In the April 5 New Yorker Atul Gawande writes about the backlash that health care reformers can expect in the months ahead. He reminds us that when Medicare passed “it faced a year of nearly crippling rearguard attacks.”
Few remember that the American Medical Association was absolutely opposed to the idea of providing medical care for all elderly Americans. They guild didn’t want the government involved, calling Medicare “the most deadly challenge ever faced by the medical profession.” The Ohio Medical Association, with ten thousand physician members, declared that it would boycott Medicare, and a nationwide movement began. (The opponents changed their mind a year later when they realized that, thanks to Medicare, their salaries had climbed by 11 percent in just on year.)
“Race proved an even more explosive issue,” Gawande reports. Hospitals were told that if they wanted Medicare dollars, they would have to integrate. Two months before coverage was to begin, “half the hospitals in a dozen Southern states had still refused to meet Medicare certification.” But LBJ stood firm on the issue.
Today, Gawande observes, the issues are different. “The medical world will wage no civil resistance. This time, the threat comes from party politics.” I would add that we are talking about more than a disagreement between Republicans and Democrats. These days the majority of Republicans in Congress are conservatives, and for them, this is an ideological issue–which explains why the opposition is so fierce.
As Gawande writes: “The major engine of opposition, remains the insistence that health-care reform is unaffordable,” I agree. Conservatives will continue to attack reform on many fronts, but as is so often the case in a debate between liberals and conservatives, beneath the rhetoric, the debate is all about money. Conservatives fervently believe in an individual’s right to accumulate as much wealth as possible– for himself and his family.. Liberals also believe in individual rights, but they are at least as concerned with equality—which sometimes means sharing the wealth.
As Jon Cohn reported after chatting with conservative protestors on the Capitol lawn the day before the bill passed, to them, health care reform “is about having their money taken for the sake of somebody else's security. When they hear stories of people left bankrupt or sick because of uninsurance, they are more likely to see a lack of personal responsibility and virtue than a lack of good fortune.”
How to Protect Reform
Gawande believes that the battle to save the legislation has just begun. If Republicans regain power, he warns, they will repeal essential parts of the legislation and “gut coverage for the uninsured. . . . The best way to protect reform,” Gawande wisely suggests, “is to prove the skeptics wrong”—and demonstrate that we can, indeed, afford to insure everyone. The truth is that there is plenty of money sloshing around within our health care system. We just need to rescue the healthcare dollars that are being squandered, and use them to pay for more effective care. Gawande points out that we know what to do: “the reform package emerged with a clear recognition of what is driving costs up: a system that pays for the quantity of care rather than the value of it. This can’t continue.”
And it doesn’t have to. He offers an example: “Recently, clinicians at Children’s Hospital Boston adopted a more systematic approach for managing inner-city children who suffer severe asthma attacks, by introducing a bundle of preventive measures. Insurance would cover just one: prescribing an inhaler. The hospital agreed to pay for the rest, which included nurses who would visit parents after discharge and make sure that they had their child’s medicine, knew how to administer it, and had a follow-up appointment with a pediatrician; home inspections for mold and pests; and vacuum cleaners for families without one (which is cheaper than medication). After a year, the hospital readmission rate for these patients dropped by more than eighty per cent, and costs plunged.”
This is what HealthBeat reader Pat S. likes to call “high intensity, low tech medical management.” (Thanks to Pat for directing my attention to this paragraph.) It’s hand’s on. It addresses public health. And rather than requiring a multi-million dollar piece of medical equipment manufactured by GE—plus a bevy of specialists and technicians to tend to the machine while no one listens to the patient– all you need are some vacuum cleaners and nurses willing to make home visits.
What more could you want?
There is just one catch. “An empty hospital bed is a revenue loss, and asthma is Children’s Hospital’s leading source of admissions,” Gawande explains. “Under the current system, this sensible program could threaten to bankrupt it. So far, neither the government nor the insurance companies have figured out a solution.
Berwick: Pay Hospitals for Empty Beds?
But Don Berwick, the man that President Obama has picked to head up the Centers for Medicare and Medicaid (CMS) has.
Here, I’m thinking about a conversation that I had with Dr. Berwick a couple of years ago. He was talking about a hospital in Sweden where the hospital director bragged about how many empty beds he had. This meant he was doing a good job—patients were not staying in the hospital longer than necessary, and they weren’t bouncing back. “Of course,” Berwick told me, “if he ran a hospital in the U.S. the man would be out of a job.” We reward hospital CEOs for growing revenues. But perhaps, under health reform, we will begin thinking about things differently. Berwick suggested. Maybe we’ll even consider “offering bonuses to hospitals with empty beds.”
Make no mistake—I’m not suggesting that this is what Berwick will do when he becomes director of CMS. Though in December, he did suggest “The best health care is the very, very least healthcare that we need to gain the long and full and joyous lives that we really want. And the best hospital bed is empty not full. . .”
Medicare’s goal is to change the way it pays hospitals so that it is paying for efficiency and value, not volume. That means that total hospital revenue should be falling, not rising. As a society, we do not want our hospital industry to be a growth industry—we cannot afford it. But we will need to find creative ways to reimburse hospitals so that efficiency doesn’t leave them in the red.
“Far From Being a Government Takeover” Reform Will Take Place on the Ground
Gawande and Berwick both understand that less intensive, less invasive—and less expensive—healthcare can sometimes be more effective than the most aggressive care. They also realize that in order to find solutions to specific problems, such as too many inner-city children suffering from respiratory diseases winding up in the hospitals, we will have to experiment.
“The most interesting, under-discussed, and potentially revolutionary aspect of the law is that it doesn’t pretend to have the answers,” Gawande observes. “Instead, through a new Center for Medicare and Medicaid Innovation, it offers to free communities and local health systems from existing payment rules, and let them experiment with ways to deliver better care at lower costs. In large part, it entrusts the task of devising cost-saving health-care innovation to communities like Boise and Boston and Buffalo, rather than to the drug and device companies and the public and private insurers that have failed to do so. This is the way costs will come down—or not.“That’s the one truly scary thing about health reform,” he adds. “Far from being a government takeover, it counts on local communities and clinicians for success.”
In December, Berwick made the same point. The legislation can’t lay out a master plan, he argued “How could Congress possibly know enough to specify for every community, the exact design for care that is safe, effective, timely, patient-centered, equitable and sustainable?” Berwick asked. “The legislation does contain long sections focusing on quality,” Berwick acknowledged, "and there legislators lay out possibilities. But it is up to health care communities to test, adapt and perfect these strategies in real world.”
Here we are talking about the pilot projects that Medicare will be sponsoring under the reform legislation. As I have discussed in earlier posts, under the new bill, if a pilot project is successful, Medicare will be able to roll it out nationwide—without having to go through Congress. In the past, lobbyists have blocked initiatives that they feared might cut into someone’s revenue stream. Under reform, they will no longer have that power. And with Berwick overseeing Medicare, we can be quite sure that the pilots will be both creative and well-designed –with the real world in mind.
What’s interesting is that Berwick and Gawande are on the same page. They understand that the ultimate power to re-design our health care system will reside, not in Washington, but in the communities where medical professionals and other healthcare leaders will implement those pilot projects, changing how we pay for care, what we pay for and ultimately, how care is delivered.
Private Insurers Will Follow
If they succeed in improving outcomes while trimming costs, private insurers will follow Medicare’s lead. They, too, want to save money, but they don’t want to show up on the evening news, portrayed as the villains who are denying Americans the care they need. If they simply incorporate Medicare reforms that are working—paying for visiting nurses and vacuum cleaners, for instance—rather than immediately hospitalizing every child suffering from asthma, they can share in the praise, without taking the risk.
Medical professionals should be in the vanguard of change, and Gawande accepts the challenge: “We are the ones to determine whether costs are controlled and health care improves—which is to say, whether reform survives and resistance is defeated,” he writes. “The voting is over, and the country has many other issues that clamor for attention. But, as L.B.J. would have recognized, the battle for health-care reform has only begun.”