As we've written a lot on end of life care, we notice when others do the same. NPR's Joseph Shapiro this week reported on La Crosse, WI where 96 percent of the adults who die have an advanced directive. That extraordinarily high figure arises from the innovations and commitment from Gundersen Lutheran hospital. Careful, sensitive discussions by trained doctors and nurses -- they use a 12 page guide -- is time consuming. Medicare doesn't reimburse them for that time, A provision in the House health care bill would change that -- the provision that was caricaturized as a "death panel." The Senate bill doesn't contain it.
Be careful what you wish for! Maggie Mahar, who writes the Century Foundation's Healthbeat blog, had a piece in the Washington Post's Sunday Outlook section calling for a public plan option -- but telling progressives who had yearned for a fully single payer system to visualize the downside. Just imagine, she wrote, if a movement conservative like Sarah Palin ends up making the rules. That could make the current controversy about abortion in the health insurance exchange seem tame. What about coverage of contraceptives? Or the ability to decline life support? Think the government wouldn't intrude on such sensitive private decisions? Ever heard of Terri Schiavo?
Of course, we do usually have checks and balances in our system. The party that controls the White House doesn't always control Congress, and it's even rarer for one party to control the White House, the House and a filibuster-proof Senate. And as anyone who has watched the long and winding road of President Obama's health reform agenda, even a filibuster-proof Senate has a mind (and politics) of its own. Still, Maggie makes a point:
We just posted on some of the measures within the House and Senate bills that may help lead us to improved care for people at the end of life. Here, Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., returns as a guest poster to tell us what it all means for his patients -- and the doctors who treat them. Byock, the author of Dying Well, has written for us before about the need to think more broadly about what kind of changes we need in our health care system -- and our communities -- to do a better job of caring for sick and frail people trying to get by in their homes.
We've often cited estimates from the Dartmouth Atlas and others that about one out of every three dollars we spend on health care (which adds up to about $700 billion) adds no value whatsoever to our health. Zilch. Now a paper from Healthcare Analytics at Thomson Reuters confirms that figure, estimating that we waste between $600 and $850 billion a year:
In this white paper, we present evidence that supports the reasonableness of these claims. This evidence has been gathered from published research studies, expert opinion, and findings from our own Thomson Reuters analyses of our large healthcare databases. We describe the types of waste that are recognized by most experts along with estimates of the magnitude of that waste.
Robert Kelley, vice president of healthcare analytics at Thomson Reuters and author of the white paper said, "By attacking waste, healthcare costs can be reduced without adversely affecting the quality of care or access to care." (A copy of the full report is attached below. Here's a summary)
Here are some of the study's key findings and how they categorize the waste:
If you wonder why we now spend about $147 billion a year on the medical costs of obesity (double what we spent a decade ago) here's a clue:
In Miami for a workshop this weekend, I woke up early and made my way to the small hotel gym. Few machines, and even fewer working machines. The one I wanted was occupied. I mean occupied, not in use. A woman was sitting ON it. Watching TV. When her show was over, she left.
When there's health reform smoke, there's tort reform fire. Or something like that.
Senator Orrin Hatch (R-Utah) requested that the Congressional Budget Office update its analysis of how certain (GOP) tort reform proposals could affect annual health care spending. The updated CBO numbers are greater than 2008 estimates (page 21 of that long report) -- when CBO found that lowering premiums for medical liability insurance would reduce annual national health care expenditure by 0.2 percent. The impact tort reform would have on annual health care spending remains a controversial matter. And of course how to define and achieve malpractice reform is also in dispute.
We aren't really "public health" bloggers but given that today is flu shot day at New America -- a few quick thoughts.
First, Michael Specter had a good short piece in the New Yorker, the "Fear Factor." He notes that it is hard to strike that correct balance between "comfort and terror" and that "fear spreads as quickly as any virus."
Nobody can predict the ways in which a new influenza virus will mutate, or how virulent it may become... With too much reassurance, people ignore the threat; with too little, they panic. The W.H.O. decided, sensibly enough, to emphasize the risks of pandemic. Then the summer months arrived, and for a while, with schools closed, the threat seemed to fade.
That hiatus provided an opening for the anti-vaccine, anti-government, and anti-science crowd, and they stormed through.
Also the ACP web site told us about this interesting program:
Hmm. New America is doing a flu shot clinic (seasonal, not swine) at the office this week, I believe for the first time.
Apparently, only two of us in the health policy program (you know, the ones who write about prevention and wellness) have signed up for this free service.
Maybe everyone else already got theirs.
With Baucus's bill now out, there will be ample and we expect acrimonious debate about subsidy levels and affordability, the mechanics of the insurance exchange, the financing, and of course the lack of a public plan option. (We wonder if the recent survey showing how popular the public plan is among US doctors will have a discernible impact.)
But we wanted to point out some of the less controversial measures (if there is such a thing as uncontroversial after this summer) that touch on some of the topics we've been writing about that aim, simply, to keep us healthy, or to reduce avoidable complications and deterioration when we get sick. As Sen. Baucus himself put it, steps toward changing how we deliver and pay for health care are often overlooked in the national debate but can have a "transformative" effect on enhancing quality while holding down costs.
Preventive care will get more emphasis, and Medicare patients won't have a co-pay for certain screening tests and preventive services proven to be effective. Medicare patients would also get a "wellness visit" annually (which isn't covered now.)
We posted twice today about cost trends in the employer-sponsored insurance, and it brought to mind some comments Dallas Salisbury, CEO of the Employee Benefit Research Institute, made at a recent Alliance for Health Reform briefing, called "The Next 100 Days: Some Final Hurdles to Health Reform " (He spoke from a vantage point a few days before President Obama's speech to Congress)
Plan A, simply stated, was to pass President Clinton's health reform plan after reshaping it more to business's liking. If that failed, Plan B was to kill it. Plan B, as we all recall, prevailed.
This time around, Salisbury said, there is no Plan B.