Courtesy of JLME

Government Intervention in Health Care Markets Is Practical, Necessary, and Morally Sound

This essay makes the affirmative case for health reform by expounding on three fundamental points: (1) one moral case for expanding access to coverage and care to all is grounded in scriptural concepts of community and mutual obligation which continue to inform the American pursuit of justice; (2) the structure of PPACA springs from an appreciation of and approach to channeling market forces that was developed and proposed by a coalition of moderate and conservative Republican U.S. senators almost 20 years ago; (3) the most humane path to a better and more sustainable health system lies in implementing (and amending where appropriate) PPACA as fast and fully as we can. The purpose of this essay is to articulate why it is not possible to make our health system better, sustainable and serve us all without government playing specific and limited but absolutely crucial catalytic roles.

Click this link for the complete article: Government Intervention in Health Care Markets Is Practical, Necessary, and Morally Sound

Image from the Hastings Center Cover

Len M. Nichols among several other authors are featured in the Hastings Center Report, September – October issue, published by The Hastings Center this month.

Abstract: 

The issues before the Supreme Court, arising as they did out of multiple cases and divergent appellate court rulings, were quite complex, and its final decision will be parsed rather differently by lawyers, health policy wonks, and economists (or metaphysical philosophers, in Chief Justice John Roberts’s memorable phrase). This essay will focus on one singular element: did the final ruling enhance or detract from our collective power to exercise stewardship over our health care resources?

Clearly Americans diverge on key features of a desirable society and on the wisdom of using government to achieve even mutually desirable goals. But before politics settles the fate of the Affordable Care Act (and perhaps also the federal role in health policy for the foreseeable future), we should focus on what the Court has allowed us to consider: if we want it to, federal power may constitutionally be marshaled to compel insurers to end discrimination against the sick and to offer more transparent products so the marketplace will better serve consumers.

Dr. Nichols’ article titled “Justice Roberts’s Health Care Stewardship” can be read here: The Hastings Center Report September – October Issue

Courtesy of Wiki Commons

NEWS RELEASE

UNDER EMBARGO UNTIL AUGUST 2, 2012, 12:00 AM ET

Health Care Organizations Find Risks and Opportunities in the Quest for Reduced Costs and Improved Quality

Groundbreaking Report in Mayo Clinic Proceedings Examines the Implications of the Accountable Care Organization Component of the Patient Protection and Affordable Care Act

Rochester, MN, August 2, 2012 – Many health care systems across the US have declined to participate in the Centers for Medicare and Medicaid Services’ (CMMS) Accountable Care Organization (ACO) program, developed under the Patient Protection and Affordable Care Act (PPACA), to improve efficiency and quality of health care delivery.  In a groundbreaking collection of commentaries in the current issue of Mayo Clinic Proceedings, representatives of six leading health care organizations write about the challenges of reducing health care costs while improving health care quality. They further explain why they did or did not choose to participate in one of the two models now operational at CMMS.

“The US Supreme Court’s decision upholding the constitutionality of the Patient Protection and Affordable Care Act provides some security for the fates of the Medicare ACO programs and the private sector’s parallel initiatives– although political rally cries for repeal of the Act continue to be raised in the build-up to the 2012 election,” comments David Ballard, MD, MSPH, PhD, Baylor Health Care System, Dallas, TX, Health Care Policy Section Editor for the journal.  “Regardless of the ultimate outcome, we should not ignore the current opportunity to learn from these activities and health care organizations’ experiences implementing (or not implementing) them. Such study can inform future national and global economic initiatives aimed at lessening health care costs and waste and improving health care value.”

The debate over the PPACA has focused primarily on individual coverage, but experts believe that the most critical issue in health care is delivery system reform.  “To put it simply, effective access for tens of millions of Americans is at risk – not to mention most other public priorities and middle class jobs in a global economy – if we fail to improve the efficiency with which high-quality care is delivered,” says Len M. Nichols, PhD, of the Center for Health Policy Research and Ethics, George M. Mason University, Fairfax, VA, a contributor to the special report.

ACOs are groups of physicians, hospitals, and other health care providers that are willing to assume responsibility for the care of a clearly defined population of Medicare beneficiaries.  If an ACO succeeds in improving care and reducing costs, they receive a share in the savings achieved for Medicare.  The CMMS created two ACO programs, the Pioneer Model, with 32 registered organizations, and the Medicare Shared Savings Program (MSSP), with 27 registered organizations. The basic difference is that the Pioneer program has a greater degree of financial risk and reward.  “Many highly regarded health systems developed concerns after initial enthusiasm about the MSSP ACO model as a mechanism for accelerating their efforts to reduce costs while improving health care quality,” notes Dr. Ballard.

Robert G. Porter, JD, MBA, and Amanda P. Tosto, RN, MS, of St. Louis-based SSM Health Care, consider the lack of beneficiary engagement in the CMMS ACO models to be a serious design flaw in the program.  “The rule provides for invisible enrollment, meaning each beneficiary is enrolled on the basis of their claims history without regard for their actual preferences.  This type of enrollment isn’t consistent with SSMSL’s transition to a patient-centered model of care that is based on the development of a transparent partnership among health care professionals, patients, and their families to ensure that decisions respect the patient’s wants, needs, and preferences,” they say.

Baylor Health Care System would like to file for Medicare Shared Savings ACO designation, but cannot.  The program requires patient attribution via the tax identification number of the physician.  Many of Baylor’s physicians practice in groups that include non-Baylor physicians, with the entire group sharing a single tax ID.  Therefore, Baylor would become financially responsible for the patients of physicians who are not part of the ACO.  Health Choice, LLC, in Memphis, TN, had concerns about retrospective patient attribution and administrative complexity.

In contrast, the Atlantic Health System has already begun to see benefits from the formation of its ACO.  Author David J. Shulkin, MD, of the Morristown Medical Center and Atlantic Health System ACO, Morristown, NJ, explains that in New Jersey’s fragmented health system, patients have a 25% greater chance of staying in an intensive care unit and 75% greater use of specialists than the national average.  “New Jersey needed a catalyst for change,” Dr. Shulkin notes, “and the MSSP presented us with just that option.”

The Atlantic Health ACO consists of four geographically based pods, each consisting of a hospital, physicians, and other community-based organizations in the region.  Clinical navigators collaborate with primary care physicians to identify patients with short- and long-term care needs and guide them through planned pathways of care.  Sixteen “Centers of Excellence” incorporate multidisciplinary approaches to care management.  The Cardiac Success program has achieved 4% to 6% 30-day all-cause readmission rates, compared to the national average of 20-25%, by incorporating protocol-based approaches.   “Little by little, New Jersey’s fragmented health care system is being replaced with coordination and integration,” Dr. Shulkin says.

Ascension Health will use its two Pioneer ACOs, Seton Health Alliance ACO and Genesys Physician Hospital Organization, to teach the rest of its large system about both medical and financial management as well as strategies for engaging physicians around values and shared business goals.  Creagh E. Milford, DO, and Timothy G. Ferris, MD, MPH, of Partners HealthCare in Boston, MA, cite key differences from the health care reforms of the 1990s that influenced the decision to participate as a Pioneer ACO, including the preservation of patient choice and improved technology and electronic health records.

Dr. Nichols comments that none of the organizations represented in this special report think that the goals of the PPACA or the ACO experiments are misguided, and in fact there is a groundswell of parallel incentive realignments in the private sector as well.  For example, Baylor has formed the Baylor Quality Alliance to develop a clinically integrated delivery organization, and is creating disease-management, population-management care delivery protocols and pathways.  The BQA expects to sign an ACO contract with the Baylor Health Center System Employee Benefit Plan, and is in discussions with several Medicare Advantage plans and commercial plans.

In an interview with Dr. Ballard, Carl E. Couch, MD, MMM, of Baylor Health Care System, notes that the recent Supreme Court ruling on the PPACA confirms that the country is headed in this direction.  “Regardless of the decision and the potential political implications this fall in terms of sustaining or overthrowing the act, the fundamental problems remain.  Health care still costs too much and the trajectory of the costs is unsustainable. And we still have serious quality problems that can be best addressed by physicians and hospitals committing themselves in an accountable way to improve them.  We have the same work to do whether the law is here or not.”

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NOTES FOR EDITORS

The articles are published in Mayo Clinic Proceedings, Volume 87, Issue 8 (August 2012), published by Elsevier.

Full text of the articles is available to credentialed journalists upon request. Contact Rachael Zaleski at 215-239-3658 or mcpmedia@elsevier.com to obtain copies. See article citations below for contact information for individual authors.

“The Potential of Medicare Accountable Care Organizations to Transform the American Health Care Marketplace:  Rhetoric and Reality,” D.J. Ballard, MD, MSPH, PhD, FACP. DOI: 10.1016/j.mayocp.2012.06.005.

Author contact: DavidBa@BaylorHealth.edu

“Accountable Care Organization Pathways: Diverse but Ultimately Parallel,” Len M. Nichols, PhD.  DOI: 10.1016/j.mayocp.2012.06.010.

Author contact: lnichol9@gmu.edu

“Ascension Health Partners With Centers for Medicare and Medicaid Services to Provide Patient-Centered Care Through the Pioneer Accountable Care Organization Model,” R.D. Anderson, PhD, E. Aderholdt, N. Chenven, MD et al.  DOI: 10.1016/j.mayocp.2012.06.004.

Author contact: Raymond.Anderson@ascensionhealth.org

“A Modified “Golden Rule” for Health Care Organizations,” by C.E. Milford, DO and T.G. Ferris, MD, MPH.  DOI: 10.1016/j.mayocp.2012.06.009

Author contacts: Cmilford1@partners.org or Tferris@partners.org

“Building an Accountable Care Organization for All the Wrong Reasons,” D.J. Shulkin, MD.  DOI: 10.1016/j.mayocp.2012.06.012.

Author contact: 973 971 5450 or David.Shulkin@atlantichealth.org

“Why Baylor Health Care System Would Like to File for Medicare Shared Savings Accountable Care Organization Designation but Cannot,” C.E. Couch, MD, MMM.  DOI: 10.1016/j.mayocp.2012.06.011.

Author contact: carlc@BaylorHealth.edu

“A Physician Hospital Organization’s Approach to Clinical Integration and Accountable Care,” G. Mayzell, MD, MBA.  DOI: 10.1016/j.mayocp.2012.06.019.

Author contact: mayzellg@myhealthchoice.com

“The SSM Health Care Approach to Achieving “True North”: Improving Health Care Quality While Reducing Costs,” R.G. Porter, JD, MBA, A.P. Tosto, RN, MS.  DOI: 10.1016/j.mayocp.2012.06.008.

Author contact: Robert_Porter@ssmhc.com

Videos of Dr. Ballard interviewing contributors about their organizations’ decision to enroll in CMMS’s ACO program, and the changes in store for physicians and health systems can be found at:

www.youtube.com/watch?v=90HMhC4e0GM (Shulkin)

www.youtube.com/watch?v=hXwp4azHLqI (Couch)

www.youtube.com/watch?v=EgCfzb6I3Bw (Haydar)

ABOUT THE AUTHORS

David J. Ballard, MD, MSPH, PhD, FACP, Baylor Health Care System, Dallas, TX

Len M. Nichols, PhD, Center for Health Policy Research and Ethics, George Mason University, Fairfax, VA

Raymond D. Anderson, PhD, Ascension Health, St. Louis, MO

Elizabeth Aderholdt, Genesys Regional Medical Center, Grand Blanc, MI

Norman Chenven, MD, Austin Regional Clinic, Austin, TX

Meredith Duncan, Seton Health Alliance, Austin, TX

Nancy Haywood, Genesys Regional Medical Center, Grand Blanc, MI

Michael James, Genesys PHO, Grand Blanc, MI

Samson Jesudass, MD, Seton Healthcare Family, Austin, TX

Amy M.H. Johnson, Ascension Health, St. Louis, MO

Gary King, MD, Genesys PHO, Grand Blanc, MI

Greg Sheff, MD, Seton Health Alliance, Austin, TX

Creagh E. Milford, DO, Massachusetts General Hospital, Boston, MA

Timothy G. Ferris, MD, MPH, Massachusetts General Hospital and Partners HealthCare, Boston, MA

David J. Shulkin, MD, Morristown Medical Center and Atlantic Health System Accountable Care Organization, Morristown, NJ

Carl E. Couch, MD, MMM, Baylor Health Care System, Dallas, TX

George Mayzell, MD, MBA, Health Choice, LLC, Memphis, TN

Robert G. Porter, JD, MBA, SSM Health Care, St. Louis, MO

Amanda P. Tosto, RN, MS, ECG Management Consultants, Inc., St. Louis, MO

ABOUT MAYO CLINIC PROCEEDINGS

The flagship journal of Mayo and one of the premier peer-reviewed clinical journals in general medicine, Mayo Clinic Proceedings is among the most widely read and highly cited scientific publications for physicians, with a circulation of approximately 124,000. While the Proceedings is sponsored by Mayo Clinic, it welcomes submissions from authors worldwide, publishing articles that focus on clinical medicine and support the professional and educational needs of its readers. The journal’s mission is to promote the best interests of patients by advancing the knowledge and professionalism of the physician community.  www.mayoclinicproceedings.org

ABOUT MAYO CLINIC

Mayo Clinic is a nonprofit worldwide leader in medical care, research, and education for people from all walks of life. For more information visit www.mayoclinic.org/about / and www.mayoclinic.org/news.

ABOUT ELSEVIER

Elsevier is a world-leading provider of scientific, technical and medical information products and services. The company works in partnership with the global science and health communities to publish more than 2,000 journals, including The Lancet (www.thelancet.com) and Cell (www.cell.com), and close to 20,000 book titles, including major reference works from Mosby and Saunders. www.elsevier.com

Please click here to read the commentary.

Anderson

Ballard

Couch

Mayzell

Milford

Nichols

Porter

Shulkin

Full press release

¹VIDEO INTERVIEWS

www.youtube.com/watch?v=90HMhC4e0GM (Shulkin)

www.youtube.com/watch?v=hXwp4azHLqI (Couch)

www.youtube.com/watch?v=EgCfzb6I3Bw (Haydar)

Contact:

Rachael Zaleski

Elsevier

Tel: 215-239-3658

mcpmedia@elsevier.com

Saint Louis University Journal of Health Law & Policy

In the Fall of 2011, Len M. Nichols published his articles “Making Health markets Work Better Through Targeted Doses of Competition, Regulation, and Collaboration” in the Saint Louis University Journal of Health Law & Policy. Please see the citation below.

“Originally published in Volume 5, Issue 1 St. Louis U. J. Health L. & Pol’y, Pages 7-25, Year 2011″

To view a PDF version of the article, please click here: Making Health Markets Work Better Through Targeted Doses of Competition, Regulation, and Collaboration – Len M. Nichols

The obesity epidemic is not only impairing the health of millions of Americans but also giving rise to billions of added dollars in health care spending. Climbing rates of obesity over the past decades are one of the predominant determinants behind the surging pro­gression of health care expenses in the United States. Moreover, the less fit and less productive U.S. work­force has gradually eroded the nation’s industrial com­petitiveness. Since the early 1970s, adult obesity rates have doubled and childhood obesity rates have more than tripled[i],while health expenditures have risen two percentage points faster than the Gross Domes­tic Product (GDP)[ii], burgeoning from 8.8 percent in 1980 [iii]to a projected 17.9 percent in 2011.[iv]4 Studies analyze that greater than a quarter of America’s health care expenses are attributed to obesity[v]. The stun­ning growth in obesity has been imputed for 20 to 30 percent of the increase in health care costs since the late 1970s. If the proportion of obese population had stayed unchanged, then health care expenditures in America would be approximately 10 percent less on a per capita average than they are today.[vi]

Abstract:

Lost in the rhetoric about the supposed government takeover of health care is an appreciation of the inherently federalist approach of the Patient Protection and Affordable Care Act. This federalist tradition, particularly with regard to health insurance, has a history that dates back at least to the 1940s. The new legislation broadens federal power and oversight considerably, but it also vests considerable new powers and responsibilities in the states. The precedents and examples it follows will guide federal and state policy makers, stakeholders, and ordinary citizens as they breathe life into the new law. The challenges ahead are formidable, and the greatest ones are likely to be political.

Implementing Insurance Market Reforms Under The Federal Health Reform Law. Health Affairs, 29(6)1152-1157.  June 2010.

Click here to view this article.

Voters are angry and distrustful of Washington. Democrats have lost their nerve. Republicans, sensing weakness, are closing in for the kill. We have seen this health care reform horror movie before.

Our leaders in Congress and the White House face a fateful fork in the road. They can follow the public’s fear and confusion down the path of perpetual inaction. Or they can lead. They can let the confusion fester or they can leverage the support of health care innovators who can explain the benefits of reform to all. This movie can have a happier ending, one that is good for our health, for our health care system, and for freeing our economy from the debt legacy of the past decade. An ending that might even help restore voters’ faith in our ability to govern ourselves.

“Be Not Afraid,” New England Journal of Medicine (February 24, 2010), v. 362:e30.

Click here to view the article.

Here I consider the migration of health workers and propose a conception of transnational justice that can best address the concerns it raises, including the perpetuation of global health inequities. My focus will be on nurses and direct care workers (DCWs), also called paraprofessionals—the vast majority of whom are women—coming from the global South to the United States. In the first part of the paper I will identify the factors behind this flow of what I will hereafter call ‘care workers’. From there, I will describe a conception of transnational justice that seems especially promising and explore selected policy options. Finally, I will conclude by offering specific prescriptions for action on the part of a wide range of agents, including institutions as well as individuals.

“Care Worker Migration and Transnational Justice,” Journal of Public Health Ethics,  vol. 2, no. 2 (July 2009): 171-183 Click this link to view the full article.

To exercise stewardship, or not—that is the question. Why put the point that way? Because one path leads to an abundant life, and the other is a dishonest, if elaborate, form of suicide. Stewards distinguish themselves first by accepting responsibility, and then by acting on that responsibility to preserve, protect, and nurture something precious, through recurrent threats, for the purpose of delivering that precious thing to future generations. Who may confer and who must accept responsibility for stewardship of our health resources and the health of our population?

Some libertarians today argue that society is a myth, that no one has responsibility for the outcome of hundreds of millions of health-related decisions, and that anyone who asserts such responsibility and tries to act upon it is both an arrogant tyrant and an existential threat to the essential freedoms upon which our nation was founded. Nothing (and no tiny group of argumentative people) has ever been more profoundly wrong.

“Stewardship: What Kind of Society Do We Want?”, in Connecting American Values with Health Reform, Hastings Center, July 2009.

Click here to view the article.

When the World Health Organization (WHO) issued its draft Code of Practice on the International Recruitment of Health Personnel on September 1, 2008, it took an important step in responding to a growing global health concern. Aimed at protecting the health systems of so-called ‘source’ countries – and ultimately the health of their populations – and shielding workers from unethical recruitment and employment practices, the WHO code joins a host of others promulgated in recent years by governments, non-governmental organizations, and health professional associations. Beyond the fact that the transnational flow of health workers has never been higher, especially troubling is that they are increasingly likely to migrate from low-income countries with a low supply of health personnel to high income countries. And the recruitment industry, involved in a range of activities related to recruitment, testing, credentialing, and immigration, is booming. Not only has the size of the industry surged in the last decade, so too has the number of countries in which recruiters operate, including those with high burdens of disease and low health worker-to-population ratios.

Unique in its global scope, the WHO Code of Practice addresses ethical concerns regarding recruitment practices, highlights the principle of mutuality of benefits, and underscores the need for national workforce sustainability, data gathering and research, monitoring, and global collaboration. But despite its seeming comprehensiveness, it is only a modest beginning, and one that may be focusing on the least problematic element of the global flow of health workers.

“The WHO Code on the Recruitment of International Health Personnel: We’ve Only Just Begun,” Developing World Bioethics vol. 9, no. 1 (April 1, 2009): ii-v

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