Why the Supreme Court Decision on Health Care Reform “Doesn’t Really Matter”.

At Forbes online, Dr. Bob Kocher and Dr. Mohit Kaushal argue why the Supreme Court decision on health care reform “doesn’t really matter”.

Find this article here: http://www.forbes.com/sites/kerryadolan/2012/06/20/why-the-supreme-court-decision-on-health-care-reform-doesnt-really-matter/

Here’s where things stand as we hear it from the many media sources: If the Court upholds the Affordable Care Act in its entirety, this will be seen as a positive for the President. If the Court strikes down some or all of law down could be a boon for the Republicans and Governor Romney’s campaign. Whatever the outcome, much punditry will follow.

The doctors write that the current and likely subsequent debate misses one essential fact: “the Supreme Court’s decision does not matter as much as political pundits think.”

Here’s why:

The American healthcare system is in the midst of intense experimentation and change that cannot, and will not be stalled by the whims of the judicial system.

The major forces behind the changes in our healthcare system are “rising costs, an older, sicker population and technological innovation,” and these show no signs of abating and do not depend on Federal legislation. Instead, they are fuelled by private sector demand, not “policy preferences” coming out of Washington.

So, according to the doctors, “while coverage may not come as soon as hoped for the uninsured, the systemic efforts to make our health system more affordable and higher quality will continue.”

Here are the things to look for:

Some changes, like the widespread replacement of paper records by electronic medical records, are visible from a patient’s-eye-view.

Other changes, such as changes in the relationship between insurers and hospitals are not immediately visible, but are “potentially even more profound.”

Some of the most important changes involve the financing of health care.

In the traditional way of doing business, insurers pay hospitals and physicians under a “fee for service” system – where providers are paid for the quantity of medical services provided, regardless of the outcome. HMOs grew in the 1990s in an attempt to fix these incentives, but patients hated their HMOs because they restricted choice without proving that they were delivering better care.

The current wave of experimentation, such as bundled payments for “episodes” of care, accountable care organizations (ACOs), and new penalties for excessive hospital readmissions are all tactics to try to fix these misaligned incentives and aim to cut costs and improve care for the patient, while preserving choice.

And here is what we don’t hear: Insurers such as United Healthcare, the nation’s largest private insurer, as well as Aetna and Humana, have pledged to follow many of the regulations anticipated under the ACA even if the law is repealed.

The doctors also note that even with congressional gridlock, CMS is driving innovation at the federal level, using its authority to experiment with a variety of demonstration projects that do not require congressional approval. Example: the current project to award bonus payments to Medicare Advantage plans which score well on the program’s Star rating system for providing better and more cost effective care.

There is also experimentation at the state level. Eighteen states representing 42% of the US population are in the process or have already laid the legislative groundwork to establish health insurance exchanges – creating a marketplace for individuals to purchase health insurance.

Again, here’s what we don’t often hear: “Many of these states, including California, have indicated that they plan to continue with the exchanges regardless of the Supreme Court’s decision.”

Finally, the doctors report that patient attitudes are also changing. Patients are increasingly worried about the costs of their care and taking steps to control it. “This means that they are more likely to scrutinize their health insurance benefits and opt for high-deductible health plans (HDHP). While attitudes can be slow to change, the inexorable force of the millions of patients choosing health plans that reward shopping for lower cost and better quality care will not be stymied by the Supreme Court’s ruling.”

The doctors conclude: “So while it is uncertain how the Supreme Court will rule, or how the ruling will impact November’s results, it is a certainty that our health system will continue on the path of more affordability, more integrated care, and more focus on patients because consumers are demanding these changes. These unassailable trends are led by the private sector and, if anything, will accelerate regardless of the Supreme Court’s views of the meaning of the Commerce Clause. Moreover, since the private sector contributes virtually all the profitability in the health system, it is a force far more powerful than politicians.”

New Website Offers Resources on State and Federal Privacy Laws

Check this out:

As described on the website: the George Washington University’s Hirsh Health Law and Policy Program, Health Information and the Law (HealthInfoLaw.org), with support from the Robert Wood Johnson Foundation, has developed a HealthInfoLaw.org to serve as a practical online resource to federal and state laws governing access, use, release, and publication of health information.

Find HealthInfoLaw.org here: http://www.healthinfolaw.org/home.

It is expected to be “constantly” updated, and the site will address “the current legal and regulatory framework of health information law and changes in the legal and policy landscape impacting health information law and its implementation with commentary and key documents.”

Here’s why:

“Health information law exists at the intersection of many crucial and interrelated fields: law, health care, consumer protection, information technology, public health, insurance. Each small change can trigger a daunting set of issues and challenges.”

The developers of the website offer a strong rationale for HealthInfoLaw.org:

“We are in an information revolution in health care, rapidly approaching an age in which all patient records and related information will be maintained electronically. Data on a scale only recently imaginable will pass between individuals and institutions and be used in ways we cannot yet predict as the current healthcare delivery system undergoes a major transformation towards a more robust, evidence-based endeavor highly reliant on health care data for purposes ranging from research to improved real-time care coordination. At the same time, access to, use and release of health information, particularly individually identifiable data, is highly regulated at both the federal and state levels."

“Although the move to electronic data raises new legal issues, it’s important to remember that many of the questions above have existed in some form for a long time. Some of the most pressing legal issues related to health information, such as privacy considerations and liability for health care quality stretch back hundreds of years, to the origins of modern medicine. However, several things make today’s landscape different. Our legal system is addressing the role of information in these age-old relationships in new ways, from the Health Insurance Portability and Accountability Act (HIPAA, 1996), the American Recovery and Reinvestment Act’s Health Information Technology for Economic and Clinical Health Act (ARRA HITECH, 2009), and the Affordable Care Act (ACA, 2010) to state regulations on health insurance exchanges.”

Some Patients Can Choose To Be Hospitalized At Home

The Kaiser Health News reports: Some Patients Can Choose To Be Hospitalized At Home.

Find the article, produced in collaboration with USA Today, written by Judith Graham (May 29), at http://www.kaiserhealthnews.org/Stories/2012/May/30/Graham-Hospital-At-Home.aspx.

KHN reports that "Hospital at home" programs fundamentally refashion care for chronically ill patients who have acute medical problems -- testing traditional notions of how services should be delivered when people become seriously ill.

There are a small number of these initiatives in place in the US: an Albuquerque, NM program, run by Presbyterian Healthcare Services (and highlighted by the KHN report), and programs in Portland, Ore., Honolulu, Boise, Idaho, and New Orleans offered through the Veterans Health Administration.

The concept has been adopted in Australia, England, Israel and Canada.

KHN says that “hospital at home” programs are getting attention in the US “with increased pressure from the national health overhaul to improve the quality of medical care and lower costs.”

According to research led by Dr, Bruce Leff, the director of geriatric health services research at Johns Hopkins School of Medicine in Baltimore who pioneered the concept, “hospital at home” programs can do both: improve care and lower costs.

In a study of 3 experimental “hospital at home” programs published in 2005 in the Annals of Internal Medicine, Leff demonstrated that patient outcomes were similar or better, satisfaction was higher and costs were 32 percent less than for traditional hospitalizations.

Go here to find Dr. Leff's study: http://www.annals.org/content/143/11/798.abstract.

KHN predicts that the model will become more common. Last year, the Cochrane Collaboration, an international organization that evaluates the evidence supporting health care interventions, published a review of 10 randomized controlled studies on hospital at home programs. That report reportedly “found that 38 percent fewer patients in these programs had died after six months, compared to those who underwent traditional hospitalizations.” 

Go here to find the Cochrane report: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007491/abstract.

So what’s the problem? KHN reports that “Resistance from Medicare and private insurers is the biggest problem these programs face. Traditional fee-for-service Medicare does not pay for hospital at home services, although individual private Medicare Advantage plans may do so.” And then, for physicians, “doing hospital-level services at home sounds scary… and a big jump.”

But, according to KHN: “That may change” as hospitals and doctors form accountable care organizations (ACOs) that are promoted in the health care overhaul and call for providers to restructure how medical care is delivered.”

IT could be healthcare reform's highest hurdle

Politico reports that “IT could be reform's highest hurdle.”


Find the article, by J. Lester Feder, May 29, here: http://www.politico.com/news/stories/0512/76825.html.

While most followers of healthcare are awaiting the next big event – the Supreme Court ruling on the constitutionality of the Affordable Care Act, and in particular the survivability of the health insurance exchanges, Politico points out that even if they do survive the constitutional challenge, HIEs “could still be brought down by a much more mundane problem: information technology.”

It reports: “Even states that are solidly committed to pursuing an exchange are facing major logistical challenges in building the computer systems that will be able to handle enrollment when exchanges open for business in 2014.”

Here’s why: “the system that will actually connect people to the right coverage will have to “talk” to many other systems, and the systems don’t use a common language. This interoperability challenge extends to the federal level, where the US Department of Health and Human Services is responsible for a yet-to-be built federal “data hub,” that will combine tax information from HHS with the other information needed to establish that people are eligible for coverage. “Hardest of all” among the technology challenges is reportedly the Medicaid enrollment systems, remarkably: “many of which are not yet fully computerized.”

The report says that fewer than 20 states are moving forward to launch their own exchanges and that even for these, there is a concern “that the technology piece” will not be in place in time for them to open in 2014. The report cites experts who predict that “fewer than a dozen” states will be running full bore.

That shifts focus of the federal Department of Health and Human Services that is supposed to be in position to offer a “partnership” exchange for those states not ready or not willing to launch their own. “The need for real-time information creates a second problem for the exchanges. They have to build a way to integrate their system with the feds’ data repository — and that hasn’t even been built yet.”

HHS is overseeing the construction of its “data hub,” but technical specifications for transmitting data on the hub have not been worked out.

The report also cites a problem that there is “no standard format for private health insurers to give details on plan benefits and in-network providers to the exchange — key information an individual is going to want to know about a plan when enrolling in an exchange.”

Trained Interpreters Seen As Necessary To Avoid Mishaps

Kaiser Health News reports: “Trained Interpreters For Patients With Limited English Can Help Avoid Medical Mishaps.”


Find the report (written by Michelle Andrews and posted May 21, 2012) here: http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/2012/Trained-Interpreters-Help-Avoid-Medical-Mishaps-Michelle-Andrews-052212.aspx.

KHN reports that there are 25 million people in the United States with limited English proficiency, creating a heightened potential for medical mishaps due to miscommunications and understandings. (The Census Bureau estimates that nearly 9 percent of the population age 5 or older has limited English proficiency, defined as people who describe themselves as speaking English less than "very well.")

The point of the article: “A trained medical interpreter can make all the difference. Too often, however, interpreter services at hospitals and other medical settings are inadequate. Family members, including children, often step in, or the task falls to medical staff members who speak the required language with varying degrees of fluency.”

And the further point is that it is more than just experience. It’s the training. A study published in March in the online Annals of Emergency Medicine concludes that “such ad hoc interpreters make nearly twice as many potentially clinically significant interpreting errors as do trained interpreters.” Find the study here: http://www.acep.org/News-/Publications/Annals-of-Emergency-Medicine/Professional-Interpreters-in-ER-Need-Training-More-than-Experience/.

The study examined 57 interactions at two large pediatric emergency departments in Massachusetts. These encounters involved patients who spoke Spanish at home and had limited proficiency in English. Researchers analyzed audiotapes of the visits, looking for five types of errors, including word omissions, additions and substitutions as well as editorial comments and instances of false fluency (making up a term, such as calling an ear an "ear-o" instead of an "oreja")

They recorded 1,884 errors, of which 18 percent had potential clinical consequences.

For professionally trained interpreters with at least 100 hours of training, the proportion of errors with potential clinical significance was 2 percent. For professional interpreters with less training, the figure was 12 percent. Ad hoc interpreter errors were potentially clinically significant in nearly twice as many instances -- 22 percent. The figure was 20 percent for people with no interpreter at all.

The article goes on to discuss the legal obligations of hospitals under Title VI of the Civil Rights Act of 1964 – which prohibits discrimination based on race, color or national origin, and therefore, as applied by the courts, health care providers who accept federal funding (Medicare and Medicaid) must take steps to ensure that their services are accessible to people who are not fluent in English.

KHN reports that this puts hospitals and other medical providers in the a tough spot because the law prohibits them from asking patients to pay for translation services, but at the same time they may not receive adequate or in some cases any other reimbursement.

On this point: some states do reimburse providers for giving language services to enrollees in Medicaid and CHIP (the federal-state health program for children). There is some debate as to how many insurers provide access to interpreter services.

On the clinical side: Hospitals and other providers realize that providing competent interpreter services can help ensure that they don't miss or misdiagnose a condition that results in serious injury or death, say experts. Trained interpreters can also help providers save money by avoiding unnecessary tests and procedures. Some hospitals provide interpreter services around the clock through different modes of communication – face-to-face, telephone and video – delivered by a mix of trained staff interpreters and outside contractors. The report also notes that hospitals that understand the importance of interpreters will make it a budget item.

Medicare Advantage Star Rating System Questioned

Kaiser Health News reports on “Second Guessing Medicare’s Star Rating System.”


Find the article (by Marilyn Werber Serafini, KHN Staff Writer, May 20, 2012, and in collaboration with the Washington Post) at: http://www.kaiserhealthnews.org/Stories/2012/May/21/Medicare-star-ratings-quality.aspx.

KHN reports that “as the federal government pumps billions of bonus dollars into private Medicare health plans to encourage better care, the quality rating system used to award the bonuses is coming under increasing fire.”

The report indicates that both the Government Accountability Office and the Medicare Payment Advisory Commission (MedPAC) question whether the $8 billion-plus program is mostly rewarding mediocre patient care. Find the GAO report at: http://gao.gov/assets/590/589473.pdf.  Find the MedPAC report at: http://www.medpac.gov/chapters/Mar12_Ch12.pdf.

The star ratings are part of a push by the Obama administration to increase the quality of care provided by private plans that contract with Medicare. The ratings are based on 36 measures, ranging from rates of hospital readmissions to the volume of consumer complaints a plan gets. See this KNH article for background: http://www.kaiserhealthnews.org/stories/2011/october/12/insurers-improve-quality-revenue.aspx.

The administration had argued that Medicare Advantage plans cost more than traditional Medicare without providing better results for patients. The 2010 federal health law tried to remedy that discrepancy by cutting plan payments by $136 billion over ten years. But the star-rating bonus system is intended to restore some of that money to high-performing plans.

Supporters say the program is a part of a broad initiative to boost the quality of patient care and point to demonstrable improvements – for instance, a San Diego physicians’ group that discovered 700 Medicare patients with diabetes who were not getting annual eye exams, even though failure to get early treatment can result in blindness. (The article provides more detail here and gives a pro and con on the data analysis providers, large versus small, may be able to undertake to achieve such results.)

The program was actually created in 2007 as a guide to help seniors compare the quality of private health plans in the Medicare Advantage program. One quarter of older and disabled people now opt out of the traditional, government-run Medicare program in favor of private, mostly managed care plans. These often have lower premiums and extra benefits, such as coverage of hearing aids and eye glasses.

But the ratings had mostly been ignored by health plans and their enrollees. KHN reports that “only about a third of Medicare beneficiaries knew about the star ratings, and only half of that group considered the scores when choosing a health plan, according to a survey that Harris Interactive conducted last September for insurer Kaiser Permanente.”

The 2010 healthcare law changed that by attaching financial rewards to the program’s ratings. But the first round of ratings last fall showed that most plans have a long way to go. Only 12 earned a perfect score of five, on a scale of one to five, and about 9 percent were below average. The majority received scores of three, or three and a half stars – enough to earn the bonus money.
Going forward, here’s what to expect: After 2014, plans will need four or five stars to get bonuses. And if they have fewer than three stars, they won't be allowed to enroll beneficiaries through Medicare's website, and risk being booted from Medicare altogether. Already, five-star plans don't have to wait until open season to enroll new customers. Poor performers are branded with an icon on Medicare's website.

And here is the bottom line: The KHN article reports that “for some health plans, the bonus money accounts for as much as 7 percent of revenues, which can translate into a couple of billion dollars for a large health plan in a large state. Compensation of senior managers in Medicare Advantage has now been oriented around achieving star ratings.”

The money is particularly attractive to Medicare Advantage plans as the health law gradually reduces payment rates to bring them in line with what the government spends on beneficiaries in the traditional government-run program. This year, they will lose $6 billion in federal payments, and the bonus money is estimated to offset that reduction by about half.

The GAO and MedPAC are questioning the strategy of rewarding plans with average ratings. Bonuses are now going to plans that cover 93 percent of enrollees “at a time when Medicare already faces serious problems with cost control and long-term financing,” according to a March MedPAC report.

KHN quotes onathan Blum, deputy administrator for Medicare: “the incentives were made available to average-rated plans to spur rapid improvements. The higher the plan rates, the larger the payment it can get and that is turned back to providing a more generous package of benefits."

Websites Provide Consumers Information on Hospitals

The Los Angeles Times reports: "Using data from government agencies and private watchdogs, several websites provide consumer information on hospitals."

By Scott J. Wilson, Los Angeles Times (May 13, 2012)

Find the article at: http://www.latimes.com/business/la-fi-five-hospitals-20120513,0,1327979.story.


The LA Times reports that "Using data from government agencies and private watchdogs, several websites provide consumer information on hospitals."

The article lists the following sites:

CalHospitalCompare.org (www.calhospitalcompare.org) enables you to compare selected hospitals on dozens of measures, including infection prevention, intensive care mortality rate and overall patient experience. The site, run by the California HealthCare Foundation, offers the option of searching by hospital name, location or medical condition.

Hospital Compare (www.hospitalcompare.hhs.gov) from the U.S. Department of Health and Human Services looks at facilities nationwide. You can compare up to three hospitals side by side or compare a hospital's track record with state and national averages. You also can narrow your search to facilities offering particular surgical procedures.

The Leapfrog Group (www.leapfroggroup.org/cp), an employer coalition that promotes hospital safety and quality, annually surveys hospitals on safety, quality and cost measures. Participation is voluntary, so not all hospitals are included.

Quality Check (www.qualitycheck.org), a site operated by the accrediting organization known as the Joint Commission, offers ratings of hospitals as well as nursing homes, home care providers and laboratories.

The Medicare site has a feature (www.medicare.gov/Dialysis) that can help compare kidney dialysis centers in your area. For each facility, the site details the services offered and provides data on effectiveness and patient survival.