The New York Times recently reported on Health Reform Private House Parties. At this particular party, the participants easily sided with the angels: health care is a right, insurance should cover everything and coverage should be available from government and businesses. There, that was easy. Bet they had a nice time.

Partygoers were not asked for solutions and the devil is always in the details, so let’s use my favorite – flu shots.

First, the New York Times reported that party participants quickly agreed that “…health care was a right…” It makes me wonder; if health care is a “right,” what of “responsibility”?

- If I have a “right” to flu shots to help prevent flu disease, do I have a “responsibility” to get them to protect myself, reduce my medical care costs, improve economic productivity and protect others around me?
- If I don’t get the shot, infect others and cause them to be ill, am I responsible for the cost of their care?
- If others I infect miss work, am I responsible for the cost of temporary workers or losses incurred by their employer? Am I responsible to the government for the loss in taxable productivity?
- What if they die as a result of the flu I transmit to them? Am I culpable?

Second, participants also agreed “…that insurance should cover ‘everything,’ not just some services….”
- If a flu shot is covered and I choose not to get one, should I be required to pay for any doctor visits and medicines I need?
- Should my employer have the right to charge me for the temporary help that might need to be hired to replace me on the job?
- Should Uncle Sam have the right to tax me for earnings I would have made if I had been on the job?
- Should the cost of something so reasonably priced be covered for everyone? Really, I mean everyone? Even the wealthy who can well afford the cost?

Third, participants agreed that “…coverage should be readily available from the government, as well as from employers….” They agreed that individuals and businesses should have to pay a “small health care tax” to fund care.
- Who are they kidding, “small health care tax?” Have they looked at cost projections lately?
- And what about non-coverage barriers? Coverage is only one barrier to care. Ask those in rural areas, anyone not fluent in English or medically literate.

And yes, I’m still harping on flu shots. The season is not nearly over and there are plenty of doses left to protect the nation from the $87.1 billion – or more – that flu could cost us this winter.¹

1. Molinari NA, Ortega-Sanchez IR, Messonnier ML. The annual impact of seasonal influenza in the US: Measuring disease burden and costs. Vaccine 2007;25:5086-5087.

In the spirit of President Elect Obama’s/HHS Secretary Designee Tom Daschle’s efforts to mobilize a grassroots “get out the health” series of house parties, I am re-posting my first Disruptive Women post:

My Top 10 Priorities for the Next HHS Secretary (NOTE: this was written prior to the selection of Tom Daschle–not surprisingly, I was holding out hope for a woman–no offense to Mr. Daschle):

The next Secretary of the US Department of Health and Human Services (DHHS) will have a plate that is not only full, but is overflowing. While all the political rhetoric is focused around access—health insurance for all—there are a number of other critical areas that need immediate attention as well.

Clearly there are many more than 10 priority areas. However, if I just so happened to find myself sitting across from the next Secretary of HHS, I would remind her (just indulge me on that) that she is the Secretary of Health AND Human Services—that for her to make a dent on the health side of things, she must take into account whether people have: the support systems they need, heat, a home, transportation, enough to eat.

Here is my list of the top 10 priorities, in no particular order:

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Thursday night on NBC nightly news, Dr. Tim Johnson said “we’re paying for treatments that have never been proven to work” presuming we’re wasting dollars on dubious medical innovations. He described this within the context of the Obama administrations’ announcement of Tom Daschle as the new Health Care Czar who may establish an independent health care board isolated from health care lobbying “interests” and prioritizing US government spending. Within this context, it will likely adopt some process of comparative effectiveness to evaluate health care interventions. Stuart Altman recently said, “we need to move aggressively forward to develop the capacity of this country to do effective comparative research…the nation cannot afford healthcare that is not supported by evidence of sufficient benefit”.

But what really is comparative effectiveness? Comparative effectiveness in the context of health is as old as “medicine itself”, an implicit and explicit comparison of one medical technique to another. If the intervention works (i.e., understanding positive and negative impacts on patient outcomes), than one may translate this into “economic effectiveness”, or “cost-effectiveness” metrics. In our quest to assess value of medical interventions based on meaningful clinical outcomes, decision makers are using a number of well-established academic methodological approaches.

Is this new? No.
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Given the historic opportunity to lead the nation as it transforms to a nation that is about to become a majority of current minority populations, President Elect Obama and his Transition Team, announced this week, should consider identifying a diverse leadership among the political appointees in the health related positions–not just HHS, VA, DOD, but at the White House-–to develop a realistic transformation in the health care reform policy making process. There is a critical need to consider health care reform that allows the health system to become more responsive to the new America with cultural competence and literacy as well as including issues based on the social determinants of health. The President-Elect plan for access to care and quality health care that addresses health disparities is a vision needed sooner than later in order to prepare for the changing population. And of course, the health of minority women and their families needs to become a priority item as the policy making starts after January with the attention to helping them through SCHIP, Medicaid and Medicare.

A Medical Home may be coming to your neighborhood soon—and it’s a welcome first step to help consumers and caregivers coordinate complex medical services for family members suffering from chronic, debilitating diseases. CMS will be hosting a public telephone “Open Door Forum” on October 28 describing Medicare’s new Medical Home Demonstration Program, set up by 2006 Medicare legislation, aimed at recruiting primary care physicians and local health clinics to sign up when the program begins next year. (more…)

Ornery Facts

As we work to cover the uninsured, a goal all Americans share, it is key to understand who they are.  Otherwise we will change the law but not achieve the goal. Let’s accurately identify who really needs a new program to provide coverage.

20% are eligible for government programs but are not enrolled. That is almost 10 million people who don’t need a new program; what they need is better outreach by existing programs. Add to that the 19%, or 9 million, that earn more than $75,000. (close to 400% of the FPL for a family of 4) and the 13%, or 6 million, that are eligible for employer coverage (only 5% of whom go uninsured). They don’t really need a new program either. Then there are the 22% who are ineligible because they are here illegally or are in their first five years of legal residence.  That’s 12 million who DO need some type of coverage. So you get some idea of the impossibility of measuring success by “47 million”. (more…)

Guest post from Dijuana Lewis

The role American health insurance companies play in providing affordable access to health care continues to be at the center of the health care debate in this country. While rising health insurance premiums are a key point of these discussions, the reasons for these increases are often missed. Health insurance premiums increase or decrease based on annual health benefit costs, which are estimated at the beginning of a policy year. After reimbursements to hospitals, physicians, pharmacies and other providers, insurers use premium dollars to foster quality care initiatives. This includes valuable investments in prevention, health IT, clinical research and, most importantly, wellness programs that help improve health outcomes and reduce future health care costs for the consumer.

The wellness trend in the health care industry is growing as consumers and employers alike search for ways to become increasingly proactive and control costs. Comprehensive wellness programs that offer nurse hotlines, care management assistance, worksite healthy lifestyles campaigns and preventive care reminders for screenings and immunizations can change the way health care providers, employers and consumers approach health care, and they ultimately enhance health outcomes and prevent health costs from spiraling out of control. When evaluating efforts to reduce costs and improve the quality of care, it is important to note that year-to-year increases in health care costs in 2007 were actually the lowest they have been in six years.

Dijuana Lewis is president and CEO of WellPoint’s Comprehensive Health Solutions Business Unit, which includes provider relations, care and disease management, and WellPoint’s pharmacy benefits management company, NextRx, and its specialty pharmacy, PrecisionRx Specialty Solutions. Throughout her WellPoint tenure, Ms. Lewis has had wide-ranging responsibility for management of utilization/medical management staff to assure proper benefit administration for the membership; case management and disease management to improve the health of the member population; and cost of care trends for Northeast Market states. Additionally, she was responsible for the oversight and direction of all quality improvement initiatives; physician, hospital and ancillary contracting; and servicing to meet network development access needs.