ways to get to universal insurance coverage: covering everyone through the tax system or requiring everyone to have coverage either through an individual or employer mandate. The Affordable Care Act chose a mix of the two approaches– expanding government programs that are tax funded and expanding private sector coverage through the mandates (with subsidies). It is the mandate that is being challenged in the courts and seems to generate the most heated debate about why health reform represents “the federal government” telling people what to do. A fully tax funded system would have been equally disliked. So, Americans may say they want universal coverage but they also seem to say they don’t like any of the means to get there.

Controlling health care spending presents another dilemma because whatever is done to reduce spending in any meaningful way generally means not providing something that someone wants (or that someone wants to provide). That’s why politicians love to talk about prevention and wellness programs and getting rid of waste, fraud and abuse. Those strategies are all approaches that are uniformly popular because they either cut spending that goes to “crooks” or they add services that people like. And, while these are all good things to do, the problem is that they don’t make any substantive impact on health care spending trends because the cost of health care is being driven far more by expanding technology than by these things. And, even though there is evidence that much care that is provided doesn’t actually improve outcomes, and may, in fact worsen them, Americans seem to have an insatiable desire for more medical care and a belief that if someone recommends less interventionist approaches, we are not getting “the best”. Such beliefs made it easy to characterize an end of life support structure as “death panels” and resulted in a comparative effectiveness process that explicitly says it cannot be used for “rationing”. So, just as with the means to universal coverage, the approaches to actually doing something significant about health care spending are not popular.

And, today’s debate about health care reform in advance of the midterms has done nothing to reconcile these issues or even shed any light on them. Indeed, the debate has been singularly uninformative – on both sides of the question. Proponents of reform have done a terrible job in explaining it to the public. Opponents, on the other hand, have done nothing to encourage a substantive discussion about the law. Rather, they have simply talked about “repeal and replace” without giving any alternatives as to what that would look like. This approach does nothing more than pander to a fantasy view of health care reform that results in no tradeoffs. As David Leonhardt put it beautifully in the Oct 20 New York Times:

“Unfortunately, today’s political debate doesn’t seem to have room for downsides. It conjures a world of free lunches — unlimited Medicare, vague spending cuts, low taxes and balanced budgets.

It’s a nice world, until it isn’t.” And therein is the rub.

The idea of the “Accountable Care Organization” (ACO) appears to have taken hold well in advance of a clear understanding of what these organizations might be or how they will fit into the overall health care system.

At Blue Cross Blue Shield of Michigan, we’ve been using the term “Organized Systems of Care” (OSC) since 2005, when we began transforming our relationship with physicians through the Physician Group Incentive Program. This term, which can be used interchangeably with ACO, implies an emphasis on and commitment to “before the fact” responsibility for creating an effective system of care and “after the fact” responsibility for the results of that system – at a population level.

I want to share with you my understanding of ACO/OSCs, and recommend how we should approach using them as key strategy in creating a high performing health care system in America.

First, let’s set the stage.

The American health care system costs much more and performs below other developed countries on population-based performance indicators on cost, quality, and access to care.

Much – but not all – of the cost difference is due to the relative advantage American health care workers and facilities have over their foreign counterparts on what they are paid for equivalent services. High (and increasing) use rates contribute substantially as well.

In this country, health care professionals earn a higher multiple of average prevailing wages than is the case elsewhere. With an increasing percentage of health care payments coming from government programs, the sustainability of these higher incomes is clearly threatened. The annual political wrangling over the formula for the “Sustainable Growth Rate” serves as a harbinger of the day when Medicare professional payment levels are reduced to a more affordable level, presumably one that does not rely on deficit financing.

The threat of declining payments on a per-service basis has created something of a consensus for replacing the fee-for-service system with one that incorporates the principles of “pay for performance.” The rationale is that a higher performing health care system can bring overall costs in line, while preserving the relative income advantage enjoyed by American health care workers. This hope (that incomes can be preserved) explains the general appeal of Accountable Care Organization/Organized System of Care prior to a general understanding of what they are.

This openness – in some cases eagerness – to change offers a unique and compelling opportunity. Can we use the widespread support for a performance-based payment model to create a high-performing and affordable system?

Now, let’s explore the root causes of our current health care system’s sub-optimal performance:

Root Causes of America’s High Cost Health Care System

Poorly aligned incentives. Fee-for-service drives increased delivery of services and members lack benefit incentives to promote better health. Lack of counterbalancing incentive to provide services efficiently from a population perspective.

Lack of population focus. Providers deliver services that are demanded and paid for, instead of focusing on the health of the overall population.

Fragmented healthcare delivery. Physicians and hospitals lack information infrastructure and integration of care processes across the care continuum.

Weak primary care foundation. Missed opportunities for care coordination and lower cost approaches.

Lack of focus on process excellence. Creates variation and re-work, not clinical process improvement.

Any organizational solution to creating a high-performing health care system must address these root causes.

The essential elements of an Accountable Care Organization/Organized System of Care will be determined empirically – by observing which organizational framework and attributes best achieve affordability while meeting the health care needs of the defined population.

The first requirement is alignment of incentives. The payment model must assure that better performing organizations are more financially successful than those delivering less value. This is how markets should work – high margins should be the result of delivering greater value relative to the quantity of resources required to deliver that value. At present, value is determined by the quantity of services delivered and the “relative value” of each service. There is no connection between payment and the outcomes of care or the impact of services on health at the population level.

Any payment model can be subverted to serve short term interests rather than the interests of achieving a high performance health care system. We’ve seen many examples of this in both fee for service or capitation-based payment approaches over the past three decades. The commitment to tying a substantial portion of provider payment to population level performance is the key to long term success. Hybrid payment approaches, including some degree of fee for service payment, may be just as successful as fully capitated payment approaches, if they include accountability for population level performance. In addition, any payment method will be strengthened if consumers have analogous incentives for effective self care and to seek care from providers committed to creating and sustaining high performance systems of care.

In the current state, primary care practices are ill-equipped to act as the foundation of a system that consistently delivers evidence-based services at the population level. A proactive model of care relies on a registry of all persons in the population, a process to determine the services that they should receive, and a system for consistently getting them done. Given that this is a core role of primary care, such practices should routinely identify and track all persons with whom they have an ongoing care relationship. HMOs have had primary care assignment for decades – but only rarely has the principle been applied to all patients in the practice.

In the Patient Centered Medical Home model, primary care teams have a care relationship that extends over time and across settings of care. The relationship includes a responsibility to assure that the process of care works to advantage the patient. This role has withered under a fee-for-service system that failed to recognize the value of communication and coordination across what is now the dis-continuum of care. Creating a system with an emphasis on process management, effective communication (including role clarity), and coordination of care can only exist under a payment model that rewards improving and optimizing performance.

So, how does the Accountable Care Organization/Organized System of Care fit in?

The ACO/OSC is the organization that accepts performance risk at the population level. The population is comprised of all persons with a care relationship with primary care physicians operating within the system of care. The population served by the ACO/OSC is, therefore, a “roll-up” of the individual patient populations of the primary care physicians operating within the system. The ACO/OSC conducts performance measurement for that population, supports effective processes for communication and care coordination across sites of care, establishes goals, tracks progress to goal, and interacts with payers to assure that the organization receives payment commensurate with the value that it delivers to the population it serves.

The model is much easier to imagine if the organization is an integrated delivery system, but “virtual” organizations led by physician organizations or physician-hospital organizations may be a more common arrangement. For all, the challenge is creating a high performance system of care for a population. Organizations aspiring to be an ACO/OSC must prepare themselves to transform the process of care to succeed in population management. And that starts with identifying the population that the organization serves.

The rest will be history.

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Thomas L. Simmer, M.D. is senior vice president for Health Care Value and Provider Affiliation and chief medical officer for Blue Cross Blue Shield of Michigan. He is the vice-chair of the board of directors of the Center for Healthcare Research & Transformation.

Almost a year ago now, new guidelines on mammography screening were released by the U.S. Preventive Services Task Force (USPSTF). The new guidelines updated 2002 recommendations, and based on recent research recommended against routine screening of women ages 40-49. Instead of routine screening, the USPSTF concluded that the decision about screening women 40-49 should be left up to individual women and their physicians based upon individual risk profiles.

The new guidelines immediately sparked a firestorm of debate that essentially accused the government of putting money concerns ahead of women’s lives. Indeed, the debate was so heated that it became embedded in the larger discussion about health care reform. Some said that if health reform passed, it would result in “terrible” decisions like the revised guidelines (aka, death panels). All sorts of politicians came forward with plans that would limit the ability of insurers and others to implement the guidelines as written.

This debate underlines the challenges we face in America in controlling health care spending. The whole idea that “more is better” is almost universally embraced in our culture and our views of health care utilization, coming into direct conflict with our stated desire to “bend the health care cost curve.”

Now two colleagues at the University of Michigan and the Michigan Veterans Administration, Kerianne H. Quanstrum and Rod Hayward, have written a very important thought piece on this issue in the New England Journal of Medicine: “Lessons from the Mammography Wars.”

Quanstrum and Hayward point out the reality that guidelines often cannot be precise black and white determinants of care. While there are some combinations of procedures and patient characteristics where guidelines leave little doubt about the right course of medical care, there are many other cases where the right course of treatment is more equivocal and patient preferences need to be taken into account.

Quanstrum and Hayward further point out that the process often used today to develop guidelines has a serious flaw: guidelines are generally developed by the clinicians who most stand to benefit from the use of the procedures in question. Thus, according to the authors, it was breast radiologists who were most vocally opposed to the new mammogram guidelines, and breast radiologists who have the most at stake financially from these guidelines.

As a society, we like to see physicians as somehow immune to financial incentives. In that context, we tend to see doctors as entirely different from other small business owners. But that view is both mistaken and dangerous. Physicians in private practice (the majority of physicians in this country) must act like small business owners: to do otherwise would be folly. They have to pay their staffs, maintain their offices and earn incomes. Even though they have gone into a “helping profession,” there is nothing inherently different about the character of physicians from the rest of us that would make them unresponsive to opportunities to influence their own finances.

As physicians, Quantrum and Hayward have called out something that we should be aware of and address in the light of day: the need to develop guidelines within a structure of checks and balances so those who have the most to gain financially are not the ones making guideline decisions. Quantrum and Hayward’s approach calls for a structure somewhat akin to that used by the Preventive Health Services task force, where clinical but more general experts lead guideline development.

Quantrum and Hayward’s recommendations are essential if we are to use our resources more wisely, especially as millions more get health insurance coverage. But changing the system for developing guidelines is only one piece of the puzzle, as we saw in the mammography example. Doctors aren’t the only ones who have to buy into a new way of doing things. The rest of us: the non-experts, non-clinicians, aka, patients must also understand and support this approach.

Any clinician who perceives financial harm from a clinical recommendation to do less is likely to complain – loudly – and try to enlist their patients to do so as well. If we are not on board with two things: (1) more care is not necessarily better care, and (2) motives should be questioned when those arguing for more (or less) care have financial incentives to do so, we had better be prepared for ever-increasing health care spending. Without a doubt, we will never, ever be able to fundamentally address health care spending without embracing these two premises.

This week our Center is releasing a report on geographic variation in health care use in Michigan. Geographic variation in the use of health care services has been well described in the literature for more than 20 years now. Jack Wennberg pioneered this kind of systematic analysis at Dartmouth and has been reporting this data on an ongoing basis looking at the Medicare population. In 1997, Jack partnered with Blue Cross and Blue Shield of Michigan to do the same kind of analysis looking at a commercial, under 65 year old population. The report in Michigan got a lot of attention when it was released in 2000 – and sparked some interesting community dialogs including one in Grosse Pointe, Michigan about why their rates of use for ADHD drugs was so high (highest in the state).

Earlier this year we decided that it was time to do a 10 year snapshot and see what has changed – and what hasn’t – since the report was first released. And, we did, indeed find some very interesting things. On the good news side of the equation, we found that overall use rates for diagnostic and interventional cardiac procedures went down. This compares favorably to trends elsewhere in the country: most recent national data shows an increase in use rates for the three services combined.

The data on cardiac care shows us what’s possible: we truly believe that there is a connection to the fact that there is now less surgical intervention for cardiac care in Michigan because of an effort that was started in 1996 between Blue Cross and Blue Shield of Michigan and the University of Michigan in partnership with all hospitals performing cardiac procedures in the state. In that partnership, called a Collaborative Quality Initiative (CQI), use trend data and best practices information is shared between clinicians performing these procedures. The dialogue in that process focuses on quality improvement. The 10 year data we see in the CHRT geographic variation report gives us some indicators about the power of this approach and its ability to affect practice patterns across the state.

Some concerning findings in the report include the very significant increase in the percentage of babies in the state now born by Cesarean section (up from 22.9 percent in 1997 to 34 percent of all Blue Cross births in 2008) and the high rates of use in some areas of the state on virtually every procedure studied (Saginaw, the “Thumb”).

The issue of Cesarean sections is national – indeed, global – and of significant public health concern. Healthy People 2010 set a goal of no more than 12 percent of births by C-section in the US by 2010. Our data (among other national studies) show that not only was that goal not achieved, but, that the trends are all in the wrong direction. This finding calls out for a CQI or other similar effort to better understand why and what could be done about it.

The reasons behind second issue of concern, the high rates of use in some regions compared to others on almost every procedure, are less clear. To the best of our ability, we adjusted the data for patient demographics: age, gender and severity of illness. So, it should not be patient characteristics that results in this variation. We will do more studies on some potential issues that might be contributing to those use differences and now that this data is available, we hope that practitioners in those areas will also consider what might be driving these differences.

Finally, there are gems in the data that should trigger some deeper looks at what is happening in the community. For example, 10 years ago, St Joseph, Michigan had the lowest rate of angioplasty in the state; today, they have one of the highest. It isn’t because their rates actually went up. Rather, the whole rest of the state came down while rates in St Joe’s didn’t change. Why not? What is happening in that community that resulted in a different trajectory than the rest of the state? That’s the kind of question that we hope this study – and others to follow – will spark.

September 23, 2010 may well prove to be a particularly important day in the health care reform journey. On that day, six months after the Affordable Care Act was signed into law, several key provisions went into effect that were designed to help people see some immediate benefits in advance of the full blown implementation of the law starting in 2014. The most significant provisions that went into effect included the:

• End to lifetime limits on health benefits;

• Ability of young adults to stay on their parent’s health policies until age 26 regardless of whether or not they are legally dependent on their parents;

• Prohibition of the exclusion of children from health coverage based on pre-existing conditions;

• Requirement that certain preventive services be include in health benefit plans without copays or deductibles; and,

• Beginning of the phase out of annual limits on health benefits.

The first two provisions are likely to have the most positive, short term impact on individuals and families. The first provision will most particularly affect a small but important segment of the population – those with a serious disease. These are individuals who have diseases like hemophilia, where the cost of the clotting factor necessary to sustain life is in excess of $50,000 per year. Or, those like the family profiled in the New York Times on Sept 23, 2010 whose daughter was born with spinal muscular atrophy and whose care had cost more than $2 million by the time she was three. These are individuals and families who have been desperate for this provision to take effect so they no longer have to fear that they will run out of benefits when they need it the most.

Young adults and parents of those to age 26 are another segment of the population that has been looking forward to the  six month anniversary of health care reform. Families USA has estimated that the ability to stay on a parent’s health policy will affect two million young adults in the country (33,000 here in Michigan). In talks I have done on health care reform, I have had employers – those who purchase health benefits – come up to me to tell me that they have just been waiting for this provision to take effect so that they can get affordable coverage for their own children. They felt they could not make this change in their health benefit plans unilaterally but are looking forward to this now since all plans (i.e., all employers) are equally affected.

These are the kinds of stories the architects of the health reform law have been waiting for in hopes that they will help the public see the benefits of the law. But, it’s too soon to tell and there are some concerning signs that this might not be the case.

First of all, other provisions of the law went into effect over the summer/early fall and did not have the kind of positive effect on public opinion that many had hoped. These included $250 rebate checks to senior citizens who had reached the “doughnut hole” in their prescription drug coverage and the launch of the temporary high risk pools designed to help people who had been excluded from coverage due to pre-existing conditions. These were important provisions of the Affordable Care Act but did not seem to register with people as having resulted from health reform.

The second concerning sign has been the reaction of some for-profit insurers to the new provision. Some of these health insurers greeted September 23 by announcing the elimination of “child only” policies, resulting in the loss of coverage for some children. When families called to express their concern, they were told that they should “blame [loss of coverage] on President Obama.” And, while this should no longer be an issue come 2014, four years is a long time for many families to wait for affordable health coverage.

It is hard to tell at this moment whether the positives that many families will experience from the provisions that went into effect on September 23 will be enough to offset the confusion and negative press that has been the focal point of much of the coverage of health reform to date (exacerbated by the politics of the mid-term elections). But, it is certain that one way or the other, September 23, 2010 was an important date in ever unfolding story of health reform and the Affordable Care Act.

September 23, 2010 marks six months since our new national health care reform law, also known as the Patient Protection and Affordable Care Act (PPACA), became effective. It remains a controversial undertaking for some, yet a positive step for others. The law’s implementation is a long and complex journey.

Much of the spotlight has been on PPACA reforms that begin in 2014, such as:

• A requirement for American residents to have health insurance

• Expansion of Medicaid

• New health insurance “Exchanges” where people can compare and shop for insurance

• Financial subsidies to help people pay for health insurance in the Exchange

• Penalties for many businesses that do not provide health insurance for their employees

• Insurance reforms–such as requiring insurers to offer coverage to everyone, regardless of health status, and prohibiting using a person’s health status as a factor in premium rates

But some pretty significant reforms have already taken place – some tied to the six-month mark – and I wanted to highlight them for you because they may be helpful to you and your families. Please spread the word!

A new website was created by the federal government to provide information to consumers and small businesses about their insurance options. People can also determine if they may be eligible for existing public programs, including Pre-existing Condition Insurance Pools, Medicaid, Medicare and the Children’s Health Insurance Program. This website does not allow consumers to buy insurance, but instead is a tool that provides information until the new insurance Exchanges start in 2014. Click here to access the website: http://www.healthcare.gov/

A new “Pre-existing Condition Insurance Pool” program, or PCIP, was created for adults with pre-existing medical conditions who have been uninsured for at least the past six months. The PCIP will end Jan. 1, 2014 when the Exchanges begin, and people in the PCIP will then transition to the Exchange for their insurance coverage. Eligible Michigan residents can apply today for coverage in the Michigan PCIP for coverage slated to begin Oct. 1, 2010. The monthly insurance premiums are set at a price for the standard population–not for a population with medical conditions. Out-of-pocket costs are capped for PCIP participants. Visit the website of the Michigan Department of Energy, Labor, and Economic Growth’s Office of Financial and Insurance Regulation for more information.

Tremendous efforts are underway by insurers and businesses to implement “near-term” insurance reforms that take effect with plan years beginning on or after Sept. 23, 2010. For many insured individuals, the “plan year” begins on Jan. 1, 2011, but you should check on your plan year date. “Near-term“ insurance reforms you may be interested in include:

Dependent coverage extended to age 26: If coverage is offered for employees’ children, eligibility must be extended to married or unmarried children of covered employees up to age 26. “Grandfathered plans” that existed on or before Mar. 23, 2010 have to do this for adult children up to age 26 who are not eligible for employer-sponsored coverage elsewhere. Starting in 2014, dependents up to age 26 must be allowed to be covered on their parents’ policy even if they have access to employer-sponsored health coverage.

No lifetime limits or restrictive annual limits: There are no lifetime limits allowed on essential health benefits, and annual limits on essential benefits must be phased out by 2014. Please note that the federal government has not yet fully defined “essential health benefits.”

No pre-existing condition exclusion period for people under age 19: During a specified enrollment period, children under age 19 cannot be denied coverage due to a pre-existing condition, nor can there be any periods where medical services related to that pre-existing condition are not covered. In 2014, PPACA requires all insurers to guarantee insurance coverage to all individuals without charging higher amounts based on a person’s health status. In Michigan, BCBSM has acted as the state’s insurer of last resort and has always accepted anyone, regardless of health status.

Prohibiting rescissions with limited exceptions: Health coverage cannot be rescinded except in cases of fraud or material misrepresentation. Rescinding means retroactively voiding the health insurance contract. As a side note, BCBSM has never rescinded policies for any reason other than fraud or material misrepresentation.

Preventive services with no cost-sharing: Certain preventive services must be included in health care coverage–without cost-sharing. This includes a large list of screenings, immunizations, and other services recommended by entities such as the U.S. Preventive Services Task Force, a Centers for Disease Control advisory committee, and the federal Health Resources and Services Administration.

Emergency services without prior authorization & cost sharing: If emergency services are a covered benefit, prior authorization for these services cannot be required. Also, cost sharing required to be paid by the insured individual for services provided by nonparticipating health care providers cannot be more than for participating providers.

These immediate and near-term insurance changes mark the beginning of health reform’s impact on all of us. Whether you are a Blues member or not, please check out our company’s health care reform website for some valuable information about reform. And for the policy wonks out there, you can find a comprehensive summary of PPACA on the Kaiser Family Foundation site and two related CHRT publications on this website: a policy brief on state and local opportunities in the Act, and an issue brief on the impact of reform on coverage in Michigan.

Good health to you all.

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Lynda Rossi is vice president of Public Policy and Social Mission for Blue Cross Blue Shield of Michigan and a member of the CHRT board of directors.

This week, the esteemed journal Health Affairs published the latest findings from the office of the Chief Actuary of the Centers for Medicare and Medicaid Services (CMS), with new estimates on the cost impact of the Affordable Care Act (ACA).

CMS actuaries are now projecting that annual growth in health spending for 2010-2019 will be 0.2 percent higher than projections before the ACA was passed, and the health care share of the GDP in 2019 will be 0.3 percent higher than what would have been likely without the law. This article triggered extensive press coverage.

Depending on your perspective, press coverage either proved the ACA wasn’t going to do enough, or that the ACA wasn’t going to make things worse. And not surprisingly, since we are in the political season, those opposed to the ACA jumped on the numbers and supporters of the ACA were characterized as “beleaguered” by the latest “bad” report on health care reform.

Neither angle on this study gave any sense that there might be some positive news about the ACA in the report from the actuaries. In contrast, I see a very different story line in this study than told by any of the news reports.

To understand the full import of the report by the CMS actuaries, it is very important to understand the health care spending trends in different chunks of time. That is, the actuaries took into account several major pre-2014 legislative changes to come up with their projected cost trends. While the pre-2014 trends are somewhat influenced by the ACA (namely the implementation of the high risk pools and the extension of dependent coverage to those up to age 26), two other major legislative changes unrelated to the ACA are also affecting cost trends: changes made to the physician Sustainable Growth Formula and the extension of COBRA coverage subsidies through 2010. From 2014 to 2019, a considerable portion of the increase in spending has to do with major coverage expansions that start in 2014. Then, starting in 2018, one of the biggest changes relating to health care spending in the law takes effect: the excise tax on high cost health plans. The actual words in the Health Affairs article are important:

“For 2015–19, national health spending is now projected to increase 6.7 percent per year, on average—slightly less than the 6.8 percent average annual growth rate projected in February 2010. However, the year-by-year pattern of growth is anticipated to be different …. Enrollment shifts associated with the Affordable Care Act coverage expansions are projected to continue, contributing to continuing relatively faster spending growth rates through 2016. Thereafter, spending growth is projected to decelerate more substantially as a result of Affordable Care Act–mandated reductions to Medicare provider payment updates and the excise tax on high-cost insurance plans starting in 2018.” (Page 4)

In other words, the growth in national spending from 2014-2019 was expected and is principally because more people will be getting coverage. And in case we have forgotten, reducing the number of uninsured is a good thing – it should be seen as a positive accomplishment of the ACA. The fact that the numbers of the uninsured can be reduced to such a significant degree and have only a marginal impact on cost trends is actually quite remarkable. Post 2018, if the policies hold as currently envisioned in the ACA, actuaries are predicting substantial decelerations in health care spending as a result of the ACA. That is also a very positive statement about the ACA. None of these messages came through in the press reports on this study. But, these are important facts to understand and if we are going to make informed policy, it is essential to truly understand the details in this study.

So – hello! Calling all proponents of the ACA: Politics got you down? How about going for the facts?

Labor Day ought to be a time to think and reflect on one’s work. This Labor Day I found myself thinking about this blog and the form of communication it represents. At the end of August, the New York Times ran an article about a change in the approach to publishing scholarly work in the humanities. The opening line of the article says:

“For professors, publishing in elite journals is an unavoidable part of university life. The grueling process of subjecting work to the up-or-down judgment of credentialed scholarly peers has been a cornerstone of academic culture since at least the mid-20th century.”

The article goes on to talk about some new approaches being tried in the humanities to publish in a more open environment: using the Internet to quickly get information out and get much broader feedback. Myriad new approaches are being tried for scholars to share their work on the web, get feedback, and broaden the dialog about whatever they are writing about. While the article is focused on the humanities, it raised a question in my mind about why such an approach couldn’t be used in other disciplines, such as health policy.

There is no question that peer review serves a valuable function of helping readers have confidence that an article has been assessed and found worthy by those knowledgeable in the field. It’s a kind of vetting process that can be very useful, and as noted in the New York Times, came about as a way of increasing the professionalism of academic disciplines.

At the same time, however, it is an extremely limiting process: many more articles are submitted for publication than ever see the light of day. And, while in some cases that may be because the articles were flawed in some fundamental way, it may also be simply because the article wasn’t on a topic relevant to or in a style appropriate for the journal to which it was submitted.

The traditional approach to vetting scholarly work is also a very lengthy: findings/insights are often delayed in reaching the public for six months to a year while articles are in review.

At CHRT, we have thought about whether we want to try and publish our work in traditional journals or distribute them through other means. For the most part, we have come down on the side of publishing the works ourselves and distributing the information widely. And, to date, our experience is that many more people are seeing and using our work (and, more quickly) than if we had waited to try and get it accepted in peer reviewed journals.

There is certainly a place for traditional journals and many of them are experimenting with getting things to the public more quickly. But, to do so, they have a tendency to rely on those individuals/scholars that they already know and whose work has already been established. While that can have great benefits in terms of quality control, it can also be enormously limiting in terms of bringing new voices and approaches to the table.

The challenges we face in health care are immediate and the answers aren’t clear: particularly when it comes to ideas to increase the quality of care, improve population health, and moderate cost trends. Being able to learn from others about what works and what has been tried is essential if we are going to make progress on these issues. And, in that context, those in health policy can learn from our colleagues in the humanities: new approaches to communication that distribute information quickly and widely and allow the reader to judge whether the information is of value may be just what we need to truly make progress.

There is an increasing consensus that many high tech radiology procedures are overused but no agreement on what to do about it.

An important review study reported in the Archive of Internal Medicine concluded that exposure to even one CT scan can produce cancer later in life. The editorial in the Archive notes that every day more than 19,500 CT scans are done in the U.S. and that almost 70 percent of non-elderly adults received a CT scan within a three year period. That amount is stunning, especially when there are no clear data to support the value of these scans in improving outcomes or quality of care. The studies reported in the Archive concluded that the sheer volume of CT scanning being done, combined with the variability in radiation exposure between machines and providers, has led to thousands of excess cancers and deaths.

So, given that we have known this for some time, why isn’t the picture changing? Steve Hillman and Jeff Goldsmith provided an important perspective on this issue in a recent New England Journal of Medicine.

Among both patients and providers in the U.S. there is an assumption that more is better. More treatment and more diagnostic tests are presumed by both patients and physicians to produce better outcomes. Whenever there is a recommendation to stop or refrain from doing things — e.g., watchful waiting vs. surgical intervention for men with prostate disease, allowing a virus to run its course rather than prescribing an unneeded antibiotic, recommending palliative vs. therapeutic care in the terminally ill, or not doing testing at all for those with low back pain, there is an outcry that someone, somewhere is withholding needed care.

Witness the outcry about recent recommendations related to mammograms, or the charges of rationing when policy makers encourage the use of care based on evidence. In particular, when recommendations like these come from health insurers or the government there is a belief that the recommendations are just ploys to reduce spending so that someone else (greedy health plans?) can benefit. It is interesting to note that device makers, practitioners, and others who have a clear and direct economic interest in doing more don’t come under the same kind of public scrutiny as academics and others who argue – based on evidence – for doing less.

In fact, years of research tell us that in many cases conservative approaches to medical care actually result in better patient outcomes than do aggressive interventions. A backlash against these evidence-based recommendations can put both the short and long term health/well being of patients at risk.

Why do so many in the U.S. equate good medical care with more medical care? Much of this belief is founded and grounded in deep-seated American values. America: land of opportunity and endless possibilities. America: home of entrepreneurs and inventors of new things. America: where we prize individual achievement pulling ourselves up by our boot straps, Horatio Alger style. Our natural optimism and belief in all things possible combined with baby boomers’ “live forever or die trying” ethic lead some to believe – deep in their hearts – that death is optional.

Indeed, many of the things that make this country great also conspire to lead us down a path of greater and greater consumption in the search for ways to avoid the inevitable. There are many who hope the Affordable Care Act will change this picture. But if health policy makers are going to change the trajectory of health care spending, they must also understand the values and beliefs that underlie it.

Policy wonks beware: change will be more difficult than you think.

The Affordable Care Act was signed into law on March 23, 2010. As health care reform is implemented and the United States continues to devote extensive resources to health care; there are real opportunities to improve health care quality and equity by improving pain care. Specifically, pain research practice and policy can substantively inform the broader national health care policy debate (Green 2008). Pain has reached epidemic proportions with nearly 100 million Americans living with acute, chronic, cancer pain or pain due to a terminal illness. Yet pain is a silent epidemic, and pain care is plagued by problems with access, assessment, treatment, quality, and disparities (Green, Anderson et al. 2003). Aging baby boomers and increased survival from catastrophic injuries, cancer, and diabetes will yield dramatic increases in the prevalence of pain and has long term implications on the nation’s health and well-being. The epidemic coincides with problems in health care access, quality, and disparities. Thus, undiagnosed, untreated, and under-treated pain is a significant public health problem.

Overall, pain complaints are a leading cause for all physician visits, health care costs, and disability in the United States. A recent issue brief from the Center for Healthcare Research and Transformation highlights the cost of pain in Michigan and the nation, as well as gender differences. Several of the most frequent diagnoses and costliest procedures were due to pain, with Vicoden™ the most commonly prescribed medication. Clearly PAIN should be getting our attention! Pain is a thief in the night that steals America’s mental health, sleep, economic productivity, physical health, and family relationships. The physical, societal, and emotional cost of pain are particularly important as the U.S. ages and diversifies.

Currently, individuals greater than 65 years old use more medications to control pain than any other segment of the population. Racial, ethnic, gender, age, class, and community-related differences in the pain experience are well documented with the pain complaints of minorities, women, and the elderly receiving less attention and lesser quality care (Green, Ndao-Brumblay et al. 2005). Thus, a tsunami of pain is approaching. Altogether these findings illustrate considerable structural barriers to quality pain care and highlight the significant public health and health policy implications. However, a clear disconnect exists between the goals for pain relief and the funding. Without needed improvements in pain assessment and treatment as well as managing the co-morbidities accompanying pain such as sleep disturbance, depression, anxiety, and disability, the increasing prevalence of pain will have devastating socioeconomic implications for all Americans. Thus, pain care provides many opportunities to direct health and social policy but state and federal funding and attention is lacking.

It is imperative that pain is included in a substantive manner in ongoing discussions regarding health care reform, continuing education for health care professionals, and public discourse. Optimizing pain care is a neglected topic in medicine with most health professionals receiving minimal education. The Joint Commission on Accreditation of Hospitals and Healthcare Organizations and others (e.g., VA) elevated pain to a health system priority. However, there is a significant gap between the health care dollars spent on doctor’s visits, medications, lost work productivity, worker’s compensation, and long term disability due to pain complaints, when compared to dollars spent on primary prevention and research (Green 2008). There is considerable variability in clinician education and knowledge, attitudes, and decision-making; complicating efforts designed to improve the quality of health and pain care. These factors contribute to suboptimal pain assessment and treatment yielding several challenges for health care planning.

The good news is that policy makers were listening to the voices of millions of people living with pain when they included the National Pain Care Policy Act within the Affordable Care Act, thereby providing hope for an interdisciplinary agenda designed to improve the science and reduce the burden of pain for millions of Americans and their families. The bad news is that this portion of the law was authorized but not appropriated. Thus, Congress must appropriately fund and make a worthwhile investment in a comprehensive pain care and research agenda to improve the health and well-being of millions of Americans living with pain. Substantial improvements in health and reductions in disability are achievable by delivering high quality, high value, and equitable pain care. The failure to commit to a worthwhile investment in a comprehensive pain agenda will have long lasting socio-economic consequences for our nation.

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Carmen Green is a Professor of Anesthesiology, Professor of Obstetrics and Gynecology, and Professor of Health Management and Policy at the U-M Medical School and a member of CHRT’s board of directors.

Other Resources

• The Healthcare Imperative: Lowering Costs and Improving Outcomes: Brief Summary of a Workshop
• Future Directions for the National Healthcare Quality and Disparities Reports
• Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care
• Coverage Matters: Insurance and Health Care

References

1. Green, C. R. (2008). “The Healthcare Bubble through the Lens of Pain Research, Practice, and Policy: Advice to the New President and Congress. Editorial.” The Journal of Pain 9(12): 1071-1073.

2. Green, C. R., K. O. Anderson, et al. (2003). “The Unequal Burden of Pain: Confronting Racial and Ethnic Disparities in Pain.” Pain Medicine 4(3): 277-294.

3. Green, C. R., S. K. Ndao-Brumblay, et al. (2005). “Differences in Prescription Opioid Analgesic Availability: Comparing Minority and White Pharmacies across Michigan.” The Journal of Pain 6(10): 689-699.