11th Circuit Court Strikes Down Mandate
Much of the news related to healthcare last week focused on those headlines. Those who have consistently argued that the Health Care Reform act is bad policy hailed the circuit court's decision as a victory. Those who believe in the mandate that every American have access to and be motivated to buy health insurance, decried the decision as just another example of "kicking the can down the road".
So who is the real winner? The real loser? It depends on who you ask (and whether the respondent already has insurance) and on who is taking care of the uninsureds' health needs. The provider community continues to be stuck with providing care to the uninsured, the cost of which is estimated to exceed 40 billion dollars per year, at last count. The tax payer, you and me, doesn't benefit by this ruling because ultimately that 40 plus billion comes out of our pockets in the form of higher insurance premiums and higher bills from the hospitals and the practitioners (it is called cost shifting).
And, believe it or not, it also impacts the cost of providing care under Medicare, because if I am an uninsured individual who does not seek healthcare unless it is an emergency—by the time I am eligible for Medicare I tend to be sicker than my insured counterpart and consequently my cost to Medicare will be significantly higher. Not a good situation, given that the Medicare ranks will swell by some 76 million people over time. Even if we account for a certain portion of Medicare eligibles dropping from the rolls due to death, without significant changes to how we finance and deliver healthcare, Medicare will become the single most costly program in the history of this country - and most of us will be around to see it and suffer under it.
In my last blog I talked about how a financial approach to solving the healthcare crises in the US is, at best, a short term approach akin to sweeping the problem under the rug (the "kick the can" analogy comes to mind one more time).
As an example, let's focus on the Medicare-eligible individual for the moment, to illustrate why a financial solution is not going to solve the problem. Assume that Medicare funding is cut across the board (that is exactly what is anticipated if the debt ceiling super committee cannot get its act together). The impact of such cuts? Providers are paid less (some suggest that they should be paid significantly less), which could result in primary care physicians and specialists closing patient panels to new Medicare patients; inpatient and other allied healthcare providers raising rates to balance out the cuts; and the individual Medicare-eligible exhausting their savings more quickly due to higher out of pocket costs. That in turn will lead to greater reliance by those individuals on other community services such as food stamps, Medicaid, state funded social and aging services, which will in turn drive up those expenditures and create significant budget issues in those programs.
By now you are probably thinking that this is just rambling with no real end purpose. Not really.
My point is that decisions we make in the healthcare field have far reaching consequences, whether they are made in a physician's office regarding how to treat a particular pathology, or whether they are made at the national policy level. Isolated decisions such as striking down the health insurance mandate set into motion a series of events, the impacts of which may not be felt for years, but can be very damaging once they become apparent.
No one disputes that the current health care reform has significant failings. This writer is amongst those who decried the process as well as the outcome. But irrespective of political leanings or philosophical differences, the Affordable Care Act and its emphasis on tying future provider reimbursement to better conceived approaches to patient communication, treatment and access is much better than the potential for an arbitrary cutting in healthcare financing as part of resolving this nation's debt crises.
All of us; providers, payers, healthcare industry professionals and patients, have a vested interest in reengineering our approach to health services delivery and financing through logic and rationality. After all, we will be customers of the system sooner or later. At that point in time, I for one would like a say in what I experience.
What Happened to the Crack-berry?
This amazing letter was written to RIM leadership by a ranking exec about the woes of their flagship product line, which you know and love as BlackBerry.
It's not often that a company* can appropriate a 1000-year-old word and completely change its meaning in the culture. It's a testament to the way RIM changed--one could say created--the smartphone category with its product. You always remember your first: mine was in 2003: the 6200, the last greenscreen model, which I promptly traded for the 7200 (color!) a year later. RIM's woes since then have been well documented and are fascinating. They go something like this: guessed wrong, got lazy, became out of touch with the market it created.
It's the last point I find most interesting. RIM defined the smartphone market by convincing businesspeople that responding to emails while on the toilet at 11pm was completely acceptable behavior. But they swiftly lost touch with this category by missing the implication of what they had created: that email and phone use were precursors to the real game, which was putting a computer in everyone's pocket. That was where the category was always headed--- it's easy to see now. But at the time, just the addition of a phone was so radical that when Blackberry first added it to its handheld--which was an overgrown two-way pager, they didn't even include a numbered keyboard.
Medicare Advantage is in a similar moment. While CMS gets credit for creating the category, seniors are now comfortable with managed Medicare. This coming generation even more so. But will the product be left behind by ACOs or other forms of integrated care? By MSAs? By something really cool that we don't even know about? Will MA learn how to integrate a phone? And will we forget to put the numbers on it?
*A CANADIAN company, at that!
Givin' Props to End of Life Care
What do you get when you combine Health Policy with Bracketology?
Modern Healthcare recently held a public tournament in celebration of its 35th birthday in order to determine what "one person, event, organization or innovation had the biggest impact on the health care delivery system in the past 35 years." The tournament began on April 4 with 64 contestants—16 in each of those four brackets: People, Events, Organizations and Innovations. And the winner? Not EMRs, not the Centers for Disease Control and Prevention, not even the runner-up Institute for Healthcare Improvement. (I guess Don Berwick's pull isn't what it used to be....)
No, it was Hospice. Low cost, humane, person-to-person end of life care. People did it long before the term was coined in 1967. As The Onion famously pointed out a few years ago, the world's death rate is "still holding steady at 100%" guaranteeing that all of us will eventually face these challenges, and hopefully not alone.
All discussion of its impact on costs aside, it's remarkable that with all the advances of medical science, we (or at least the Modern Healthcare readership) still haven't lost sight of what can be fairly called the spiritual dimensions of care--- and most particularly the importance of humane intimacy between a caregiver and a patient in their final days.