A report issued today by the Commonwealth Fund further bolsters the case for fundamental health care reform.

The report, the second national scorecard prepared by an influential health policy research group, provides evidence of just how frequently the country falls short of its own standards of care and those of its global peers. While the United States spends more than twice as much per capita on health care as most other industrialized countries, including France, it has fallen to last place among those countries in being able to prevent deaths with timely and effective medical care, according the report by the Commonwealth Fund, a not-for-profit research group in New York.

Denis Cortese, M.D., Mayo Clinic’s CEO, was quoted in the International Herald Tribune article, saying “We need to generate better value in this country.” For more information about Mayo’s perspective on producing high-value health care through payment reform, see this post about a related New York Times editorial.

Recent health reform news highlights:

The Wall Street Journal’s Health Blog covered the story of Wisconsin Congressman Steve Kagen (D), the only member of the U.S. House to refuse health insurance coverage. He introduced a bill this year, says the WSJ, that “would bar insurers from denying coverage or raising rates because of pre-existing conditions. He’d also require companies to disclose all of their rates.” Jacob Goldstein also wrote about IBM’s consumer-driven health care project in Georgia.

The Associated Press ran a background piece yesterday comparing the leading presidential candidates’ proposals with the systems in Great Britain and Canada.

The Kaiser Family Foundation also issued a Background Brief on Health Care as a 2008 Election Issue.

The Pittsburgh Post-Gazette ran an article on employer-sponsored wellness programs aimed at cutting insurance costs.

On HealthPopuli, Jane Sarasohn-Kohn analyzes reports from Watson Wyatt on factors that will influence retirement timing and a Zogby poll for the American System for Advancing Senior Health. Here are some of the most relevant statistics:

One in 3 older Americans said they need more help with their health decisions, and 71% said they want to be able to find more information about their own health care. 9 in 10 older Americans want to be in control of their health decisions.

One-half of older people believe they themselves are in the best position to help improve the quality of their health.

Read the rest of Jane’s post for additional background and her analysis.

Denis Cortese, M.D., the president and CEO of Mayo Clinic, and Mayo Clinic Health Policy Center director Jeff Korsmo, who also is chief administrative officer for Mayo Clinic Rochester, began the LaCrosse Leadership Luncheon on Health Care Reform with a presentation that highlighted Mayo Clinic’s health reform efforts. Their slides are embedded below, and you can read more about the presentation here, or you can view the webcast of the entire event.

Here are the questions and comments, submitted via laptops at each table, from the LaCrosse, Wisc. community leaders who attended the Leadership Luncheon on Health Care Reform on Monday, Apr. 28. Please feel free to add your input and contribute to the discussion in the comments below:

Questions and Comments
LaCrosse Leadership Luncheon, April 28, 2008

Dr. Cortese asked us whether we would want to be a patient tomorrow or go to a hospital, and we all answered no.  This is because we see receiving medical care as being a negative thing.  We only seek medical care when we are sick.  However, if the healthcare system put as much emphasis on proactive, preventive, wellness-based care, I would be happy to go to a hospital tomorrow and be their patient in an effort to live a healthier life.

How can a new system integrate a wellness, prevention component and still meet the public’s healthcare needs?

~~~~~

I’ve read that commercialization (markets, investors, profits, etc.)  of medicine is driving the problem with health care. Please comment.

~~~~~

How do we deal with people not wanting to get preventative care because of the costs associated with copays, coinsurance, and deductibles?

~~~~~

Can you describe how this model will impact schools and local governments, that have good health care benefits for employees, but face increased costs each year that far outpace the ability of these organizations to pay?

~~~~~

What are the suggestions that will reduce paperwork (insurance, federal program related, etc)

~~~~~

Why are reimbursement rates lower in the Midwest?

~~~~~

What can be done to reduce prescription costs in this country?  Why do Canadians pay so much less than we do?

~~~~~

The discussion and model focuses on reforming health care delivery.  How do we move the value proposition to focus on improving health, as opposed to the delivery of medical care?

~~~~~

The majority of us either started with, or will aquire a disability.  Please describe the policy direction we should take regarding disabilities as we work towards health care reform.

~~~~~

Will caps on medical care measures be applied to all care measures to control costs?
~~~~~

It seems Mayo has identified Information Technology as a key component to health care reform.  When HIPAA was enacted several years ago I seem to recall that one of the “benefits” of the initiative was to enable sharing of information.  Is this (HIPAA) an avenue of shared information?  It seems the HIPAA initiative has only resulted in emphasis on confidentiality/privacy.

~~~~~
In an individual owning insurance environment, how does an individual of one determine value of one’s care?

What is your vision of the entity that will provide the care coordination activity?

In 1948 the United Nations, including the United States signed the Declaration of Human rights.  Article 26 declares that all have the right to healthcare.  All other industrial nations have universal health care for all.  The US currently has made healthcare a privilege for those who can afford. It would seem that the country needs to address this issue prior to entering into ideological discussions over economic considerations.

~~~~~

If our system here in the Upper Mid-West works so well (as you all seem to agree) why can’t it be duplicated and exported elsewhere?

~~~~~

How does the current physician salary/payment model (RVU’s) reconcile itself against paying for value versus volume, particularly in light of the concerns that a physician may have relative to failing to order sufficient tests (oftentimes redundant) to avoid potential litigation?

~~~~~

How do you envision enforcing mandated insurance?  My understanding is that many young people voluntarily forego insurance and in most cases they will win that bet?  This is particularly true of healthy males.

~~~~~

Where does “access to healthcare” fit into your idea of measuring value? Universal insurance could lead to extended waiting times for the patient.

~~~~~

Please comment on the national movement to bring mental health benefits to parity with other illnesses across the treatment spectrum.

~~~~~
Part of the budget discussion in Madison is a 1% tax on hospital revenue. Is throwing more money at the problem, part of the solution for Wisconsin’s health care?

~~~~~

How do we convince the rest of the country to adopt a value-based health care system, particularly if it means lower reimbursement for providers in those areas?

~~~~~

We hear from Health insurance representatives that the “new system” would put health insurance companies out of business.

Since the Health Insurance business spends the 2nd largest amount of lobby dollars in Washington DC (second to the drug companies) - how can we get past the barriers both the insurance industry and the drug companies will set down if they fear a threat to their business income??

~~~~~

If we pay for good performance/outcomes, won’t providers be leery about taking the most serious, complicated cases where success is less likely?

~~~~~

what can providers and consumers do to get drug manufacuters and insurance companies to stop influencing the political process and candidates?  Increasingly they are making political contributions that have to influence the likelihood that their profits will be affected or reduced.

~~~~~

How have you addressed pay for performance on care for persons with more critical prognosis who will not be fiscally attractive to providers?

~~~~~

How have your discussions addressed the unique needs of persons with mental illness who may not be able to adequately contribute to their own care (i.e. smoking, weight reduction, etc.)?

~~~~~
No one trusts Congress, lowest confidence rate in history… no one trusts the drug companies…no one trusts the insurance companies…most, if not all in this room are covered.  What can the average person, not here,…one of the 47 million uninsured, retirees who are going broke because of this broken system, families…what can they do?  How are you going to reach them?  What will you do for their frustration now, since nothing has been done for the past 20 years.

~~~~~

Medical Research and Medical Education are two fundamental underpinnings of our current system…and judging by where we are they obviously need to be looked to usher in change.  Does the panel have thoughts on improving the medical education of our physicians, or in enhancing research to be more focus on causes of diseases rather than symptoms (many times driven by the pharmaceutical industry)?

~~~~~

Where do the Health insurance companies fit into this equation or vision?  We sometimes hear of patients being restricted because of the insurance limitations.  Also we hear of the aggressive lobbyists in Washington serving the interests of the health insurance companies.

Who do you see leading and developing the timeline for this project and keeping it on track? Hospital leaders?  Washington?

~~~~~

Do the equations change at all when we talk about comprehensive health care - not just acute and primary but mental health, dental, eye care, etc.

~~~~~

How does your proposal address the issues of custodial care (example: long term care)  Would this type of care be included in the coverage?

~~~~~

Are there any short term initiatives?  Baby steps to impact change?

After the scene-setting from Dr. Cortese and Korsmo, a panel discussion ensued, in which they were joined by Congressman Ron Kind, who represents western Wisconsin in the U.S. House; Mary Jo Werner (with the Wipfli accounting firm), and Rusty Cunningham (Publisher, LaCrosse Tribune).

Congressman Kind raised concerns about IT innovation, which is exciting, but said proprietary interests are being built into competing systems. The systems need to be interoperable…they need to talk to each other, making information available to patients but also protecting their basic privacy.

Werner, a partner in a CPA firm, said the issues are transparency and accountability. Entitlement isn’t appealing to a business owner. There needs to be an ownership interest in their own health care among employees, so they have economic incentives to take care of themselves.

Cunningham described the people in the room as “partners” and said there is a great spirit of cooperation within the community. They have promoted many health and wellness community collaborations aimed at weight loss, smoking cessation and other healthier behaviors and lifestyles. He suggested looking for ways to bring health care professionals and patients together as a team on a more collaborative, group setting instead of sending patients from one specialist to another. Instead of just creating teamwork among providers, involve patients in the team.

In response to a question on paperwork reduction, Korsmo said Mayo has a large group of people devoted to interpreting thousands of pages of Medicare reimbursements, while contracts with private insurance companies are typically just a few pages.

Rep. Kind says a barrier to moving toward individual ownership of health care is fear of the unknown, because people are accustomed to their employer-sponsored insurance.

Dr. Cortese says the major barrier to getting some of the reforms Cunningham suggests is that “nobody pays for it.” The financial incentives are all wrong. High relative value is paid for specialists, while primary care is underpaid. Right now you only get paid if the patient comes to the office. Virtual consults and team interaction outside the office require significant payment reform.

For example, Intermountain Healthcare manages 25,000 diabetics with four endocrinologists. Success is when people don’t need to come to the office. We need to find ways to reward healthier behaviors and systems that reduce utilization.

Dr. Cortese says The Commonwealth Fund has done a report that highlights six states that outperform all European countries. Wisconsin is #1 in some categories, Minnesota in some others. There are about 15 states that are comparable to the European systems. Elsewhere in the U.S. the problem is the culture in the physician communities, where people aren’t accustomed to work in teams.

In response to a question about whether costs could actually be reduced, Dr. Cortese said “that’s what value is all about.” He says the top five disease account for about 60 percent of Medicare costs, and these are typically chronic conditions. Finding ways to manage these conditions more efficiently in a team environment could lead to significant savings.

At the end of the event, the participants voted again on priorities, on a scale of 1-10:

• Payment reform got an 8.6
• Universal Clinical IT an 8.4
• High-Cost Service Programs - developing programs for managing these chronic conditions - an 8.7
• Care Coordination - 8.6
• Benefits to Improve Health - defining minimum standard benefit packages to improve health in addition to treating disease - 8.6

Please add your comments and ideas below in the comments.

Denis Cortese, M.D., Mayo Clinic president and CEO, and Jeff Korsmo, the Chief Administrative Officer for Mayo Clinic Rochester and Director of the Health Policy Center, followed the participant voting with an overview of the HPC activities from the last couple of years.

Why is Mayo Clinic engaging in this? Demographics alone will force Medicare reform, and how Medicare is reformed will affect Mayo and its patients. Dr. Cortese alluded to a quote from Jerry Garcia:

“Somebody has got to do something, and it’s just incredibly pathetic that it has to be us.”

The importance to US:

• Too many citizens without insurance protection
• Huge opportunities in efficiency and effectiveness
• The needs of the patient come first

Dr. Cortese says we need a Learning Health Care System, because the diffusion of information is far too slow. Right now the best-performing aspect of health care is in breast cancer, where patients get the state-of-the-art treatment and recommendations about 85 percent of the time. For atrial fibrillation (an abnormal heart rhythm), it’s more like 15-20 percent.

Dr. Cortese says we should focus on:

1. Value - outcomes, safety and service, divide by cost over time.
2. Integration and Coordination - lower costs, better outcomes, better quality. Wisconsin ranks highly in coordinated care. People on the East coast haven’t experience the kind of coordination and integration that people in the Midwest take for granted.
3. Individualized Medicine - tailoring therapies to the individual, based on the genomics revolution
4. Science of Health Care Delivery - System engineering for health care.

Dr. Cortese calls for payers to “Pay for Value” and reward providers that provide the best value. Medicare is the largest insurance company in the world, and it reward delay in diagnosis, incorrect diagnosis and bad outcomes.

“Pay for Peformance” is not the same as “Pay for Value.” Don’t just reward process steps, but the outcomes for patients. You can read an article about the differences here.

Dr. Cortese also calls for “Insurance for All” and favors something like the Federal Employees Health Benefit Plan model. All people own insurance, and everyone should participate. Employers can still contribute to insurance, with government contributing on a sliding scale for individuals who can’t afford it.

Jeff Korsmo says Mayo’s role is convening the discussion, and keeping patients at the center. He then gave a whirlwind tour of Mayo’s convening and outreach activities, including linking with AARP, SEIU, AMA and many other national organizations. The Health Policy Center Web site has more background.

Part of the special contribution of the Mayo Clinic Health Policy Center’s approach to health reform is its insistence on bringing the patient perspective to the discussion. That’s why the Your Voice, New Vision trailer is in La Crosse today, giving patients the opportunity to share their stories and perspectives.

The luncheon program today also is beginning with an interactive “audience response” session, enabling the 160 attendees to go beyond being an audience, and to participate themselves. Each of the 22 tables also has a laptop that can be used to submit questions.

On a scale of 1-10 (with 10 being most optimistic), voters estimated the likelihood of our ability to effectively reform health care on a national level at 3.8, so they were somewhat pessimistic. Still they said it was highly important: 47 percent say there are major problems, with another 16 percent saying the situation is even worse, and 51 percent say we need major reform. Hopefully we will be able to post the results in their entirety soon after the luncheon. Now we’re getting ready to hear from Denis Cortese, M.D., president and CEO of Mayo Clinic.

The Mayo Clinic Health Policy Center is taking its show on the road today, with a Leadership Luncheon on Health Care Reform at the Radisson in LaCrosse, Wisc.

The Health Policy Center held its 2008 National Symposium on Health Care Reform in early March, and now the HPC is seeking deeper input into its recommendations by hosting regional meetings.

You can view a webcast of today’s events on the Mayo Clinic Health Policy Center Web site.

At the 2008 Mayo Clinic National Symposium on Health Care Reform, a panel of expert guests joined with representatives of the three remaining major-party presidential candidates to discuss how the candidates’ health reform proposals coincide with or differ from the principles developed through the symposia and policy forums convened through the Mayo Clinic Health Policy Center. The panel was moderated by Cokie Roberts and featured Steven Pearlstein from the Washington Post, Karen Davis from the Commonwealth Fund and Elizabeth McGlynn from RAND Health, as well as representatives from the Clinton, McCain and Obama campaigns.

Panel Discussion on Presidential Platforms

Today’s New York Times has an editorial entitled “Quality Care at Bargain Prices” that focuses on the findings from the most recently updated Dartmouth Atlas of Health Care. The editorial concludes:

Reducing the cost of medical care will require changing longstanding habits — no easy feat. It may not happen until the medical profession reaches consensus on which treatments will truly improve the health of patients and which are superfluous. The Dartmouth researchers estimate that Medicare could save tens of billions of dollars annually — without reducing the quality of care — if all hospitals mirrored the practice patterns of the Mayo Clinic. That is a very good reason to change.

Here is the press release from The Dartmouth Institute announcing its findings. The Times’ editorial lends support to Mayo Clinic leaders’ call for payment reform, what they call “Pay for Value,” that considers both cost and quality in determining how health care services are reimbursed.

Sacrificing quality to meet budget targets isn’t a desirable solution to the problem of rising health care costs. The good news, as the Times and Dartmouth have pointed out, is it isn’t necessary either.