By Carrie Winans

The Disruptive Women in Health Care blog continually aims to encourage discussion and debate among readers about emerging issues and topics in the health care world. Historically, one of the ways that we have done that is through our weekly round-ups – that is, posts containing summaries and links to some of the big stories in health care news for the given week, with some original commentary and content sprinkled in as well. The way we see it, there is just too much happening in this burgeoning industry; it’s hard to keep up, especially when you’re busy disrupting and making headlines in the health care world yourselves. We know the weekly round-ups have been on hiatus for a while, but are happy to report that they’re finally making a comeback. Each week, we’ll be gathering some of the biggest health care news you can use from at home and abroad for posting on Wednesdays. Feel free to comment on what’s included and send us some links to articles to be considered for next week!

Has your week been too disruptive for you to keep up with the news?  Disruptive Women are on the case!  Here is this week’s round up of some of the most pressing issues here in America and around the world.

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By Hope Ditto. Hopefully it is no secret to our blog readership that above all, the editorial team here strives to be Disruptive – in more than one sense of the word. As a news outlet in this century’s ever-changing media landscape, the niche we pride ourselves on filling is just that – disruptive, at least in the sense that we will have the conversations no one else is having, raise the questions no one else is asking and explore the angle no one else is pursuing. We don’t shy away from controversy, nor do we balk at intimacy – as long as topics are well-researched, provide substantiated arguments and at least acknowledge there is an opposing viewpoint, there are almost no topics we consider off-limits.

There is, however, one area we don’t touch (in fact, we avoid it at all costs): partisan support for a candidate. While certainly all of our individual bloggers have opinions and perspectives, points of view and inherent biases, we will never run posts that are blatantly promoting one candidate for elected office over another.

I say this as a caveat to this post, the purpose of which is to announce a new series we’ll be running this year on the Disruptive Women in Health Care blog in which we explore the presidential candidates’ positions on health care and health policy, where they stand on particular aspect or aspects, what they envision to be an ideal health care system for this country and what role they envision the federal government playing in it.

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CMS Administrator Marilyn Tavenner addressing Care Innovations Summit attendees. Image courtesy of Kaiser Health News.

“I think we would all agree that these are not ordinary times, that this is not an ordinary conference, nor is it an ordinary time in health care,” commented Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner, in her address at the first ever Care Innovations Summit Thursday. In saying so, Tavenner captured not only the essence of the problems facing our nation’s health care system and the reason that over a thousand national thought leaders, senior government officials and industry experts had gathered, but also inspiring attendees with the idea that, by being there, they had the opportunity to be a part of the solution.

Driving the day at the Care Innovations Summit, which was hosted by the Center for Medicare and Medicaid Innovation (CMMI), Health Affairs and the West Wireless Health Institute, was the notion that American innovation could solve any problem, and the thousand-plus attendees were the innovators to solve this one. Emphasizing CMMI’s founding mission of better health, better care and lower costs, speakers across sectors, industries and areas of expertise continued to echo each other’s cries that it was all possible, if people began collaborating and innovating across fields.

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By Hope Ditto

If you chose to partake in what HuffPo referred to yesterday as “ your country’s empty displays of patriotic kitsch” — aka a State of the Union Drinking Game — last night, I certainly hope health care wasn’t one of your buzzwords.

President Obama delivered his 4^th State of the Union (SOTU) address to Congress last night, outlining his goals and his priorities for the nation in the coming year, and – as Sarah Kliff from the Washington Post’s WonkBlog put it  – “For health policy wonks, Tuesday night’s State of the Union speech wasn’t a thriller.”

In fact, in his nearly 70-minute, 7,000 word address, “President Obama mentioned Medicare and Medicaid… once. ‘Health care’ got two shout-outs. The Affordable Care Act? Not even a name-check,” (per Kliff).

To think of it another way, consider how Daily Briefing editor Dan Diamond broke it down — the president spent 44 words on health reform, accounting for 0.6% of the total speech.

As Politico pointed out, “Obama spent so little time on the [health reform] law that he didn’t even acknowledge an audience member the White House had brought to the speech — a cancer survivor who could have been an example of someone with a pre-existing condition who was helped by the law.”

The White House had announced earlier Tuesday that this young man, Adam Rapp, would be sitting in the first lady’s box. Rapp was diagnosed with testicular cancer on his 23^rd birthday, the same day that he would have lost health insurance coverage were it not for the Affordable Care Act (per CBS) – a potentially powerful testament touting the impact of ACA, and yet one that went unmentioned.

All of this is more staggering when you consider what a departure it represents from years past.

Medscape Medical News reports that, “Obama mentioned either “healthcare” or “health insurance” only 3 times, compared to 6 references in 2011 and 10 in 2010.”

The California Healthline blog lays it out a bit differently, explaining that, “Two years ago, the president spoke for several minutes — a total of 570 words — in urging Congress to pass the Affordable Care Act. Last night, Obama devoted just 44 words to his health reforms — never once touting the law’s actual impact, like 2.5 million young Americans gaining coverage through the ACA. In comparison, the president spent more than 130 words on his renewed cause of streamlining the government.”

And for you visual learners and/or infographics enthusiasts like myself out there, Dan Diamond tweeted this graphic a few hours ago, which I think best serves to drive the point home.

Wondering what Obama spent 70 commercial-free minutes talking about, then? According to the Washington Post, the economy mostly. Check out WaPo’s interactive infographic breaking down the speech by time spent/mentions per subject, and how this year’s spread compares to his previous SOTUs, here.

Meanwhile, the GOP rebuttal, delivered by Indiana Gov. Mitch Daniels, was only marginally better to us health wonks – at least for our interest’s sake. While it steered clear of “repeal and replace,” it did echo Rep. Paul Ryan’s pitch for an overhaul of entitlement programs.

“Medicare and Social Security have served us well, and that must continue. But after half and three-quarters of a century respectively, it’s not surprising that they need some repairs,” Daniels said. “We can preserve them unchanged and untouched for those now in or near retirement, but we must fashion a new, affordable safety net so future Americans are protected, too.”

No one would deny that the SOTU, above all, is an act of political theater. But were there even more theatrics occurring last night than usual? Many Beltway insiders have seemed to indicate this, saying that the SOTU was not only a list of goals for the year, but also, as Kliff put it, “an opening campaign gambit.”

If that is the case, it raises some interesting questions about what we can expect to hear in the fall. After all, as The Hill’s Healthwatch blog pointed out, “Although Democrats insist that Obama will be able to campaign on the healthcare law, it was almost entirely absent from a speech that helped establish the themes and frames of his reelection campaign.”

Just because the president seems to be steering the narrative away from health care so far doesn’t mean it won’t be issue in the upcoming presidential election. Odds are that the Republican nominee – whoever it turns out he (or she… hey, you never know!) may be – will want to discuss health reform, as it has certainly been a hot topic on the campaign trail.

How important of an issue do you think health reform will be in the upcoming election? Will a candidate’s position on health reform and the Affordable Care Act impact your decision to support him or her? Tell us your thoughts in the Comments section below!

For the past several years I have run this post and just as it was those years, it is this year a very important message.

By Robin Strongin. We, as a nation, have made progress and I believe Dr. King would be proud.  But our work is far from complete–particularly where health care is concerned.  Another doctor, Dr. John M. Eisenberg, a physician of tremendous stature whose life was also tragically cut short (not by an assassin’s bullet but by brain cancer) was equally passionate about the dignity of life and justice for all Americans.   Dr. Eisenberg, who among other things, served as the Director of the Agency for Health Care Policy and Research (as AHRQ was known back in the day), cared deeply about access to and the integrity of health care for all Americans– regardless of skin color.

Twelve years ago, on January 14, 2000, Dr. Eisenberg gave what is, in my opinion, a brilliant speech to the employees of the Department of Health and Human Services.  As with the past two years I want to share his words with all of you today — as a reminder of how far we’ve come, and how far we still have to go.

BIRTHDAY OBSERVANCE OF DR. MARTIN LUTHER KING, JR.: REMEMBER! CELEBRATE! ACT! A DAY ON, NOT A DAY OFF!

When I was invited to welcome you to the Department of Health and Human Service’s 26th observance of Martin Luther King Jr.’s birthday, my first thought was about how honored I was to be asked.  My second thought was about what Martin Luther King’s birth could mean to a rebirth of health care in this country.  Few have had as much impact upon American consciousness.

But what did Martin Luther King think about health care?

My colleagues and I searched through his writings and his speeches, and realized that he didn’t give speeches about health care.  Martin Luther King Jr. was confronting the basic nature of American society.  He had mountains to move–and mountaintops to climb–for this country so that today we can address the issues of high quality health care for all Americans.

If Dr. King were alive today he’d be 71 years old.  He’d be eligible for Medicare.  Like many 71-year olds, he might be dealing with a chronic medical condition–maybe arthritis, or hypertension, or diabetes.  What would he think of the health care system we have today?  What would he think of the medical care he might receive?  And what advice would he be giving the Department of Health and Human Services?

No, Dr. King didn’t give many speeches about health care.  But like the rest of society, health care had to change too.

When I was a teenager in Memphis, before the Medicare program was passed, the Baptist Hospital was the biggest in town, and the proudest of the care it gave.  But if you were African American in Memphis and you went to the Baptist Hospital, you’d go in through a back entrance.  And you’d go to a segregated ward, where you would be in a big room with about 15 or 20 other people.  And your doctor, if he was black, wold not have privileges on staff.  And the same would have been true for Dr. King in Montgomery or in Atlanta.

Dr. Vanessa Gamble, who is the new director of minority afairs at the Association of American Medical Colleges here in Washington, has documented the incredibly important role that Medicare and Medicaid played in helping to desegregate hospitals.  Medicare was a lever that lifted equity and equality in hospitals.  In 1965, our Department issued regulations madating that hospitals had to be in compliance with the Civil Rights Act–which had been passed just the year before–in order to be eligible for Federal assistance or to participate in any federally assisted program.  The passage of Medicare and Medicaid legislation that year made every hospital a potential recipient of federal funds, and therefore obligated every hospital to comply with civil rights legislation if they wanted to get paid. (more…)

By Hope Ditto

For me, November’s Man of the Month needs no introduction (… because he is my father). For the rest of you for whom he is not a genetic relation, here goes…

The Disruptive Women in Health Care team is pleased to introduce our November Man of the Month — Dr. Peter Ditto, Department Chair and Professor of Psychology and Social Behavior at University of California, Irvine and a leading authority on the psychology of advance medical directives and end of life decision making.

Dr. Ditto is best known for the series of studies he conducted examining key psychological assumptions underlying the effective use of advance medical directives, so much so that he was one of the few psychologists invited to participate in the 1993 Squam Lake conference convened to establish a national agenda for research on advance care planning. He is also a member of the Advisory Panel for the American Psychological Association’s Ad Hoc Committee on End-of-Life Issues.

I sat down with Dr. Ditto (who I more commonly refer to as Dad) to learn more about the psychological aspects of end of life decision making, his research on the subject and more.

You often use the Terri Schiavo case  as an example of the decision making challenges families who must make choices about the use of life-sustaining medical treatment for an incapacitated loved one face. In what ways does the Schiavo case encompass your “traditional” case? In what ways does it diverge?

In many ways, the Terri Schiavo case is not at all typical.  She was a young woman who was struck down unexpectedly in her 20’s. Most end-of-life decision making occurs with elderly people, often with a lot of advance warning that a situation is approaching where the person is going to lose decision making capacity. It is actually interesting that the cases that have most captured the public’s attention and most shaped law and policy on end-of-life decision making have involved these quite rare and unusual cases of young people left in persistent vegetative states (Schiavo, Karen Ann Quinlan, Nancy Cruzan). This is likely because these are cases where the issues are displayed most poignantly – a person who has lost the ability to speak for themselves, about whom everyone is uncertain what the incapacitated person would want done if they could speak, and where family members (and public opinion more broadly) have strong and differing opinions about what is the morally appropriate course of action.

But it is important to point out that these are exactly the problems that occur writ small – in less dramatic and less poignant forms – in homes, hospitals and hospices every day in the US. It is typically older people who have become too sick to speak for themselves, have not completed a little will or conveyed their wishes in any way to their loved ones, and this uncertainty can easily lead to family conflict because people have differing beliefs about the person’s likelihood of recovery, and bring different moral views and emotional vulnerabilities to the situation.

You say that, while many think the presence of a living will would have negated what quickly disintegrated into an ugly situation for the Schiavo and Schindler families, it is not always that simple. What steps can people take to avoid (to the extent it is possible) leaving their loved ones in a similar situation?

In many ways, my scientific work on end-of-life decision making can be seen as a psychological critique of living wills. The problem with living wills isn’t the idea – it is a wonderful and noble concept to try to honor people’s wishes near the end of life by having them record those wishes while they are still able – it is the execution. Quite simply, it is just a really difficult situation to find oneself in, and there are no simple band aids that are going to fix it all up. (more…)

By Diana J. Mason, PhD, RN, FAAN. The “death panel” rhetoric that arose during the debates about health care reform is an example of what’s wrong with the conversations about health policy in this country. The sound bite was fear-mongering at its best–or worst, depending upon your view. The phrase was based upon the fabrication that the health care reform law, if passed, would authorize a government panel to decide which Medicare recipients should live and which should die. Nothing could be farther from the truth.

The proposed legislation included the authorization of payments to physicians for conversations about advance directives and end-of-life preferences on a periodic basis, even among Medicare beneficiaries who were healthy. The “death panel” rhetoric created such a firestorm among average citizens that it stopped public conversations about informed choices about planning for how one prefers to die.

In October of this year, the American Academy of Nursing sponsored a public forum entitled “Critical Conversations on Advanced Care Planning and Decision Making: Models That Work” at the Kaiser Family Foundation with the intent of restarting a public conversation about these important issues. The event was co-sponsored by the Archstone Foundation, California Healthcare Foundation, Jonas Center for Nursing Excellence, Rita and Alex Hillman Foundation, and the John A. Hartford Foundation. All of these foundations know that we cannot improve care at the end of life until we have more thoughtful conversations about how to educate the public, health care professionals, and payers about best practices in this realm.

One of the panelists, Amy Berman, RN, Senior Program Officer for the John A. Hartford Foundation, has been sharing her story about being diagnosed with incurable breast cancer and her decision to forego aggressive treatment that may or may not prolong her life but would certainly have made this first year since diagnosis one of coping with major surgery and the adverse effects of chemotherapy and radiation therapy. She announced at the forum that she was about to celebrate her first year post-diagnosis anniversary and that it had been the best year of her life. For Amy, her treatment choices have been about how she wants to life the rest of her life, not just how she wants to die. (more…)

By Randi Kahn. As many of you may have read, Evelyn Lauder, the senior corporate vice president of Estee Lauder Companies and daughter-in-law of founder Estee Lauder, a champion of breast cancer research, died of ovarian cancer at her home in Manhattan Saturday. Her death came on the same day I finally got around to watching “The Education of Dee Dee Ricks,” a documentary that follows the journey of a woman battling breast cancer while attempting to raise millions of dollars to help treat other breast cancer patients without resources, and also shares the story of a woman named Cynthia who was uninsured and ended up passing away in a hospital after her breast cancer, which was caught late, spread to her liver.

I have been unable to get these strong, Disruptive Women out of my mind, and could not help thinking about both Evelyn and Cynthia while listening to the National Journal’s “Living Well at the End of Life” event on Tuesday, wondering what their conversations about end of life care were like with their clinicians, and if there was a difference between them as a result of their insurance and financial statuses. Did Cynthia choose to live her final days in the hospital?  Did her medical situation necessitate it? Was she given proper information about her hospice and palliative options?

Although we’ll never know the answers to those questions, it is interesting to take a look at barriers that exist for clinicians in end of life care that are likely impacting potential disparities. (more…)

By Mary Grealy. This past Sunday, Ezra Klein had a fascinating piece on the Washington Post website regarding the Cleveland Clinic (a Healthcare Leadership Council member) and its efforts to achieve a higher degree of wellness within its workforce.

In Cleveland, Clinic CEO Delos Cosgrove has essentially declared war against preventable chronic disease.  Smoking is completely banned anywhere on the campus (and, in fact, physicians have been fired for violating this prohibition), deep fryers and sugared sodas have been removed from the Clinic premises, and Clinic employees pay higher health insurance premiums if they don’t take part in some form of fitness or stress management classes.  Employees’ health conditions – blood pressure, blood sugar, weight and other measurable – are monitored to make sure they are being proactive in improving their health.

The results, as Klein writes, are indisputable.  The Clinic has reduced its employee healthcare costs.  Smoking rates and blood pressure are way down.  Employees have lost a collective 125 tons of weight since 2005. (more…)

By Mary Grealy. Yesterday, USA Today devoted its front page to a topic many of us have been discussing intensely for some time – how to address Medicare’s escalating costs. 

The newspaper listed five ways to “squeeze” Medicare spending and then discussed the political arguments for and against each.  Some, such as gradually raising the Medicare eligibility age from 65 to 67 and requiring higher-income beneficiaries to pay full premiums for their Medicare Part B (physician services) and Part D (prescription drug) coverage are recommendations that the Healthcare Leadership Council has made to the congressional deficit reduction “super committee.”

But, in a number of ways, the USA Today article missed the mark:

In discussing cutbacks to Medicare providers, including physicians, hospitals and pharmaceutical companies, the newspaper expanded on the likelihood that those health sectors would strenuously argue against any cuts, but there was no reporting on the impact those reductions would have upon beneficiaries.

This is a pet peeve of mine, as I’ve noted previously.  Too often, both politicians and commentators speak of the value of cutting providers instead of patients, obscuring the fact that reduced payments to providers has an impact on both the accessibility and quality of healthcare.  If, as the Obama Administration has proposed, pharmaceutical companies are required to send over $100 billion in rebates back to the government, can there be any other outcome besides higher prices for consumers and less money available for research and development of new innovative medicines? (more…)

By Robin Strongin. In the 1993 movie Dave, the temp agency owner posing as the President of the United States (if you haven’t seen the film, just trust me on this) is determined to come up with the funding to save a federal homeless shelter program.  Gathering all of the cabinet officials together with pencils, legal pads and calculators, they brainstorm different wasteful programs that can be cut, totaling numbers as they go, until they come up with the necessary $350 million.

A bit of Hollywood silly escapism?  No doubt.  But, you can say this for President Dave and his fictional cabinet.  At least they approached the budget process with a constructive purpose and vision.

We can only hope that the same holds true for the supercommittee, the panel of 12 Senators and Representatives created as part of the cobbled-together solution to the debt ceiling debacle.  By Thanksgiving, the supercommittee must come up with $1.5 trillion in deficit reduction that must then be ratified by the full Congress no later than December 23.

There’s no question that health care will play a key role in those calculations.  When it comes to finding ways to reduce federal deficits, health spending is the rapidly growing elephant in the room. 

And that leads to genuine concerns about this process.  Already, policymakers are bouncing around ideas to extract more money from the healthcare system and tighten belts further.  Medicare provider payment cuts.  New home health care co-pays and budget reductions.  Mandated Medicare Part D prescription drug rebates.  The upshot of each of these steps will be a health care system that’s more expensive, less accessible, but not necessarily better. (more…)

By Mary Grealy. I wonder how long it will take before people who should know better stop implying, or even saying outright, that payment cuts to Medicare providers don’t affect beneficiaries.

This weekend, I was among those following the cable news shows to see if Congress would finally reach agreement on a debt ceiling package.  It appears now that, even though it may be a “sugar-coated Satan sandwich” to some, a legislative approach has been crafted that will raise the debt ceiling and establish a process for achieving approximately $2.5 trillion in budget cuts over 10 years. 

In this process, a congressional super-committee will be charged with identifying $1.5 trillion in deficit reductions by Thanksgiving.  If they fail to do so, automatic cuts will occur and fall most heavily on the defense budget and Medicare.

As I was watching the news analysis, though, I saw a continued misunderstanding of what it means to cut Medicare provider payments.  One commentator praised the deal for protecting the most vulnerable in society, pointing out that Social Security and Medicaid were exempt from cuts, and Medicare cuts “would only affect providers.’  We’ve seen the same type of analysis several times today in print reports.

This kind of verbage creates the impression that an acceptable way to reduce Medicare spending, in a way that doesn’t do harm to patients, is to ratchet down payments for physicians, hospitals, medical devices, pharmaceuticals and medical supplies. (more…)

Many of the debt-reduction plans being considered by Congress and the Administration include proposals that would achieve substantial savings from the Medicare program over time. A  side-by-side summary of the proposals allows users to easily compare the key Medicare provisions found in five major debt-reduction plans put forward by the White House, Congress and independent, bipartisan commissions. The five plans are: the President’s Framework for Shared Prosperity and Shared Fiscal Responsibility; the House Concurrent Budget Resolution; the Senate “Gang of Six” Proposal; the National Commission on Fiscal Responsibility and Reform (Bowles-Simpson); and the Bipartisan Policy Center Debt Reduction Task Force (Domenici-Rivlin).

The summary also includes brief descriptions of Medicare proposals in other deficit reduction proposals from American Enterprise Institute; Cato Institute; Center for American Progress, Sen. Tom Coburn; Congressional Progressive Caucus; Dr. Bill Galston and Ms. Maya MacGuineas; Heritage Foundation; Institute for America’s Future; Sen. Joseph Lieberman and Sen. Coburn; Our Fiscal Security; Dr. Alice Rivlin and Chairman Paul Ryan; Republican Study Committee; Roosevelt Institute Campus Network; and Chairman Ryan.

The side-by-side summary is part of the Foundation’s Project on Medicare’s Future, which focuses on producing timely analysis of leading Medicare reforms affecting people on Medicare.  .The Kaiser Family Foundation is a non-profit private operating foundation dedicated to producing and communicating the best possible analysis and information on health issues.

By Hope Ditto. Most of the country is sweltering its way through this week’s heat wave, but there is one thing here in DC rising faster than the mercury in our thermometers – tensions on the Hill as the debt ceiling stalemate continues. Whispers [well, tweeted whispers] of default “what ifs” abound here in the nation’s capital as lawmakers continue to play a high-stakes game of chicken through day after day of floor debates, committee hearings and negotiating sessions. With interest rates, Social Security payments and America’s credit score dangling in the balance, and the clock ticking towards the Aug. 2 deadline, the air is even thicker with panic than it is with humidity (though my frizzy hair would say otherwise). (more…)

By Mary Grealy. It wasn’t a head-to-head battle, as such, but Congresswoman Allyson Schwartz (D-PA) squared off against the USA Today editorial board yesterday on the subject of the Independent Payment Advisory Board (IPAB), and I believe the lawmaker clearly made the better arguments.

USA Today’s editorial made the point that the IPAB, created as part of the Affordable Care Act to curb Medicare costs, is essential to do the job that Congress won’t in cutting program spending.  The newspaper compared the new board to the base closing commission that successfully shuttered unneeded military installations.

That’s a dubious argument, though, at best.  The base closing commission carefully studied the value and usefulness of military bases before choosing which ones could be closed without undermining national security.

IPAB will function in a completely different way.  If Medicare spending goes above arbitrary levels, then the board will bring the ax down on program budgets without regard to quality, value or seniors’ access to healthcare.   We’re facing a near future in which the senior population will be rising in number while physicians will be in shorter supply.  Simply cutting provider payments is the wrong answer.

Congresswoman Schwartz, in her response, acknowledged that Medicare costs must be contained, but she wrote that the solution is to reduce costs through innovations in health delivery to “reduce errors, eliminate duplication and waste, use technology to safely share information, and coordinate care between practitioners and settings.” 

She said it best when she wrote, “The threat of reduced payments is the least imaginative option.”  She’s absolutely right, and Washington can and should address the Medicare cost issue more creatively and effectively without diminishing healthcare for those who need it most.

Originally posted on the Prognosis Blog on May 24th.