Field Notes Inside an Integrated Communications Agency

Kaiser Health News posted a terrific article today debunking the popular -- but utterly misguided -- notion that repealing health insurers' limited anti-trust exemption will reduce health care costs.  It is remarkable to me that members of Congress and public option fans are so passionately devoted to a concept that is obviously a red herring upon even a cursory review of the facts.

The authors – a Seattle anti-trust attorney and a Boston University health economist – also point out that overregulation on the health insurer side could well have the unintended effect of raising health care costs if it tips market balance in favor of large hospitals and provider groups.

Eighty to eighty five cents on the premium dollar goes to hospitals, doctors and drug companies.  No matter how unpopular insurers are, their cut just isn't big enough to significantly change health care costs no matter how hard you squeeze it.

We need health care reform -- not just health insurance reform.

Any remaining hopes that Congress might abandon the battle for partisan advantage to get something done on health care were definitively dashed by the recent Health Care Summit. Both sides stuck like glue to the intractable positions that have deadlocked the issue. Is anyone really surprised?

Both parties' stances are disheartening – poll-driven, cynical and oblivious to practical policy decisions that must be made to move forward. For their part, the Democrats continued to hang their hats on the vilification of insurers, an approach that polls well, but shoots the messenger while ignoring the real cost drivers in the system. Repealing health insurers' anti-trust provisions or creating additional layers of rate regulation will be popular with the left flank of the Democratic base, but do nothing to rein in health care costs or expand access.

Too much of the debate was wasted arguing over whether the CBO found that costs would go up or down under reform. Republicans are right that there is a fundamental difference between bending the cost curve and shifting costs through taxpayer subsidies. But they're wrong in asserting that this means doing nothing is the answer. The President would be better served by admitting there is a hefty cost, and explaining the long term benefits that investment could buy.

Republicans say legally requiring Americans to buy a product is a slippery slope. Fair enough, but I believe we have already crossed the Rubicon on that issue. Under 1986's Emergency Medical Treatment and Active Labor Act (EMTALA), anyone who shows up in an ER gets treated, regardless of their ability to pay. So if Federal law already requires health care to be provided to citizens, then it has to either compel them to contribute towards its provision or come up with another funding mechanism.  Once again, government proves equal to the popular task – guaranteeing care – and unable to complete the considerably less popular task of paying for it. Hence our crazy quilt of cost shifting and hospital charges that bear little relation to actual costs.

I find it intriguing that in 1993 some of these same Republicans argued in favor of mandates on individuals to buy health insurance. At that time the individual mandate was seen as an "individual responsibility" approach superior to the employer mandates championed by the Clintons. Now, they argue that such mandates are patently unconstitutional. This is not a simple issue and it is very possible that the U.S. Supreme Court will agree with them.

Even more painfully, Rep. John Boehner (R-OH) trotted out the old saw about the U.S. having the "greatest health care system in the world."  Such mindless boosterism ignores the inequity and inefficiency of health care in America.

We have already created a system where there is guaranteed access to care – too little, too late in many cases, but guaranteed nonetheless. Fair enough. Now Congress needs to find the backbone to require everyone to pay their fair share, too.

Unfortunately, the GOP has apparently decided that its members can comfortably run on "defeating" health care. Getting Democrats to commit to a difficult and complex reconciliation approach to run over them will be difficult – especially with unfavorable polling on health care looking like a major liability to moderate Democrats nervously facing stiff mid-term opposition.

It makes you wonder.  If neither the majority nor minority party can get what it wants done, why are they fighting so hard to run Washington?

Nowadays everyone carries a mobile phone whether it be an ordinary flip phone, an iPhone, Blackberry, etc. With over four billion mobile phone subscriptions worldwide, accessibility to patients, via mobile devices is beginning to garner much attention in health care.

Several pharmaceutical companies and health care provider groups are using SMS messaging to remind patients of upcoming appointments and prescription refills and even opportunities to join clinical trials. This list can go on, but early study results have shown that such methods of communication are increasing patient adherence to medication and reducing the number of missed appointments -- which are key steps to improving patient care.

But what if this type of interaction between provider and patient was taken to the next level, say on Twitter? A recent blog post suggests Twitter may be a good avenue to communicate health care "support" activities. Below are a few ways that health care providers and pharma companies can use Twitter to disseminate information:

• • Prescription management, including pharmacy refill reminders
• • Daily health tips from authoritative sources
• • Clinical trial awareness & recruitment
• • Issuing dietary/lifestyle tips
• • Exercise management and encouragement

**For a complete list visit Phil Baumann's blog post here.

So I pose the question to you…have any of you opted in to receive text messages or other digital communication from your health care providers? What are your thoughts on the role of Twitter in this arena? Does it have a place? Is it crossing the line? Is it too public?

There's an article in today's Wall Street Journal about a radically new idea in Massachusetts: pay global fees to groups of doctors to encourage efficiency and better coordination of services.  Wow, what a radical notion.  Man, that's never been tried. 

Oh, wait.  That does sound a bit like the capitation models pioneered and eventually abandoned by managed care companies. You know, those (onimous major chord here) HMOs that were bigger than grunge rockin the early  90s?

Problem was then that NC's supposedly integrated groups (primary care plus multiple specialists) weren't really all that integrated.  Flat, shared fees or not, doctors pretty much practiced as they always had. Fast forward a few months to the stunning, conclusive failure of many of these early integrated groups. 

Doctors argued that capitation didn't work because 1) the fees just weren't high enough and 2) incentives "to withhold care" are a fundamentally bad idea anyway. 

We can argue endlessly whether the fees were "right." But it's not like the practices came up a little short.  Some of them were 90 percent off the utilization rate needed to be profitable. My sense is that the potential savings from more efficient patient handoffs never materialized, because such teamwork never really happened.  Doctors can be fiercely independent and neither traditional medical training nor fee-for-service payment systems foster teamwork skills.

And as for capitation encouraging overly parsimonious care, you have to balance that concern with the tendency for  traditional-fee-for-service payments to promote unnecessary, duplicative or inefficient care. Organized medicine at the time seemed to argue that with incentives to do too much, doctors could be trusted to make good choices, but with incentives to do too little, they couldn't. Huhn?

As the stories of Michael Jackon's final days indicate, doctors actually have a pretty hard time telling patients no, even when the services they're are dubious or just plain dangerous.

So here we are again, twenty years after capitated fees were decried as a horrible, demonic plot by HMOs and other nefarious characters.  (As an HMO lobbyist, I was once called a fascist and a communist in the same physician rant).  

In the end, doctors will have to operate on some kind of budget. Either it will be of their making (capitation or something similar) or a top-down rationing system that no one will like.  Too early to tell which the people of Massachusetts should expect. 

There was a terrific article in the New Yorker last week that points out why the debate is Washington over how to "fix" health care is focused on the wrong things.

Fans of a single-payer system -- as legion and ardent as any crowd of Deadheads you'll ever meet -- subbornly equate "reform" with a government run system.  Period.  Anyone with doubts about putting 16 percent of our nation's GDP in the hands of the same folks who brought us FEMA trailers are painted as reactionaries, obstructive, self-interested or worse.

This confuses universal coverage with public sector control. Yes, Canada and England have a single system, but Germany and Australia get the job done with a public-private mix.  Or think about how Medicare and private supplemental coverage works.  While our current system doesn't pool risk as effectively as it could, the primary problem is not the funding mechanism.

Which brings me to a terrific article in the New Yorker by Atul Gawande.  Dr. Gawande examines two Texas towns of similar demographics and health status, but startlingly different health care costs.  Why, Gawanda asks, is McAllen, Texas, the "most expensive town in the most expensive country in the world?"  An interesting question, especially since Medicare costs in the demographically similar population in nearby El Paso county are HALF what they are in McAllen.

The good folks at the Darmouth Atlas program have been documenting such oddities in great detail for a quarter of a century.  Yet local health care providers, from specialists to hospital administrators, couldn't explain this cost differential, and some were surprised to find that their costs were high in comparison to other markets.

The evidence supports none of their guesses as to why this is.  We give better care.  (But outcomes aren't measurably better.)  We have so many sick and poor people here. (But McAllen's population is not very dissimilar from many other locations with much lower costs.)  Our town is more litigious. (But Texas tort reform has significantly curtailed malpractice costs.)

What seems to be the problem is that McAllen's health care providers simply provide more care, LOTS more care, of virtualy all kinds. And there are more of them in McAllen doing it.  Why not?  That's what our do-more, earn-more reimbursement system rewards.

We could, instead, pay for the most cost-effective care. Federal stimulus legislation funds studies on comparative quality in health care that would make this possible.  Creating a comprehensive database on what methods, devices and drugs work best should be a road map on how we should reimburse health providers and manufacturers. 

Resistance to this small section of the bill was fierce, and it only passed when it was specified that this research would not impact reimbursement practices.  See, you can't cut health care costs without someone making less money.  And what group or organization will volunteer to do that? 

Any system, public or private, that doesn't break this logjam won't give us the real reform we need.  

In the distant future, health care is a commodity the average person can access only by winning a highly publicized lottery. A bad sci-fi movie, possibly starring Sylvester Stallone or Bruce Willis? No, it's a real program underway in Oregon.

Can't a country routinely affording $3.60 cups of coffee can do better than to let citizens gamble their lives on the long odds of winning a lottery?

House Bill 267 requires that all North Carolina businesses with alcohol permits sort and have collected all glass, plastics and cans. Furthermore, any new businesses wishing to obtain alcohol permits must provide proof of contracted service to have recycling picked up. I salute such a huge step in the direction of sustainability. Business owners are sure to feel the pinch, however, and there is little doubt that consumers will share in that discomfort. It's important that the General Assembly run with the ball it's picked up and not drop it. Currently only 5 of 100 counties are offering to collect businesses' recyclables. Only 51 are going to allow businesses to drop off at community collection centers. Hopefully this burden will continue to be eased. As the old adage goes, you can certainly catch more flies with honey than vinegar.

Senate Bill 862 - Smoke-free UNC - serves to:

"Allow regulation of smoking on the campuses of the UNC Health Care System, the facilities of the East Carolina School of Medicine and Physicians Practice Plan, and the buildings and grounds of the constituent institutions of the University of North Carolina."

To clarify, 'constituent institutions' means all member schools in the University of North Carolina system, and 'regulation' is defined as the prohibiting of smoking inside and within 100 linear feet of any building on the campus of any aforementioned institution. Legislation like this, and programs such as the North Carolina Health Wellness Trust Fund, are helping to shape and articulate national opinions on a number of important issues, from the economics of health care to the responsibility required of all of us in order to affect change. North Carolina is clearly ready to honor its legacy on Tobacco Road with smart, progressive decisions that will help safeguard its future.

Both pieces of legislation deserve kudos, and both have me feeling pretty great about Capstrat, and about my work that matters. To read more about new NC legislation ringing in with the new year, try these tips:

• Download the PDF . WARNING! EXTREMELY DRY READ!

• Grab your nearest Google search bar and type: "effective january 1, 2008" legislation inurl:ncleg. Takes you straight to the meaty bits. Supplement this search with additional keywords ('recycling,' for example) to further narrow the search. 

And if you see something you don't like, or otherwise have a strong opinion about, track down your representative and voice it.