1. The Doctor Is In Donald Berwick, Harvard Medical School professor, physician, and head of the Institute for Health Care Improvement, was given a recess appointment last week by President Obama to fill perhaps the most important position that determines if health care reform will succeed: chief administrator of the Centers for Medicare and Medicaid Services (CMS). The President nominated him in April, to almost unanimous acclaim by health care experts, including former Republican leaders of this agency. As Maggie Mahar, in her June 28 Health Beat blog, noted:

"Berwick enjoys support that ranges from the AARP to three former directors of the Centers for Medicare and Medicaid (CMS) who served under Republican presidents. "This is not really about Don Berwick," John Rother, executive vice president for policy and strategy at the AARP told McClatchy Newspapers. "In ordinary times, the nomination of somebody with Don's record and standing in the field would not be controversial." Thomas Scully, who led the CMS under President George W. Bush, agrees: "He's universally regarded and a thoughtful guy who is not partisan. I think it's more about... the health care bill. You could nominate Gandhi to be head of CMS and that would be controversial right now."

Berwick also enjoys warm endorsements from the American Association of Family Physicians, the American Medical Association, and the American Hospital Association. He is known for his ability to listen to other medical professionals, hear their concerns, and collaborate with them."
(click here)

Mahar's column provides a fascinating analysis of how even supposedly impartial reporters like New York Times' Robert Pear have used suggestive language describing Berwick that play into the hands of those claiming that he will encourage "rationing" of health care.

So, as reported on July 6 in Politico (click here), Republicans were preparing to stall his appointment and use the hearings to relaunch a debate about the health reform bill:

"His nomination has drawn vicious criticism from Republicans, who have seized on his professed admiration for Britain's National Health Service as an 'example' for the United States to follow.

'Many Republicans in Congress have made it clear in recent weeks that they were going to stall the nomination as long as they could, solely to score political points,' White House communications director Dan Pfeiffer wrote Tuesday on the White House blog.

'With the agency facing new responsibilities to protect seniors' care under the Affordable Care Act, there's no time to waste with Washington game-playing. That's why tomorrow the president will use a recess appointment to put Dr. Berwick at the agency's helm and provide strong leadership for the Medicare program without delay.'"

As head of CMS, Berwick not only need to manage the two programs covering about 80 million people and responsible for the greatest concern about federal and state budget deficits. But, as the largest payer of health care services, he will be able to use these programs to drive changes throughout the health care delivery system, promoting the efficiencies that should result in both improved care and lower costs. As we noted several times last year, many studies and simple comparisons with the cost of health care in other industrialized countries, suggest that a third to half our costs are wasted.

Washington Post columnist David Ignatius endorsed the recess appointment in his July 9 column (click here): "Obama was positively dictatorial about it. Rather than wait through a protracted confirmation process and another Republican circus about "death panels" and "rationing" of care, he pushed through a "recess appointment" of Dr. Donald Berwick as administrator of the Centers for Medicare and Medicaid Services (CMS), which oversees how these giant programs spend their hundreds of billions.

Berwick's specialty is studying how the system can provide better care at lower cost. His nomination, announced in April, had been held up partly by a bogus debate about funding for his Institute for Healthcare Improvement, a nonprofit think tank in Cambridge, Mass., where Berwick is also a professor at Harvard Medical School.

The CMS post has been unfilled since 2006 and Obama finally decided enough, already. The White House said Republicans "were going to stall the nomination as long as they could, solely to score political points." This is one job that truly can't wait: The longer we delay efforts to cut costs, the worse the health-care mess will be.

In a rational world, Republicans -- caring about the fiscal dangers for the country if we don't reform the delivery system -- would have endorsed Berwick's nomination by acclamation. But Washington isn't a rational world...

One of the good features of Obamacare (redeeming its many flaws) is that it mandates such experiments in the public health-care programs. As Atul Gawande noted several months ago in one of his superb New Yorker essays, such a process of experimentation makes more sense right now than trying to impose, at one stroke, a change in the nation's entrenched culture of fee-for-service health care. Such pilot programs will demonstrate what works -- and build momentum for comprehensive change.

That's Berwick's challenge -- to encourage an urgent process of innovation. If you want a sense of what he will bring to the job, check out the web site of his institute (http://ihi.org). He describes some of the ideas he has been developing over the past several decades for implementing change. The list includes "breakthrough series collaboratives" to share knowledge; "bundles" of procedures that establish protocols for treating common problems; the use of medical records to better forecast bad events; and the use of operations research to improve the efficiency of emergency rooms.

These experiments will take the nation into new and difficult territory. The system that's coming is one in which doctors won't be so quick to order tests and procedures; it will force us to take better care of ourselves; it will require that we plan how we want to be treated at the end of our lives.

Republican critics who claim to be worried about funding for Berwick's institute can review online its detailed rules for avoiding real or perceived conflicts of interest, and its refusal of funds that are linked to specific drugs, medical devices or diagnostic tools. Members of Congress might consider adopting similar ethical standards."

One of the false criticisms of Dr. Berwick by Republicans in Congress is that he really wants to move us to something like the British national health care system. But as Maggie Mahar, in her Health Beat blog, explains, Berwick simply made some positive comments about certain aspects of the British system when he was invited to speak at a conference celebrating its 50th anniversary. Of course, he would focus on some positive elements when invited to speak at such an occasion, and of course the Republicans have lifted some of his remarks out of context. For a full assessment of Berwick's real "patient-centered" philosophy, read Mahar's column (click here).

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2. Malpractice Reform - At A Deliberate Pace Despite claims by opponents of the final health bill that malpractice reform was being ignored, the bill enacted does address this area of reform. Since states already govern malpractice legislation and there is no consensus on what should be done in the first place, the intent of the reform bill was to implement several pilot projects to test different approaches – probably too subtle a concept for some news outlets to try to do a story on. So on June 11, the administration announced 20 grants to various states by the federal Agency for Healthcare Research and Quality (AHRQ) to rigorously test and collect data.

According to a White House blog post by Dr. Ezekiel Emanuel:

"The grants were praised by J. James Rohack, M.D., the President of the American Medical Association who said "The AMA is pleased that federal medical liability reform demonstration projects are quickly moving forward, with $25 million in grants to state programs announced today."


The HHS Patient Safety and Medical Liability initiative program represents the largest investment in malpractice reform by the Federal government in at least 20 years. It will give states and health systems the information they need to improve their malpractice systems, making them more fair and efficient for both patients and doctors.

Read the full post, click here.

A recent report based on a survey conducted last year by the Archives of Internal Medicine suggests that fear of lawsuits is still a big concern of physicians. The results:

"The survey asked two questions: "Do physicians order more tests and procedures than patients need to protect themselves from malpractice suits?" And, "Are protections against unwarranted malpractice lawsuits needed to decrease the unnecessary use of diagnostic tests?" Overall, 91 percent of doctors surveyed agreed with both statements."

Read more, click here.

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3. Most Backward State Contest Implementation of health reform may be proceeding on track in some ways. But 21 states are doing their best to maintain the status quo, thanks to politicians who now oppose individual responsibility (but didn't in the legislation that their party proposed in the early 1990s). They claim to be defending the "right" of individuals to go without health insurance (or, as they call it, not to buy a product) and instead mooch off the contributions and taxes of others when they turn up in the emergency room for free care, as required by most states. (Perhaps they have the right to refuse to pay taxes for fire and police protection and schools as well).

A July 1 New York Times article summarized the latest developments, starting with a federal district judge's hearing of a lawsuit filed by the Commonwealth of Virginia. The judge said he would issue a ruling by the end of the month. Then 20 other states will begin a joint hearing in September.

Read more, click here.

Meanwhile, as Princeton economics professor and health care expert Uwe Reinhardt notes in his New York Times blog on June 25:

"The current, vehement opposition from Republicans to the mandate stuns me. After all, there was a time, in the 1990s, when prominent health-policy analysts allied with Republicans in Congress fully endorsed the idea of the mandate, as did the officeholders whom they advised.

... four Republican co-sponsors [of the main Republican bill proposed in 2003] -- Robert Bennett and Orrin Hatch of Utah, Charles Grassley of Iowa, and Christopher Bond of Missouri -- remain in the Senate today."

How times have changed! In any case, Reinhardt suggests a two-part fall-back approach if the state challenges go through: 

• Auto-enrollment (where everyone is assumed to be enrolled for at least the minimum plan available), with the opportunity to opt out or elect a richer plan, and
• Anyone opting out, must sign a formal acknowledgement "that they will forfeit for a number of years the right to purchase health insurance on the terms provided for in the recent legislation. [Princeton colleague] Professor [Paul] Starr proposed a five-year period.

Those who choose to opt out would then find themselves for at least five years (and possibly longer) in today's insurance market -- without guaranteed issue, without community rating, without public subsidies and with very rapidly rising premiums."

Read more, click here. Also, Reinhardt's preceding blog on June 11 explains why the mandate is needed if we want to require insurance companies to accept all enrollees, use community rating (vs. rating each individual by health status and risk factors). Click here.

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4. Health Care Reform May Spur Coverage of Contraceptives According to a July 6 Washington Post article (click here), the new requirement under the health care reform law to cover preventive services in full, starting on plan anniversaries on or after Sept. 23, might spur consumers to push for full coverage for contraceptives:

Many people, including women's health advocates and some employer groups, think contraception should be one of the required free services.

"It's basic preventive health care," says Laura Hessburg, a senior health policy adviser at the National Partnership for Women and Families. Among other health benefits, women who plan their pregnancies are more likely to get necessary prenatal care and avoid closely spaced births, which can put a strain on their bodies and their parenting skills, and may result in low-birth-weight babies.

Many health plans already cover prescription contraceptives. Twenty-seven states have laws that require some level of coverage. Improving access and coverage even further could help reduce the estimated 3 million pregnancies a year that are unplanned...

Many employers support covering contraception because it ultimately saves them money: Even the priciest birth control is a lot cheaper than the $8,000-to-$11,000 price tag for an employee's prenatal and maternity care. "We don't think there's any benefit to cost-sharing on contraceptives," says Helen Darling, president of the National Business Group on Health, which represents large employers...

A PriceWaterhouseCoopers study commissioned by NBGH estimated that the cost to health plans of providing preventive family planning services is about $40 per member annually. A typical family [health care] policy costs about $13,000 a year.

Sounds like a real bargain.

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5. The VA System - Government Can Get Things Right It was noted last year, but a recent article on the CBS Market Watch financial web site provides more evidence that the government can do some things right: the Veterans' Administration consistently provides the highest quality care in the U.S. The article notes that:

"The VA has its own system-wide electronic health record, sophisticated quality-measurement tools, a coordinated approach to care, long relationships with patients and close ties to teaching hospitals, which supply a steady stream of medical residents.

Some other health systems also provide excellent patient care, and every place has it weaknesses, but the VA generally stands out on quality, said Elizabeth McGlynn, associate director of Rand Health, a division of the Rand Corp., in Santa Monica, Calif.

"You're much better off in the VA than in a lot of the rest of the U.S. health-care system," she said. "You've got a fighting chance there's going to be some organized, thoughtful, evidence-based response to dealing effectively with the health problem that somebody brings to them."...

As the U.S. enters a new era with the passage of the health-reform law that takes full effect in 2014, experts say the VA's evolution offers lessons because many of the pilot projects and quality-improvement initiatives the new law calls for are similar to the
VA's approach."

Read more, click here.

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6. Electronic Medicine Also Moving Ahead, Thanks to Stimulus Bill Funding The independent eHealth Initiative and Foundation (eHI), which represents all stakeholders in the healthcare industry, released a report this month on the progress made towards what's variously called electronic medicine, health care IT, or computerized health care record-keeping. While the organization started its major initiative in 2007, the early 2009 "stimulus bill" (known as the American Recovery and Reinvestment Act, or ARRA), included $30 billion in funding to speed the pace of implementing electronic health care systems.

The eHI organization recently conducted a survey to get perceptions on the progress in this area and found that: "The majority of respondents believe significant progress has been made: 61 percent of respondents agree or strongly agree with the statement that significant progress has been made in the successful adoption and use of HIT since 2007." It also found that "the American Recovery and Reinvestment Act (ARRA) was the key driver of progress. ARRA will provide a policy foundation and financial support for programs at the federal and state level to drive provider adoption of certified technology and drive the exchange of health information."

It's not all good news though. The report also concludes there is a lack of understanding and appreciation of health information exchange technology, and lack of patient appreciation of the need for electronic records. Further stakeholders in the survey noted problems coordinating across federal and state laws protecting privacy of patient data, and the seeing the impact on care delivery so far. You can read the report or summary, click here.

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7. Another Big Fat Reason for High Health Care Costs Despite the fact that we've known for years that the country as a whole is getting too fat, the pounds just keep piling on. According to a June 29 MSNBC News web site article: "obesity rates increased in 28 states last year. Mississippi continued its six-year reign as the country's fattest state in the study's yearly rankings." In addition to four states previously, four more states met the unenviable distinction of having almost 1 in 3 - 30% of their citizens - as obese! Indicating how bad the trends are, the Trust for America's Health and the Robert Wood Johnson Foundation notes that, "More than two-thirds of states now have adult obesity rates above 25 percent. In 1991, no state had an obesity rate above 20 percent."

A symptom of the problem: like the Lake Wobegon parents who think their children are all above average, "The new survey finds that 84 percent of parents believe their children are at a healthy weight, even though nearly a third of children and teens are considered obese or overweight."

Read more, click here.

The Robert Wood Johnson Foundation has a new report out about obesity that gives recommendations for addressing the epidemic. The Executive Summary report on "How Obesity Threatens America's Future" can be accessed here: How Obesity Threatens America's Future.pdf

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8. The Medicare Doctor Shortage Scare There have been claims, especially in certain parts of the country, such as Texas, that the new health care reform law will aggravate a shortage of doctors seeing Medicare patients. According to Health Beat columnist, Maggie Mahar, this claim is overblown. Part of it stems from the fear that doctors would get a sudden cumulative 21 percent pay cut under Medicare as a result of Congress not stepping in (as they have done every year since the early 2000s) to the halt the formula cuts that a Republican controlled Congress passed in 1997.

Mahar notes that: "The Centers for Medicare and Medicaid Services says that 97% of doctors accept Medicare. The agency doesn't know how many have refused to take new Medicare patients." But more importantly, "in its annual report to Congress in March, MedPac found that Medicare patients actually have an easier time finding doctors than their privately insured counterparts who are age 50 to 64."

Read more, click here.

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