Last week we continued our ongoing MEDecision Webinar Series with an interesting look at the benefits of integrating interactive, Web-based technology into the care management process. The session featured our Director of Strategic Alliances Lori Walsh and Vice President of Clinical Programs and Clinical Content Development Marie DiPrinzio, along with Bob Tavares, Vice President of Care Management for Emmi Solutions.

We started working with Emmi a few months ago. They’re a market leader in interactive patient engagement programs. Our partnership allows us to incorporate Emmi’s award-winning Emmi programs into our Alineo platform.  As a result, we can offer our customers the ability to furnish their members with email links to interactive and trackable Web-based content regarding certain conditions, procedures, medications and related information specific to the individual patient. For example, an asthma patient who is thought to be incorrectly or inconsistently using an inhaler would be sent a link to an Emmi program demonstrating how to better use the device. The member may then interact with care providers through the Emmi program by securely sending any questions or comments.

I think this is a fantastic example of how technology has and will continue to impact care delivery, particularly with reform measures and ARRA placing such a big emphasis on health IT. Lori, Marie and Bob do a great job in the webinar of explaining the many benefits that patients and payers alike can gain from access to intelligent communication resources like Emmi’s interactive Web-based technology. The webinar is archived here and is very much worth watching.

Aside from the health care reform bill being passed by the Senate Finance Committee, the other big story on the reform front last week may have been the report AHIP released finding, among other things, that the legislation in its current form would significantly raise the price of premiums for most consumers. (I discussed the AHIP report and a more comprehensive one from Oliver Wyman, Inc., in another blog.)

It was very disheartening to see the Obama administration almost immediately discredit the reports as nothing more than insurance industry propaganda (“lies”) intended to disrupt Tuesday’s Senate Finance Committee vote. For me it reprised a most unfortunate if-you’re-not-with-us-you’re-against-us attitude I sensed from the Obama team earlier in the reform debate, one that had seemed to be fading in recent weeks. As I have stated previously in this space, just because a certain entity, in this case the health insurance industry, doesn’t agree with every last detail of the proposed reform measures doesn’t mean it is against reform altogether. In fact, I believe the insurance industry is being very unfairly characterized as obstructionist when, actually, it has eagerly endorsed reform for quite some time. AHIP president Karen Ignagni rather eloquently makes this point, along with a number of other worthwhile ones, in an October 20 Washington Post article. 

To say that the AHIP report was an attempt to derail Tuesday’s vote is rather shortsighted. If the insurance industry really wanted to obstruct reform, it would hardly wait until two days before a subcommittee’s vote on proposed legislation. It would have launched a far more organized and intense offensive many months ago, one that in all likelihood would have been successful by this point. Instead, the insurance industry has been seated quietly at the table, working closely with Senator Max Baucus and other reformers without fiat. In exchange, the industry receives public vilification as reform’s arch enemy any time it voices opposition to certain aspects of the plan.

As I’ve said numerous times, the insurance industry has no interest in blocking the reform effort. It has had its own positive agenda for changing the system for quite some time. Insurers merely want reform to be fair, equitable and amenable for all of the parties it will inevitably impact. That doesn’t seem like much to ask, yet it seems more and more likely that it’s not going to happen.

On an unrelated note, congratulations to the Philadelphia Phillies on winning the National League pennant and making a second consecutive trip to the World Series! 

I felt the health care reform news out of Washington last week was decidedly mixed. For those of us who have advocated reform for many, many years, the mere fact that legislation made it past the Senate Finance Committee and one step closer to becoming reality is quite historic. A lot of folks never thought we’d even get this close, so it is indeed something that gives one great pause.

The legislation itself is another matter.

The iteration of the bill that the committee passed needs a lot of work to make it affordable before it goes up for a final vote in Congress. By now, most people are aware of the report AHIP released concluding that the current legislation would raise insurance premiums for a family of four by about $1,500. Although its authors admitted having to make simplifying assumptions that made the analysis less than comprehensive, I found it very troubling that the White House was so quick to dismiss the findings simply as insurance industry propaganda timed to derail last Tuesday’s vote. In fact, the existence of a second report that somehow flew much further under the radar not only corroborates the results of the AHIP study, it almost makes the $1,500 premium increase seem acceptable in comparison.

Oliver Wyman, Inc., the renowned actuarial consulting firm, released a more inclusive study saying that the legislation in its current form could ultimately raise rates upwards of 48 percent for approximately 94 percent of the population. Among other things, the Wyman report called for the bill to include market stabilizers to help offset such drastic cost increases. For example, it said, if the proposal calls for the elimination of pre-existing conditions, it should then also make health insurance mandatory for all. As it stands, the bill calls for the elimination of pre-existing condition rules immediately while taking a few years to implement penalties for not having coverage. And even then, the penalties are minimal. This will enable a large number of young and otherwise healthy people to wait until they’re sick to buy insurance, driving up the cost of premiums for the remaining population. No proponent of the currently proposed legislation has been able to undermine the analysis, so they’ve chosen to simply lump it in with the AHIP report as “lies.”

This is just one challenge with the legislation. There are other instances in which the bill doesn’t properly address affordability and that’s why it needs to be amended significantly before making its way to Congress. It is very important that the folks on Capitol Hill recognize that affordability goes far beyond what people pay for health insurance. It extends into what we as a society can afford to pay and, if the legislation passes as-is, the price may be very steep.

One of the things that struck me after taking a quick look at Senator Baucus’s health reform bill is that it doesn’t seem to contain a lot of detail around cost control. Obviously one of the most discussed issues in the entire reform debate is that of containing costs. For many people, the “cost of health care” simply means the amount of money consumers pay for insurance. Their reasoning is that the best way to control the price of insurance premiums is to implement a government-run insurer or a single payer system. 

While this theory is logical, it’s not very plausible. Simply by virtue of the fact that a single insurer could set rates and fees at whatever levels it chooses, insurance rates would in fact go down in the short term. But they won’t stay down unless we address the most problematic costs in the health care system which are those associated with care itself – the expense of tests, medications, hospitalization, procedures, devices and so on. It’s really our insatiable demand for health care services, drugs and devices – paid for by “other people’s money” – that creates the inexorable climb in health care costs. This is where the real cost is and the primary reason insurance rates have gotten so high in the first place. We must each focus more on wellness. Healthier consumers require less health care which, obviously, saves money. Regulation also plays into the equation. If we revise medical malpractice laws so that physicians aren’t overusing tests and treatment methods simply to avoid being sued, we can save millions.

These are just a few examples; there are myriad other factors that contribute to the rising cost of health care and this where we need to focus our attention in order to legitimately change the system. It’s not simply a matter of what we pay for coverage. It’s far more complex than that. Attempting to simply lower the cost of insurance is a band aid for an ailment that requires major reconstructive surgery. 

Senator Max Baucus’s strategy to push forward with his long-delayed health care reform plan without any support from his Republican counterparts reeks of politics-as-usual in Washington. It’s ironic that it came a mere seven days after President Obama urged bi-partisan cooperation, openness and collaboration in his reform address to Congress. Perhaps the Democrats who believed that Senator Grassley was simply stalling and not negotiating in good faith had it right all along. 

The myriad implications of Senator Baucus’s decision to move along with his plan without Republican buy-in will undoubtedly be debated and analyzed ad nauseum by the cadres of pundits, talk show hosts and government commentators on both sides. A good many of them are likely to assume (and perhaps accurately) that Baucus’s stubbornness is a sign that compromise season is over in the nation’s capital and, therefore, that progress on true reform in and of itself will slow or even stop. And I would be willing to bet that a good many talking heads will believe that the existing health care establishment will breathe a collective sigh of relief and proceed to crack open the victory champagne.  

Wrong. 

One of the things that has gotten lost in all of the debates, bickering and controversies is that the health care industry itself is welcoming, if not hoping for, reform. Each of the various entities with a vested interest in how our system works is fully aware that it doesn’t work well for all of us (after all, their employees, families and friends are patients, too) and has an express, legitimate interest in helping to improve it. Naturally, not all of constituents necessarily agree with every aspect of every various proposal. Most (rightfully) have concerns about how particular plans and ideas will ultimately impact them, but in general all parties are eager to see meaningful and sustainable change that fosters a simpler, more accessible and affordable system for us all.  

So there won’t be any high-fives and chest-bumps among health care industry executives should the whole reform thing go to pot. Just a lot of people, like their fellow Americans, saddened to see political shortsightedness and vitriol once again hamstringing progress.

MEDecision’s Vice President of Content Development Marie DiPrinzio joined Dr. Lavdena Orr, the Chief Medical Officer at DC Chartered Health Plan in Washington D.C., and the plan’s Senior Director, Rosalyn Stephens, for a presentation at the recent AHIP Medicaid Conference. The three discussed how Chartered has successfully implemented MEDecision’s Alineo collaborative health care management platform to manage care for its rather challenging Medicaid population.

Some of the difficulties in managing Medicaid patients stem from the fact that they are frequently transient; they may change addresses regularly or be homeless altogether. In addition, as a rule, Medicaid members can change their insurance coverage monthly, so they often bounce in and out of Chartered’s system. Chartered’s population is also culturally diverse and sensitive, representing different ethnic backgrounds, cultures and languages; many have limited resources.

With Alineo, Chartered is better able to manage its members simply by being better able to keep track of them. The technologies provide a centralized view of each patient that is available to care team members no matter how frequently or infrequently a specific member has touched the Chartered system. They have at their fingertips a comprehensive view of prior visits, existing conditions, treatments, medications, tests and so on, all in one centralized resource — no need to access a variety of systems and technologies. Chartered has also found that Alineo has allowed it to improve communication internally and with providers and other entities. In some instances, the system can help to facilitate communication between the care team and a patient’s caregiver even if the individual patient can’t communicate themselves. 

Chartered’s experience with MEDecision technology is a fascinating case study and an excellent example of how information technology can improve health care management and delivery. Apparently the 60 or so payer attendees at the presentation agreed as each was very well engaged in an energetic follow up conversation. Congratulations to Marie, Lavdena and Rosalyn on a job well done.

When South Carolina Congressman Joe Wilson shouted “You lie!” during President Obama’s address to Congress last week, he not only displayed incivility and boorish disrespect for the leader of our nation, he also exemplified the need for us all to pay very close attention to the specifics of the language being used to advance the health care reform debate. Whether it’s the result of crafty semantics on behalf of some or selective hearing on behalf of others, we’ve been getting so distracted by the rhetoric that we’re often clearly missing the message.

In his address, the President stated: “There are also those who claim that our reform efforts would insure illegal immigrants. This, too, is false. The reforms I'm proposing would not apply to those who are here illegally.” And this is when Wilson launched his sophomoric outburst. What Mr. Obama said was absolutely, 100 percent the truth: his reform plan in no way, shape or form provides insurance coverage for people who are in the country illegally. However, as some may recall, the law that President Reagan championed in the 80s makes it illegal for anyone seeking care in an emergency room to be denied services because they are uninsured. Therefore, regardless of any proposed reform legislation, illegal immigrants can get treatment. Apparently, when Mr. Obama said “insurance coverage” Congressman Wilson somehow heard “receive service.”

Similarly, earlier in his address the President stated: “…if you are among the hundreds of millions of Americans who already have health insurance through your job, or Medicare, or Medicaid, or the VA, nothing in this plan will require you or your employer to change the coverage or the doctor you have.”  Again, a true statement — on the surface.  As I explained in an earlier blog, the proposed legislation wouldn’t directly require anyone to change anything, as the President stated. However, in many cases there will be myriad incentives, financial and otherwise, that could convince employers to significantly change or drop their existing health plans. In that case, individuals working for these organizations will indeed find themselves with different coverage and/or having to change doctors.

As we move ever closer to a reform bill and its eventual passage — which I believe to be inevitable at this point — it would behoove us all to listen very carefully to the various issues being discussed, particularly the most controversial ones. We could all learn a great deal from that which is being said — or not said.

A recent op-ed piece in the New York Times describes “A Public Option That Works” for health care in San Francisco. Briefly, the city has enacted legislation that creates the Healthy San Francisco program which deploys a medical home to coordinate care at designated public clinics and hospitals within the city. Low income participants receive heavily subsidized access while others have the option of participating in the program at rates lower than they would pay for an individual private insurance policy. The NYT article itself provides further details, including the structure San Francisco has devised to pay for the program.

Whether or not the Healthy San Francisco model would work on a national scale is open to debate, but if nothing else it proves that there are different varieties of “public options” out there and that each can mean something radically different. In other words, it’s rather disingenuous for those in Washington to propose a Medicare-like public option as the only option. It’s also a bit premature for any of us to support or oppose a public option until we learn the specifics of what a particular proposal actually entails. All of this underscores the need for cooperation. Perhaps we can take elements of a number of ideas that might not work on their own and combine them into one that will. Maybe with some rational objectivity and bi-partisan input we could devise an altogether new strategy that’s better than any we’ve seen so far.

As with so many other aspects of health care reform, there are many ways to approach the public option. We owe it to ourselves to consider all of them. Or to at least recognize that they exist. Personally, I don’t believe a federally-run public option is necessary or helpful, but as the issue continues to stir emotions and prompt heated discussion, we should at least know what it is we’re debating.

President Obama has said repeatedly that he favors a government-run health plan option because it would increase competition and help keep private insurers “honest.” What the president and many others don’t realize is that soon we may actually need private insurers to keep the federal government honest.

Right now the federally-funded Medicare program carries more than $30 trillion (yes, trillion – and counting) in unfunded liability. That essentially means that Medicare has promised over $30 trillion in benefits that it does not actually have the money to fund. There are two ways the government can make up that shortfall: by directly raising taxes or by shifting costs to private insurers. In either scenario, consumers will ultimately foot the bill. Medicare obviously provides essential benefits to millions of Americans, and has for a long time. But clearly, promising $30 trillion in benefits that you can’t actually pay for, and then expecting taxpayers to make up the difference…well, that’s really no way to run a business.

When it comes to unfunded liability, perhaps the government could learn a lesson from private insurers, who don’t have any. Yes, parts of the private insurance industry are profit-driven, and it usually enjoys billions of dollars in earnings or surpluses each year (a very small percentage of revenue when compared to other industries), all of which is subject to review by state insurance commissioners empowered to intervene. Sure, that aspect of the system may warrant increased scrutiny, but we have many very healthy insurers (which are also required to build up reserves so as to eliminate unfunded liabilities) that are not-for-profit, community-minded entities. And there is no denying that the health care system itself is in dire need of comprehensive reform. But it is disingenuous and downright hypocritical for the federal government to lay the brunt of the blame for the crisis at the feet of the “greedy” insurance industry when federal programs themselves are operating with staggering amounts of unfunded liability. One has to ask which is worse: a private industry turning a profit, or a government program rolling up mounds of debt it will ultimately ask the American people to pay off?

It is unfair and diversionary for the administration to continuously characterize the private insurance industry as a sinister force responsible for all of the nation’s health care problems – especially when the government and its trillions in unfunded liabilities are as much a part of the problem as anything. In fact, given that Medicare will run out of money in about nine years if it continues on its current trajectory, I would say the unfunded liability issue needs to be a much larger consideration in reform discussions. The only way to achieve true and honest change in our health care system is by having a true and honest debate about all of the relevant issues, not just those that conveniently support one side’s agenda.

I’ve been reflecting on the death of Senator Edward Kennedy today and thinking about how the Kennedys have always been part of my political landscape. My earliest recollection of politics is being a child in Puerto Rico and seeing euphoric crowds celebrating the election of JFK to the presidency. My earliest encounter with real tragedy came just a few years later with his assassination. Bobby Kennedy raised my hopes as I approached voting age, but his death — so soon after the killing of the Rev. Martin Luther King — affected me as it did many of my generation.

Needless to say, Teddy Kennedy had a very difficult time living up to his brothers’ respective legends. His various challenges — most often of his own doing — made the late 60s and 70s a time of trial for him, his family and his constituency. Many of us probably had periods in our own lives that were just as challenging, but we didn’t have John and Robert Kennedy’s legacies and the public spotlight following us everywhere we stumbled. Many of us were simply “children of the ‘60s,” and Teddy was like us in certain ways: he came of age in the same period, emerging from behind his brothers chronologically older, but was still as immature as we were.

In my opinion, Teddy became “Senator Kennedy” only decades after being elected to the Senate. Although I grew up and remain a staunch Democrat, most of Teddy’s views were far to the left of mine. Senator Kennedy and I had much more in common in recent years, especially when it came to two things: improving access to and affordability of quality health care in America, and the need for bi-partisan solutions to major initiatives.

Now, I suspect that many heard his passionate speeches for causes like “economic justice” and assumed that he was such a fundamentalist “progressive” that he’d happily tell his opponents across the aisle to go pound sand, as the saying goes. But, from what I’ve read and heard from others, that was very, very seldom the case. He succeeded as the leader he clearly became by working doggedly to craft legislation together with his Republican colleagues, not by staying within the confines of his own party.

If the U.S. Senate wants to live up to the legacy that Senator Kennedy has left us, its leaders will gather once again in quiet meeting rooms and work out a reasonable compromise around the (relatively few) issues causing passionate disagreement. Everyone – and I mean everyone – knows that our country needs true “health care reform,” not the “health insurance reform” that the Democrats are now touting by demonizing for-profit, not-for-profit and self-funded company insurers, or the “let’s-deregulate-and-let-the-free-market-decide” policy that the Republican fringe elements are pushing upstream.

Sixty-three percent of Americans who receive traditional insurance through their employers (about 55% percent of whom are actually insured by their employer directly, not a third-party “private insurer”) are either “extremely satisfied” or “very satisfied” with their current coverage. But we know we can do better, and the insurance industry has already accepted many of the proposed changes. We know that fee-for-service medicine has twisted the way doctors and hospitals must treat patients, and most physician groups and hospital associations agree that we need to change reimbursement to better reflect outcomes, not just services rendered.

Consumers, on the other hand, are still the wild card in the game. We want it all, at essentially no cost to us or our families. We want to be able to dictate what treatments we get, whether or not they’ve been proven to work, and we want to use other people’s money to pay for them. We want to be able to ask for unlimited care at the end of our lives, even if it will extend our lives (often in pain or in a coma) for only a few days, and we expect to use other people’s money to pay for that, too. We still refuse to seriously consider “comparative effectiveness” and what that might mean for the choices we and our doctors ought to make about how we spend other people’s money. We want no limits placed on us at all, even as we grow more obese and less healthy with every passing survey. No insurance reform, no reimbursement reform will help us control costs if our demand for care, regardless of efficacy, keeps accelerating.

A compromise reform bill will need to do the best we’ll allow it to do, but we can’t count on it to cure all of our ills. Even Senator Kennedy recognized, in middle age, that he needed to take accountability for his life and his legacy. He changed his lifestyle, he changed the way he worked, and he changed the institution around him. As consumers and as participants in OUR health care system, we should look at that lesson and take heed.