Sunday, November 6, 2011

California Physicans Call for Regulation and Legalization of Medical Marijuana

It would be an understatement to call Legalization a hot topic, particularly so after Gallup found majority support for the first time in poll history. I had the privilege of representing UC Davis at the California Medical Association (CMA) 2011 House of Delegates this past October, where the CMA Board of Trustees unveiled adoption of official policy that recommends legalization and regulation of cannabis. The new policy came as a result of a CMA Legalization and Taxation of Marijuana Technical Advisory Committee (TAC) report that put forth several recommendations:

  • “Reschedule” medical cannabis in order to encourage research lending to responsible regulation. 
  • Regulate recreational cannabis in a manner similar to alcohol and tobacco. 
  • Tax cannabis 
  • Facilitate dissemination of risks and benefits of cannabis use. 
  • Refer for national action.
The medical community has been put in a difficult situation in the pot debate, as California has recognized it as a 'decriminalized medical benefit' yet the substance remains illegal at the federal level. Yet, there is insufficient evidence to truly assess the drug's effectiveness. To be sure, cannabis is strictly classified as a Schedule I substance, which severely deprives current literature of any assessment of dosage, benefit, or risk. As such, physicians are calling for rescheduling of the drug in order to allow for expanded research.

Advocates equate this to legalization, but CMA urges sustained regulation and control similar to that found with alcohol and tobacco. Given the contentious nature of the topic, CMA has taken a bold stance on the topic and should be commended. Creating a rational scope of debate at both the state and federal levels should finally foster an adult conversation to move towards a thoughtful solution.

Browse through the CMA white paper here:  
Cannabis and the Regulatory Void, Background Paper and Recommendations

Thursday, September 22, 2011

A New Perspective on Health Care Costs from the Institute of Medicine: Your Breakfast

The unsustainable growth of health care costs will be a topic of continued national debate for decades to come. With the properly aligned incentives of near universal coverage expected through health reform (nationally, TBD, but actively unfolding in Massachusetts), this cost growth can be more appropriately addressed head-on. The Institute of Medicine (IOM) released a report entitled The Healthcare Imperative: Lowering Costs and Improving Outcomes that highlights many of these strategies, and puts in perspective just how large these costs have grown.

For example, many have seen their premiums continue to chip away at their wages:

...but did you know that if other prices grew at the same pace of health care, breakfast would cost a fortune??

See more of these informative graphics here.

Sunday, July 31, 2011

44.7 Gallons of Soda

That's how much the average American drank last year, and this doesn't include non-carbonated sweetened beverages (another 17 gallons). Why so much? Because it's cheap. Worse? It's getting comparatively cheaper:

See Mark Bittman for the NYT article that accompanies these images, who calls for actions similar to those I have discussed in the past in order to begin to tackle America's obesity epidemic (this month the CDC reported that 33.8% of Americans are now obese).

I should also mention a recent UCLA study whose authors calculated an interesting index to measure local food quality, dubbed The Home and School Retail Food Environment Index (HSRFEI). The index assesses the density of food outlets less likely to carry healthy foods (fast food, liquor stores, dollar stores, etc.) relative to those that would be more likely (grocery stores, warehouse stores, etc.) within given California radii of school and home. The study found that teens were 7.9 times more likely to have unhealthy food outlets nearby compared to healthy outlets, where nearly 75% of California teens live and go to school in less healthy food environments (HSRFEI of at least 5.0), while only 21% do so in healthier food environments (HSRFEI of less than 5.0).

Friday, July 15, 2011

The Dual Eligible Population: A Vulnerable (and Costly) Group

As seen on the ITUP Spotlight on Health Reform post, "Creating a Sysytem of Care for California's Dual Eligible Population"

This past summer, I had the opportunity to intern at the California Department of Health Care Services under their new Medical Director, Dr. Neil Kohatsu. With so much going on in health reform implementation at the state level, it was an exciting time to be involved at DHCS on a day-to-day basis.

In my work at the Department, I developed a report entitled Cost Containment Strategies for California’s Dual Eligible Population. The dual eligible population, individuals who qualify for both Medicare and Medicaid, is a particularly vulnerable subset of America that must navigate a severely fragmented delivery system. While representing only 16% and 18% of the Medicare and Medicaid populations respectively, duals account for 24% and 46% of each program’s total spending. In all, health care for duals is roughly 10% of national health spending, and this number will continue to rise as the baby boomer generation ages.

The inefficiencies and disincentives that plague the delivery of care for this population, in addition to unprecedented flexibilities offered through the Affordable Care Act, provide California with ample opportunity to improve care for duals while lowering extraneous costs. In a time of perpetual budget crises and unpredictable program cuts, California is well positioned to streamline care for one of the costliest and most vulnerable populations. The special DHCS report provides an overview of California’s dual population as well as several forward thinking strategies in this regard, including federal collaboration, payment reform mechanisms, quality measure improvement, health information technology, and prevention.

Wednesday, June 29, 2011

My Next Steps for Health Reform

I recently submitted an essay to the Kaiser Family Foundation Essay Contest...didn't win unfortunately, but I think I made some worthy enough points to post it here! What do you think the next steps should be?

It is also worth noting that the first ruling from a federal appeals court found the health reform law constitutional today; the 3-member 6th U.S. Circuit Court of Appeals ruled 2-1 (with a Bush-appointed judge joining a Dem-appointed judge ruling for) upholding the individual mandate. Again, this should make its way to the Supreme Court by year's end.

Prompt: You’ve just been hired as a health aide to member of Congress (choose one) who has asked you to prepare a memo summarizing what the next steps should be on health reform. In 1,000 words or less, please explain and justify your recommendations, identify major challenges, and discuss how they could be addressed.


To: Senator Barbara Boxer
Subject: Next Steps in Health Reform

The Patient Protection and Affordable Act is the most comprehensive health reform legislation to pass since Medicare. Much like its 1960s predecessor, the Affordable Care Act created a sharply divided electorate that renewed the fundamental debate as to what the role of government should be. With its passage, access to basic health care became a right for all Americans and in turn every individual has a responsibility to contribute for the care they receive.

As you know, many newly elected Republicans ran on the ‘Repeal Obamacare’ mantra this past fall, and have since fulfilled campaign promises by voting to do just that. While the effort of full repeal amounts to little more than political theater, it is important to realize that the complex legislation can and should be improved upon.

Full implementation of the law and its benefits will take years to realize, and you and your colleagues should focus on how best to process the transition. Rather than rehashing the debate of the last two years, there should be consensus around the fact that portions of the law should be preserved, while others should be retooled if not fully removed. More so, the new law left out several important provisions and these should be addressed in separate legislation.

What To Keep

Much like Congress, the American public remains divided in their opinions of the Affordable Care Act.[i] Many remain confused with the law’s provisions and unsure of what it means for them personally. This trend will most likely continue until the major pillars of the law are brought to fruition in 2014, including the expansion of Medicaid, the institution of the individual mandate, and the availability of health insurance subsidies through the state based exchanges.

The major insurance market reforms remain the most popular provisions of the law.[ii] The bans on pre-existing condition exclusions for children and rescissions for all persons exemplify these positive views, and as more regulations preventing the most abusive practices of the insurance industry roll out overall perceptions of the law should continue to gain approval. Market reforms like guaranteed issue of insurance and a comprehensive minimum benefits package are essential provisions that must be preserved. Lawmakers should continue to relay the fact that unless everyone is in the insurance market, incentives will be improperly aligned towards ‘cherry-picking’ only the healthiest enrollees. The ‘three-legged stool’ composed of the individual mandate, adequate insurance subsidies, and guaranteed issue will not be functional unless every leg is preserved at the risk of the adverse selection and skyrocketing premium costs. As such, it is imperative for you and your colleagues to preserve these co-dependent provisions.

The law’s financing mechanisms must also be maintained in order to preserve fiscal responsibility, as spending measures such as the expansion of Medicaid, closure of the Medicare Part D doughnut hole, and insurance subsidies for individuals and small businesses have proven wildly popular.[iii] It would be advisable not to shy away from the fact that the law does indeed increase revenue, and any attempt to dismantle the taxes on high cost insurance plans and high-income payrolls would be harmful. Medicare savings realized through efforts like the Independent Payment Advisory Board (IPAB) and crackdowns on fraud and abuse should bring significant cost reductions to the program[iv], and there may be additional opportunity to collaborate with members on the other side of the isle along these efforts.

What to Change

As much of the responsibility of implementation rests with the states, it would be helpful for you and your colleagues to allow maximum flexibility to achieve meaningful progress for their unique populations. As such, expediting the provision for a state flexibility waiver that satisfies a determined ‘federal floor’ should be considered, which is now set to go into effect in 2017. By moving up the start-date to 2014, states could immediately pursue novel mechanisms to expand coverage and act as laboratories for health care payment and delivery models. Senators Ron Wyden (D) and Scott Brown (R) have introduced The Empowering States to Innovate Act along these lines, and your support could add significant momentum to the effort.[v]

What to Add

Majorities in both parties realize the necessity of controlling rising health costs. Though the Affordable Care Act makes meaningful strides to help bend the cost curve, additional steps must be taken to preserve the fiscal health of programs like Medicare and Medicaid. Funding for dynamic delivery models like Pay for Performance and the Patient-Centered Medical Home must be expanded. A permanent solution to the flawed Medicare SGR provider payment formula must also be addressed. The political realities of today will limit any new financing sources, though, and as such it may be necessary to redistribute appropriations in the Affordable Care Act towards these necessary endeavors.

As you are aware, Medicare and Medicaid are the major drivers of the nation’s long-term deficits, and it is important to begin thinking outside the box about how best to curb costs without sacrificing the quality of these vital programs. Tort reform such as the HEALTH Act[vi] will begin to reduce the need for physicians to practice costly ‘defensive medicine’, while research through the new Medicare Innovation Center and Patient Centered Outcome Research Institute will yield meaningful proposals on how to best improve the value of provided care.  It may also be time to start considering ambitious proposals such as retooling the Medicare payment index (RVU) in order to truly bolster primary care, and negotiating drug prices in Medicare Part D.

The passage of the Affordable Care Act was a monumental achievement, but only the beginning of the effort. Health reform is forever, and looking forward solutions must be able to transcend political party in order to contain the growth of health care costs and improve the health of every American. This will not only foster a uniquely American health system worthy of the name, but also more importantly preserve and bolster our global competitiveness through the 21st century.

[i] Kaiser Family Foundation, Kaiser Health Tracking Poll, February 2011 at
[ii] ibid
[iii] ibid
[iv] CBO, Cost Estimate for HR 4872, Reconciliation Act of 2010 (Final Health Care Legislation, March 20, 2010 at
[v] The Library of Congress, S. 3958 The Empowering States to Innovate Act at
[vi]The Library of Congress, S.218 Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011 at

Tuesday, June 14, 2011

Leadership in Health Care

Last weekend, I had the opportunity to attend the 14th annual California Health Care Leadership Academy in Indian Wells, CA. The overarching theme of the conference was to understand how best to deal with the opportunities and challenges presented in a new era of health reform. There were many great discussions and panel presentations, and the spectrum of physician perspectives was fascinating to witness. Below are some quotables from the weekend that really hit home as far as where the Body of Medicine is at present, and where it needs to be in the future.

"Modern medicine is a team sport. The task for us is not to hold the tide back but renegotiate our social contract. The current trend is health care costs unsustainable...and anything unsustainable will not be sustained. The question is do we want to have those changes imposed on us or do we want to embrace our own futures. We must be good stewards of the limited health care resources we have."
-Mark D. Smith, MD, MBA, President and CEO, California HealthCare Foundation

"Inland Empire is the perfect microcosm of the challenges we face: lots of solo docs, a large uninsured population, and low provider ratios. To be successful, where you are practicing has to change: FQHCs, big groups, and ACOs are the future."
-Bradley Gilbert, MD, MPP, CEO, Inland Empire Health Plan

"Physicians need to be more involved in the management and governance of the health system."
G. Aubrey Serfling, President and CEO, Eisenhower Medical Center

"Who would have thought that me, once a young mexican girl living in labor camps, would today be able to sit down with elected officials and be an advocate for my community.  I encourage all of you to step out of your comfort zone, and be a voice for your patients."
Katherine Flores, MD, Director, UCSF Fresno Latino Center for Medical Education and Research

"Hospitals grew up as extensions of physician practice. Today we have two hierarchies of clinicians and administrators, with very different goals and visions. We are going to have to move past the relationship between doctors and hospitals of the last 30 years, finding common ground as full partners to invest in social capital. The same holds true for medicine and public health."
Sharon L. Levine, MD, Associate Executive Director, The Permanente Medical Group

"It is necessary, as part of professionalism, to increase the value of services we offer in order to reduce costs and avoid the risk of draconian and harmful cuts and restrictions. Medicine today is a fiefdom. We are so fragmented and the need to create a unified profession is great. Bigger things are happening around us, and only we will be able to save ourselves."
Jack C. Lewin, MD, CEO, American College of Cardiology

Thursday, May 5, 2011

Top 10 Worst Pathogen-Food Combos

In honor of our microbiology final tomorrow, here is a list of the ten pathogen-food combinations that have the greatest effect on America's health. The study from the University of Florida Emerging Pathogens Institute is noteworthy in that instead of measuring illness in terms of incidence as is commonly the case, the analysis shifts the focus to long-term impacts like greater health care costs and disease burden in the form of Quality Adjusted Life Years (QALYs) lost. Toxoplasma, for example, represents less than 1% of foodborne illness but holds two of the top ten spots on the list costing us almost $2B a year and 7,000 QALYs. Investigations such as the Florida study show that better synthesizing data across a historically fragmented health care and food safety system through health information technology (HIT) can help to target limited resources toward preventive efforts in the most effective and efficient way possible.
  1. Campylobacter in poultry: $1.3 billion annually, 9,500 lost quality adjusted life years (QALYs)
  2. Toxoplasma in pork: $1.2 billion, 4,500 QALYs
  3. Listeria in deli meats: $1.1 billion, 4,000 QALYs
  4. Salmonella in poultry: $700 million, 3,600 QALYs
  5. Listeria in dairy products: $700 million, 2,600 QALYs
  6. Salmonella in complex foods: $600 million, 3,200 QALYs
  7. Norovirus in complex foods: $900 million, 2,300 QALYs
  8. Salmonella in produce: $500 million, 2,800 QALYs
  9. Toxoplasma in beef: $700 million, 2,500 QALYs
  10. Salmonella in eggs: $400 million, 1,900 QALYs
And of course, remember to wash everything and cook it through thoroughly! 

Monday, April 18, 2011

Rufflin' Some Feathers: Abortion and Physician-Assisted Suicide

Thought I'd forward along an article that I and my classmate Olivia Campa published in this month's edition of the Sacramento and Sierra Valley Medicine Journal. The piece is a response to a previous commentary (whose author happens to be one of our Faculty) regarding the ever-contentious and hot-button topics of abortion services and physician-assisted suicide. Many thanks to Dr. Nate Hitzeman for his input and assurance that such a response would not torpedo our academic futures with said Faculty.


The article “Assault on Conscience” published in the January/February 2011 edition of Sierra Sacramento Valley Medicine describes an impending attack on physicians who do not wish to participate in procedures contrary to their conscience.

Most notably, the author is concerned with potential legislation that would force physicians to participate in controversial services such as abortion or physician-assisted suicide. While the author gives an example of language removed from the recent Assembly Bill 2747, the argument can be made that there are far more real and existing threats to the physician-patient relationship.

We believe that bills have already been passed that threaten a physician’s ability to practice within a “shared moral integrity” and “in a manner that best serves the patient.”

For example, many states have passed a variety of laws to limit the access of patients to abortion services. In Oklahoma, the law requires abortion providers to read a script providing details of the fetus’ development and suggesting the fetus may feel pain during an abortion.1 We students see these punitive state statutes as a far greater threat to physician conscience.

As first year medical students, we are taught to prioritize the safety of our patients, despite gender, race, or age. It is difficult to justify concerns about a near attack on physician conscience when a more unjust attack is already occurring on women’s rights and access to safe and timely care.

A human society does not exist where a significant proportion of women will not, at some point in their lives, seek out abortion services.2 In this country, 1.37 million abortions are performed annually and 52 percent of these abortions are performed in women younger than 25.3

An estimated 43 percent of all women will have at least one abortion by the time they are 45 years old. Black females are three times more likely than white females to receive abortion services, and Hispanic females are two times more likely.

This racial disparity is very much thought to be due to lack of access to preventative care and contraception services — the very services threatened by cutting federal funds to Planned Parenthood.1 Hence, rhetoric cloaked in the guise of physician conscience that serves to limit access to patients seeking reproductive services disproportionately affects minority women living in low-income areas. This is a dangerous step backwards in terms of social consciousness and women’s rights. 

Regarding concerns about physician-assisted suicide, shortsighted rhetoric among politicians like “death panels” and “rationing” detracts from a much-needed honest discussion on end-of-life care. 

It does not seem likely that a bureaucrat will force a lethal dose of pentobarbital into a physician’s hand anytime soon, while it does seem highly likely that skyrocketing health care costs and inappropriate heroic care will break the back of our aging populace and tech-driven economy in this very decade!

The hijacking of legitimate strategies such as reimbursing for advanced directive conversations, improving access to hospice, and promoting patient centered comparative effectiveness research by politically-driven agendas not only limits our society’s ability to move the conversation forward in how to get the most of our health care dollars, but severely threatens the physician’s ability to best serve the patient.

As first year medical students, we learn to put our own judgment aside in the interest of our patients. We learn to actively listen to patients’ concerns and help guide them through their medical crises. We worry far less about patients dictating their own care than them being afraid to openly discuss their concerns out of fear of judgment. Over four years, we learn history-taking, then physical examination skills, and finally the art of diagnosis. The ability for a provider to connect to a patient in a way that solicits the patient’s trust is endearingly termed “the art of medicine.”

Before we enter into discussions about “poking a vengeful finger in the eye of those whom we disagree” perhaps we should discuss how we as a community of physicians can maintain patient safety while enjoying our work and chosen specialties, how medical educators can increase medical student interest in areas where there is a high need for services, and how best to protect a patient-centered focus in medicine.

— Olivia Campa, MS I
— Adam Dougherty, MPH, MS I
Copyright © 2000-2011 Sierra Sacramento Valley Medical Society - All Right's Reserved

Sunday, March 27, 2011

The ACA Turns 1, How Well Do You Know It?

This past Wednesday marked the first birthday of health reform's passage into law. Much like a  toddler beginning to walk, the Affordable Care Act and those responsible for its implementation are still learning how to best develop its balance, coordination, and communication abilities.

So how well do you know the little guy? The Kaiser Family Foundation put together a short quiz to gauge the public understanding of what the law will actually do. Here are the 10 yes-no questions, and you can plug your answers in here to see how you compare nationally:

  • Will the health reform law require nearly all Americans to have health insurance by 2014 or else pay a fine? 
  • Will the health reform law allow a government panel to make decisions about end-of-life care for people on Medicare?  
  • Will the health reform law cut benefits that were previously provided to all people on Medicare? 
  • Will the health reform law expand the existing Medicaid program to cover low-income, uninsured adults regardless of whether they have children?
  • Will the health reform law provide financial help to low and moderate income Americans who don't get insurance through their jobs to help them purchase coverage? 
  • Will the health reform law prohibit insurance companies from denying coverage because of a person's medical history or health condition? 
  • Will the health reform law require all businesses, even the smallest ones, to provide health insurance for their employees? 
  • Will the health reform law provide tax credits to small businesses that offer coverage to their employees?
  • Will the health reform law create a new government run insurance plan to be offered along with private plans? 
  • Will the health reform law allow undocumented immigrants to receive financial help from the government to buy health insurance?
KFF released some informative poll data on results from the quiz and found that 59% of Americans did equal to or worse than a coin flip:

This means a couple things. Firstly, it means that bloggers like myself will have no shortage of opportunity to separate fact from fiction and fill the knowledge gap. Hooray relevance! More importantly, it means that the bill is experiencing a marked developmental delay in its communication skills and needs something along the lines of a speech therapist. Whether it is public agencies, the media, advocacy groups, or simply word of mouth there is a clear need to better disseminate even its most basic elements. Even more interesting is the breakdown of scores based on a number of other qualities:

In general we see that those who are not fans of the law perform consistently worse on the quiz than supporters. Whether the disapproval is caused by a belief in misinformation about negative claims or vice-versa, there seems to be is a significant correlation between knowledge and support (and of course, source of information). As more of the law's provisions roll out and individuals begin to directly experience benefits like some of those listed above, the knowledge gap will undoubtedly reduce. Until then, though, data like that seen here shows there is long way to go towards sufficient public awareness, which is a vital tool that will be needed in deciding how best to implement and augment the law across our diverse populace. 

Saturday, March 5, 2011

A California Soda Tax: How it Can Help the Obesity Problem

Last week, Assemblymember Bill Monning (D-27) introduced AB669, a bill that would impose a one cent per ounce tax on every soda and sugar sweetened beverage sold in California. The bill would create the Children's Health Promotion Fund, raising $1.7 billion a year for programs that are facing severe cuts due to the state budget crisis including school lunch programs and physical education programs. Funds could also be used to develop new programs targeted at obesity prevention in children, including enhancing community parks and other targeted endeavors.

Is a soda tax a realistic solution? Here are some numbers to consider from CCPHA and Michael Pollan:

-Per capita soda consumption has increased nearly 250% over the last 30 years
-Added sweeteners represent 16% of the average daily dietary intake
-Since 1985 the percent of personal income spent on food has decreased from 15% to 10%, but the real price of fruits and vegetables has increased by 40% while the real price of packaged food and soft drinks has decreased by 25%
-56% of California adults are obese or overweight, and now 28% of children are as well
-An estimated $41 billion is spent every year in California as a result of chronic disease costs, most notably diabetes.

Food prices are a significant factor in regard to these trends, and people are inherently cost conscious in what they purchase, especially low income individuals. Research has shown that food cost plays a significant role in diet, and overall economic factors may be a much larger influence than lifestyle or personal will. Simply put, the current system is geared to make the most unhealthy calories in the marketplace the only ones that poor people can afford (who also tend to have higher obesity rates). 

It is hard to argue against the fact that obesity rates have reached epidemic proportions. Strategies to combat the epidemic must be multifactorial, and a modest fee on one of the greatest culprits would not only help raise funds to better target obesity, but also justify the issue as a top public priority in order to reduce future health care costs. Skeptics of a new levy may see this as just another 'tax and spend' maneuver, but it is important to understand that the health and productivity costs associated with complications from obesity are astronomical. As such, a concerted effort to target this risk factor will pay off as savings in the long term in both community ratings for health insurance (your premiums) and Medicare costs.

Moreso, it seems quite irrational to have public dollars funding an unhealthy system that public health dollars try to combat. Taxpayer supported agricultural subsidies (to the tune of the Farm Bill's $25 billion a year) for products such as corn, soybeans, and wheat have decreased the price of energy-dense foods. As a result, we are now experiencing lowered food quality with manufactured low-cost substances like high fructose corn syrup in soda. In order to truly curb the obesity epidemic, it will be necessary to examine quality and health ‘costs’ in addition to quantity and market costs in food production. Shifting subsidies to healthier food products would not only promote cheaper and healthier choices in the market as a whole, but would more importantly set the national agenda as being more health-conscious as opposed to solely market conscious. Consumers will continue to search for the best value (calorie) per dollar, and though it is ultimately their choice as to what food they purchase it is of the utmost importance for future policy to protect and promote the nutritional values of our food products.

Wednesday, February 16, 2011

Are You Medically Homeless?

I attended a very interesting evening talk a few weeks ago from the George Snively Visiting Professorship in Family Medicine lecture series, where we heard from Robert Reid of the Group Health Research Institute in Seattle, Washington. The Group Health Cooperative is a consumer-governed nonprofit health care system that coordinates both health insurance coverage and provision of care itself in the Seattle area, serving over 600,000 individuals.

The Group Health system is a model of care that has been exemplified by many as the necessary future of health care in the United States. Similar structures can be seen with Kaiser, Intermountain Healthcare, and the Geisinger Health System. The model provides an integrated delivery system of health care, where insurance, providers, financing, and care coordination are organized around what has become known as the patient-centered medical home. The idea goes that once a patient is in such a system, incentives are more properly aligned to keep the patient healthy and maximize health care efficiencies in order to provide the most value for the costs of services. This not only provides better care for the patient, but also results in better long-term outcomes at a lower cost.

What was most interesting at Group Health was the attempt in the early 2000s to lower short term costs through strategies like cutting down on doctor appointment duration times and increasing patient:provider ratios throughout the system. Since Group Health is uniquely positioned to collect large volumes of data throughout such experiments, they quickly realized that short-term techniques like this actually decrease quality of care, while increasing the longer-term cost per patient. When Group Health decided to return more patient-centered strategy, they saw a return of better-value care.

Care integration will be key as the nation moves into the meat of health reform implementation, through consumer-governed cooperatives like Group Health and in the similarly structured state Health Insurance Exchange systems. Such models allow for streamlined care coordination across every spectrum of health care, while providing gigabytes of reliable data on how to more effectively improve outcomes and patient satisfaction at a lower cost per patient. In short, the insurer is incentivized to actually make the patient well, the physician is salaried and thus incentivized to not just provide more care but better care (and is fully protected from malpractice worries), and the patient is incentivized to stay well. The medical home model will be central to these efforts, and to learn more about what they actually are I recommend this informative short video.

Sunday, January 23, 2011

Bad-Mouthing Big Tobacco

This one definitely pulls on my public health heart strings. As part of the Tobacco Control Act and following the recent expansion of tobacco into FDA 'jurisdiction', cigarette packages and advertisements must now include color graphics depicting the negative health consequences of smoking. Travelers to Europe and Asia may be reminded of similar strategies, as several countries have had these requirements for years.

The regulations require that at least 50% of the real estate on the front and back of cigarette packs must be covered by the graphics, with 20% of the space reserved on other advertisements. The finals rules will be issued on June 22, and the new packages hit the shelf no more than 15 months after that date. Some health advocates are hesitant to pursue 'shock value' movements like this, but given the system-wide costs of addiction (in both personal health and health spending) and the industry's blatant targeting of vulnerable populations I can think of few more effective ways to both deter purchase and remind the populace of the severe repercussions tied to a product that cuts 443,000 lives short every year. Below are some of the better examples under consideration. What do you think?

Friday, January 7, 2011

Can the GOP repeal the Affordable Care Act?

The 112th House of Representatives has scheduled a vote to fully repeal health reform on January 12th. Could this actually happen?

Short answer: No.

Long answer: As many of the new members ran on the ‘Repeal ObamaCare’ mantra, the vote is little more than a political stunt to appease the base and reiterate the fact that Republicans did indeed gain the House majority in the 2010 midterm elections; the vote to repeal will pass the House and be killed in the Senate, where Dems still enjoy the majority.

The symbolic vote is only the start of the attacks on the new law, though. Over the following months, there will be numerous attempts to defund certain provisions in the law that are required to first be appropriated by Congress in the annual budget. Every year, Congress must approve the federal spending package, and numerous pieces of health reform face this second hurdle. Provisions that could be threatened include the new long-term care insurance program (CLASS Act), the new Public Health and Prevention Fund, and some of the funds needed for expanded federal regulatory personnel to implement the law.

That being said, the central pillars of the ACA are more or less protected from Congressional action and enjoy permanent funding authority. These include all the funds related to insurance expansion like the insurance exchange subsidies and Medicaid expansion, investments in primary care and community clinics and payment/delivery reform pilot programs (Pay for Performance, reducing hospital readmissions, etc). Interestingly, the law provides expanded authority to the Department of Health and Human Services (HHS) allowing for the Department’s independent funding of ‘related provisions’ without seeking appropriations through Congress, essentially creating a backdoor to funding streams that may not survive the appropriation process. And of course, the individual mandate is facing it's own battle in the courts

Curious as to what the effects of repeal would be? Here are just a few of the more immediate effects:

-Allows insurance companies to drop children under 26 from their parents’ plan
-Adds $230 Billion to the federal deficit
-Increases drug prices for seniors, and removes their ability to receive free preventive screenings
-Allows insurance companies to deny coverage to individuals with pre-existing conditions

To be clear, there are a number of things that do need to be tweaked in the law. Until the politically-driven nowhere-votes cease, though, these adult legitimate conversations can never happen.