1. Health Care Opinion Leaders' Views on Delivery System Innovation and Improvement Okay, maybe some believe Glenn Beck and Sean Hannity know how to cut health care costs or improve the quality of care, but in case anyone cares about what those "elitist" experts who actually have studied medicine or the health care system think, the opinions are pretty positive:

"The latest Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey finds strong majorities of leaders report that providing special payment arrangements and incentives to providers--like those in the Patient Protection and Affordable Care Act--will be effective strategies for fostering coordination and integration in health care delivery. More than eight of 10 leaders feel that developing performance metrics, implementing provisions to increase transparency and public reporting, and establishing an Innovation Center within the Centers for Medicare and Medicaid Services should receive high priority from the Secretary of Health and Human Services. Survey respondents support development of a national accreditation system for accountable care organizations and public utility-type regulation of payment rates in areas with insufficient market competition."

Read more: Click here

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2. Realizing Health Reform's Potential: Women and the Affordable Care Act of 2010 According to a Commonwealth Fund study, "...over the next decade, the Affordable Care Act (ACA) is likely to stabilize and reverse women's growing exposure to health care costs. Up to 15 million women who now are uninsured could gain subsidized coverage under the law. In addition, 14.5 million insured women will benefit from provisions that improve coverage or reduce premiums. Women who have coverage through the individual insurance market and are charged higher premiums than men, who have been unable to secure coverage for the cost of pregnancy, or who have a preexisting health condition excluded from their benefits will ultimately find themselves on a level playing field with men, enjoying a full range of comprehensive benefits."

Read more: Click here

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3. Poll Shows Most Seniors Are Ignorant or Misinformed about the Healthcare Reform Law According to the web site, The Hill (Click here): "The majority of the nation's seniors have little understanding of what the Democrats' newly enacted healthcare law actually does, according to poll results released Monday.

The survey, sponsored by the National Council on Aging (NCOA), an advocate for seniors, found that only 17 percent of respondents could answer even half of the 12 questions about key provisions in the law selected by the NCOA.

Only 14 percent of respondents, for instance, knew that the new reforms don't include cuts to doctors treating Medicare patients; just 24 percent were aware that the changes will extend the solvency of the Medicare program; and only 14 percent were aware that the reforms are projected to cut deficit spending...

James Firman, president and CEO of NCOA, said the poll results reveal the unfortunate consequence of a months-long healthcare reform debate that was "long and complicated and often dominated by political spin that confused seniors."

Wonder what TV network or talk shows they got their (mis)information from? To find the truth, check out the links at our "Myth vs Fact" section of our Bucks Voices web site.

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4. Over 4 Million Small Businesses Will be Helped by the Affordable Care Act Families USA and Small Business Majority commissioned a Lewin Group study to quantify the number of employers who will be eligible to receive help from the small business health care tax credit. The key findings from A Helping Hand for Small Businesses:

"More than 4 million (4,015,300) small businesses will be eligible to receive a tax credit for the purchase of employee health insurance in 2010. That's 83.7 percent of all small businesses in the country.

In 11 states, more than 90 percent of small businesses will be eligible to receive a tax credit in 2010. These states are Arkansas (94.2 percent), Montana (94.0 percent), Nebraska (93.8 percent), South Dakota (93.6 percent), Mississippi (93.2 percent), Indiana (92.9 percent), North Dakota (91.9 percent), Missouri (91.8 percent), Iowa (90.8 percent), West Virginia (90.3 percent), and Maine (90.1 percent).

Approximately 1,198,700 American small businesses will be eligible to receive the maximum tax credit in 2010."

Read more or get the report: Click here

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5. 5 Myths and Facts about Medicare A great analysis on July 22 by health care blogger Maggie Mahar refutes five myths about Medicare. Her text below refers to certain tables and charts with the supporting data (available at: click here).

MYTH #1 Physicians have been refusing to take new Medicare patients; many have a hard time making appointments. FACT: As charts 5-3 and 5-4 reveal, Medicare patients report as good or better access than privately insured patients--even to primary care physicians.

MYTH #2: The bulk of our Medicare dollars are spent on acute care during the final weeks of life. FACT: About 25% of Medicare dollars are spent on patients during the final year of life--not during the final weeks. In most cases, it is not possible to know how much time the patient has left---one year, two years, three years...particularly if they suffer from heart or lung disease or are simply "dwindling"--growing frailer as they grow older.

MYTH #3: Medicare reimbursements to physicians have remained flat to down over the past decade. FACT: As chart 1-2 reveals, from 1998 to 2008 Medicare fee-for-service reimbursements to physicians climbed by 75%. Of course, over the same ten years, the cost to the doctor of providing services also has risen. In some specialties, doctors who are solo practitioners or working with a small group of physicians have watched their real income drop, particularly if they are located in an area where the cost of labor and real estate is high.

But many doctors in more lucrative specialties have seen their income rise over the same. And those working in large groups that enjoy economies of scale have not been hard-hit by rising expenses. The 75% increase reflects the fact that Medicare has raised fees for some services, but, as chart 8-2 shows, most of the hike in income can be traced to higher volume: doctors have been "doing more" as they prescribe more tests, and  recommend more procedures.

MYTH #4 Medicare has been underpaying hospitals for years. Reimbursements rarely match the cost of actually treating the patients, which is why hospitals must charge private insurers more. FACT: From 1998 to 2008, Medicare fee-for service reimbursements to hospitals for outpatient services climbed by 85%. Payments for inpatient services rose by more than 40%. (Chart 7-4) During this time hospitals were treating more patients, but as Chart 7-7 shows, reimbursements outstripped growth in the number of patients served.

MYTH #5 If Medicare tries to rein in spending on hospital care, the quality of care will suffer. Most hospitals are already operating on tiny margins. And there just aren't many ways for hospitals to cut the cost of caring for patients. FACT: After adjusting for differences in patient mix, wages, outlier (extremely ill) patients, transfer cases, interest expense, the costs of teaching, and the effect of low-income Medicare patients, MedPac researchers have discovered that when hospitals are under financial pressure either because they have fewer patients, a larger share of Medicaid patients--or because private insurers are paying less--some hospitals manage to become more efficient, and turn a profit on Medicare patients. (See table 7-20)

Hospitals that cannot make a profit on Medicare reimbursements tend to be those that are under little financial pressure, enjoying profit margins of 5 percent or more on their non-Medicare patients. (Note: most hospitals in the U.S. are non-profits; for a non-profit this is a very comfortable margin. Some, especially large academic medical centers, also boast huge endowments.) This shouldn't come as a surprise. Like most other organizations, hospitals spend more lavishly when plenty of money is available. When money is tight, they are more likely to concentrate on avoiding waste.

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6. Medicare Trust Fund Report Shows Why We Needed Comprehensive Health Reform As required by law, the trustees of the Social Security and Medicare programs issue annual reports on the funding status of these programs. As an August 5 article on CNN's website notes:

"The newly passed health care law will boost the financial strength of the nation's massive Medicare program, the government said Thursday.

The controversial law extends the life of the Medicare Trust Fund by 12 years, to 2029, according to the annual report from the trustees who oversee Medicare. At that time, Medicare will only be able to cover 85% of beneficiaries' hospital costs."

The article also cites a concern by Medicare's chief actuary, Richard Foster, that much depends on Congress allowing the provisions modifying and tightening payments to Medicare health care providers to stick. You can read the article here: Click here.

But as reported by Andrew Leonard in Salon (Click here), even conservative economics columnist Bruce Bartlett admits that "over the long run, ‘Medicare's unfunded liability fell from almost $90 trillion in 2009 to less than $30 trillion, a two-thirds improvement in one year.'" (Inner quotes are Bartlett's.)

For a balanced assessment of the issue, read "Will Health Care Reform Increase the Deficit and National Debt?" This analysis, published in August by the Urban Institute, describes the various uncertainties on both sides of the Medicare cost projections: while some risks might raise costs more than anticipated, others, like the delivery system reforms and eventual excise tax on high cost plans, might steer costs below projections. As we've noted in the past, the Congressional Budget Office and the Medicare Trustee actuaries give no credit for the potential savings from the PPACA's delivery system reforms, since they are mostly too new for solid savings evidence to exist. For a copy of the report, click here.

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7. Study Shows Palliative Care Extends the Length and Quality of Life Near Its End - Despite Tweets from the Ursine Mind of Sarah Palin According to a study published in the New England Journal of Medicine, that on the effects of end-of-life care, "doctors have found that patients with terminal lung cancer who began receiving palliative care immediately upon diagnosis not only were happier, more mobile and in less pain as the end neared -- but they also lived nearly three months longer."

Sarah Palin, Betsy McCaughey, and other quacks - please note the following from the August 18 New York Times:

The findings, published online Wednesday by The New England Journal of Medicine, confirmed what palliative care specialists had long suspected. The study also, experts said, cast doubt on the decision to strike end-of-life provisions from the health care overhaul passed last year.

‘It shows that palliative care is the opposite of all that rhetoric about ‘death panels,' " said Dr. Diane E. Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine and co-author of an editorial in the journal accompanying the study. "It's not about killing Granny; it's about keeping Granny alive as long as possible -- with the best quality of life."

You can read more: Click here.

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8. Coordinated Care - Better Results, But Not an Easy Sell The magazine U.S. News & World Report has provided a series of great articles over July and August on the how the new health care law should result improving patient care, or what we often call the delivery system. In an August 23 article, physician Kenny Lin outlines "4 Changes to Expect at Your Doctor's Office" (Click here): 

• More effective treatment, due to collection and dissemination of research on what works well and what is a waste of money or too risky.
• More coordinated care from a team of professionals, including not only your physician, but also nurse practitioners, nutritionists, physician assistants, case managers, and others.
• More outreach, such as to remind patients about upcoming screenings, or to follow up with patients with chronic conditions or adjusting after a hospital stay.
• Electronic records to prevent errors, edit for adverse drug interactions, allow physicians anywhere access to your records (with your permission).

These changes will all take several years to materialize, of course, but as the writer notes, they are clearly needed and should be welcomed by the health care community.

Another excellent article is in the July 26 U.S. News & World Report ("A Team Effort to Re-Engineer Care at Hospitals: How the Cleveland Clinic is applying manufacturing principles to improve patient care," Click here). It profiles the Cleveland Clinic as one of the institutions that already has moved forward on more coordinated care among various specialists and other health professionals for several chronic and other health conditions. While the concept sounds great, it finds that a health care institution has to overcome three hurdles:

• convincing doctors with evidence that it will indeed lead to better care for their patients,
• that it will not hurt their incomes (Cleveland Clinic physician staff are salaried), and
• they have or will install an electronic health records system to track care processes and outcomes to demonstrate the value of this approach.

A third related article ("The Hospital, Your Care Coordinator") by the same magazine profiles Montefiore Medical Center (in the Bronx in New York City) as an early adopter of the "accountable care organization" (ACO) model of coordinated care. Because most of its physicians are salaried staff, they can do what they feel is needed to care for members in the community, including many on Medicare, such as by making house calls. As the article states, according to the new health reform law, "By Jan. 1, 2012, Medicare must establish a program that would share any money it saves from coordinated care within a community with the ACO responsible for the savings." The lesson from Montefiore and other such ACOs, according to the article, is that "ACOs won't work under the fee-for-service system, which rewards doctors for the number of services rendered, not for quality of the care." To read the article, Click here.

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9. The Bubble That Never Pops Unlike the housing market, tech stocks in the late 1990s, and the Holland tulip market in the 1600s, health care costs just keep going up, up, and up. Unfortunately, it's not the kind of bubble you can make money off of, or that will pop once it reaches a ridiculous size.

A recent survey of 63 large employers, published by National Business Group on Health (at Click here), indicates they expect costs to rise by about 9% (actually 8.9%) again for 2011 (after expecting a 7% increase for this year). Some carriers, and of course many opponents of heath care reform, will claim that these increases are due to the health reform law. But, as the article notes, "Consultants have said they expect reform to boost benefits costs by anywhere from less than 1 percent to 2 percent next year." So the increases otherwise are still as high as ever—and one of the big reasons why we need to move forward as quickly as possible on the cost control provisions in the PPACA.

Of course, what the large health insurance rate increases translate into are lower (if any) pay raises again, higher contributions, and higher deductibles and other cost-sharing provisions. Of the survey's respondents, 63% said they plan to increase the percentage of costs that employees have to pay, 46% will increase patient out-of-pocket maximums, and 21% will increase doctor co-pays. Further, the percentage of employers offering only "consumer directed health plans" will double from 10% to 20%. Such plans have large deductibles and include employee or employer-funded accounts to build up over time to pay for the costs incurred before the deductible is satisfied.

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10. What's Next from Health Reform? What's changing when, according to the health reform law, can get very confusing for many of us, and the biggest changes don't even occur until January 2014. But here's a quick refresher of things to come in the near future:

• As of this September 23 or the first policy anniversary after it:
• Insurers cannot exclude children (up to age 19) with preexisting conditions from coverage.
• Adult children may remain on their parents' policies until their 26th birthday.
• All new policies must cover preventive services such as cancer screening, with no out-of-pocket costs.
• Insurers are barred from canceling coverage when a policyholder becomes ill.
• Insurers can no longer set lifetime limits on the amount of benefits paid; annual limits are restricted and will be phased out.
• Unrestricted access to the plan's network of pediatricians and OBGYNs (i.e., no need for prior approval).
• Access to any emergency room without cost penalties for legitimate emergencies.
• A patient-centered claim appeals process, allowing for both an internal and external appeal route and requiring provisional payment of the claim while it is under appeal.

However, as we noted before, employers with health plans that existed on March 23 of this year can delay changing these provisions if they do not make certain other changes which pass more costs onto employees, such as by increase employee contribution percentages, co-pays (increasing faster than the plan's overall cost), and other similar changes. However, other surveys suggest most employers would rather have the flexibility to shift more costs on to employees than worry about the minor cost impact (about 1%) of the improvements cited above. According to a survey of 466 large employers by Hewitt Associates, 90% expect to comply with the above changes within the next two years, including 51% in 2011. In any case, employers will have to tell employees this fall's open enrollment periods whether they will meet the above requirements or seek an exception, known as "grandfathering" in employee benefits jargon. You can read about the survey results here: Click here.

• Next, you'll see the following changes in 2011:
• A voluntary national insurance program to cover home health services for the elderly.
• Those hitting the Medicare drug benefit "doughnut hole" will get a 50% discount on brand-name drugs.
• Medicare will offer free annual wellness visits and personalized prevention plans.
• Small businesses that establish wellness programs will be eligible for grants.
• Chain restaurants and vending machine companies must disclose the nutritional content of their products.
• Medicare will pay a 10% bonus to primary care physicians practicing in areas with doctor shortages.

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11. Hospital Ratings U.S. News and World Report Magazine for the past few years has come out in August with its annual rankings of U.S. hospitals. You can see the results for Saint Mary Medical Center on their web site at: Click here. From here you can go to the general input screen and find hospitals homes near various zip codes and select by specialty, like "heart and heart surgery," or see an overall ranked list. You can also find the "best" nursing homes and health plans, based on their criteria, which are also provided on the site.

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12. Cool Visualizer of How Unhealthy We Are OK, that doesn't sound so cool, but it still makes an effective point. Check out GE's interactive chart of some major health conditions in the US population at: GE: Take a New Look at Health. I can't say for certain, but looking at the obesity data, I would not be surprised if the government started warning that due to all this extra weight, the continental US could sink to the bottom of the ocean, along with Atlantis, thereby creating the legendary East-West passage from Europe to Asia. (Glenn Beck, this is my theory--hands off!).

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13. "Doctor Watson, Please Call Doctor HAL" An article in Daily Finance suggests that artificial intelligence may be needed to fill the shortage of doctors in the future. According to the article, "enrollment in medical schools is going down. One report by the Association of American Medical Colleges predicts a shortfall of 150,000 doctors in the U.S. in the next 15 years. Europe, Japan, New Zealand and other countries are facing similar challenges in health care."

But coming to the rescue could be advanced computers, like IBM's "Watson," which can be loaded with the equivalent of millions of pages of information and will be tested in 2011, by playing a version of Jeopardy. The X-Prize Foundation is also now sponsoring a $10 million prize to create an artificial intelligence "physician." The hope is that such a system could "handle a lot of routine medical questions, easing the traffic to doctors."

So the race is on. Hopefully its handwriting will be legible and it allows you to win at chess sometimes.

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14. McKinsey IT Reports For those involved with health care information technology (IT), the consulting firm McKinsey & Company has two timely articles in its summer report, "McKinsey on Business Technology." One covers "Reforming hospitals with IT investment" and the other "The New IT Landscape for Health Insurers."  You can find the articles on our web site, or by clicking the links.

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