National Health Expenditures Data Released

Money in syringeAccording to a report released today in Health Affairs by the CMS Office of the Actuary healthcare spending growth is projected to average 5.8% over the period 2014 through 2024. In the three decades leading up to 2008 the average annual growth rate was 9%.

So let’s see. Demographics will really begin to swell Medicare participation in the decade ahead. It is likely that more states will politically have to embrace Medicaid expansion. Diagnoses and treatment innovation is still being largely driven by private investment seeking high-risk returns. Industry consolidation on both the provider and insurer sides is eliminating market price competition. And we’re only going to see 6% annual cost increases they say . . . you buying it?

Here are some highlights from the CMS press release:

Spending in 2014 is projected at $3.1 trillion, or $9,695 per person, an increase of 5.5 percent over 2013. Prescription drug spending increased 12.6 percent but private health insurance increased at 5.4 percent, Medicare at 2.7 percent and Medicaid at 0.8 percent.

Medical price inflation was 1.4 percent, while hospital, and physician and clinical services increased at 1.4 and 0.5 percent, respectively.

Per-capita insurance premium growth in private health plans is projected to be at 2.8 percent in 2015 based upon the assumptions that there will be an increase in relatively healthier enrollees and a greater prevalence of high-deductible health plans offered by employers.

Is is estimated there will be 19.1 million new enrollees in Medicare over the next 11 years.

While per capita Medicaid spending is projected to have decreased by 0.8 percent in 2014 (owing to new enrollees being relatively healthier), overall spending is projected to have increased by 12.0 percent due to Medicaid expansion.

The rate of insurance coverage in the US is projected to increase from 86.0 percent to 92.4 over the next 11 years.

The full OACT report is available online via the CMS website.

  ~ Sparky

Advance-Care Planning

The cover story of this coming week’s edition of Modern Healthcare (subscription required) focuses on end-of-life directives. The now infamous death panels phenomenon that became coupled with fears over the Independent Payment Advisory Board (IPAB) and rationing of knee and hip replacement procedures for Medicare recipients. I first wrote about this topic in November of 2012.

So here we are going on three years later and to my knowledge there have been no elderly individuals dragged before a panel of subjective arbiters charged with determining whether or not a person shall live or die. Not to diminish the reality of systemic rationing, as I have also written upon here – and that it will increase dramatically as an issue and concern in proportion to the demand for healthcare of an aging society.

But it has and continues to seem certain that admonishing public policy that raises awareness about the challenges of rationing and end-of-life care through increased and improved communication is rather wrongheaded. Fortunately, pragmatism seems to be winning over irrationality, and there are continued efforts to recognize the realities of having to address how scarce healthcare resources are allocated.

CMS announced last week that its proposed 2016 Medicare Physician Fee Schedule would incorporate physician payment for end-of-life conversations with patients. Though Medicare already provides for advance care planning upon enrollment the new rule would create new and separate advance care planning codes. Numerous medical societies and health organizations have pushed for reimbursement of advance-care planning as a separate, stand-alone service.

In good part much of the support was a desire to be paid for work already being performed. But to some extent it also represents an incentive to provide a service. And there’s the rub: what’s being incentivized? Education and awareness – or an inherent bias to abridge care and treatment options in favor of resource conservation that could be manifested in income to the clinical practitioner?

Indeed, it’s a slippery slope, and we need to be vigilant in understanding the impact of frequently dramatic differences between how an end-of-life is planned and what actually takes place at care settings in the hands of clinicians whose primary directive is to preserve life. From a policy perspective there are multiple elements that may yet contribute more to this discussion (e.g., the apparently defunct IPAB and the Patient-Centered Outcomes Research Institute).

For now, however, there is a greater opportunity to empower patients with more knowledge and information to assist them in their personal decision making regarding end-of-life care. That’s a good thing.

  ~ Sparky

Image credit: Martin Kozlowski for WSJ

Of Flags & Windmills

I’m sure today’s contribution (one of two hopefully) will come as a great relief to those (both) of you who have been waiting patiently for a new post to the PolicyPub. I hadn’t planned on taking such a long hiatus, but the further it went along the easier I found it to escape the self-prescribed responsibility of producing blog content. I do truly enjoy writing, but I have to say I’ve also very much enjoyed some other distractions in the interim. Maybe I will write some about that down the road.

Anyway, I haven’t decided yet whether to still focus only on healthcare policy or expand the Pub’s spectrum to include general policy interests that appeal to a much broader audience. If anyone is still out there reading, perhaps you can give me some feedback.

I thought I might start back by dipping my toe in the water with a timely, non-healthcare policy issue.  And in keeping with the soggy great lakes summer this has been, as long as I am choosing to get my toe wet why not get entirely sucked into and soaked by the whirlpool of controversy surrounding the Confederate flag. Not only is the issue timely and more widely of interest than ICD-10 implementation, but so is my perspective having just returned this week from an annual trip to Gettysburg with my twelve year-old son.

Having been a student of the Civil War since his age I could easily turn the Pub into a daily diatribe on that subject alone. Whether it would be interesting or not – well, let’s just say there are fortunately many others who know quite a bit more about it and have both the time and artistic ability to cover it better than me.

But what I have learned over the years is the connection between slavery and the Civil War is as complex a study as you could hope to find in American history. Those having just a smidgeon of that understanding will admit candidly at least to themselves that the Confederate battle flag stands for a lot more than the institution of slavery to a great many people – then and now.

For starters, a fair reading of soldiers’ diaries on both sides of the conflict will quickly help one understand that slavery was not in the least a primary motivation that caused men on either side to risk and experience death in very often the most horrific fashion imaginable. The same could not be said for the powers that be responsible for starting the war – and hasn’t that always been the case throughout history. 

This is what to a historian is fascinating, complex and confusing. As the author Shelby Foote said, “people who say slavery had nothing to do with the war are just as wrong as those who say slavery had everything to do with the war.” But if you take slavery away as an issue then there most likely would have been no war. So it’s ultimate role cannot be diminished even if not fully understood.

That 19th century perspective of the flag notwithstanding, the 20th century was witness to countless occasions when the confederate battle flag was carried as part of protests and rallies that were blatantly racist, vitriolic and bigoted in both foundation and intent. And so to those generations alive today it is understandable their symbolic association of the flag is one of hatred, intolerance and fear. From this perspective I find it impossible to argue against removing it from government properties as was done yesterday in Columbia.

But to and for the memories of the thousands of men who died on the wrong side of history and morality I hope we will remember that symbols can mean many different things to many people. One cannot meaningfully judge history without being able to walk in the shoes of its actors.

Walking the battlefields and reading and hearing about the tremendous sacrifices that were made by all of the men who died in Gettysburg the Confederate battle flag has served as a symbol for a great deal more than the unfortunate place it occupies today in the hearts and minds of many.

I think there is more to this story, however. Beyond all of the symbolism and rhetoric that has provided salable content for media outlets in a manner and fashion normally ascribed only to sausage making is a very scary reality: we are becoming a country with a phenomenal ability to tilt at windmills. Not only have we become overly adept at tilting, we do so now at full gallop whilst trying to pass the horse ahead of us in order to be first off the cliff.

We have lost our common sense, balance and perspective – our ability to have intelligent, factual and candid debate. Social media has become a sadly expedient venue for pretending to express individual thoughts and ideas while the substance supporting those ideas is void.

So what does all this mean from my perspective on the Confederate flag issue? I think South Carolina made the right call to remove the confederate battle flag from statehouse grounds. No brainer. But the National Park Service removing items for sale containing the Confederate flag from its book store in Gettysburg? Just another example of more lemmings not wanting to be left at the station.

  ~ Sparky

WHCOA Regional Forum

I am delighted to have received an invitation to this Monday’s regional White House Conference on Aging forum. The fourth in a five part series and being held in Cleveland, the regional forum is designed to focus public attention on the key issues of ensuring retirement security, promoting healthy aging, providing long-term services and support and protecting older Americans from financial abuse and neglect.

The Conference on Aging has been held once a decade since the 1960s, “to identify and advance actions to improve the quality of life of older Americans.” Input and engagement is being sought from older adults, as well as a variety of stakeholders sharing an interest and passion for addressing the difficult issues of providing housing, services and care for an aging population with limited resources.

The Cleveland forum is being held at the Global Center for Health Innovation, which showcases the confluence of best practices and emerging technologies impacting how care is provided and received. Northeast Ohio is a leader in advancing innovative solutions to the challenges facing older adults navigating their way through successful aging. With organizations like the Benjamin Rose Institute on Aging and the McGregor Foundation (most proud to note that both are clients of Artower Advisory Services), Greater Cleveland has a well-respected history of supplementing the area’s world class medical care with strong community-based services that enrich and protect the lives of seniors.

It is truly an honor to share the day with individuals served by organizations such as these and to hear firsthand their expectations for successful aging in the years ahead. I promise to take good notes and report back here on the key issues being discussed and debated. And with any luck, maybe a few pub patrons will want to weigh in on those issues.

  ~ Sparky

Chasing Population Health

A few years back when the ACO concept was starting to gain traction as a result of the Affordable Care Act’s Shared Savings Program, Mark Smith, MD of the California Healthcare Foundation remarked that, "the accountable care organization is like a unicorn, a fantastic creature that is vested with mythical powers. But no one has actually seen one." I am starting to wonder, as are many others, whether that analogy might even more adeptly describe population health and the tidal wave of efforts now being directed toward managing same.

In a post today on the Health Affairs Blog David Kindig argues that in light of the definitional challenges that have led to confusion of what population health is – or is not – what’s now required are “multiple definitions.” Counterintuitive as that may seem, Mr. Kindig explains how the term is today being increasingly applied to populations characterized by disease state and/or chronic condition (i.e., a clinical perspective) rather than the traditional understanding of populations defined primarily by geographic origin.

The latter’s focus is rooted in public health officials’ efforts to observe, quantify, assess and understand a multitude of personal and environmental considerations that impact the health of individuals – and how that impact is manifested in health characteristics of a defined population over time. The former is a growing focus of new delivery and payment models that aim to lower costs by decreasing demand – while assumedly concurrently not affecting safety, quality or having a negative impact on outcomes.

More importantly, population health in the clinical sense is being touted as a primary means of assessing the success of those models – and in turn, providing financial reward for that success. And further, in contrast, it is being used as a disincentive to pursue activities that are not proven to improve population health.

And there’s the rub, isn’t it. One of the two obstacles that currently prevent us from being able to leverage value in healthcare as Porter, et al have envisioned as the market mechanism that will curb costs and increase performance is the ambiguity surrounding how to define a patient outcome (the other being 19th century cost accounting practices still in place in healthcare). If we haven’t yet been able to adequately define and agree upon the comparative merits of individual patient outcomes, then how the hell can we suppose to find benefit from applying that shortcoming exponentially?

  ~ Sparky

Health and Housing Task Force

BPC_logo2The Bipartisan Policy Center, founded in 2007 by former Senate Majority Leaders Howard Baker, Tom Daschle, Bob Dole and George Mitchell, today announced a new Health and Housing Task Force that seeks to help address the needs of an aging US population. The one-year initiative is to be led by former HUD Secretary Henry Cisneros, former Senator and HUD Secretary Mel Martinez and former Representatives Allyson Schwartz and Vin Weber.

In echoing research and observations made in the recently released report, Housing America’s Older Adults: Meeting the Needs of An Aging Population, prepared by Harvard Joint Center for Housing Studies and the AARP Foundation, the BPC notes the glaring disconnect between forecasted housing, services and care needs as compared to our current ability to meet that demand.

In explaining the task force’s direction Mr. Cisneros noted that, “our aim is to call attention to this emerging challenge facing our nation. This challenge offers incredible opportunity in the near-term, yet is on track to become a major crisis in the coming years if left unaddressed.” Specific goals outlined by the task force include:

Find cost-effective ways to modify homes and communities to make independent living for seniors safe and viable. Identifying potential funding sources will be critical.

Highlight best practices from states and localities for integrating housing, health care, and long-term services and supports. The task force will seek out programs that work and investigate how they can be replicated elsewhere.

Identify barriers to offering home-and community-based services and supports through Medicaid.

Seek opportunities for further collaboration between the Departments of Housing and Urban Development and Health and Human Services.

The fourth goal is something that I have been scratching my head about for more than a decade now. I once even had the chance to personally ask a former HHS Secretary why the two departments couldn’t find more ways to collaborate, and that person was surprisingly candid in not knowing why either.

I know it may seem intuitive to those working in senior housing and care, but still much of the healthcare industry is only starting to recognize and understand that if services and care need to be provided “long-term,” then those individuals requiring such care need a place to live – they need a home. Further, we are learning more every day that underscores how important it is to have hospitality services provided in coordination with that care in order to achieve a beneficially holistic approach to health and wellness. Thus I believe any successful delivery model that addresses the crisis this task force sets out to address must reflect a deep understanding of four core areas:

Real estate – a place that can be called home wherever that may be

Operational & clinical performance: consistently safe and high quality services that are unique to the populations being served

Hospitality: recognizing and respecting the human spirit’s desire to live a fulfilling life

Underwriting: understanding the unique financial challenges of providing extended services and care

I would encourage the task force – and any other organizations involved in assessing and contributing to the knowledgebase that increases access and affordability of senior housing and care – to adopt these as the four pillars of any successful delivery model.

  ~ Sparky

To Sleep Perchance to Die

Hamlet___Skull_Study_by_PaulJulianBanksEarlier this week the French parliament acted in a compassionate – and certainly controversial – fashion by passing a law that will allow terminally ill patients to opt for “deep sleep” as an alternative to and/or palliative care. Lawmakers there believe (and by a substantial majority) the measure does not legalize euthanasia, but not everyone agrees. And the applicability of such a policy decision to America’s struggle with healthcare cost containment could not be more profound.

Depending on which study you want to believe, it is estimated that between 25% and 30% of all Medicare spending each year goes toward the 5% of beneficiaries who die in that year. Of that, approximately one-third of expenditures occur in the last month of life. If it weren’t for the realty that life is the most precious commodity on earth, it would be a rather simple fete accompli that such investment is ludicrous.

But any discussion of healthcare policies touching upon end-of-life care is rife with raw emotion and often political hysterics. Death Panels anyone? While Sarah Palin may have done more personally than anyone in history to obfuscate rational, intelligent discussion on reconciling individual rights with social responsibilities she nonetheless hit the mark in connecting the end-of-life care conversation to rationing: because that’s a core element of the policy debate – and it needs to be.

The talking points surrounding healthcare policy that affects end-of-life care are, however, spreading beyond just rationing – as the actions in France indicate. There is a shifting cultural perception of death as not so much a medical problem as it is a spiritual reality that can only be effectively addressed by one person – one moment at a time. And the quality of life vs expenditure is an emerging debate that will be owned by the Baby Boomer generation in a way this country has never seen.

Do the actions of the French lawmakers reflect a cultural awareness that is progressively ahead of where we stand in the US? Or do they reflect the further advance of progressive abandonment of respect for the sanctity of life that we must stand fast to defend?

Before answering, consider . . .

To be, or not to be, that is the question—
Whether ’tis Nobler in the mind to suffer
The Slings and Arrows of outrageous Fortune,
Or to take Arms against a Sea of troubles,
And by opposing, end them? To die, to sleep—
No more; and by a sleep, to say we end
The Heart-ache, and the thousand Natural shocks
That Flesh is heir to? ‘Tis a consummation
Devoutly to be wished. To die, to sleep,
To sleep, perchance to Dream; Aye, there’s the rub,
For in that sleep of death, what dreams may come,
When we have shuffled off this mortal coil,
Must give us pause.
~ Hamlet, Act III, Scene i

  ~ Sparky

Picture Credit:
Hamlet – Skull Study by PaulJulianBanks

DocFix is D O A

pic_related_022514_SM_A-Doc-Fix-Thats-Not-a-Fix_0Things have gotten so pitiful in Washington that political reporters – being anxious to share any news their audiences might find not depressing – are apparently falling over one another buying into the idea that a divided city can suddenly  come together and address the $174 billion political juggernaut of Medicare reimbursement for physician services. Using words like momentum, enthusiasm and optimism they report that Congress is advancing on a permanent Doc Fix.

Oh, please.

The rightwing of the Republican Party has already made clear its intent to use intransigence as the primary tactic to implement a strategy of growth through attrition in this 114th Congress.  And the only hope for securing Democratic support to bridge the voting gap left in their wake will be if those Democrats subscribe to Ms. Pelosi’s edict of not reading healthcare legislation before voting on it. Because if they actually read it, they will in all likelihood not be happy at the entitlement program cuts needed to fund the fix.

Alternatively, funding offsets could be achieved on the backs of other clinical providers and Medicare recipients. Those have always been pushover constituencies with poor lobbying representation, right? Or, to steer clear of that minefield legislators could assume funding offsets will come from expanding value-based payment models and continued implementation of other ACA reforms (e.g., lowering of hospital readmissions). That should be an even easier sell with Conservatives in Congress (yeah, more sarcasm).

And let’s not forget the public and private enterprise investments made into ICD-10 implementation, which Republican lawmakers would probably seek to delay as part of SGR repeal. That will be a contentious ideological battle separate from not having $174 billion at hand.

See what I’m getting at?

All this has to be worked through before physicians face an average reduction of 21.1% in Medicare payments in less than three weeks. Physicians who are already nearing their human capacity and ability to fight through the regulatory obstacles that impede helping their patients.

So don’t buy into the hype: 2015 looks a lot like 2002, 2003, etc. – time once again to kick the can down the road.

  ~ Sparky

Mental Health: Change Perception–Change Reality

Reprinted from the SAMHSA blog:

Changing the Story about Mental Health in America · by SAMHSA · March 9, 2015

Today, in support of her Joining Forces initiative, the First Lady spoke at the launch of The Campaign to Change Direction, a nation-wide effort to raise awareness around mental health in America. Spearheaded by Give an Hour and co-sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), the campaign is designed to change the story of mental health across the nation by urging all Americans to learn the five signs that someone might be in distress.

While there has been much media attention on mental health in the military and veteran community, it is incredibly important to understand that mental health isn’t just a military issue — it is a human issue. Mental health conditions impact our children, our grandparents, and our neighbors. Every year, roughly one in five adults — or more than 40 million Americans — experience a diagnosable mental health condition like depression or anxiety.

"I want to encourage everyone in this country to go to" —The First Lady on learning the five signs of mental illness

— The First Lady (@FLOTUS) March 4, 2015

It’s up to all of us to change the conversation by encouraging everyone to reach out when a friend, co-worker, veteran, or loved one might be struggling, and to ask for help when we need it for ourselves.

As the First Lady said today at the Newseum in Washington, D.C.:

It’s time to tell everyone who’s dealing with a mental health issue that they’re not alone, and that getting support and treatment isn’t a sign of weakness, it’s a sign of strength. That’s something that my husband believes strongly as President. Because in this country, when you’re fighting an illness — whether that’s mental or physical — you should be able to get the help you need, end of story.

Rory Brosius is the Deputy Director of Joining Forces.

Campaign to Change Direction, First Lady of the United States of America, FLOTUS, Joining Forces, Michelle Obama, The First Lady

  ~ Sparky

OBAMACARE: Was The Runner’s Knee Down?

NFL-REF-WATCH-BREAKING-BAD-bigger-300x211The play lasted only eight seconds out of 3,600 in the entire game. The distance traveled roughly 16 inches out of 3,600 across the field. Yet what occurred during those 8 seconds and 16 inches could make the difference between immeasurable joy or profound sadness. It all depends on how the referees view the play.

Of less substantial consequence in the minds of most Americans, starting tomorrow the Supreme Court will begin hearing arguments over 6 words of the Affordable Care Act – out of roughly 382,000: “through an exchange established by the State.” In November of last year when the Court determined (or at least four Justices did) to hear King v. Burwell I wrote, Does Legislative Negligence Trump Legislative Intent? I discuss there the background and ramifications of this case.

Here I am more interested in briefly sharing some thoughts on the relative influence of sociopolitical factors in SCOTUS’s review and consideration of this case. Whereas our historical view of the Court is one of great reverence and respect – the last bastion wherein ethics and morality trump politics – I think the image I chose for this post today more accurately reflects public opinion of that institution today – right or wrong.

I am not about to argue that politics has only recently become an unsightly element of the Court. Justices are appointed and approved by those who are elected, and they don’t get to the position of being considered by living out an apolitical professional career. From accusations against President Grant for court packing to FDR’s proposal to add members (conjectured to dilute a conservative bench) to more recent skirmishes over presidential nominees (e.g., Bork and Thomas) the Court has been steeped in political undertones for decades.

But what we are witnessing today is beyond just the politicization of appointees and the legacy influences of political ideologies. Like all things touched by our modern media the Court is engulfed by a sea of opinions and editorials in anticipation of a “wrong” decision – having not even heard one word of oral argument. How can the justices not hear the deafening crowd noise any less than the referees on the field looking under the video replay monitor. What influence, if any, will that carry on how they view King v. Burwell?

Regardless of how you hope the case is adjudicated you must see the irony in 8 million lives potentially being negatively impacted by 9 individuals out of 320 million based on the arbitrary interpretation of 6 words among 382,000.  Welcome to 21st century democracy in America.

  ~ Sparky