Post-Election Healthcare Reform

Posted on | November 3, 2008 | Comments Off on Post-Election Healthcare Reform

Armageddon or brave new world? With the economy in a tailspin and the federal government experiencing a record national debt (about $47,000 owed for every American), Draconian changes in healthcare are on the horizon. The twenty-two months of political campaigning and advertizing have really not given us much insight as to how the presidential candidates will actually implement their “chicken in every pot” healthcare reform rhetoric. Indeed, most health care leaders know that post-election policies are seldom in synchrony with pre-presidential campaign promises.

In the October 30, 2008 issue of the New England Journal of Medicine, Dr. Henry J. Aaron, a Brookings Institute senior fellow, addressed what is, from my perspective, the lynch pin for all future healthcare design proposals – CMS-directed, Rand-researched clinical outcome studies that will adjust/restrict/eliminate payments for CPT codes (procedures) demonstrating little benefit in a patient’s well-being.¹

Aaron points out that as much as 1/3 of all U.S. healthcare is inappropriately delivered. He mentions that Congressional Budget Office Director, Peter Orszag, estimated the dollar amount for wasteful care to be $700 billion, exactly the same amount as the savings bank bailout. I’m sure the amounts were coincidental because his comments predated the bailout by two months. Nonetheless, I couldn’t help but feel that this magnitude of savings makes healthcare spending the tallest rose in the government’s cost cutting garden.

With CMS covering not only 37% of Americans’ but arguably some of the oldest, sickest and most indigent, their policies have and will continue to motivate third party payers to immediately conform to the CMS’ new policy, which usually lowers payment or restricts access to care. CMS by law cannot assess and control medical practice. Refusal to pay customary fees and/or restricting payment as was recently announced for thermal intradiscal procedures (TIPs) for 65 year-old patients, however, does govern practice in our current system of third party payment. ²

Aaron’s editorial raises a very salient concern, “…what, really, do we mean by waste?” He succinctly reminds us that extending life can cost a few dollars (cessation of smoking or nutrition control) to millions of dollars (transplants and extended ICU care), and the studies that evaluate their outcomes usually produce different or even opposite results. Waste in the case of medical delivery is most certainly subjective and depends on whether you are the recipient, the provider, or the payer. The real concern, however, will deciding which of these groups will assess waste and where, on the continuum of cost vs. benefit, will the line for wasteful spending be drawn.

The traditional government approach to reforming health delivery historically follows a bureaucratic path – political task forces, congressional testimony from experts in the field, committee white papers, federal register announcements, new policy announcements, etc. For some reason, healthcare strategic planning continues to ignore the value of engaging physician experts, like the Institute of Medicine (IOM), to re-shape our health system. Ironically, IOM had published a monograph in 2001 on just how we should begin to construct the framework for such an endeavor. ³

Almost everyone who has pondered how to resolve this boondoggle can agree of a few points:

1. It will take at least a decade before the final product takes shape

2. The solutions will not be homogeneous but will reflect regional strengths and weaknesses

3. There will be losers and winners (?)

4. It will be a tiered system of care

Every facet of health care will need to be addressed, for the spin-offs to each change will have far-reaching and unforeseen consequences on the suppliers and support systems to health care delivery – much like the auto industry. Some will view the changes as Armageddon. Others will experience medical care much like the citizens in Brave New World, with a sense of “Community, Identity and Stability” but certainly not with individuality.⁴ I can’t believe that the first few products to come out of Washington will ‘hit a home run’ with all stakeholders.

Once again, I can’t end without printing one of Sir Winston Churchill’s famous World War II quotes that will also sum up our attempt at developing a new healthcare paradigm in the U.S.; “You can always rely on the Americans to do the right thing…after they have exhausted every other possibility."

Fasten your seat belts for a wild ride over the next four years.

References

1. Aaron HJ. Waste, We Know You Are Out There. NEJM 359; 18: 1865-67. 30 Oct. 2008.

2. CMS Administrative File: (CAG-#00387N), Decision Memo for Thermal Intradiscal Procedures. 29 Sept. 2008.

3. Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine Press, Washington. 2001

4. Huxley A. Brave New World. Chatto and Windus, London. 1932