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The Body Politic

Note: The perspective below is grounded in facts interpreted by a skilled and active intellect. In soliciting input from a person who knows what he's talking about, I am deliberately resisting the Romney campaign's insistance that voters do not want to hear such things. We are not a mob. As I have been suggesting for a couple of weeks now, this election should not turn on political party allegiance, but rather on the degree to which our collective reason is tempered by empathy. And now, please welcome Doctor DeBunk.

Thanks Inda for inviting me to share a few thoughts.

I'm a practicing general internist, the primary physician for about eight hundred people from all walks of life who live in and around Boston, Massachusetts.  I do this job in part because I love people.  At this point in my career I'm very connected to my patients and even on my most hectic, hair-pulling-out days my spirits are buoyed by the privilege it is to help them work at maintaining and improving their health.

What's great so far about the Obama administration's initiatives on health care is that they have twin goals squarely in their sights:  Better care and lower cost.

Owing to this, the last four years have been very exciting in terms of flexible, innovative approaches coming out of Washington to deliver better care at lower costs, all the while partnering with and spurring on institutions like mine so that we can figure out a thing or two and spread the word to others.  (I don’t name my hospital because I’m not writing this as its official spokesperson.)  The Patient Protection and Affordable Care Act, often called the ACA or “Obamacare,” included the establishment of the Center for Medicare and Medicaid Innovation, the brainchild of Don Berwick, MD, the person who, as much as anyone, helped launch the field of quality improvement in medicine back in the ‘80s.  (You may recall that he was the President’s recess appointment to head Medicare whom the Republicans found so unpalatable that he could not even go through the confirmation process.) 

Here are some examples of recent innovation:

Pioneer Accountable Care Organizations (ACOs) have just formed around the country.  The ACO is a partnership between Medicare and a larger physician group (or hospital system) that provides monetary incentives - benefits and risks - to deliver higher quality care at a lower cost, all the while preserving access and physician choice for patients.  This initiative harnesses the innovating power of these different physician groups specifically by not telling them how to achieve their goals.  It's a win-win for the taxpayers and Medicare.  If this better care costs less, great.  If it doesn't, the physician groups, not the taxpayers, are on the hook.  By trying this with many groups around the country, Medicare will replicate the most successful tactics as it expands the program.  (I would be remiss if I didn’t mention that Mark McClellan, MD, PhD, a Republican appointee in 2004 as the head of Medicare, was one of the early architects of this program.) 

Some private insurers are getting involved as well, creating what are called Alternative Quality Contracts.  These are similar to the ACO approach in that hospitals have contractual incentives - again, both risks and rewards - to provide better care at a lower cost. 

There are also some very detailed pilot programs starting up.  For years now, a Medicare patient has had to be in the hospital for three nights before Medicare would pay for that person to go to a skilled nursing facility (SNF).  The rationale for this rule was that Medicare wanted to make sure that it was paying for the people who really needed to be in a SNF.  If you needed to be in the hospital for three nights then you must have been sick enough, or so the reasoning went.  In practice, though, patients are often held up in the hospital to make sure that they fulfill their "qualifying stay" of three nights.  What was designed to save money for the sickest patients is probably costing more money because some hospital stays are lengthened unnecessarily.  Worse for the patient and worse for the system.  Over the past year, certain hospitals around the country have been part of a "three-day waiver program."  It's just what it sounds like; we don't have to keep our patients for three nights.  An appropriate patient who needs SNF services can go there straight away, even from the ER. 

What's more, we're keeping a close eye on this trial and learning from it.  We haven't just scrapped the old system.  Medicare is proceeding in a reasoned path that will be informed by data.  Depending upon the results, Medicare will figure out whether and how to expand this idea to the rest of the country. 

One noteworthy Medicare initiative was launched during President Bush’s tenure.  The Care Management for High-Cost Beneficiaries Program has provided more out-of-hospital resources for the highest risk Medicare patients.  Each person has a dedicated care coordinator who works to ensure that no ball is dropped and, if needed, no stone left unturned.  By focusing on the timely delivery of care the hope is to eliminate or decrease ER visits and hospital stays.  Better for the patient and better for the system. 

This program has been very successful at my hospital by every measure:  A 7% reduction in costs, a decrease in mortality, and an increase in satisfaction for both patients and doctors.  Unfortunately, these results haven’t been replicated so far by other hospitals.

This is the nature of true innovation.  Not everything you try works everywhere.  Of course, the Republicans in Congress seize upon this in their typical anti-intellectual vein.  It’s always hard to argue with people who play dumb.

I don't know what Mitt Romney and Paul Ryan actually understand about the delivery of health care to most Americans, but if we take them at their word then it appears to be very little.  Governor Romney, of course, should know better; his wife, Ann, has had serious medical problems.  Health care should be more than just a campaign issue to him and when he was the Governor of my state that appeared to be the case.  On the other hand, Representative Ryan and his family, as far as we know, are young and healthy and get great, taxpayer-provided health care at no cost.  It’s easy to see how health and health care probably don't rise above the level of abstract concepts.  Dollars and cents only.

To be fair, the same criticisms could be leveled at President Obama.  He’s a young, healthy guy (presuming he really doesn’t smoke anymore).  He and his family get great health care at little or no cost.  One of Mr. Obama’s key strengths, though, is that he has managed to attract the best and the brightest to Washington to help out in making health care better for all Americans.  There are hundreds and thousands of serious, non-partisan people across our country who dedicate their professional lives to improving the health of Americans.  Thanks to the President, many of them are now in the nation’s capital. 

Every serious, non-partisan person involved in health in the U.S. sees these sorts of initiatives as the wave of the future.  Our system now is neither good enough nor cheap enough.  By creating incentives - real risks and real rewards - the government has gotten most every health care professional in the country thinking about how to tackle our problems.  Of course, there are still a few ostriches around with their heads in the sand, but this is no longer a defensible approach. 

When Romney says that he's going to repeal "Obamacare," he says something that really doesn't make much sense.  (He might as well be saying that he’ll repeal the Iraq war.)  He could try to chip away at some of the various initiatives but this horse is out of the barn, thankfully.  We're already moving forward and the experts of all stripes I speak with agree. 

And, by the way, what about the follow up question to Romney’s statement:  "What, Mr. Romney, would you do instead?"





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