Medicaid Agencies ARE Public Health Agencies

We all remember the Golden Rule from our childhood days, "do unto others as you would want them to do unto you." But all too often in health care, regretfully, it seems a different Golden Rule prevails, "He or she with the gold, rules."

What got me thinking about this was some recent debate in the state of Florida about merging the Agency that oversees Medicaid and the Agency that oversees Public Health (as reported by Florida Health News). Apparently, leaders in the Florida Legislature think that the missions of these two agencies are mutually exclusive. To me, that just does not make sense and is further evidence that the current Medicaid program is not a model we want to expand as part of any major reform effort.

Government speeches are not typically the kind of thing to get excited about and in my five years at CMS, I can remember only one that fits this bill. In a speech given by Dr. Mark McClellan back in 2004, he stated that CMS was a public health agency, "seeking to use its influence, reimbursement systems, regulatory authority and leadership to seek widespread transformation of the United States healthcare system in order to meet the six [IOM] goals." [see CMS Quality Roadmap]

It may seem self-evident now but at the time, this was a pretty radical concept and the culture change at CMS is a work in progress but as they say "acknowledging you have a problem is the first step to recovery." Fact is, STATE MEDICAID PROGRAMS AND CMS ARE PUBLIC HEALTH AGENCIES by virtue (or vice) of the other Golden Rule, "he or she with the gold, rules."

Even though some states are ahead of this curve in that they have a "strategic plan" including public health objectives and various strategies and tactics (including Medicaid) to achieve those objectives, most do not. It is time for all states to transform their Medicaid programs from "claims payment shops" to purchasers of high value care so that increasingly limited resources can stretch farther and provide for the health of the Public. ~BAA

US Healthcare and Reform

Ok, enough is enough. After years of arguing for the private sector marketplace to reform itself, with all manner of managed care, managed competition, disease management, care management, cost management, consumer directed health management, patient-centered medical home management, chronic care management, Medicare Coordinated Care Demonstration, Medicare Health Support, and many other in which I have personally been involved, I give in. I give in to those who show our medical costs and health premiums are growing faster than our wages.













I give in to the fact that our Medicare and Medicaid program costs are mushrooming.











I admit you only get the "best" evidence-based care about half the time you see a physician. In other words, seeing a physician has many benefits, but expecting a physician to know everything there is to know all the time, well, it only happens about half the time.
I have seen the journal article by Dr. Steve Jencks, showing the inverse relationship between the amount you pay for care and the quality of the care you receive.

And the fact that the number of uninsured, although dropping in 2007 (the latest government data) is still quite high. Although people who are uninsured can get medical care, the amount of cost shifting it takes to fund uncompensated care and the inequity in charging an uninsured person more than the actual cost of care, makes you pause and think there has to be a better way.

Tipping Points

There are three "tipping points" in play that will combine to reform and revolutionize healthcare. The first is the economy. With every 1 percent increase in the unemployed in the United States, there are 1 million new Medicaid eligible persons and 1.1 million uninsured persons. This alone would start the engines rolling on serious health care reform discussions. The fact that the Democrats, traditionally in favor of government instigated health care reform, are in control of both the Executive and Congressional branches of government makes consideration of health care reform inevitable. This past week we saw continued negotiations between Congress and the Administration over the process for healthcare reform this year (which, by the way, tracks the November 17, 2008 predictions of this blog for healthcare reform to happen this year).

But the third impetus for reform is disruptive, and at the heart of American innovation and ingenuity. As we saw this past week, Walmart announced it is entering the electronic medical record market. This is the latest of several Walmart efforts to disrupt healthcare, including low-cost drugs and offering health coverage to most employees. But look for innovations to come from other players, including CVS/Caremark and Walgreens.

With everything that is happening, we will see health reform happen one way or another. Either through government fiat, or private sector disruption - and perhaps both.

Health Wonk Review – Watchmen Edition (03/05/09)

For those who don’t follow such things, Watchmen is a movie coming out tomorrow that is probably the most ambitious comic book adaptation ever made. It is based on a twelve-issue limited series created by writer Alan Moore and published by DC Comics and its translation to the big screen has been a tumultuous 20 years in the making (sounds kind of like health reform).

The movie is set in an alternate reality which closely mirrors the contemporary world of the 1980s (except Richard Nixon is in his fifth term). The movie’s primary point of divergence from our reality is the presence of superheroes and it examines what would happen if they had human frailties. The main theme (adapted by me here to health care policy) is to trust in openness, transparency, and dialogue (like in these blogs) as opposed to blindly trusting ‘heroes’ who often operate with ‘power politics’ and shallow idealism. So in that regard, I guess we are attempting to turn the tables so that we are the new Watchmen (and women) of the health policy world (see Peanuts picture below).

Ah, you ask “why Watchmen?” First off, the movie comes out tomorrow and we can all use a bit of escapism and secondly, two of the submissions were about IBM and there is a “big blue” superpowered being in the film called Doctor Manhattan.

So, now to the posts….drum roll please.

Doctor Manhattan

Newcomer Jeffrey Seguritan at Nuts for Healthcare points out how IBM is taking a leading role with the new administration on healthcare IT and that IBM is a large proponent of the Medical Home. For example, they helped found the Patient Centered Primary Care Collaborative and they are partnering with UnitedHealth to demonstrate the model in Arizona. This is kind of like Doctor Manhattan in that he was thought to be emotionless, but certain tragic events show that he still cares.

Nite Owl (think Batman)

At BostonHealthNews, Tinker Ready ponders the significance of Jim Kim’s appointment as President of Dartmouth College. Kim’s experience as co-founder of Partners in Health is a nice partnering of the phrase “evidence-based” with public health (no, not that EBM where evidence means the care is likely to lead to better outcomes but the EBM where the evidence means the care DID lead to better outcomes). Ms. Ready then crosses home plate by noting Kim’s appointment is to lead the entire college, not just the medical school and she says “he brings with him a sensibility that says - we need to do more than the right thing. Let’s do the right thing and make sure it works.” This is kind of like Night Owl in that Mr. Kim has demonstrated he can build some pretty cool stuff that makes a difference in people’s lives.

Ozymandias

In Glenn Laffel’s post at Pizaazz, he takes a somewhat tongue-in-cheek view of the recent partnership between Google Health and IBM and at PHRs in general. He notes “Come to think of it, only a few hundred thousand people use Google Health and HealthVault combined, according to Parks Associates. A hundred times that still watch TVs running Rabbit Ears.”

On the other hand, over at HealthBlawg, David Harlow has an interview with Dan Greden, Head of eHealth Product Management at Aetna, where he speaks about Aetna's PHR system, its above-average rate of adoption by members, its portability with Microsoft HealthVault, and the benefits that it provides to members, clinicians and ultimate payors.

Ah, PHRs…they are kind of like Ozymandias in that he is one of the smartest persons on the planet and he thought he was a good guy but actually was a bad guy…who knows in the murky world that is Watchmen? Same with PHRs, they promise a lot but have delivered little to date…who knows in the murky world that is HIT? Only time will tell.

Rorschach

Over at the Health Business Blog, David Williams has some interviews that he conducted with business leaders right after the Transforming Healthcare 2009 Summit. Yes, this is a bit of a stretch but Rorschach is a crime-fighting vigilante who wears a mask that has constantly shifting ink blots. Kind of like the shifting gears of health care reform and the efforts of business leaders to do good even while many have unfairly been brushed with the broad stroke of “outlaw.”

The Comedian

Bob Vineyard, over at Insureblog, explores the little-known world of “ophan drugs.” The Orphan Drug Act (ODA) of January 1983 is meant to encourage the development of drugs for diseases that have a small market (a drug for a disorder affecting fewer than 200,000 people) by instituting certain patent protections and tax incentives for manufacturers and the resulting drugs are often very necessary for beneficiaries. But manufacturers have come under increasing criticism because of the drugs’ high cost, which are often measured in terms of tens, if not hundreds, of thousands of dollars per year.

Bob wonders what effect the increased scrutiny will have on drug development, cites Pfizer’s discontinuation of two drugs, and notes that even though the new drugs may be no better or cheaper than existing drugs, if manufacturers don’t develop them, how will we know? This one is easy as the Comedian is killed off before the movie even begins…kind of like Pfizer’s drugs.

[OK folks, that does it for MFP’s take on the Health Wonk Review. I hope you found it both informative and entertaining. Look for the next edition of HWR at David Harlow's HealthBlawg on March 19th. Until then, enjoy. ~BAA]