Much has been written about Donald Berwick’s recent resignation under fire as Director of the Center for Medicare and Medicaid Services. He has been described as a visionary, a heretic or more accurately, a thoughtful physician and quality expert who tried to keep the concept of patient-centered care at the heart of the administration’s health policy.
I’ve read many of these articles and found Harris Meyer’s detailed history in Health Affairs of Berwick’s too-brief tenure at CMS , including a first-hand glimpse of his last few days at the helm of the agency, to be especially insightful. But I also wanted to direct readers to a speech given by Berwick earlier this month when he accepted the Picker Award at the Institute for Healthcare Improvement’s (an organization he co-founded) national meeting. It’s a speech that is humble, offers gratitude to many, many people who helped along the way, is prescriptive and yet, also manages to implicate the culture of cynicism crippling Washington and impeding progress in truly reforming health care.
First a brief background: President Obama appointed Berwick to the CMS job in April 2010—a month after the historic health reform legislation was passed—while Congress was in recess. This tactic was deemed controversial but necessary as Berwick’s regular appointment would surely have been blocked by GOP critics who accused the Harvard professor of pediatrics and health policy of advocating rationing and of trying to turn the American health care system into a version of the UK’s “socialized” health program.
During his time at CMS, Berwick made significant progress on advancing government policy to support accountable care organizations, better coordination of care and made inroads in getting doctors to adopt electronic health records. He calls the Affordable Care Act “a majestic law” that serves as a “framework,” like an “architect’s sketch” that through regulations and guidance can be transformed into real programs and services that reach people. He tells Kaiser Health News, “I think Medicare and Medicaid were are and remain brilliant social investments.”
Mostly, Berwick tried to avoid responding to his most vociferous critics. But now free from the demands of public office, his Picker speech offers the opportunity to glean how he really felt about his run as CMS director. Read more…
In a move clearly meant to appease social conservatives, the Obama administration took the highly unusual step yesterday of overruling the FDA’s decision to allow Plan B, the so-called “morning after pill” to be sold without a prescription for women of all ages. When I say highly unusual, I mean that such an overrule of an FDA approval has never happened before for any drug.
Dr. Robert Block, president of the American Academy of Pediatrics, called the decision “medically inexplicable,” saying that it defies strong data that shows emergency contraception is safe and effective for girls and women of all ages.
Competing statements released by Margaret Hamburg, Commisioner of the Food and Drug Administration and Kathleen Sebelius, Health and Human Services Commissioner reveal an ideological split masquerading as a concern about safety and the ability of younger teens to make an informed choice about using Plan B.
In her statement offering insight into the FDA’s decision to remove the “prescription-only” option for teens under 17, Hamburg says: “Based on the information submitted to the agency, CDER (Center for Drug Evaluation and Research) determined that the product was safe and effective in adolescent females, that adolescent females understood the product was not for routine use, and that the product would not protect them against sexually transmitted diseases. Additionally, the data supported a finding that adolescent females could use Plan B One-Step properly without the intervention of a healthcare provider.” She added, “I reviewed and thoughtfully considered the data, clinical information, and analysis provided by CDER, and I agree with the Center that there is adequate and reasonable, well-supported, and science-based evidence that Plan B One-Step is safe and effective and should be approved for nonprescription use for all females of child-bearing potential.”
But in her statement, Sebelius said HHS felt that evidence was still lacking:
“The science has confirmed the drug to be safe and effective with appropriate use. However, the switch from prescription to over the counter for this product requires that we have enough evidence to show that those who use this medicine can understand the label and use the product appropriately.” Her statement continues; “The average age of the onset of menstruation for girls in the United States is 12.4 years. However, about ten percent of girls are physically capable of bearing children by 11.1 years of age. It is common knowledge that there are significant cognitive and behavioral differences between older adolescent girls and the youngest girls of reproductive age. If the application were approved, the product would be available, without prescription, for all girls of reproductive age.” Read more…
At the heart of health reform is the idea of “patient-centered care.” The Institute of Medicine defined the term a decade ago as: “Healthcare that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.”
The Institute for Healthcare Improvement (IHI), a non-profit organization that works with providers on developing new models of care that improve safety and outcomes further calls for taking into account, “patients’ cultural traditions, their personal preferences and values.”
In recent years, the term has become ubiquitous, used to promote not only health insurers, hospitals, out-patient clinics and a whole range of other commercial health care enterprises, but also to describe wildly different proposals from both ends of the political spectrum for retooling the nation’s health care system.
But despite being so widely co-opted, the idea of engaging patients in their own care—and taking an individual’s preferences and unique “story” into account when deciding treatment and end-of-life decisions—promises to not only improve the experience and quality of health care, but will also reduce waste, over-treatment and, ultimately costs. An article in the British Medical Journal, for example, finds that “reduction in blood pressure was greater in patients who, during visits to the doctor, had been allowed to express their health concerns without interruptions; and, in patients with headache, improvement was most likely in those enabled to discuss their condition in full.”
The problem is that aside from all the lip service devoted to patient-centered care, there are significant barriers to really achieving the ideal. (The BMJ article defines them as Time, Motivation and Wisdom.) From the provider side, the reality is that it is very hard for physicians and other providers to work all that “engagement” into a standard 15-minute office visit, (or an even shorter bedside consult in the hospital). And many practitioners still operate under the “more procedures, more profits” concept that has personified fee-for-service medicine for so long. Read more…
Another day, another poll tracking how the public feels about the health reform law.
This one comes from the Kaiser Family Foundation and finds that fewer Americans have an “unfavorable” view of the Affordable Care Act than they did in October, but outright support for the legislation isn’t exactly staggering. Kaiser reports that;
“Americans remain somewhat more likely to have an unfavorable view of the law (44%) than a favorable one (37%). That is a narrower gap than the 51 percent unfavorable/34 percent favorable split seen in October, when the share of the public with a favorable view reached a low point in Kaiser polls”
Not surprisingly, as was the case last month, some key ACA initiatives remain very popular: requiring insurers to provide clear summaries of plan benefits; tax breaks for small businesses offering health insurance; closing the Medicare prescription drug “doughnut hole,” and new rules that would prevent insurers from denying coverage to people with pre-existing conditions.
And the bad news;
“Far and away the least popular element of the health reform law is the individual mandate…More than six in ten (63%) Americans view this provision unfavorably, including more than four in ten (43%) who have a “very” unfavorable view. Only among Democrats do a majority (53%) register a favorable view of the individual mandate. Just 29 percent of independents and 17 percent of Republicans have a favorable view of it.”
Are you wondering why so many Americans still oppose the requirement that they purchase health insurance? Well, aside from the reasons I’ve discussed elsewhere, it seems that many in the public are just plain misinformed about the health care law. According to the Kaiser poll, fewer than 4 in 10 know that the law eliminates cost-sharing for preventive services and that insurance companies are now required to spend up to 85% of what they take in from premiums on medical care. These are very popular initiatives, among members of the public who know they actually exist.
The recent poll also shows that scare tactics used by the ACA’s opponents have been difficult to overcome. Conservatives continue to refer to health reform as a “government takeover of health care,” and the Kaiser poll finds that more than half (56%) of those polled believe that “the law includes a new government-run insurance plan to be offered along with private plans (while another 13% don’t know if the law does this”. As for the “death panels” that fear-mongers warn are poised to pull the plug on Granny; the poll finds that a third (35%) of the public still thinks “the law allows a government panel to make decisions about end-of-life care for people on Medicare (with another 12% saying they don’t know)”.
What this poll tells me is that Americans see plenty to like in the health law and are already benefiting from some of the early initiatives. But until the administration and its allies in the wider world of opinion begin setting people straight about what is and what is not in the legislation, support will continue to move incrementally up and down–in some cases depending on the individual pollster and how the survey questions are asked. Where are all the spin doctors when you need them?
Out of the rubble of the failed budget deficit negotiations, it seems a new movement is afoot to transform Medicare into a “premium support” program with the goal of moving more seniors and the disabled into the private insurance market.
As Robert Pear reported last week in the New York Times;
“Members of both parties told the [budget deficit] panel that Medicare should offer a fixed amount of money to each beneficiary to buy coverage from competing private plans, whose costs and benefits would be tightly regulated by the government.”
Before we go any further, let’s be clear: Premium support means very different things to different people. And the “supercommittee” Democrats flat-out rejected any notion of privatizing Medicare once it became clear that their Republican counterparts wouldn’t budge on accepting revenue increases (i.e. raising taxes on the very rich) to go along with cuts to entitlements like Medicare, Social Security and Medicaid.
To Republicans who support Rep. Paul Ryan’s (R-WI) plan to “change Medicare as we know it,” premium support means providing seniors and other beneficiaries with a government voucher that is paid directly to private insurance companies. These private policies will be more expensive than traditional Medicare with its enviable rate of scale and bargaining power. And because the value of the vouchers in the Ryan scenario would increase at a rate slower than actual medical costs, many seniors will end up having to pay a huge portion of their insurance premiums—or be forced to enroll in inadequate plans that leave them unable to access needed services. Read more…
If they sold a pill for happiness how many of us would be taking it? That question came to mind when I read that 20% of Americans now take a psychiatric drug of some type or other—including antidepressants, anti-anxiety meds and pills to treat attention disorders.
And what segment of the population is fueling the rise of the sublimely medicated? According to an “analysis of trends” compiled by pharmacy benefit manager Medco Health Solutions, Americans across the board are turning to psychiatric drugs to “ease their mental woes” but “women lead the trend.” It turns out that one quarter of all adult women now take at least one psychiatric drug.
Here are a few highlights of Medco’s analysis, called “America’s State of Mind;” over 20% of all women are taking a drug usually prescribed for depression with some 24% of older women (over age 64) taking antidepressants, 11% of women 45-60 depend on anti-anxiety drugs and, perhaps most surprisingly, the percentage of young women (20-44) taking medication to treat attention deficit hyperactivity disorder (ADHD) rose a whopping 264 percent over the last decade. Overall, the number of women on ADHD drugs was 2.5 times higher than in 2001—putting them ahead of men in terms of sheer numbers using these drugs.
In the last decade or so a lot of attention has focused on the increasing use of psychotropic drugs to treat mood and attention disorders in children. That trend has abated somewhat when it comes to traditional antidepressants ever since the Food and Drug Administration issued a warning in 2004 that SSRI drugs such as Prozac and Zoloft increase the risk of suicidal thinking in children. Use of ADHD drugs has also leveled off in both boys and girls since a high in 2005. But use of a newer class of drugs called atypical anti-psychotics—strong medications that were developed to treat serious ills like schizophrenia and have troubling side-effects—continues to increase for treatment of depression and other mood disorders in kids. Such “atypicals” as Abilify and Serequel can lead to weight gain, increases in cholesterol levels and incidence of Type-2 diabetes in young people. Last year, a similar Medco analysis reported that use of these drugs in kids doubled between 2001 and 2010.
But the spike in psychiatric drug use among adult women stands out as the most striking finding in Medco’s current analysis. Dr. David Muzina, a psychiatrist and national practice leader for the company says that it’s not clear if more people, especially women, are “developing psychological disorders that require treatment, or if they are more willing to seek out help and clinicians are better at diagnosing these conditions than they once were.” Women, he continues, tend to be, “more frequent users of healthcare, but they may also be bearing the emotional brunt of a decade that started with the horror of 9/11 and since has seen several wars and economic turmoil.” Read more…
When the Supreme Court begins examining the federal health reform law next March, much of the focus will be on the constitutionality of the individual mandate—the provision in the Affordable Care Act that would require most Americans to purchase health insurance.
Beyond all the rhetoric about a “government takeover of health care,” or the dreaded “death panels” and threats of rationing and imminent financial collapse, this is the key issue that that divides Americans. In fact, the mandate originally divided then-presidential candidates Hillary Clinton (who believed it was integral to the success of health reform) and Barack Obama, who held out hope that his vision of universal care could succeed without mandating coverage.
Once elected, under pressure from an insurance industry that threatened to oppose health reform unless they could be guaranteed millions of more customers for their plans, the President did change his mind and included the insurance mandate in the legislation. The administration also saw it as a fiscally sound move; the Congressional Budget Office estimates that removing the individual mandate will cut the number of individuals newly insured in half (from 32 million to 16 million), and will cause premiums in the nongroup market to rise by 15 percent to 20 percent.
But opposition to the mandate has persisted, and it is now a rallying point for conservatives who would like to dismantle the health bill in its entirety. According to the National Council of State Legislators, a total of 18 states have passed binding legislation opposing elements of health reform—most calling for repeal of the individual mandate. This occurred most recently in Ohio, where 66% of voters favored opting out of the federal insurance mandate—even as they rebuffed the Republican-led state’s new law limiting the collective bargaining power of public unions. (Parsing this confusing message from Ohio voters has eluded pundits from both political parties.) All together, 44 states have filed more than 200 of these anti-reform measures or have proposed their own alternatives to the federal law.
With all this legislative activity percolating at the state level, one might imagine that there is strong grassroots opposition to all of “ObamaCare”. But the picture is far murkier. First of all, even as some legislators advance bills that would flout the federal authority of the ACA, most of their home states are quietly using federal grants and technical assistance to help plan how they will set up health insurance exchanges, extend Medicaid to millions more enrollees and make other fundamental changes to meet the requirements of the 2014 roll-out of the health law’s major initiatives. Read more…
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