Editor's Column: The Coordination Of
Chronic Care
By JOSEPH WEISS, MD
From 1999 until now, the Centers for Medicare and Medicaid Services
(CMS) have conducted 35 pilot programs for management of chronic
diseases. The purpose of these efforts is to identify how to
coordinate care for chronic pulmonary disease, congestive heart
failure, coronary artery disease and diabetes; that is, conditions
in which patient education and self-care efforts are important.
The general goals of disease management are to improve the
health of the patient and to demonstrate a reduction of health care
costs net of the expense of the disease management program itself.
Disease management as conducted by CMS has centered on nursing
intervention and patient education; to reduce expense, physician
involvement is limited. To date these pilot programs have cost over
$750 million, with no program showing a net savings and several
resulted in increased outlays, as high as 11 percent.
Physicians whose patients were in such pilot programs stated
that these pilots failed to help their patients deal with
contradictory information received by primary physicians and
specialists, did not reduce poly-pharmacy, did not increase
evidence-based care, and failed to improve coordination of care
between physicians.
The experience of CMS indicates that the use of nurses
directing care by telephone contact does not work. Patients are not
motivated, contact is not frequent enough, and phone contact alone
often fails to recognize the need for scheduling a timely visit or
changing treatment immediately.
Optimum care for a chronic condition requires a
physician–patient relationship. In turn, that relationship is best
nurtured by an incentive. It should be similar to the incentive
physicians receive for prescribing generic drugs, $5,000 or more
given through their Physician Organization (PO).
Now Physician Organizations should give healthy bonuses to
physicians who keep their patients with chronic lung disease, heart
failure or diabetes out of the emergency room and hospital wards.
The PO is big enough to garner data, obtain norms of emergency room
and in hospital use, identify physicians who do better than those
norms and reward those physicians with bonuses that reflect the
savings accruing to the Physician Organization.
A band of nurses working a bank of phones cannot equal the
effect of a single physician caring for one heart failure patient.
Until CMS accepts that personal care, not organizational expertise,
is the basis for care of the patient with a chronic disease, their
pilot studies will fail.
Eventually, organizational medicine comes down to finding
the best way to bring one patient and one doctor to one room.
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In My Opinion:
National Health Care: Why Such Public Interest?
By ALLAN
DOBZYNIAK, MD
As a lifelong Detroiter, I am very interested in the plight of the
Big Three auto companies. Associated with government “bail-out,”
there has been political demonization of auto company management and
the CEOs in particular. There is a likelihood of more taxpayer debt,
more government regulation of these private-sector companies and
even intervention into their very operation. An auto czar has
additionally been proposed to oversee these enterprises.
Considerable
debate and general public skepticism about not only the commitment
of these funds, but also the implications has resulted. There is
angst regarding this degree of government insertion into the private
sector and what this will mean to the economy. This skepticism by
American citizens is unfortunately justified as there is a
historical dearth of well run, successful, efficient, non-political
and non-bureaucratic government businesses.
Our current
financial catastrophe has government’s footprint all over it. The
Community Reinvestment Act aided by the US Department of Housing and
Urban Development during the Clinton Administration required
outcomes parity in mortgage lending. This philosophy was fueled by
mortgage guarantees by Fannie Mae and Freddie Mac along with
inappropriately low interest rates and access to money. There was
also lax and incompetent supervision of Fannie Mae and Freddie Mac.
The result of this government meddling was to forcibly encourage
mortgage lenders into loans that could not reasonably be repaid.
Since financial
leveraging cannot go on forever, we have now ended up with a
de-leveraging catastrophe. Consumers are overly leveraged. The
federal, state and local governments are overly leveraged. If the
solution to this problem is to throw more borrowed dollars at it
through enormous increases in governmental spending, there must be
the assumption that there will be enough future economic growth to
repay these huge and increasing, state, local and federal debts.
This degree of economic growth sadly has no historical foundation.
Also, raising taxes on the private sector has limits since that will
eventually undermine the very growth engine needed. The point is
that arguments can be made for again a failure of government and not
free markets.
With this as a
background and with passionate negative sentiment regarding taxpayer
bail-outs by the federal government, there is a remarkable
enthusiasm for government-run health care. Under this new
entitlement, management likely will be by a group of presidentially
appointed “health care experts.” Premiums, benefits and subsidies
will be determined by this group. Congress then will be the new
regulator of premiums, overhead expenses and cost sharing. Costs
will not decrease as government programs have never generated
savings. We will end up with the most complex of all industries
dominated by the government in control American health care choices.
This, I fear, will occur without a properly framed, well thought
out, properly scrutinized social consensus. And, like all other
middle-class entitlements, once in place it will never be rescinded.
I find it
remarkable that the debate and negative sentiment is so intense
regarding government’s use of taxpayer dollars to insert itself into
the economy, yet there be so much enthusiasm for government-run
American health care.
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Health Care Key In
Obama Address
Obama This Week
To Address Economy, Health Care Reform in Summit, Address to
Congress, Budget Proposal
[Feb 23,
2009]
President Obama on
Monday at the White House will host a "fiscal responsibility summit"
as he begins discussing the federal deficit,
USA Today
reports (Jackson, USA Today,
2/23). During the summit, Obama will seek to address the longer-term
fiscal issues posed by entitlement programs, such as Social Security
and Medicare, the tax system and the budget process
(Weisman/McKinnon,
Wall Street
Journal, 2/23). The summit will include five
sessions on specific issues, with White House
Office of Management and Budget
Director Peter Orszag scheduled to lead a session on health care
(Connolly/Montgomery,
Washington
Post, 2/21). In addition, Obama plans to hold a
separate summit on health care in the coming weeks (Alonso-Zaldivar,
AP/Boston
Globe, 2/21).
According to the
Washington
Post, Obama "faces the long-term challenge of
retirement and health programs that threaten to bankrupt the
government years down the road, as well as the more immediate
problem of deficits bloated by spending on the economy and financial
system bailouts" (Montgomery/Connolly,
Washington Post,
2/22). Obama likely will "outline some broad themes of his budget
request" during the summit, the
AP/Globe reports (AP/Boston
Globe, 2/21). In addition, budget experts at the
summit likely will consider proposals for a long-term plan to reduce
the federal budget deficit (Sanchez,
CongressDaily,
2/20).
Speech to
Congress
Obama on Tuesday evening will address a joint session of Congress
about the current state of the nation and discuss proposals for
health care and other areas (Parsons,
Los Angeles
Times, 2/22). According to the
New York
Daily News,
Obama plans to "argue in favor of moving toward the goal of
universal health care by expanding coverage for children and at-risk
and out-of-work Americans" (Bazinet, New York
Daily News, 2/23).
Obama does not plan to "announce significant new policies ... but
intends to explain how his agenda can advance despite the deepening
recession and monumental budget deficit," with the speech "heavily
weighted toward domestic priorities and the economy," the
New York
Times reports (Zeleny,
New York Times,
2/23). In addition, he likely will not announce plans to "deal with
long-crumbling entitlement programs," the
AP/Globe
reports (Elliott, AP/Boston
Globe, 2/23).
Budget Proposal
Obama on Thursday will release an outline of his fiscal year 2010
budget proposal, which will include efforts to reduce the budget
deficit (USA Today,
2/23). Obama will release full details of his budget proposal in
April (Calmes,
New York
Times, 2/22).
According to White House spokesperson Jen Psaki, the Obama
administration estimates a budget deficit of $1.3 trillion, or 9.2%
of gross domestic product, and seeks to reduce the deficit to $533
billion, or 3% of GDP, in four years. White House OMB spokesperson
Kenneth Baer said, "The budget will cut the deficit that the
president inherited upon assuming office at least in half by the end
of his first term" (USA
Today, 2/23).
The budget proposal likely will include a reduction in spending on
the war in Iraq, an increase in income taxes for higher-income
residents, measures to increase government efficiency and the
elimination of inefficient federal programs, according to an Obama
administration official (Colvin,
Reuters/Boston
Globe, 2/21). In addition, the budget
proposal likely will include mandatory, across-the-board reductions
in spending to offset any new spending or reductions in taxes that
would increase the deficit (Wall
Street Journal, 2/23).
'Down Payment'
on Health Care
"While some people have predicted that Mr. Obama would have to
shelve his priorities given rising deficits, his determination to
proceed, especially on health care, reflects his economic advisers'
conviction that the government cannot control its finances without
reforming health care," the
New York
Times reports (New
York Times, 2/22). An Obama administration official
said, "The budget will kick off or facilitate a focus on getting
health care done this year" (Washington
Post, 2/22).
According to the
Philadelphia Inquirer, the budget proposal likely
will include a "down payment on health care reform" (Fitzgerald,
Philadelphia Inquirer,
2/22). The budget proposal is "expected to take steps toward his
campaign promises of establishing universal health care" (Sidoti,
AP/Boston Globe, 2/21). In his budget proposal, Obama
"will suggest ... that expanding health coverage to the more than 46
million uninsured can be done without adding to the deficit, both by
making cost-saving changes in the delivery of care and by raising
revenues," the New York
Times reports (New
York Times, 2/22).
The budget proposal likely will seek to reduce certain spending for
health care, a move that might provide funds for later efforts on
broader reform (Los Angeles
Times, 2/22). The reductions in spending likely will
target extra reimbursements for private health insurers that operate
Medicare Advantage plans. Administration officials and outside
experts said that "the most likely path to revamping the health
system is to begin with Medicare ... and Medicaid," as "policy
changes in those programs -- such as rewarding physicians who
computerize their medical records or paying doctors for results
rather than procedures -- could improve care while generating
long-term savings," the Post
reports (Washington Post,
2/22).
Omnibus
Appropriations Bill
In related news, lawmakers this week will begin work on an omnibus
appropriations bill that includes the FY 2009 Labor-HHS-Education
appropriations bill and the eight other unapproved FY 2009
appropriations bills (New
York Times, 2/22). Lawmakers plan to introduce the
omnibus appropriations bill in the House as early as Monday and seek
to hold a vote on the legislation on Wednesday. The Senate likely
will consider the omnibus appropriations bill either later this week
or early next week.
Since last October, the federal government has operated under a
continuing resolution that will fund most Cabinet departments and
federal agencies at FY 2008 levels until March 6. The omnibus
appropriations bill would fund those departments and agencies from
March 7 until Sept. 30, the end of the fiscal year. According to
CQ Today, the
omnibus appropriations bill "should sail through the House given its
large Democratic majority, but if Republicans do not agree to allow
it to move quickly in the Senate, another continuing resolution may
be needed to buy time beyond March 6." Some Republicans "would
prefer to extend the continuing resolution through Sept. 30 ...
which would cost billions of dollars less than the omnibus,"
CQ Today reports
(Clarke/Krawzak, CQ Today,
2/20). The omnibus appropriations bill would increase FY 2009
spending levels by 6% from FY 2008 (Miller,
Washington
Times, 2/23).
Editorial
"Obama says that it's time to stop kicking the can down the road
when it comes to dealing with runaway entitlement spending and the
grim long-term fiscal picture," and although this week he "will put
those words to the test," the "signals are mixed, at best," on
whether that will occur, a
Washington
Post editorial states. The editorial adds, "The
fiscal responsibility summit ... has turned into something of a
fiscal responsibility improv" and seems "destined to end up being
yet another gabfest about the dire fiscal situation -- albeit a
presidential gabfest."
In addition, in the event that Obama plans to "propose -- and find a
way to pay for -- a broad expansion of health insurance, he should
reconsider his opposition to changing the preferential tax treatment
of employer-provided health insurance," according to the editorial.
The editorial adds, "Why should some taxpayers without health
insurance subsidize the overly generous policies enjoyed by others?"
(Washington Post,
2/22).
Opinion Pieces
§
Joe
Conason,
Salon:
Neither the fiscal responsibility summit "nor any other serious
discussion of fiscal problems can be confined to entitlement
programs -- because the underlying issue is health care costs,"
Salon columnist Conason writes. He writes that the "real
agenda of the fiscal responsibility summit, as White House sources
have explained on background, is to introduce health care reform."
According to Conason, "This is the same holistic and progressive
outlook that informed the stimulus program, which includes spending
on information technology that will help make universal coverage
affordable and successful." Conason concludes, "To get what he wants
from this summit, the president should be prepared to brush back the
slashers and privatizers and insist that they talk about the need
for a health care system that is less expensive and more equitable"
(Conason, Salon,
2/23).
§
Robert Kuttner,
Washington
Post: Fiscal conservatives "are using the
temporary deficit increase to attack a perennial target -- Social
Security and Medicare" -- and have proposed "big cuts" because of
concerns that the programs will "depress the economic growth and
crowd out other needed outlays," Kuttner, co-editor of the
American Prospect and a senior fellow at
Demos writes in a
Post opinion piece.
He writes, "What's wrong with the story of entitlements wrecking the
economy? Plenty." According to Kuttner, "Medicare really does face
big deficits," but "that's because Medicare is part of a hugely
inefficient, fragmented health insurance system." He writes, "If we
just cap Medicare, needy seniors would get bare-bones care while
more affluent people could supplement their insurance out of
pocket." He adds that the "decent cure for Medicare's cost inflation
lies in comprehensive universal health insurance so that the entire
system is more efficient and less prone to inflation." Social
Security and Medicare "are the two bedrock programs that keep tens
of millions of elderly Americans from destitution," Kuttner writes,
adding, "The attack on social insurance is really an ideological
assault, dressed up as fiscal high-mindedness" (Kuttner,
Washington Post,
2/23).
Reprinted from
kaisernetwork.org. You can view the entire
Kaiser Daily Health Policy
Report, search the archives, and sign up for email
delivery at www.kaisernetwork.org/dailyreports/healthpolicy . The
Kaiser Daily Health Policy
Report is published for kaisernetwork.org, a free
service of The Henry J. Kaiser Family Foundation. © 2009 Advisory
Board Company and Kaiser Family Foundation. All rights reserved."
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