Lie of the Year. Not?

Paul Krugman's post today highlights an important aspect of the debate about the Affordable Care Act.  The issues: when are facts lies, when are lies facts, and is it even possible to capture complex issues in sound-bites that don't distort?  

Here is Krugman's post its entirety:

Politifact, R.I.P.  

This is really awful. Politifact, which is supposed to police false claims in politics, has announced its Lie of the Year — and it’s a statement that happens to be true, the claim that Republicans have voted to end Medicare.   

Steve Benen in the link above explains it, but let me just repeat the basics. 

Republicans voted to replace Medicare with a voucher system to buy private insurance — and not just that, a voucher system in which the value of the vouchers would systematically lag the cost of health care, so that there was no guarantee that seniors would even be able to afford private insurance.  

The new scheme would still be called “Medicare”, but it would bear little resemblance to the current system, which guarantees essential care to all seniors.  

How is this not an end to Medicare? And given all the actual, indisputable lies out there, how on earth could saying that it is be the “Lie of the year”?   

The answer is, of course, obvious: the people at Politifact are terrified of being considered partisan if they acknowledge the clear fact that there’s a lot more lying on one side of the political divide than on the other. So they’ve bent over backwards to appear “balanced” — and in the process made themselves useless and irrelevant.   

Way to go, guys.

First, here's the link to the actual Politifact article.  I'm disappointed that Krugman didn't include it but rather linked to the Benen piece.

I had read (well OK, skimmed the first several paragraphs of) the Politifact story the other day. What I read seemed consistent with what I understood to be true, and quite honestly, I left it being disappointed in the Democrats' spin.

Then I read Krugman today, and thought, "Whoa! Maybe I missed something!"

Take a minute and read the Benen piece referenced by Krugman and let me know what you think. 

Has Politifact damaged its credibility in your eyes? It has for me.  

I'd have chosen Politifact's top vote-getting lie ("The economic stimulus created "zero jobs.") as lie of the year, myself.

A local success story

This success story by Allen Weiss, M.D., President and CEO of Naples Community Hospital (NCH) is just wonderful ... and worth sharing.

October 6, 2011

Dear Friends and Colleagues,

We did it! Working together, 3,750 colleagues— along with our spouses and insured children—have bent the healthcare cost curve downward. We have better health, better health benefits, and, as a result, no increase in the cost of our health insurance!

In fact, all of us are now spending less for healthcare than we did in 2008. Compare that to the national average annual healthcare premium for family coverage, which is rising 9% a year—with many places around the nation experiencing double-digit increases. Meanwhile, here in Naples, our costs are down, and our colleagues enjoy access to the best care locally available, and we are objectively healthier.

How did we do it?

I am pleased to share our story as viewed by our partner Willis, a risk manager and insurance company (www.Willis.com), who collaborated with former Chief Human Resources Officer Brian Settle, Chief Financial Officer Vicki Orr, Chief Nursing Officer Michele Thoman, Chief of Staff Kevin Cooper, Chief Operating Officer Phil Dutcher, and the whole benefits team, which orchestrated our coverage.

Two-and-a half years ago, our team recognized that people working in hospitals and medical offices have physically and emotionally demanding jobs. They confronted a challenging environment for reimbursement. And they were motivated by the ideal that we in healthcare should be a model for the community we serve.

We also understood from the Department of Health and Human Services study in 2007 that 87.5% of health care claims costs are due to an individual’s unhealthy lifestyle. So we focused on “keeping the well people well”; helping the chronically ill improve; ensuring the sick had good and quick access to care; and screening all who volunteered with age and gender-specific tests to detect occult disease early. As I think you’ll agree, all common sense solutions.

Results have been heartening. More than 88% of our colleagues, spouses and insured children see a health coach, don’t use tobacco, and have undergone basic screening tests such as height and weight ratios, waist to hip ratios, simple blood tests, and, when appropriate by nationally accepted guidelines, mammograms and colonoscopies. As expected, the first year saw a large increase in spending, driven by the cost of testing and treating abnormalities which if left untreated would have evolved into cancer or worse. Indeed, 43% of colleagues had polyps removed when they had colonoscopies. Mammography services increased by 21%, and there was a 19% increase in individuals establishing a relationship with a physician. Initially, reports of diabetes increased significantly; but with treatment the number of emergency room visits for diabetes dropped, and we’ve improved overall outcomes for diabetics by avoiding diabetic complications.

Year-over-year results reflect more than a 17% reduction in cost and a savings—more than $6.5 million over the past year and that saves us from having to increase employee’s insurance costs. Starting this month we are no longer hiring those who use tobacco. NCH is becoming the prime example of a community already recognized for having the nation’s longest life span for women and second longest for men, according to University of Washington studies. And we want to keep it that way—and bend that healthcare cost curve even further.

Respectfully,

Allen S. Weiss, M.D., President and CEO

P.S. Feel free to share Straight Talk by emailing me at allen.weiss@nchmd.org to be added; and join us on Facebook at www.facebook.com/nchflorida.

While there's no new news here, it's great to hear that my local hospital - the largest private sector employer in the county - is being proactive in managing both the health of its employees, and its health care costs.

Is yours??

Readers’ questions and where they led me

Two readers questioned the statistics about Medicare spending I presented in my blog post the other day. The statement in question:

About 25 percent of Medicare spending is for people in their last year of life; and slightly more than half of Medicare dollars are spent on patients who die within two months.

They were right to question. How could both these statistics be true?

The original source for my statement was WNET New York Public Media’s 1997 series “Before I Die,” “How Much Do We Spend on End-of-Life Care?”:

Medicare, the health insurance program for the elderly, spends nearly 30 percent of its budget on beneficiaries in their final year of life. Slightly more than half of Medicare dollars are spent on patients who die within two months.

I changed the “nearly 30 percent” to “about 25 percent” based a 2001 Health Affairs article, thinking it was a more recent statistic, but left the rest of the statement as WNET wrote it. Unfortunately, the WNET statement is not attributed, but something is clearly wrong since the two statements ARE inconsistent.

I’ve done some further research trying to find another source. I found a report by the Centers for Medicare & Medicaid Services, Office of the Actuary, on its “Last Year of Life Study.” It found:

The percentage of Medicare expenditures attributable to those beneficiaries in their last year of life increased from 26.5 percent in 1994 to 27.9 percent in 1999.

I also found a post titled “28% of Medicare spent during last two months of life” on a discussion forum for the Mississippi Estate Planning Community. The post included a slide containing this statement:

It’s notable that ~28% of average Medicare recipient spending occurs in the final year of life and 12% occurs in final two months of life.

The slide (including the erroneous blog post title) was taken from a February 2011 publication titled USA, Inc., which examines the US economy as if it were a public company. (A very interesting report, by the way.  More about it below.)  The data on the slide were sourced to “CMS, Medpac, Report to the Congress: Medicare Payment Policy, 3/10," but when I searched that document, I couldn’t find the information.

My conclusion: It’s probably safe to say that about 25% of Medicare spending is for the last year of life, and that about half of that is spent in the final two months. Wish I could find a better source and more recent information.

Thanks to Bob and Rob for being such thoughtful readers.

More on the USA, Inc., report:

The report was created and compiled by Mary Meeker, a partner at Silicon Valley venture capital firm Kleiner Perkins Caufield & Byers. In the 1990s, she was a highly-regarded Morgan Stanley analyst covering the early internet industry.

From “About USA, Inc.” --

This report looks at the federal government as if it were a business, with the goal of informing the debate about our nation’s financial situation and outlook. In it, we examine USA Inc.’s income statement and balance sheet. We aim to interpret the underlying data and facts and illustrate patterns and trends in easy-to-understand ways. We analyze the drivers of federal revenue and the history of expense growth, and we examine basic scenarios for how America might move toward positive cash flow. It includes a 2-page foreword; a 12-page text summary; and 460 PowerPoint slides containing data-rich observations. There’s a lot of material – think of it as a book that happens to be a slide presentation.

Thinking about mortality lately

A man I worked with early in my career died last week. Receiving the email notification from my former firm’s alumni group brought back memories of him and that time in my life. Rather than just send a card, I wrote a letter to his wife, telling her of the role he’d played in my career and sharing my memories of him. It got me thinking.

I realized that I’ve written a lot of condolence cards lately. Several friends or their family members are seriously ill, and CaringBridge has become a “favorite” in my web browser. When did this start to happen?

As I am faced with the mortality of my family and friends, I’m forced to also face my own. I notice that I struggle with two issues: wanting to be able to control and direct my own end-of-life care when the time comes, and being aware of the cost to society (Medicare) of that care. (I’ve written about the end-of-life costs of medical care before, but as a reminder, here are two statistics: About 30 percent of Medicare spending is for people in their last year of life; and slightly more than half of [those] Medicare dollars are spent on patients who die within two months.)

I’ve been reading quite a bit about these subjects recently – not by plan, just by coincidence – but then, nothing’s really a coincidence, is it? 

Most of you (my readers) are in the same stage of life as me. You too have probably lost friends and family members, or have others who are seriously ill.  I recommend several articles and podcasts if you - like me - are thinking about these issues:

“The Good Short Life” -- A very moving and thought-provoking Opinion piece in last Sunday’s NYTimes by a man in the final stages of ALS. The last sentence is “It’s time to be gone.”

“Death and Budgets”-- David Brooks’ Thursday column. It brings together the issue of end-of-life-care choices and health care costs.

“Being mortal, and other tragedies: Why modern medicine so often fails people facing the end of their lives; how America can have better; and other discussions with a medical writer”— A compelling and informative discussion taped in April in LIVE from the New York Public Library with surgeon/writer Atul Gawande.

“Letting Go: What should medicine do when it can’t save your life?” – A wonderful article by Gawande in the April 2010 New Yorker Annals of Medicine.

In both the interview and the “Letting Go” article, Gawande movingly describes his experiences as a physician struggling to have “the conversation” about end-of-life choices with several of his patients. He talks about four questions shared with him by palliative care specialist Dr. Susan Block that he found to be helpful:

1) What do you understand to be your prognosis?
2) What fears do you have about what’s to come?
3) What are your goals as time grows shorter?
4) How much suffering are you willing to go through for the possible trade-off of added time?

I encourage you to read these articles, and especially to listen to (or watch – both are available at the website) the Gawande interview.

Let me know what you think.

The Business of Health Care: Defining the Future - FREE AND ONLINE!

In January, I attended the University of Miami's Global Business Forum “The Business of Health Care: Defining the Future” and shared my experience on this blog. (See three posts starting here.)

Today UM issued the following release:

The University of Miami School of Business Administration has unveiled a multimedia website featuring insight on The Business of Health Care from some of the world's most prominent industry executives and government leaders - the nation's Secretary of Health and Human Services, the FDA Commissioner, the CEOs and presidents of General Electric, the American Medical Association, and the American Hospital Association, among others.

These thought leaders were among 800 top executives and other health industry professionals who gathered for the University's 2011 Global Business Forum to explore health care reform, aging, medical innovation, global health challenges, wellness and prevention, hospital design and delivery, and more.

View videos and photos, download session papers, and access the presentations to learn more about The Business of Health Care and the 2011 University of Miami Global Business Forum.

Thanks to UM's generosity and the wonders of the internet, I can re-visit some of the excellent sessions I attended, catch up on some I missed, and share it all with you. Enjoy!

Advance Directives, Hospice Benefits and Palliative Care

Grim? Macabre? Maybe, but important to know.

That’s how I’d sum up what I learned last week at a meeting 20 League of Women Voters members and I had with Dr. Paul Mitchell, Medical Director and VP of Physician Relations at Avow Hospice in Naples, FL. He is also on staff at NCH Healthcare System with a specialty in palliative care. Dr. Mitchell had been invited to speak to the League’s Social Policy Committee about the greatly maligned and misunderstood advance care Medicare consultation I wrote about previously (“An unhelpful distraction from an important national discussion”).

It was clear from the outset that Mitchell was frustrated with the politicization of this Medicare provision, like all doctors I’ve heard speak on the topic. He began his remarks with what an advance directive is and why it’s important. An advance directive is a general term that describes two kinds of legal documents: living wills and medical powers of attorney. These documents protect our right to refuse medical treatment we do not want, or to request treatment we do want, in the event we lose the ability to make decisions for ourselves.

Mitchell told us that it’s important to have an advance directive so that our wishes will be known and can govern our end-of-life care. Without an advance directive, when we become unable to participate our health care decisions will be made by someone else who may not know how we’d want to be treated. Especially at a time when doctors admit they practice defensive medicine, an advance directive could prevent treatment that may (or may not) prolong our life and make us miserable in the process.

It’s especially important to choose a health care proxy you think will actually be willing and able to carry out your wishes when the time comes. For example, while it might seem logical for spouses to name each other, it might be wiser to choose someone who is less emotionally-involved. It depends, of course, on the people, but it’s really important to have “the conversation” with your family members while you’re healthy, and decide.

It’s also important to avoid having multiple surrogates (deciders) who would have to reach agreement on a course of action. (Can’t you imagine?) But it’s possible to name one person to act, and to specify that in that person’s absence or inability, another person is authorized to act.

Talk of advance care planning led to talk about palliative and hospice care. Palliative care is a medical specialty focused on improving the quality of life of people facing serious illness. Emphasis is placed on pain and symptom management. Many people with chronic conditions that cannot be cured but are not immediately life-threatening receive palliative care. Importantly, palliative care is not necessarily end-of-life care. It is not the same as hospice care, although hospice care is a subset of palliative care.

Hospice care is focused on providing quality care to people in the last months of life who have decided to stop treatments meant to cure them, and is ideally provided in one’s own home. Most people don’t know that hospice care is covered by Medicare Part A (hospital insurance), and that it requires little or no out-of-pocket payment – including for prescription drugs. For more on the Medicare hospice benefit, click here.

Once again, the League of Women Voters of Collier County, FL’s Social Policy Committee provided a great service for its members by inviting Dr. Mitchell to speak to us. Our group had lots of questions, and Dr. Mitchell was exceptionally knowledgeable and willing to answer them.

If you haven’t done so already, I hope you will look into preparing your own advance directive and medical power of attorney (or health care proxy). Click here and get started.

Local experts on health care reform share their insights

The League of Women Voters of Collier County, FL, recently held two meetings at which local experts addressed the topic of health care reform:

• Allen Weiss, M.D., President and CEO of the NCH Healthcare System, Naples, FL, spoke on January 10th on “Health Care Reform: What’s Next … and What About Me?”, and 
• Ronald Riner, M.D., President and CEO of the Riner Group, a health care management consulting firm in Naples, FL, spoke on January 12th on “The Impact of Health Care Reform on Small Business.”

The Naples Daily News summed up Dr. Weiss’s remarks as: “U.S. health-care overhaul is needed to survive.” From the article:

Ninety-two percent of government spending could be spent on health care by 2050 if cost controls and change isn’t made, Dr. Allen Weiss, president and chief executive officer of the NCH Healthcare System, said Monday.

“We won’t be able to pay back China,” he said.

Speaking to members of the League of Women Voters during a luncheon at the Naples Hilton, Weiss provided a big picture perspective about today’s anxiety over health-care reform passed last year under the Patient Care and Affordability Act [sic]. He said the country went through similar unease when the Social Security program was started in the late 1930s and later when Medicare began in the mid-1960s.

“People hate change,” he said, adding that people will get over the current anxiety as they did after both Social Security and Medicare were up and running.

...[But] “One way or another, the health-care bubble is going to burst,” he said.

In other words, reform of the health care delivery system is both necessary and inevitable, and the current agitation (such as calls to overturn the law) is nothing more than a to-be-expected fear of change which too shall pass.

Weiss has been actively moving NCH toward more efficient high-tech medical care for years, and began implementing Cerner Corp. solutions including Electronic Medical Records as early as 2005. In an August 30, 2010, piece in the Naples Daily News titled “The power of information in health care,” Weiss wrote:

Information, they say, is power. And nowhere is that truer than in health care, where the information we acquire and record about our patients gives us the power to heal and even save lives.

It’s no coincidence that information technology has become a top-level priority at NCH. In particular, our integrated medical record infrastructure enables us to link all healthcare providers — from the time a patient expresses medical concern through visiting a primary care physician, referral to a specialist, potential admission to the hospital, post-hospital care in a rehabilitation center or skilled care facility, to home care.

This robust, computerized information infrastructure allows us to determine best practices and establish treatment benchmarks. This is a quantum change from the standard paper analog record, where medical research about processes — such as the time needed to stop a heart attack — had to be calculated manually. With an Electronic Medical Record (EMR), all digital records can be analyzed in moments for any period of time. The data collected digitally becomes new knowledge about how best to care for patients and obtain the best outcomes.

Referring to another characteristic of “Health Care 21” (my new term for health care in the 21st century), Weiss told the LWVCC that local medical providers are moving toward forming accountable care organizations (ACOs). An ACO is a health care delivery model that offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs.

My take-away from Weiss’s talk was that he is on-board and well ahead of the curve in terms of understanding what hospital systems have to do to succeed in the 21st century. While he made it clear that he is a-political on the subject, my impression was that he accepts the Affordable Care Act’s requirements as the law of the land, not necessarily anything he disagrees with. While he expressed some sympathy for the disruption and cost local practitioners have to deal with in adapting to Health Care 21, he left me with no doubt that he knows where things are headed.

In a January 17th Naples Daily News Guest Commentary, Weiss wrote:

Both short and long term, health-care reform will make our local delivery system better.

Dr. Riner spoke to the League of Women Voters’ Social Policy Committee on January 12th. His presentation is available here.

In Riner’s view, “the overall impact of health care reform is likely to be neutral to positive for small business.” In the short term, the health care law’s requirements will have a “small effect,” he said, with the major impact occurring in 2014 as a result of these provisions:

• Creation of insurance exchanges, allowing small businesses to purchase from a multitude of plans in their state;
• Tax credit for small businesses providing health insurance;
• Exemption from the pay-or-play provisions imposed by the ACA on medium-to large-sized firms; 
• Employees of small businesses not offered insurance through work are allowed access to insurance exchange, with subsidies available for low-income individuals and families, and acceptance of pre-existing conditions.

Long term, Riner said, the impact on small businesses is likely to be “neutral in terms of cost.” Businesses with 50 or more employees will be required to offer health insurance coverage or pay a penalty. But offsetting this cost, businesses are likely to see these savings and quality improvements:

• Lower insurance cost to employers purchasing via an exchange;
• Tax credit for small business offering insurance;
• Shift of insurance cost to individual from employer as individuals have additional purchase options via exchanges;
• Improved worker productivity with improved access to health care;
• Larger pool of candidates if health care insurance benefit is not tied to size of employer.

The second part of Dr. Riner’s presentation was review of the effect of the health care law on future health care spending. He made the frequently-stated point that the law did not do enough to bend the health care cost curve.

I asked Dr. Riner what he would have liked the government to have included in the law to address the cost issue, and I got the same thing I get whenever I ask that question: not much. Riner said practitioners need to “involve the patient” in the health care purchasing decision (“If it’s an entitlement, it’s a freebie”) and “talk more about the fraud issue” so people will begin to question the need for tests and procedures being ordered. He also said “the medical community needs to police itself.”

Well, we’ve seen where that’s gotten us!

He also talked about the lack for tort reform, an oft-cited complaint despite the fact that studies show the cost of malpractice claims to be no more than a drop in the bucket when it comes to health care costs. “These costs, all told, have been estimated to be only about 2 percent of healthcare expenses,” says Leemore Dafny, Kellogg School Assistant Professor of Management and Strategy, an economist and expert in healthcare competition, just one of many sources of this statistic.

After hearing Dr. Weiss on Monday and Dr. Riner on Wednesday, I went off to Miami for the Global Business Forum on the Future of Health Care I wrote about earlier this month.

Looking back on the entire week, I’d say that despite the probably-valid concern that not enough has been done to curb health care costs, the kinds of changes encouraged and/or required by the Affordable Care Act are inevitable and for the best.

The smart practitioners like Dr. Weiss know it, and are on-board.