Sunday, December 28, 2008

Live from Pawtucket: A Transition Discussion

12 citizens in a room, talking health care:  how does that influence the flow of change?  Our group was certainly not representative of America.  For one thing, we were mostly all invested in the development of a single payer system, and acutely aware of the economic forces that are working against the change that we all need.  For another, we all thought that there were major systemic reforms that need to be put in place to complement the change in the way in which we think about health care.  A few great quotes:
"The Obama folks haven’t thought this through- a soft sell for a needed revolution. This stuff is pap for the common people."
"Why aren't employers out in front of this stuff?  This is costing them so much..."
"We need to build systems which actually provide health care, rather than focusing on who should get insurance."
""Health care for profit" is just doesn't work"
"We need to get away from talking about health insurance and talk instead about health care."
"We shouldn’t be apologetic to spend more money to help people do better."
Like Paul Krugman, our group seemed to feel that the real danger in this current move to reform is that the action will not be bold enough.  I'll try to get more notes up soon, but the commentary is too fast and too passionate.  We really need this change.  (The Obama folks suggested a 6o minute discussion, and we are at 90 minutes with no sign of stopping.)
So, here's my first draft of the report back to the Obama folks.  Not live, but close to it:

Health Care Community Discussion
Group Submission
28 December 2008, 3 PM
Home of David Keller and Julie Meyers
Pawtucket RI 02860
General Questions:
􀂃 How many people attended your health care community discussion? Thirteen. We had a mixture of physicians (3 pediatricians, an internist and a family practitioner), a nurse, a speech pathologist, an attorney, an architect, 2 small businesspeople (one profit and one non-profit), a poet and a teacher.
􀂃 Please summarize compelling personal stories from attendees about the need for health care reform in our country and provide their contact information.
Central point of the stories was that the current healthcare system is too complex, and that we need to develop a system that is built around the needs of the patient and family.
PA: Spoke of an elderly couple who could not coordinate their care
because of the separate systems of care for veterans and non-veterans.
CM: Spoke of the need for coverage for the immigrants seen at the hospital where he volunteers.
SD: Spoke of her struggle to get coverage for testing ordered by her physician and not covered when her health insurance was changed by her employer.
JM: Spoke of the needless complexity of the system, which would be poorly comprehended by anyone without a medical degree.
Summary of Responses from Discussion Questions:
􀂃 What does the group perceive as the biggest problem in the health system?
1) Value received for money spent: “The biggest problem is the amount of money that we spend on health care. As an employer, each year we got a shocking increase in the cost of health care. Nothing can be done until the cost per person is reduced.”
2) Cost of pharmaceuticals: This was seen by many are a major area that needs to be addressed. Pharma is really influencing decisions of physicians in order to maximize profits. All of the physicians in the room can recall talks designed to promote the idea that a disease was prevalent, needed to be treated and required urgent treatment. Direct to consumer advertising puts doctors on the spot by asking people to “Ask your doctor about this or that?” Most of the new drugs that are developed are “Me too” drugs, that are not as needed in many circumstances. Detailing gets doctors to forget about generic drugs. Federal regulations need to: Ban direct marketing to consumers. Include efficacy in the FDA approval and test drugs against existing ones. Create a registry of all clinical trials through the FDA. Make it illegal to “datamine” physician prescribing habits.
3) Lack of systems thinking: The solo practitioner does not allow for adequate monitoring of patient safety or use of evidence based approaches; we need to encourage the creation of systems that are family friendly, the work effectively, and that use a primary care model to focus families on appropriate levels of services and help them coordinate care. In retrospective, this seems to be the “medical home concept” long championed by the AAP and recently endorsed by the AAFP and SGIM. In addition, we need to find a “no fault” way of dealing with medical mistakes besides the malpractice system as currently structured. Currently 25% of our healthcare budget is administrative, which is terribly wasteful.
4) Inter- and intra-systems communication: Compatible electronic medical records are part of the solution, but also need to be incentives for the various parts of the system to talk with each other. Within systems, various parts (doctors, nurses, allied health folks) need to talk to each other. Lack of communication between doctors and hospitals and PTs and schools is even more complicated because of the privacy laws. The difficulties that families have are extraordinary, especially for those with special needs. This business of dumping it all onto the school and the parents is unconscionable. How to help the underserved? The system is just too complicated; if you are not a medical person, it is really hard to navigate the system.
5) Access to care remains a problem for many people: Medicaid (Rite-Care) frequently cuts people off for no apparent reason and many poor folks don’t have the energy or resources to fight back. In Rim, poor people have rouble getting specialty care; some hospitals set up obstacles for care. Care for poor people is just not adequate, and they can’t fight their way through the system, because of a lot of little obstacles. In Rhode Island, access to health services is also in danger for low income residents by the pending Medicaid waiver, which we think should not be permitted to go through.
6) Training and workforce issues: Medical education system needs a lot of fixing: Primary care is denigrated as a field, especially family medicine and the provision of mental health services. How can we make the curriculum match the needs of the community? Mental health and primary care are the most important parts of the system, and yet get the least attention in the curriculum.
􀂃 How do attendees choose a doctor or hospital? Where do attendees get information in making that decision? How should public policy promote quality health care providers? One participant choose her doctor through her health plan (Fallon) and was very happy with that choice. Others used word of mouth. Concern was raised regarding the “lone wolf” solo practitiotioner- efforts should be made within the Federal government to encourage doctors to practice according to guidelines and in concordance with “best practice”. Government should play a larger role in workforce management- coordinate decisions with medical schools, including loan forgiveness, incentives to go into the areas of medicine that we need such as psychiatry and primary care. Currently, the salary structure drives the market in the wrong direction. If there are no guidelines, then the public is vulnerable. Information systems that hype “lack of lawsuit” as a criterion for quality are not useful. In RI, primary care doctors get paid even less than in other states, driving down supply. There just aren’t any Primary Care doctors in RI. Medicaid waiver will drive us further down the tube.
􀂃 Have attendees or their family members experienced difficulty paying medical bills? How can policy makers address this problem? One member of the group is currently fighting with a health plan over covered labwork- it was approved by her original healthplan, but when she changed plans in mid-treatment, suddenly it was not covered.
􀂃 In addition to employer-based coverage, would the group like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare? Employer purchased insurance is a major source of the problem. Employers in Canada and Denmark don’t have these sorts of problems. Doctors are pushed around by the industry. We can’t just shut it down, but we need to work out a way to make it change and to get employers out of the health care market. People in the room really wanted a single payer system, most thought that we needed to get their incrementally..
􀂃 Did attendees know how much they or their employer pays for health insurance? What should employer’s role be in a reformed health care system? Single payer is the only way to get a handle on the cost of medical care. The beauty of the European doctors and dentists are that they have a guaranteed income, and are not driven to crazy practice styles by the economic demands of the practice. We should have done it 70 years ago. Doesn’t think that employer has no role in paying for health care. Most people don’t know how much is actually costs. People don’t look at they paychecks.
􀂃 Were attendees familiar with the types of preventive services Americans should receive? Had attendees gotten the recommended prevention? If not, how can public policy help? HMO gets her a primary care doctor. EMR helps them to track the needs for screening and preventive care. There were many other comments in support of protable, usable electronic medical records.
􀂃 How can public policy promote healthier lifestyles?
Some of this will take a culture change: we will need a massive campaign promoting “slow medicine” in the same way that we are promoting “slow food”. We need to focus on preventive things that are outside of the hospital. In Europe, they are much more aggressive about restricting exposure t

General Comments:
Some folks were concerned by the lack of detail in the Obama health plan: “Did I misread this, or is there not a lot of information about children with disabilities?”
“I am not sure that this is a major priority for the administration.”
We directed people to read the website for more information (
Others were concerned that the change was not bold enough: “Why are employers not clamoring to change this?”. “The Obama folks haven’t thought this through- a soft sell for a needed revolution. This stuff is pap for the common people.”
Other countries have done this better: “We should look at Taiwan- how do they cover everyone in a for profit model?” This requires that we look at ourselves and at society in a different way. “It needs to be part of a societal campaign.” We cannot forget the poor among us “ How can we care for ourselves if we don’t care for the immigrants, legal and otherwise, in our midst?
All wanted the Health Care Transition/Reform Team to know that they need to involve us in the change, and that they need to include incentives for us to change. This has to be a win-win for all of us.
Final thoughts: “We shouldn’t be apologetic to spend more money to help people do better.” In regards hospital care, the nurse-patient ratio is a problem. At least part of the nursing shortage is caused by working conditions: people don’t want to work in the hospitals because of the quality of the workforce.” Finally, don’t forget quality: Many of the folks in solo practice have marginal qualifications and would benefit from the support of a group.
That captures a lot of it.  I actually audiotaped the session and will try to get it transcribed. Transcription is posted on the Obama-Biden website

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