Legislative Malpractice

Posted on March 10, 2011 by Kathleen

Nothing Is more terrible than ignorance in action, Goethe

With the news that the Senate will not confirm Don Berwick, MD, CMS, Administrator, that expression has moved from ‘ignorance in action’ to ‘maliciousness in action.’

CMS has been leaderless for years, with decades of acting administrators.  http://www.cms.gov/History/Downloads/CMSAdministratorsTenure.pdf

Leadership actually matters—without it programs wither, they have no advocates; beneficiaries become voiceless.  It is bad enough being leaderless, but it is sheer idiocy not to confirm one of the nation’s leaders for patient safety!  Estimates are 100,000 people die every year from preventable medical errors in hospitals alone!  Berwick has been an ardent independent advocate to change this.

Not only is patient safety good for the patient. It saves money.  One program in Washington State—SCOAP (Surgical Clinical Outcomes Assessment Program—part of the Foundation for Health Care Quality www.qualityhealth.org) saved $50 million over a three year period by eliminating errors and reducing variations in care practices. 

For the first time in a long time we have an outstanding nominee who is a patient advocate in a critical and influential position—who is also a physician who understands clinical practice and has the respect of his colleagues. 

Not to approve his nomination is a slap in the face to seniors who deserve a knowledgeable and thoughtful advocate to guarantee their safety and access to the best possible care, not just pumping them full of addictive medicines in obscenely profitable ‘pill mills.’

We need to confirm him or we will face even more years of leaderless inertia in agencies that have a direct impact on health care practices and patient safety. 

Not to confirm Berwick is truly legislative malpractice.

Kathleen

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Disposable

Posted on March 3, 2011 by Kathleen

They come in all forms—diapers, razor blades, cell phones.   We use them, wear them out and toss them without a thought into the trash to go to some land fill somewhere we will never see.  Hauled off, out of sight.  Forgotten.

Just as we dispose of some people.  Not directly.  Just sanitarily with budget cuts.  Cut Medicaid; erase primary care from public health clinics.  We need to balance state budgets.  We have to cut somewhere, don’t we?   We don’t know these people. We only pass them on the street. They are not in our Rotaries or our schools.  They are not working.  Are they?  What are they contributing to our society?  Why would we need them?   We have to build new roads and fund some schools.  Don’t we? 

In 2003, the State of Mississippi was going to balance its budget by cutting 13,000 Medicaid nursing home beds. I actually followed the story, called the Governor’s office, and yes it was true that was what they were going to do.  The bill went back and forth between the Governor’s Office and the State legislature and was eventually defeated.   Do you have any idea of how poor and resource less you would have to be to be in a Mississippi Medicaid nursing home bed?  Half of Mississippi residents live on income below the poverty level. 

My mother had Alzheimer’s disease at the time.  She had the funds to pay for her nursing home care.  Had she not, I do not know what I would have done.  If I did not have a place to take care of her, I would have had to care for her myself in my home, which meant I could not work.   If I did not work, I would have had no income to pay for her care or a place for us to live.  You cannot leave an Alzheimer’s patient alone for 8+ hours a day.  Nursing home care for people with Alzheimer’s disease starts at $5,000+ a month.  Where are you going to get the money to pay for that when you can’t work and don’t have a trust fund or an inheritance?  States and Medicaid are the last resort.  Medicare doesn’t cover long-term care. 

Medicaid is a political football again. It is easy pickings. The folks are poor, sick or disabled.   They don’t donate to political campaigns.  I will be the first to admit there are problems and abuses with Medicaid.  But they do not rival the greed, waste fraud and abuse, for example, as the ‘pill mills’ in Florida:  http://www.npr.org/2011/03/02/134143813/the-oxy-express-floridas-drug-abuse-epidemic

Medicaid recipients don’t have the time and resources to think up plots like these.  They are too busy trying to make ends meet and/or caring for a family member—parent or child. They may overuse some services.  They are not the only ones who do so. 

But Medicaid abuses pale in comparison to ‘pill mills’ for seniors on Medicare.  Seniors, after all, are disposal as well. Aren’t we? We have lived our time.  We have Medicare and a prescription drug benefit that covers our prescriptions, so it is not like these pill mills are taking money out of our personal pockets.  Just public.  So what could be a better deal?   Seniors get addicted to pain meds and our tax dollars pay the bill. 

But, it is not just seniors.  All these drugs are permeating our society.  All medications at home are now addicting children and their babies. http://www.npr.org/2011/02/16/133805289/number-of-newborns-addicted-to-painkillers-rising?ps=rs

AARP in a recent article estimates that 4.3 million people over 50 use illicit drugs and over 2.5 million boomers in 1999 had trouble with substance abuse.  National agencies expect that abuse to bloom to 5 million boomers by 2020, all covered by Part D Prescription drug benefit.

http://www.aarp.org/personal-growth/life-stories/info-11-2010/addiction-i-am-an-addict.2.html

When I was a Medicare marketing director in the late 1980’s, I met seniors who told me they were so healthy—they never had to see a doctor their entire life.  Now we are selling sickness and drugs everywhere, and drowning in ads for new knees and hips.  And we wonder why our health care costs so much. 

We need to re-think our health care.  We don’t have to make the false choices we face  today of  paying more taxes or cutting programs. It’s a false paradigm.  We need to change how we organize our health care payment and delivery system so you and I are not ATM machines.

In the meantime, we have a hero in the wings.  US District Judge James Robert took a stand against our ice floe approach to balancing the budget.  He said when faced with a conflict between financial and budgetary concerns and “preventable human suffering, the balance of hardships tips in the favor of preventing human suffering.” 

 http://seattletimes.nwsource.com/html/localnews/2014361030_dshs01m.html

This should not be buried at the bottom of the page in the second section of The Seattle Times on a weekday.  This should be banner headlines.   

We must stop thinking about disposables.  The next disposable could be you and me–for either poverty or profit.  

Kathleen O’Connor is an author and 25+ year consumer advocate in health care. www.oconnorhealthanalyst.com; www.codebluenow.com

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National Prevention and Health Promotion Strategies

Posted on February 24, 2011 by Kathleen

The current Integrator Blog looks at a new study from Group Health Cooperative on including CAM (complementary and alternative medicine) providers in patient satisfaction and health outcomes.   See the story and a link to the article

http://theintegratorblog.com/index.php?option=com_content&task=view&id=724&Itemid=189

The timing is good on this study, because there is now a new national advisory panel on health promotion and disease prevention.   If there is one element of reform we do not want eliminated it is this one. 

http://www.healthreform.gov/newsroom/preventioncouncil.html

We are not going to reduce costs without reducing the incidence of illness.  This is an important step in the right direction. 

But, it needs our support to make this work. 

Cheers and more later.  Kathleen

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Some thoughts about Medicare Advantage and Medicare HMO’s

Posted on February 17, 2011 by Kathleen

This op-ed originally ran in The Seattle Times in July 2000.  At that time, the Medicare HMO’s were being dumped in droves.  When thinking about changes in Medicare now and the Medicare Advantage program–the same thing is going to happen.  As part of Medicare Part D act, insurance companies were paid subsidies by the federal government to get them back in the Medicare market.  They were even paid the subsidies before the companies were enrolling Medicare members.  So, what is going to happen to ‘fix’ Medicare Advantage is the subsidies will be cut.  When that happens, there go the Medicare enrollees back onto the regular Medicare.  So before we rush into action, it might be wise to look at what happened last time. 

Cut Off:  HMO’s Trim Elders for Profit

It’s simple economics. Medicare HMOs (Health Maintenance Organizations) are not making enough money. They whine they can’t make money given what Medicare pays. So, they dump seniors and try to con the governor and others into suing the Health Care Financing Administration (HCFA) that oversees Medicare to get better rates.

But these plans knew the rates from the get-go.

First Choice is dropping 3,200 seniors. PacifiCare will ditch 1,500 in Walla Walla, but keep its other 61,500 members. Premera will toss 6,000 in Western Washington, but keep 13,000 seniors in Eastern Washington. Aetna will drop 10,700 members and Regence Blue Shield, 8,000.

Only Group Health announced no changes for its 62,000-member HMO.

Nearly 30,000 Washington seniors have to find new plans – more than 700,000 nationally.

Here’s why:

Medicare HMOs used to be managed care’s cash cow. In the 1980s, HMOs promised the government they could reduce Medicare costs. HCFA would give the plans a flat fee each month for every senior who enrolled. In return, the HMO would manage all the Medicare benefits plus whatever additional benefits they wanted to include. The plans got 95 percent of the fee-for-service rates in their communities. The HMOs would see that seniors got Medicare Part A and B services. They could keep any savings they made.

Touting they could manage Medicare better than the government, plans across the country threw virtually irresistible packages to gobble up the lucrative senior market: zero premiums, prescription drugs, whatever it took.

And, sign up they did. But, now they are being as quickly dumped for lack of enrollment.

In King County, each Medicare HMO is paid roughly $492.23 per person each month for Medicare Parts A and B, or nearly $6,000 per year per person depending on age, gender or disability. Group Health or PacifiCare, with about 60,000 seniors each, receive nearly $360 million a year.

The trick is having enough members. That’s where Regence, Premera, First Choice and others got caught. First Choice had the fewest members at 3,200 and gets about $20 million a year. But, it doesn’t take too many cancer and chemo cases at roughly $100,000 each to run up the tab and eat up the profit. It would take many such cases to use up the annual $360 million a Group Health or a PacifiCare receive. They can absorb the costs of a few very sick members and not lose money, much less their shirts.

But, Medicare HMO members are healthy: 84 percent say they have no limits on their daily activities. Nearly 81 percent of all Medicare HMO members report excellent health; only 20 percent say their health is poor or fair.

Medicare spending per person has remained pretty constant. Only 5 percent have costs in excess of $25,000 per year. In fact, HCFA spends $1,000 or less on 52 percent of all beneficiaries each year. This 52 percent represents 45 percent of all Medicare spending.

So, while the HMOs are getting the cream of the crop in terms of health, they somehow cannot make money? Our HMOs now say they aren’t getting paid as much as other states. Foul. They knew this all along.

Yes, rates vary. In King County, a Medicare HMO receives about $492.23 each month. In Pierce County, its $465.97; in Walla Walla $442.01 and in Spokane, it’s $477.10. So, now it’s easy to see why Premera kept Spokane and PacifiCare dumped Walla Walla.

That Dade County, Florida, plans get $809.90 or LA plans get $673.86 per member per month has nothing to do with what our plans accepted. They knew these differences when they signed their contracts. Medicare HMOs are optional programs. No one forced them to do this. Some just didn’t get enough members.

That’s the bottom line. Calling out the guard in a proposed lawsuit against HCFA is a straw dog. These plans don’t have enough members to make enough money. It’s that simple.

What this public/private partnership tells us is that partnerships work as long as they make money.

The problem is structure. Medicare is more than 30 years old – an entire generation. Life expectancy when Medicare began was 65, the age of eligibility. Medicare A and B cover hospital costs and outpatient care. They don’t cover prescriptions; long-term nursing home care; adequate home health care; as well as many other things. When it was created in the ’60s, Medicare focused on the disabling medical costs seniors faced then: hospital costs. But our health landscape changed.

Few could have anticipated our longevity burst. The current Medicare generation experienced one of the largest explosions in life expectancy in world history – virtually a 20- to 30-year addition to the previous generation. We have been trying to make a horse-and-buggy benefit design keep pace with unprecedented medical and technological advances that enable us to live longer with more chronic care needs. Now, the average Medicare beneficiary is a 75- to 80-year-old woman with three or more chronic diseases.

The original model can’t meet today’s needs. But, instead of facing that issue head on, we design experiments that work as long as the private sector makes money. And, we create reams of rules to assure consumers are not being fleeced, yet ignore the health-status demographics of our society. Present policies simply chart new directions for a sinking ship.

What we must do as a community and a society is define what we want a health-care system to do. We cannot count on Congress or HCFA to call the shots and make decisions for the good of country or community. They are locked into meeting local constituent needs.

That means it’s up to us. We have to tell our elected officials not just what does not work. We have to tell them what we want.

And that is? A health-care system that supports the health and well-being of all Americans, that provides a safety net for those who need it, that assures an aggressive oversight and appeals process and a system of care that is not dependent on the latest payment fad. We deserve this not only for our seniors, but for all Americans.

Medicare HMOs are the canary in the coal mine. As Medicare goes, so goes the nation. Because of its size and influence, whatever it does will be copied by the commercial plans that follow the path of least resistance.

And, don’t listen to anyone who says, “who’s going to pay for it?” We are all paying for it now. Just ask any senior who has to change plans. Unless and until we say what we want – a system that supports the health and well-being of our seniors and the health and well-being of our communities and our nation, then we will remain stuck with a crippled system that is more concerned about cash than care.

If there were ever a time to start a community dialogue about what a health-care system should do and how to marshal existing resources to make it work, now is that time.

This discussion will be more profitable and less expensive than yet another tax-supported lawsuit against yet another tax-funded agency to fiddle with yet more complicated formulas. Better ways exist.

But, without goals, health care will remain a mess.

Kathleen O’Connor, MA, is a health care industry analyst, consultant, speaker and writer, based in Seattle, WA. She served as one of the first Medicare HMO marketing directors in Washington State

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A terrific resource

Posted on February 10, 2011 by Kathleen

If our health care system were simple, it might be easier to make out what is happening legislatively and who is and who isn’t impacted by the Affordable Care Act.  For health care policy novices, there is a law called ERISA (Employee Retiree Income Security Act) from 1974.  Among other things, it exempts self-funded, self-insured employers from any state regulation of health care benefits.

What this means is that these ERISA Plans are not subject to state insurance regulations.  Which raises the question?  Are they subject to Federal regulations and provisions?   The answer is:  it depends.

Thanks to a very nice man in the Washington State Insurance Commissioner’s Office, who led me to a great resource I would like to share with  you.  The Congressional Research Service which conducts research and makes reports to Congress.   http://www.loc.gov/crsinfo/

I found a useful, easy to read summary of the provisions of the new law. http://www.nhpf.org/library/handouts/Fernandez.slides_05-14-10.pdf

I wanted to share this with you as I prepare an upcoming series on the landmines ahead for health care reform.  And, possible ways to avoid them.

Cheers and more later, Kathleen

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Health Care for the Economy

Posted on February 3, 2011 by Kathleen

I have recently compiled my columns from The Seattle Times from 2000 to 2004. 

http://blog.oconnorhealthanalyst.com/wp-content/uploads/2011/01/kathleens-selected-columns-2000-04-final.pdf

I am re-printing below one of them which I thought was of particular interest.  It ran in October 2003. We would have to change only a few minor numbers to make it current today.

We publish this as an indicator of why we need to press for reform.

Guest columnist

Health care for the economy 

By Kathleen O’Connor

Special to The Times, October 14, 2003

What if health-care reform were a straightforward question of jobs, America’s national economic interest and our international competitiveness? It is. Just look.

Here’s the quick end of the story first. Administrative expenses devour a 150-percent larger share of America’s health-care spending than our competitors in the Economic Group of Eight.

If we reduced this to only 25 percent more on non-care expenses than the worst of our competitors, the American economy would save $300 billion every year. That’s twice the annual tax savings claimed for the Bush tax cuts.

Put another way, these savings happen if our level of administrative efficiency were just 25 percent worse than most of the rest of the world. If we achieved equal efficiency, we’d save $400 billion a year.

Best of all, these savings wouldn’t reduce spending on care delivery or medicines, leaving our quality of care and technological edge unaffected.

How many jobs would $300 billion savings create? How much more competitive would our products be?

How much more productive would we be as a nation, if we had generally healthier people who did not live in fear of losing their health-care benefits or of facing medical bankruptcy?

Health-care cost is the albatross hanging on the neck of the American economy. If companies have 10 to 20 percent annual health-care increases, they certainly aren’t going to give raises or add new jobs.

We spend 14 percent of our gross domestic product on health care, but we don’t cover everyone. Our competitors spend about half that and manage to cover all their people. We spend $1.4 trillion, or nearly $5,000 for every man, woman and child, and leave over 40 million hard-working Americans without coverage. In return for that investment, we ranked 37th in the world for our health outcomes, below Singapore, Chile, Cyprus and Costa Rica, according to the World Health Organization in 2001.

Actually, we don’t spend $1.4 trillion on health care; only about $825 million actually goes for patient care. Take a look.

About 31 cents of every American health-care dollar goes for administration. Another 10 cents goes for other “non-care” expenses. That’s a total of 41 cents for non-care expenses, according to a study in the New England Journal of Medicine in August. (This does not include medical-malpractice costs, which would add another 4 or 5 cents). The worst case among our competitors is about 15 cents per dollar for non-care expenses. That means the part of our health-care dollar spent on bureaucracy is two and a half times more than our competitors. Put another way, we are 250 percent less efficient.

So, if our administrative costs were reduced to 20 cents per dollar (versus 15 cents elsewhere), we’d save $300 billion every year. If we equaled the administrative efficiency of our competitors, we’d save $400 billion a year. The $825 billion we currently spend for patient care would remain unchanged.

This is theoretical, of course. Much of our political establishment and many deep-pocket special interests have huge stakes in the status quo. These savings are not an abstraction. All our economic peers and competitors can do this.

But what happens when we try to discuss this? The knee-jerk “socialized medicine!” mantra. That universal coverage means “socialized medicine” is hogwash.

Most of our competitors give more control for private-sector care providers than we do and they rank higher in health outcomes. Even Canada. Our health care could just as easily be called “privatized socialism” because private entities (versus the government) dictate which doctors we can see, how much they can charge and the kinds of medicines they can prescribe. Does that happen in Canada, France, Germany or Japan? Of course not.

This private-sector bureaucracy is the major culprit and significant reason for the economic strains on our businesses and our provider practices.

Think about it. More jobs are going overseas through “outsourcing.” We have lost 2.5 million manufacturing jobs since 2000. With 25 to 30 percent of their payroll going for health insurance, companies will do more outsourcing. Higher health-care costs mean more job creation over there — not here.

What’s happening here? Loss of domestic jobs and no wage increases because of health-care costs. Our products are also less competitive, with a larger share of costs going to health care than is the case with our competitors.

When we talk about health care, all we do is talk in ideologically driven terms rather than focus on what is economically viable. Change is summarily dismissed as “socialized medicine,” which derails the real debate.

How long will we accept name-calling to protect the status quo? Are you better off with your health care than you were 10 years ago? Are you better off economically than you were five years ago? It’s time we changed the terms of the game.

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Selected Columns

Posted on January 27, 2011 by Kathleen

I wrote a column for The Seattle Times for four years.  I compiled them recently only to be astonished how little the issues have changed.

You can take the content and change the date, and a few dollar amounts, and here we are today.

Kathleen’s Selected Columns 2000-04

As we are resolving our blogging software mailing, I offer these to you to read and, I hope, enjoy.

Cheers and more later. Kathleen

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CCMC Final Recommendations: 1932

Posted on January 20, 2011 by Kathleen

The CCMC’s final report summarized its earlier findings and recommendations, but it added a new fifth recommendation that would be the final nail in the coffin of the Committee’s work:  Education.  The CCMC believed a group practice model would wholly or in part eliminate the problems of the fee for service system by having better coordination between the primary care doctor and the specialist, assuring better quality care, reducing duplicative overheads and equipment, and reducing complexity of care. 

Recommendation 1:  Organization of Medical Services:

“The Committee recommends that medical service, both preventive and therapeutic, should be furnished largely by organized groups of physicians, dentists, nurses, pharmacists, and other associated personnel. Such groups should be organized, preferably around a hospital, for rendering complete home, office and hospital care. The form of organization should encourage the maintenance of high standards and the development or preservation of a personal relation between patient and physician.  (CCMC op.cit. 109).

While the final chapter includes minority comments in footnotes, they will be covered in the next installment.

Community Medical Centers, it noted, was the most fundamental recommendation to develop hospitals into comprehensive Community medical centers with local branches and rural stations  where the medical profession and patient participate in providing care and paying for it.  The centers had to have some plan of group payment plan.

It also thought that another ideal model would be paid for jointly by employee and employer.  The Report also outlined how some employer models could work, it also discussed how to transition University Medical Services into comprehensive medical centers and how to use subsidiary health care personnel, such as trained nursing attendants for long-term care and advocated wider use of mid-wives.

The Recommendation also included a range of clinics:  private group clinics, which could be an extended to become comprehensive medical centers; pay clinics for people who are not indigent, but who could not afford the health care premium and which would be funded by tax dollars, but would be closely linked with other medical centers and a hospital; middle-rate hospital services which would include a fee schedule of all professional and hospital charges, so patients of moderate means had an understanding of the costs and a way to pay for services afterward; private physician offices in hospitals would be a major step in associating general medical services with the facilities they use; organized nursing services should be developed in conjunction with comprehensive health services; county medical society clinics could be successfully implemented in rural areas to provide care for those people unable to pay for professional care services. Care would be paid for by city and county governments.

Recommendation 2:  Strengthening of Public Health Services: 

“The Committee recommends the extension of all basic public health services—whether provided by governmental or non-governmental agencies—so that they will be available to the entire population according to its needs. Primarily this extension requires increased financial support for official health departments and full-time trained health officers and members of their staffs whose tenure is dependent only upon professional and administrative competence.” (CCMC op.cit.118)

Health officers would be employed by local or state governments, but their work should be independent of political considerations. In addition, the Recommendations listed proper public services which could not necessarily be provided as well by the private sector. The Committee saw public health services as including:  the collection and analysis of vital statistics; the control of water, milk and food supplies; control of sanitation; the control, through quarantine, and supervision of communicable diseases; laboratory services; and the promotion of maternal, infant and child hygiene, including the medical and dental inspection and supervision of school children; and popular health instruction. The Recommendation also included the development of a public health nursing service.

Public health was also to have responsibility for diagnosis and treatment of certain conditions, such as tuberculosis, venereal diseases, malaria, hookworm, or any other disease that represented a health threat to the community.

Recommendation 3:  Group Payment for Medical Service

“The Committee recommends that the costs of medical care be placed on a group payment basis, through the use of insurance, through the use of taxation, or through the use of both these methods. This is not meant to preclude the continuation of medical service provided on an individual fee basis for those who prefer the present method. Cash benefits, i.e., compensation for wage-loss due to illness, if and when provided, should be separate and distinct from medical services.”   (CCMC op.cit. 120)

The Report noted that all the members of the CCMC, with the exception of those who disagreed in the minority report, supported this payment model. Different models were outlined:  Voluntary Cooperative Health Insurance in which an organized group of consumers would come together to pay a monthly fee, and work with an organized group of medical practitioners to provide those consumers with complete medical care; Required Health Insurance for Low-Income Groups, some members of the Committee thought the industrial states should immediately begin to prepare legislation to require all individuals in certain income groups and certain occupations and geographic areas to subscribe for health insurance; Aid by Local Governments for Health Insurance was seen as essential to cover the costs for those who could not afford coverage, and essentially recommended a sliding fee scale approach, with support also from local tax dollars. The Committee members felt strongly, however, that as much as possible the individual must participate financially for services received; Salaried or Subsidized Physicians in Rural Areas were seen as necessary in order to assure services were available in rural areas, and tax support from one or more counties might be a way to assure these subsidies; State and Federal Aid was considered to be essential. The state would provide care for the low income, but in states where there were serious public health problems, such as malaria and tuberculosis, services should be paid from federal tax dollars. Supplementary or Temporary Use included such things as Voluntary Hospital Insurance; Tax funds/districts for local hospitals and Tax funds for the indigent and ‘necessitous.’

Recommendation 4:  Coordination of Medical Services

“The Committee recommends that the study, evaluation and coordination of medical service be considered important functions for every state and local community, that agencies be formed to exercise these functions, and that the coordination of rural with urban services receive special attention.”  (CCMC op.cit. 134)

The Recommendation went on to identify particular steps to do so:  Temporary Professional Groups with Lay Participants.  The Committee thought that professional health care societies should appoint committees to work together to create models of coordinated care; Permanent Local Coordinating Agencies needed to be created to evaluate and coordinate existing services, eliminate unnecessary services, and stimulate the addition of new and needed services. State Coordinating Agencies should be created as soon as possible to evaluate needs in the various counties and begin to outline and coordinate services and create a state plan. Control of Drugs and Medicines required state and federal legislation to prevent “the sale of drugs and medicines with secret formulas” (CCMC op.cit. 136).  The Committee wanted very specific labeling and annual licensing of manufacturers by the federal government.

Recommendation 5:  Basic Educational Improvements

“The Committee makes the following recommendations in the field of professional education: (A)That the training of physicians give increasing emphasis to the teaching of health and the prevention of disease; that more effective efforts be made to provide trained health officers; that the social aspects of medical practice be given greater attention; that specialties be restricted to those specifically qualified; and that postgraduate educational opportunities be increased; (B) that dental students be given a broader educational background; (C)that pharmaceutical education place more stress on the pharmacist’s responsibilities and opportunities for public service; (D) that nursing education be thoroughly remoulded to provide well-educated and well-qualified registered nurses; (E) that the less thoroughly trained but competent nursing aides or attendants be provided; (F) that adequate training for nurse-midwives be provided and(G) that opportunities be offered for the systematic training of hospital and clinic administrators.” (CCMC op.cit. 138)

Specifically, Preventive Medicine in Private Practice “Future Medicine, the Committee believes, will be concerned increasingly with the prevention of disease and defectiveness as well as its alleviation and cure. Medical students, therefore, should be thoroughly instructed in the conduct and use of periodic health examinations, in the basics principles of psychiatry, and in the prevention of specific diseases. Such emphasis should not be confined to special courses in public health or preventive medicine but should, as far as possible, permeate all courses. This involves the reorientation of the entire curriculum.” (CCMC op.cit. 138-139). 

Training of Health Officers needed to be expanded because most of the public health schools were largely populated by foreign students, not Americans.  The Committee wanted more scholarships and advocated eliminating the apprentice system of public health education. Social Medicine was viewed as an integral part of the practice of medicine. Medicine was seen not just as a biological science, but one that included social, economic, psychological and sociological relationships. This should also permeate the entire curriculum. Specialism “The practice of specialties should be limited to those persons whose training or experience gives them a skill in their field distinctly above that which ought to be possessed by all well-trained general practitioners. According to the Committee’s studies, the real needs of the people call for three to five times as many well-trained general practitioners as specialists; and most schools, therefore, should concentrate their energies on producing well-qualified general practitioners.” (CCMC op.cit. 139-140.  Post graduate education should be expanded in order for practicing physicians to keep up with the rapidly expanding body of medical knowledge.

Dental Education: Dental education needed to be expanded as dentistry was seen no longer as just a matter of mechanical maintenance and restoration of teeth, but a profession that was becoming an important part of a patient’s overall health.  The dental curriculum should be expanded to include chemistry, anatomy and physiology.

Pharmaceutical Education:  The Committee saw many medications as being dangerous and wished to leave the production of medications to pharmacists who had the training to protect the public.  Training of pharmacists should be expanded to emphasize their importance in public health.

Nursing Education:  The Report blamed hospitals for the oversupply of nurses and recommended an overhaul of nursing education and the nursing curricula so the nursing schools would “produce socially-minded nurses with a preparation basic to all types of nursing services.”  (CCMC op.cit. 142).

Training of Nursing Attendants:  The Committee thought more trained nursing attendants were needed to help with simple services under the supervision of a visiting graduate nurses, so the attendants can work at lower wages, but provide services from nursing care to housekeeping.

Training of Nurse Mid-wives:  The Committee also believed that nurse mid-wives played an important role in the provision of maternity care, especially in rural areas.  It advocated for the expansion of schools for mid-wives.  (Expansion of mid-wives is of interest, in that in 1927 the AMA had Congress repeal the 1921 Sheppard-Towner Act, which gave matching federal funds to states for prenatal and well child clinics, staffed primarily by public health nurses and women physicians. (Paul Starr, The Social Transformation of American Medicine, 1982, Basic Books, Inc. pg.  260-261).

Training of Administrators: Recognizing that clinic administration is not only technical, but economic, with the expansion of the new committee medical centers, the need for well trained administrators would increase.

The Committee did not advocate replacing or duplicating existing institutions, but rather building and expanding on the foundations of existing programs.

These profoundly strong recommendations on professional education would have completely changed the direction of American medicine.  Which may explain why the Report was treated as Rapunzel with a haircut and why the Committee’s 28 research studies are housed in the archives on the top floor of the AMA.  (Charles C. Smith, Jr. MD, The Committee on the Costs of Medical Care, Paper Presented to Innominate Society for the Study of Medical History, April 10, 1984).

The Committee completed its report with a call for leadership and action at the local levels.  “The outstanding need is for effective leadership.  Wars are not won without it.” (CCMC op.cit. 147).

It concludes it report with a sense of urgency, citing more infants died each year (135,845) than the number of Americans killed in battle during WW I (50, 285). (CCMC op.cit. 148)

Their final paragraph is a hauntingly familiar plea. The diseases may have changed, but the needs are no less urgent. These conditions remain today:

“Delay can no longer be tolerated. The death rates from cancer, diabetes, and appendicitis are rising threatenly. More babies are dying each year from, many of them needlessly, than there were American soliders killed in the World War.  Every year tuberculosis kills its thousands and costs the country more than half a billion dollars. By early application of our knowledge we could double the cured cases of cancer. The venereal diseases still levy a heavy toll of blindness and mental disorders upon the nation. A great army of rheumatics remains untreated without hope of alleviation or cure. Many diabetics still remain without insulin or receive it too late.   Human life in the United States is being wasted, as recklessly, as surely, in times of peace as in times of war. Thousands of people are sick and dying daily in this country because the knowledge and facilities that we have are inadequately applied. We must promptly put this knowledge and these facilities to work.”   (CCMC op.cit. 150)

But there was never the leadership at the national or local levels to take on the Report’s vocal critics, as  we will see next in the minority report.

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CCMC: Ways to Pay for Care 1932

Posted on January 19, 2011 by Kathleen

 This post was erroneously omitted from the series. 

In earlier blogs, we noted that the CCMC wanted a health care system founded on community health centers organized around a hospital and managed by a citizen/public non-profit board of directors.

But, the Committee did not intend to eliminate the private practice of medicine; “….the proposed medical centers will never supersede or embrace all the existing medical institutions and agencies. Individual private practice, particularly among the well to do, may continue indefinitely; public health activities are a permanent governmental responsibility; industrial organizations will continue sanitary and preventive services to employees and governmental provision of hospitalization for tuberculosis and mental patients will probably increase…the work of the medical centers should be coordinated with the work of all other agencies.”  (CCMC, pg. 66)

Each community, therefore, would have a local coordinating body to examine and address the preventive and therapeutic medical services of the community and to limit unnecessary activities.  They saw the need for a comparable agency at the state level. This state agency would also supervise the development of medical centers and their branches and stations across the state.

The Committee recognized that the medical centers and their branches and stations would differ by community because of difference of maturity in existing centers and that compensation of physicians would vary by costs of living in different communities.  They estimated, however, that the costs of services would be somewhere between $20 and $40 per capita per year.

Paying for Services:  Everyone Pays

The Committee thought these costs could be met in one of three ways:  1) insurance paid for in full by families and individuals “with or without the assistance of their employers;”

2) from taxes at the local or state levels, or both; and 3) by a combination of insurance and taxes.

The problem, however, is one that remains today.  How to pay for those who could not afford these premiums.  They went on to say about taxation as a source of funding as follows:  “Although taxation might spread the cost in a fairly equitable manner, it would relieve patients of all direct individual financial responsibility. While this has been a reasonably satisfactory plan for the financing of education, highway development, and certain  community activities, most members of the Committee believe is not desirable for medical service when other plans are practicable.”  (CCMC op.cit., pg. 67).

The Committee opted instead for the third method—a combination of taxes and insurance. Each person would be required to pay something to have “a direct financial responsibility on the part of each patient.”  (CCMC op,cit., pg. 68).

If there were funds necessary to fill the gaps, it would come from taxes at the state or federal level.  They imagined that taxes would be necessary to pay for services.

However, the Committee could not reach agreement on whether insurance should be voluntary or compulsory. The insurance model proposed also required medical organizations to maintain adequate reserves and practice medicine on an actuarially sound basis. 

Their insurance model differed from European models in that it 1) was predicated on services provided by organized medical groups rather than individual practitioners; 2) economies would be realized in group practices that cannot be found in individual practices; 3) the insurance is completely divorced from any system of income protection.  “Many of the worst abuses of health insurance abroad have arisen because of the desire of insured persons for financial rather than medical assistance. Unquestionably,  there is a need for income protection, but any system of cash benefits should be separate from the provision of medical services.” (CCMC, op.cit., pg.70). 4) This insurance also differed from those provided abroad because it included full medical services for prevention, early care of incipient disease, and preventive and curative dentistry.

The Committee’s recommendations for a group practice model, however, was subject to it being a non-profit model and that the practitioners be fairly compensated with regard to their  education, responsibilities and community status. 

The Committee’s recommendations, they concluded:  “Society as a whole would receive substantial and hitherto unrealized dividends from its investment in  needed medical research and education. With the facilities of the country more effectively utilized, there would be marked improvement in the health, happiness and peace of mind of the American people.” (CCMC op.cit. pg, 71).

But, that was never to happen.  Despite concurrence among over 50 of the Committee’s members, it took only 11 members in two different minority reports to prevent the Committee’s work from seeing the light of day. 

Coming Next Week:  The Final Recommendations.

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CCMC: Philosophy Behind the Final Recommendations: 1932

Posted on January 13, 2011 by Kathleen

Note:  These principles were a complete surprise to me.  It was a surprise in terms of the thoughtfulness of these principles; the recognition of the limitations of the recommendations; and their heartfelt tone.  We would be well served now to keep these principles as a possible framework for current health care reform efforts.

We would also actually be well served now to have a comparable Committee to oversee implementation of health care reform:  a Non-Partisan Citizen’s Advisory and Oversight Committee for Health Care Reform.  It is possible and it is not too late to do so.  

Perhaps the eight foundations that funded the Committee on the Costs of Medical Care, and others, could find their way to fund this for at least three years.  We don’t need more research studies. We do need independent oversight and integrity, outside Congress.

These are the 10 principles that drove their recommendations:

1)      The problem of providing satisfactory medical service to the people of the United States at costs within their means is one of paramount importance.  Its solution will be of immense economic and social significance.

2)      Some of the social problems facing civilization today present almost insuperable barriers, barriers arising from the very biological nature of man.  This problem is not among them. It can be solved.

3)      The problem is complicated and differs from one region to another. No panacea is available; no solution is applicable to all areas of the country….Forty-five percent of the population of the continental United States in 1930, lived in cities or metropolitan areas containing at least 100,000 persons.….

4)      Goals are more important than institutions, since service is the only purpose of organizations. None of the recommendations proposed subsequently is value, in the Committee’s estimation, except in so far as it contributes to providing the people with satisfactory medical service or assists them in meeting the costs of such services….

5)      The recommendations vary in importance, in scope and in immediate applicability. Some are applicable only to urban areas; others only partially solve the problem….The Committee believes that its obligations require it to think ahead for twenty or thirty years, as well as for the next five or ten years and to present distant as well as immediate goals.

6)      The Committee’s obligation is not merely to recommend those steps which it deems immediately expedient but also those which, in the judgment of the Committee, communities must eventually take if they are to solve the problem.

7)      An evolutionary process is now going on in medical practice and in the relationships between medical science and medical practice.  This process is greatly influenced by rapidly changing economic and social conditions….

8)      The present economic depression is forcing economy in nearly all expenditures, no matter how desirable their object. The Committee does not propose the immediate adoption of programs which involve sudden large increases in expenditures from public or private funds.…

9)      The interests of the 1,100,000 persons in the United States who furnish medical services and the 123,000,000 who receive it are clearly interwoven. The professional standards of physicians, dentists, nurses, pharmacists, hospitals and other practitioners and agencies which furnish medical care must be carefully guarded in behalf of the people who are served, as well as in behalf of those who provide services.

10)   The Committee is not dogmatic in its recommendations. They are based on the study of certain groups of facts which have revealed needs or which give ground for believing that methods tested in some undertakings will be of benefit if wisely applied on a larger scale.  The aim should be to adopt objectives which at present seem sound, and to develop definite and purposeful, experimental methods of approaching those objectives, preserving, insofar as it is compatible with effective service, the maximum amount of local self-government and self-control, and the greatest freedom consistent social welfare, for the professions and the agencies involved.  Although too great decentralization of authority limits competence and threatens economic effectiveness, too great centralization of authority in any plan carries with it elements of ultimate weakness.  (CCMC op.cit. pp 104—108)

Note: These principles and recommendations were from a Committee of over 50 people from physicians and dentists and nurses, to bankers, economists, and consumers.  It took two minority reports of 10 members to take it down.  Which we will get to in two weeks.

When you review the Committee’s recommendations, many of them have been recognized and implemented, using different terms.  The ideological harangues, however, have not. 

American health care reform is like a record with a stuck grove–you hear the same notes over and over, when you should just turn it off and change the record.

We have that chance.

Coming Next Week: The Final Recommendations. 

 

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