Health care law

[woodjack]

I am curious about it, the talk was to bring down costs and have health care for the vast majority and they base the earnings of the projected health care law on how much it will cost and save.

Yet to bring down drug costs they had a perfect opportunity to do this but had closed door meetings with Big Pharm and shut down the talk of using foreign drug companies which would have brought down prices almost immediately. Not only that the back room deals they used on Unions and actual states, all to pass this bill. Very strange; on top of that they could have garnered support on the opposite aisle by using a little bit of tort reform, Doctor malpractice insurance is a huge part of why prices are high, that and the use of emergency rooms by illegals and others without Healthcare insurance. I am not saying the broad sweeping changes that the Republicans wanted but an enticment to change it.

To me this seems like it was designed to make alot of money for the government and would not bring costs down. All the ideas I have seen to bring it down were thrown out. So how will this help in the long run? And the fact that hospitals in biger cities may be way way over booked, would this overbooking cause poor service? especially if someone is paying a huge amount in Premiums, if they have poor service because of a large influx of people that are only paying a small fraction if any at all of a premuim, it just does not seem very fair to me.

 

[Greenbeard]

To me this seems like it was designed to make alot of money for the government and would not bring costs down. All the ideas I have seen to bring it down were thrown out. So how will this help in the long run?

It's important to understand what's going on right now. "Health reform" is a very broad concept--a wide range of interlocking activities--and it isn't just confined to the Affordable Care Act (ACA) law, though that's obviously the centerpiece. There are three pieces--three laws passed in the previous Congress--to the reform puzzle and the general themes they share are pretty simple: we have a lot to learn and a lot of work to do to ensure we're indeed able to learn and improve. Which is why the very core of reform is a massive push for innovation, particularly using states as laboratories.

For example, first of those puzzle pieces, the Children's Insurance Program Reauthorization Act (CHIPRA), was aimed squarely at kids and it 1) established a Pediatric Quality Measures Program, which is part of a broad-based (i.e. public and private) effort to make sure we actually have the tools to gauge the quality of the care children are getting, and 2) funded quality demonstrations grants supporting 10 initiatives involving 18 states. These states are pioneering lots of approaches to improving care quality for kids, from implementing new models of care delivery to testing out a template for a pediatric electronic health record that's being developed right now. That's a perfect example of states working as laboratories, innovating to find the approaches that work best for improving health care for kids.

The HITECH Act, another piece of the puzzle, was a massive investment in health information technology, one that's providing incentives for doctors and hospitals to start using electronic health records and one that's seeded learning communities among health care providers to help them figure out and spread best practices for implementing and effectively using electronic health records to improve care.

On top of that, HITECH is helping states to build the infrastructure they need to facilitate the electronic exchange of health information (that means not only sorting out the technical details but also devising mechanisms to sustain it financially, putting together transparent public-private bodies to oversee it, updating state privacy laws to protect health information in the digital age, etc); states of a great deal of autonomy in figuring out what will work best for the state and there are a number of different approaches being pursued in different states right now.

The promise of all this is not only better care (fewer errors, better clinical decision support tools for doctors) but significantly more data-driven quality improvement. You can't improve what you can't measure--the performance of your doctor, your hospital, your health plan, and the quality of the care you're getting--and most of our measurement efforts right now are sorely lacking a robust clinical component; they're based heavily on measuring things like your bill (i.e. what items is your doctor billing for), which of course isn't necessarily all that revealing about the quality of the care delivered. This is where we loop in with the concepts in CHIPRA of improving measurement of child health care quality and actually evaluating the effectiveness of those new models being tried out by the demonstration states.

Then you get to the final piece, the big f'n deal--the Affordable Care Act--which is often just called the health care law because the others are now in its shadow. Most people are at least loosely familiar with the insurance market reforms in the law but again it's that overarching philosophy--improving care through innovation, experimentation, and learning--that's really interesting.

I'm not sure what you mean when you say all the ideas for slowing cost growth were thrown out. If you look at ideas that have gained some traction in health policy circles, like those outlined in the bipartisan Brookings proposal two years ago or the Commonwealth Fund's report a few years before that, you'll find that most of them made it into the law (no, not all). Things like investments in prevention and the primary care workforce; realigning the incentives of payment policies to promote quality and efficiency through things like paying for performance, bundling payments, encouraging accountable care organizations, giving states new options to institute advanced models of primary care in their public programs, shifting toward value-based purchasing; restructuring health insurance markets to force competition on price and quality; investing in comparative effectiveness research so we discover which treatments work best for which conditions; and ending the limitless subsidy to employer-sponsored health insurance coverage.

But again, the point here is that we don't know what works best and it's time we start trying to find out, primarily by letting states act as learning laboratories. Will enacting global payment systems in state Medicaid programs cut costs? Will it improve quality? Very possibly, which is why up to five states are going to get to apply to try it out. Will developing accountable care organizations specifically for kids improve care? The states that decide to give it a shot will give us a decent idea. What's the best IT design for states to use to hold up their insurance markets and ease the enrollment/customer service functions? As I mentioned the other day, a handful of early innovator states are blazing the path on that question.

The federal government isn't known for being particularly nimble but built into the ACA is a new mechanism--a center for innovation--that's empowered to roll with ideas that are showing themselves capable of improving quality and lowering costs in the states' demonstrations. In the past, the lack of this authority has sunk innovations that were showing signs of improving the cost/quality equation.

You bring up tort reform but the approach to that in the ACA is the same: supporting innovation in the states. In fact, it's extraordinarily similar to the approach taken in one of the major Republican health care bills, Tom Coburn and Paul Ryan's Patients Choice Act (this idea also appears in Ryan's roadmap).

Ryan's bill:

`(a) In General- The Secretary may award grants to States for the development, implementation, and evaluation of alternatives to current tort litigation that comply with this section, for the resolution of disputes concerning injuries allegedly caused by health care providers or health care organizations.

`(b) Conditions for Demonstration Grants- ...​

The ACA:

`(a) In General- The Secretary is authorized to award demonstration grants to States for the development, implementation, and evaluation of alternatives to current tort litigation for resolving disputes over injuries allegedly caused by health care providers or health care organizations.​

Moreover, Obama has already tried to build upon the ACA's initial effort in his budget proposal by one-upping it:

Obama's budget calls for $250 million in Justice Department grants to help states rewrite their malpractice laws in line with recommendations that his bipartisan debt reduction commission issued last year.

So how will this help us in the long run? Consider that we're currently in a world where we often don't know the most effective treatment to offer or the best way to pay for it, we're in the infancy of measuring how good our care is and how effective the people offering it are, the potential of the digital age for getting information to your doctor where he needs it when he needs it and offering him support in making clinical decisions is largely untapped, and the notion of getting better value of out of system (i.e. wringing more quality out of every dollar spent) is still in many ways just a dream because the infrastructure for pursuing value in a systematic, evidence-based way is still largely absent.

I would argue that changing all of that is absolutely necessary for slowing cost growth without harming patient or population health. And the current era of health reform (all three parts of it taken together) is a tremendous first step toward doing that and remedying many of the deficiencies in our health care system. Is it a panacea? Of course not. It's not meant to be and it certainly doesn't pretend to have all the answers (as I've pointed out, the philosophy underlying it is that we don't have all the answers but we need to figure out how to get them). It's meant to be revisited--that's how learning works. It casts a wide net (with lots of help from innovative states and researchers), while at the same time building up the infrastructure and offering up the tools we'll need to evaluate what gets caught in the net, something we haven't been all that good at doing to date.

The best metaphor I've seen for explaining the promise of reform--and the ACA in particular--is that it's a toolbox. It has lots and lots of things we can use to try and fix our system to preserve and improve quality while getting a handle on costs, if we're committed to doing that and are willing to experiment, innovate, and learn from our efforts. There's a lot of peril, there's a lot of promise but this is absolutely an approach for the long run, primarily because (aside from the coverage expansions) it's going to be several years before the returns start coming in, in so to speak.

 

[Quantum Windbag]

The best metaphor I've seen for explaining the promise of reform--and the ACA in particular--is that it's a toolbox. It has lots and lots of things we can use to try and fix our system to preserve and improve quality while getting a handle on costs, if we're committed to doing that and are willing to experiment, innovate, and learn from our efforts. There's a lot of peril, there's a lot of promise but this is absolutely an approach for the long run, primarily because (aside from the coverage expansions) it's going to be several years before the returns start coming in, in so to speak.

Toolbox, I like that.

The PPACA is a rusty old toolbox with a bright and shiny paint job. If it is chocked full of all the tools you need to be a TV repairman, and you just got a job as a plumber.

That is a very good metaphor, thank you.