Experts | University of the Sciences

One Year Later - What Happened to Real Healthcare Reform?

Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

Last year, as President Barak Obama addressed Congress, he said, “Let there be no doubt: healthcare reform cannot wait, it must not wait, and it will not wait another year."

A year later we are still without healthcare reform. And in the Jan. 27 State of the Union address, the President changed the focus to health insurance reform. And like big banks, health insurance companies are now being labeled as enemies of the state.

And while the President even promised that patients would be able to keep their doctors, the delay in healthcare reform looks to actually do the opposite for older Americans.

The problem is that there are some major components of healthcare that actually can’t wait any longer to be addressed. One of the most pressing timelines is the one governing physician reimbursement. As it stands today, in just about four weeks, physicians caring for Medicare patients will have a 21 percent cut in their reimbursement. Without congressional action, Medicare beneficiaries are likely to find it increasingly difficult to find a physician who will take their Medicare insurance because many physicians will likely stop seeing Medicare patients. And while Congress has historically acted to pass one year corrections to these Medicare cuts, in the face of massive debt and a focus on deficit reduction, this year might actually see those reimbursement cuts go through.

The question is what will be the effect on Medicare patients?

As a practicing geriatrician and health policy expert, I appreciate the concern of older adults. These fears come out of the concern that a large number of physicians will opt out of Medicare and privately contract with their Medicare patients. Older adults who find their physician has opted out of Medicare can choose to find a physician who does still take Medicare or they can pay privately out of their own pocket for services traditionally covered under Medicare. The delay in health care reform could actually cause a major break in the relationship patients have with their physicians.

Real healthcare reform is possible. It can start with focusing on just a few key issues:

Extend Health Insurance Coverage – providing coverage for the majority of those Americans who are currently uninsured can happen by:
- moving Medicare to 55 (this action would also move pre-retirees out of the work force, opening up opportunities for those currently unemployed)
- lowering the eligibility requirement for Medicaid
- providing tax breaks for those seeking personal insurance
- make mandatory the requirement for health insurance

Develop Efficient & Effective Systems – lower the cost of healthcare through promotion of integrated systems of care rather than the current fragmented silo’ed process.

Expansion of Information Technology – promote the use of electronic health records that are integrated among providers that can reduce unnecessary and ineffective treatments.

Reduce Administrative Burdens – the administrative burden is currently causing great waste and inefficiencies.

Support Primary Care Services – shift the financial incentives from procedures to primary care services.

Reform Malpractice – provide reform that works to eliminate nuisance lawsuits and the need to practice defensive medicine through a specialized court system absent of juries, governed by a skilled judge.

Promote Personal Responsibility – work to promote personal responsibility to reduce obesity, tobacco abuse, and sedentary life styles.

While time will tell the direction of healthcare reform – time is certainly running out at least perhaps on the promise that patients, especially older adults, will be able to keep the relationships they enjoy with their doctors today. Instead of the break of existing patient-doctor relationships perhaps real healthcare reform will happen.

Dr. Richard Stefanacci, Director of the Institute for Geriatric Studies at University of the Sciences. As an internist/geriatrician, Dr. Stefanacci has a longstanding interest and commitment to geriatric health, particularly the frail elderly and long-term care.

 

iPad Touches Electronic Medical Records Adoption

 
By Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

The most positive news to impact healthcare in quite some time may not have been the words of the President in his State of the Union address but rather the words coming out of Silicon Valley. Yesterday, Jan 27, Apple unveiled its latest product, the iPad. This device may actually have the ability to improve patient care and reduce healthcare costs.

With some $21 billion set aside in the Stimulus Package to provide funds to physicians and hospitals that use electronic health records (EHRs), part of these funds may be used to purchase the new Apple iPad. Already the iPad will enjoy apps that are currently available to the iPhone/iPod Touch and more are in the works. The Mayo Clinic recently announced production of several healthcare apps.

Major electronic health record systems like Epic have already developed electronic health record applications for the smaller devices. The increased screen and key board size of the iPad will make these systems much easier to use.

One of the greatest advantages of the iPad over the use of PC-based EHRs is that it fits better in the work flow of physicians that patients are already comfortable with. One of the largest criticisms by physicians and patients, including my own, is that the use of the PC appears to make the office visit less personal. A tablet device like the iPad could eliminate that distances and actually improve the link between physicians and their patients.

Apple’s iPad improvements could be the link between physicians and their patients combined with the benefits in efficiency through the use of EHRs. The iPad could do what Washington has long promised but has yet to be able to do – improve patient care and reduce the cost of healthcare.

As a practicing geriatrician who has utilized EHRs for more than a decade, this is long welcome positive news.

Dr. Richard Stefanacci, Director of the Institute for Geriatric Studies at University of the Sciences. As an internist/geriatrician, Dr. Stefanacci has a longstanding interest and commitment to geriatric health, particularly the frail elderly and long-term care.

PA EMR Exchange: A Step in the Right Direction

Dr. Richard Stefanacci, Director of the Institute for Geriatric Studies at University of the Sciences, submitted the following post in reaction to the Philly.com story "Pennsylvania crafts a health information exchange plan" posted on Dec. 1, 2009.

 

"What will it take to realize the long held vision of easy wide spread access of individual comprehensive health records? Well, while the State of Pennsyvania is moving all players in the right direction, unfortunately much more is needed.

"Having had the opportunity to be involved personally in a dozen parties over the last 10 years, I can tell you that the four practices that utilized electronic health records shared the common financial model of being responsible for the efficient and effective use of resources. Those practices where electronic systems are not being utilized would actually be hurt financially if they were to utilize EHRs. So, while PA and the federal stimulus funds will help, they will fall short of the vision which is only possible through providers being held responsible for improving health outcomes through the efficient use of resources."

The Senate Bill: Access But What About Costs and Quality?

An expert commentary from Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

 

Under the recently passed Senate Finance Committee, access for health insurance would be advanced for both the insured and uninsured. Of course, this bill still has a long way to go before being signed into law. While the Senate bill focuses on access it pays, much less attention on cost and quality improvement.

 

For the insured there is the promise of more security and stability through:
• regulations against denial of coverage because of a pre-existing condition
• elimination of arbitrary caps on the amount of coverage over ones lifetime
• limits on out-of-pocket expenses
• required to cover, with no extra charge for routine checkups and preventive care

 

For the some 36 million uninsured Americans there is a requirement to obtain insurance, and they will be aided by insurance available through a Consumer Operated and Oriented Plan or CO-OP. These CO-OPs will be non-profit, member-run health insurance companies in all 50 states and District of Columbia that is different in scope and oversight from the government run national public option being proposed by the House. This CO-OP will be available with other plans through state-based exchanges.

 

To further assist the uninsured gain coverage, tax subsidies will be made available to individuals and small businesses and penalties will be levied against those forgoing this mandate. The penalty will be phased-in according to the following schedule: $0 in 2013; $200 in 2014; $400 in 2015; $600 in 2016; and $750 in 2017. It’s not clear whether or not these penalties will be sufficient to force healthy individuals into the insurance pool.

 

COSTS
Costs are consider in the Senate bill although it is not clear how these provisions would change the slope of the climbing cost curve. Instead these cost reductions are mostly one time events more focused on funding the access expansion. These cost provisions focus on:

• Fraud & Abuse
• CMS Innovation Center
• Medicare Cuts ($404B)
• Excise tax on high cost insurance plans ($201B)
• Malpractice Reform ($54B)
• Administrative simplification
• Medicare Prescription Drug Coverage

In actuality, the main reason that the Senate bill was so significantly below the $1 trillion is that unlike the House bill which includes some $228 billion to solve the longstanding problem of Medicare physician reimbursement, the Senate bill choose not to address this issue. The House bill assumes that Congress will continue preventing the provider cuts which have been set to go into affect for the last several years but instead been simply postponed in favor of slight reimbursement increases. As a result, the 22 percent reduction set for 2010 has once again been postponed.

 

QUALITY
Quality is also included in the bill with some continued focus on value based purchasing and bundling of payments to provide incentive for efficient and effective care. There is also creation of new delivery groups under the title of Accountable Care Organizations (ACO). These are similar to the PHOs (Physician Hospital Organizations) of years ago that were supposed to deliver better care without the administrative overhead of a traditional managed care organization.

 

The concern is that this bill misses the opportunity to decrease health care costs. Instead, it may actually accelerate costs through the significant increase of coverage. Real cost reduction can only come from promotion of a healthier population cared through a system delivering PCP dominion patient centered coordinated care.

 

If we do not achieve significant cost reductions now, we will in the future have costs reduced through rationing both on demand and supply side of health care delivery. On the demand side, the rationing will be forced meaning that patients will see a decrease in available benefits. On the supply side, if the significant provider reimbursement reductions eventually go through such many will likely opt out of the insurance system, the result of this large decrease in providers will be a forced rationing because patients will be unable to find the help they need.

 

This scenario can only be averted if health care reform is comprehensive covering not only access but cost and quality improvements.

 

Dr. Richard G. Stefanacci is the executive director of the Institute for Geriatric Studies at Mayes College of Healthcare Business & Policy at University of the Sciences in Philadelphia.

Commentary on the Healthcare Debate

Dr. Richard Stefanacci has provided his expert opinions to WHYY in relation to various elements of the healthcare debate.

 

Listen: 

Congress considers health insurance cooperatives

WHYY – Sept. 29

WHYY’s Taunya English spoke with Dr. Richard Stefanacci about the debate over health insurance cooperatives. Listen to the report here.

Paying docs to save costs
WHYY – Sept. 22
WHYY’s Kerry Grens spoke with Dr. Richard Stefanacci about several hospitals in New Jersey that are currently testing a program to save money by rewarding doctors for efficient care. To listen to the segment, click here.

Real Healthcare System Development

by Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD

Despite all the talk about healthcare reform the only thing being talked about is insurance reform. President Obama’s speech to Congress on Sept. 9 highlighted only improvements to insurance coverage and cost reductions primarily through reductions in waste and abuse in the Medicare system.

As a practicing geriatrician, former CMS Health Policy Scholar, and associate professor at the University of the Sciences, I can tell you what is needed is real healthcare reform which involves a total change of our current delivery model.

Notice I said “current delivery” model and not “healthcare system” because for most us delivering care the thought is that we are not operating in a system. Rather, healthcare in the United States is delivered through fragmented silos focused on specialty procedures used to treat episodes of acute illnesses.

Instead what is needed is a true system of care that is built upon:

1. Integrated payment model
2. Support for a primary care focus
3. Early preventive care

Many of the elements exist in part in the health systems that are tattered as best practices such as Kaiser Permante and PACE (Program for All-inclusive Care for the Elderly).

What was probably more telling is what was not mentioned in the President’s speech. For example there was no mention to quality, improvements in access to primary care services or cost reductions focused on system improvement or factors that could really improve the health of Americans such as those that would reduce the rate of obesity.

There does appear to be some clear winners and losers in the current healthcare reform movement. Those benefiting most include:
- Those currently uninsured but moving to government subsidized insurance coverage
- Those individuals that are high risk and either insured or uninsured as the insurance reform would likely lower their premiums
- Those paying high premiums currently that move to a lower cost Public Option or Co-op.

Those likely to be made worst off from where they are today include the following:
- Those that are healthy either with or without insurance as they will be forced to pay more for coverage
- Insurance companies who would face greater regulations and decreased reimbursement
- Uninsured businesses as they would be forced to cover their employees.
- And through the Public Option providers as a result of a decrease in reimbursement. In addition because of a Public Option insurance companies would also experience a decrease in enrollment.

In the end what is needed is to focus our attention on development of a US system of healthcare that again is primary care focused and patient centered with a heavy emphasis on preventive practices such as reduction in our obesity rate. Through this type of focus we can begin to realize true and sustainable reductions in our healthcare costs, improvements in our quality of life and the ability to provide coverage for all Americans.

Dr. Richard G. Stefanacci is the executive director of the Institute for Geriatric Studies at Mayes College of Healthcare Business & Policy at University of the Sciences in Philadelphia.

When one examines the President’s speech to Congress the following points fall out:

Three basic goals:

ACCESS (COVERAGE) 1. INSURED - It will provide more security and stability to those who have health insurance.

1. against the law for insurance companies to deny you coverage because of a pre-existing condition
2. against the law for insurance companies to drop your coverage when you get sick or water it down when you need it most
3. arbitrary cap on the amount of coverage you can receive in a given year or a lifetime
4. limit on how much you can be charged for out-of-pocket expenses
5. required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies - because there's no reason we shouldn't be catching diseases like breast cancer and colon cancer

This could be cured through simple legislation that insurance companies can’t drop someone if they complete insurance applications based on their best understanding of their health – applicants for insurance can’t lie about something of material substances but not penalized for failing to mention something insignificant Also, one should note that by forcing insurance companies to provide more coverage and cover high risk member at lower rates will result in increased payment on others in that plan.

2. UNINSURED - It will provide insurance to those who don't.

1. creating a new insurance exchange -- a marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices. Insurance companies will have an incentive to participate in this exchange because it lets them compete for millions of new customers. As one big group, these customers will have greater leverage to bargain with the insurance companies for better prices and quality coverage.
2. exchange will take effect in four years
3. making a not-for-profit public option available in the insurance exchange.
4. tax credits, the size of which will be based on your need
5. the public insurance option would have to be self-sufficient and rely on the premiums it collects. But by avoiding some of the overhead that gets eaten up at private companies by profits, excessive administrative costs and executive salaries, it could provide a good deal for consumers. It would also keep pressure on private insurers to keep their policies affordable and treat their customers better, the same way public colleges and universities provide additional choice and competition to students without in any way inhibiting a vibrant system of private colleges and universities. (College example is not entirely accurate because of the heavy subsidies applied within)
6. For example, some have suggested that that the public option go into effect only in those markets where insurance companies are not providing affordable policies. Others propose a co-op or another non-profit entity to administer the plan. These are all constructive ideas worth exploring. But I will not back down on the basic principle that if Americans can't find affordable coverage, we will provide you with a choice. And I will make sure that no government bureaucrat or insurance company bureaucrat gets between you and the care that you need. (This last statement is already untrue – Medicare will not pay for IV therapy for a nursing home resident unless they first go to the hospital for 3 days)
7. In the meantime, for those Americans who can't get insurance today because they have pre-existing medical conditions, we will immediately offer low-cost coverage that will protect you against financial ruin if you become seriously ill.
8. individuals will be required to carry basic health insurance

COST 3. And it will slow the growth of health care costs for our families, our businesses, and our government.

1. more spending cuts if the savings we promised don't materialize
2. savings within the existing health care system -- a system that is currently full of waste and abuse.
3. unwarranted subsidies in Medicare that go to insurance companies- subsidies that do everything to pad their profits and nothing to improve your care.
4. create an independent commission of doctors and medical experts charged with identifying more waste in the years ahead.
5. common-sense best practices by doctors and medical professionals throughout the system - everything from reducing hospital infection rates to encouraging better coordination between teams of doctors
6. insurance companies a fee for their most expensive policies,
7. Malpractice reform: put patient safety first and let doctors focus on practicing medicine

Fitting mental health into the health care equation

WHYY's Maiken Scott talked to Stephen Metraux about mental health as part of health care reform. Listen to the report here.

Patient, Heal Thyself in the Digital Future - ABC News

Patient, Heal Thyself in the Digital Future - ABC News Shared via AddThis

Compromising on health reform

The debate over how to reform the U.S. health care system has some experts looking anew at the strengths and weaknesses of state and regional programs, including one in Pennsylvania. In an interview for WHYY on June 22, 2009, Dr. Robert Field, who leads health policy studies at Philadelphia’s University of the Sciences, says taking Pennsylvania’s AdultBasic idea nationwide would create big regulatory challenges. Read more.

USING ACTIVITIES TO PROMOTE HEALTH

It is a rainy, cold spring morning.  Most people would prefer not to be outside but the thought of  disappointing my dogs motivates me to put on the clothing needed to keep somewhat dry, venture out and tend to my morning energizers--Otis and Bea.  After a fast-paced round of fetch, I realize that my treat pack is lighter, my feet wetter but my buddies are eager for more.  So a jog-walk over obstacles is next and as the dogs lap up fresh water, I am amazed to look at my watch and see that 30 minutes have evaporated.  Such is the joy of what researcher Mihaly Csikszentmihalyi would call "flow" or a highly focused state of consciousness that requires complete absorption in a meaningful task.  Elements of flow are clear goals, immediate feedback, balance between skills and challenges, an action-awareness merger and a disregard for distractions.  Time is forgotten (1996, p. 113).

Deep down I know the drill.  Using a meaningful trigger to motivate exercise is a proven strategy to build a habit.  For me, feeding the dogs begins the daily habit of morning exercise, a chain of events that are linked to a pattern of behavior.   If I delay, Otis and Bea will circle around and shift my attention back to getting outside.   They are not influenced by weather reports or other distractions.

If you are considering new ways to increase your daily exercise, try developing a set of trigger behaviors.  The behaviors should be organized into a "chain" of events so that one leads to the next.  Once you begin the chain there is no backing out.  After 6 weeks, your habit will be strong enough to withstand some modifications but the pull of the first step  should pull you  back to completing the entire chain.