SOUTH FLORIDA BUSINESS JOURNAL
Health care reform has dropped on President Barack Obama’s priority list after Democrats lost their Senate supermajority, but our panel of health care experts say too much is at stake to just walk away from the process.
“I think the whole issue of health care in this country is far more important than a single election and the political consequences,” said panelist Fred Lippman, a former state legislator and chancellor of Nova Southeastern University’s Health Professions Division.
The health care panel marked the second of South Florida Business Journal’s monthly Critical Conversations. The series drills down into the region’s most pressing issues. January’s topic was the economy, while technology and manufacturing will be covered in March and April.
Meanwhile, political observers noted that Obama didn’t refer to health care reform until about halfway through his State of the Union address on Jan. 27. House Speaker Nancy Pelosi still wants some sort of reform enacted, but Senate Majority Leader Harry Reid said there’s no need to rush to reach a new strategy.
When our panelists met before the State of the Union address, Joseph Caruncho, CEO of Preferred Care Partners, said he thought sweeping health care reform was DOA.
Caruncho said he recently received an e-mail from a lobbyist that read: “This thing is toast.” Preferred Care Partners is one of Florida’s largest privately owned Medicare Advantage health plans.
Caruncho said politicians are going to be focused on getting re-elected, and may feel as if Obama can’t protect them on the health care issue.
U.S. Rep. Debbie Wasserman Schultz, D-Weston, who participated on the panel via phone, disagreed.
“It is most definitely not DOA. The election [to fill Edward Kennedy’s Senate seat in Massachusetts] on Tuesday [Jan. 19] was a message that we need to focus on jobs and the economy. It definitely was not a referendum on health care reform.”
Still, she said, “I think the clear message we have from Tuesday is we need to pare this bill down and keep it simple.”
Wasserman Schultz, who is widely viewed as a rising star in the Democratic Party, said the current Senate bill is not passable in the House, and is essentially dead.
She said progress could be made by focusing on reforms that are the most basic and beneficial, such as helping people with pre-existing conditions get coverage, and getting rid of what she called gender discrimination against women in insurance policy costs.
There are reforms Republicans have said they support, but whether they will vote for them is the question, Wasserman Schultz said. “I think we will end up daring them not to.”
Focus on costs
The price tag of any successful bill won’t be anywhere near $900 billion, Wasserman Schultz said. “You have to delight in incremental success when you are a legislator.”
Francisco Maderal, president of the Dade County Medical Association and a doctor specializing in gastroenterology and internal medicine, said with Republicans having a little more say, the cost of programs may come into focus.
Wasserman Schultz said she would still like to focus on accomplishing three broad goals:
- Cover as many as people as possible.
- Bring down costs.
- Provide stability and security to those who are covered.
As an example of providing more coverage, she said young adults could be allowed to qualify for coverage under their parents’ policies until the age of 26 or 27.
One of the main problems with a piecemeal approach, said Penny Shaffer, market president in South Florida for Blue Cross and Blue Shield of Florida, is you need everyone in the system to help fund coverage of more pre-existing conditions or easing lifetime maximums for coverage.
That’s one reason there has been a push to make young adults covered by health care as they have low utilizations rates and would help pump more money into the system.
Mitch Feldman, CEO of West Boca Medical Center, said access to care has to be expanded for more of the population to get service and to extend acute care coverage beyond 45 days.
One way to save money is to shift care to lower-cost settings outside of emergency rooms, such as clinics and urgent care services.
The health care reform bill was 1,000 pages, and there are plenty of concepts that don’t necessarily deal with the sweeping issues, said Linda Quick, president of the South Florida Hospital & Healthcare Association. For example, she said, some deal with additional training and education of health care workers – ideas that have been encouraged for years by health care providers and the federal Centers for Medicare & Medicaid Services.
Pay for performance
Jeffrey P. Freimark, CEO of Miami Jewish Health Systems, said there’s not enough discussion about access and quality of health care.
“I would firmly come down on the side of pay for performance,” he said.
Freimark’s organization gets $220 a day for Medicare patients, but the cost of care is $280, he said, which generates a loss of $8 million to $9 million a year.
“You try to subsidize that with ancillary businesses,” he said. That includes rehabilitation, biofeedback, pain management and assisted living.
There’s little in Florida’s Medicaid system that reimburses based on acuity levels as well as the outcomes and experiences of patients. For example, institutions willing to handle patients with more needs and nurse them to health – ensuring they won’t be coming back right away – are not properly compensated, he said.
Shaffer agreed, saying Miami Jewish Health handles many complex cases. Payments are based on each and every procedure, rather than providing incentives to look at the most efficient ways to provide care.
Caruncho said the fee system that Medicare uses – and Medicaid, to some extent – “is an inherently ineffective system” that forces providers to do ancillary activities that may not be necessary in order to generate a profit margin. He would like to see a system based more on outcomes, as well.
Feldman said the diagnosis-related groups developed 20 years ago have “become a budget tool subject to the whims of Congress.”
About a sixth of patients get implantable devices, such as stents or artificial joints, and government payments don’t keep up with prices.
Quick, who also chairs the Greater Miami Chamber of Commerce’s health care and bioscience committee, said one piece of health care legislation she likes is comparative effectiveness research and dissemination of results. Without pay for performance, there is little incentive to align the doctor and hospital, and do best-of-class care, she said.
Quick, who has been part of a study group with Wasserman Schultz, also said she hoped that measures that encourage prevention and wellness might stay in any forthcoming compromise legislation.
Wasserman Schultz said these types of measures would stay in the bill, so long as they don’t add to the cost.
Encouraging use of electronic medical records, which could cut down on unneeded tests, is an example of a cost-cutting measure that could still be popular.
The issue of electronic medical records came up in a 2009 Business Journal health care panel discussion, but some expressed concern about the cost of purchasing the systems.
But, NSU’s Lippman said, “people bitch and complain that it takes so much time and effort up front. But, it helps people and prevents medical error.”
Electronic medical records could also help build a system of evidence-based care, which could lead to tort reform, Shaffer said. If doctors followed protocol, they would be better protected in court.
A major problem is that the public just doesn’t understand health reform legislation, Lippman said.
The biggest cost to the system is uncompensated care, he said. While the stereotype might be someone in poverty not paying, it’s often the working poor who are not covered by insurance.
For example, Lippman said, if a 31-year-old worker falls off a roof and is taken to Broward General Medical Center as a trauma patient, he stays there 10 to 14 weeks and the bill is $600,000 to $800,000, he said.
“No one pays for it. That’s what people say,” Lippman said, adding that, in reality, “you pay for it. I pay for it.”
That can happen with property taxes in the case of Broward General, which is part of the Broward Health. Paying patients also subsidize uncompensated care, which is why a Tylenol tablet costs so much.
Lippman suggested that American Recovery and Reinvestment Act funds could be used to help bring about more efficiencies and help reduce medical errors.
“Those are incredibly important pieces of reform,” Wasserman Schultz agreed.
One small business owner told her of having a 172 percent increase in premiums because of a single sick employee, Wasserman Schultz said. “That’s not sustainable.”
Lippman said the fiscal impact of not doing anything with health reform is so dramatic that it could bring down the nation financially.
“You are so right,” Wasserman Schultz said, adding that health care is the most significant factor in the federal deficit and the overall economy.
Shaffer said there should be more emphasis placed on health and wellness, which would improve employee productivity.
“I think the public has unrealistic expectations of the health care system,” Quick said. “What most people know about medicine they have seen on television.”
That leads to questions like: “How come my aunt didn’t get the organ she needed?” and “How come it was my cousin who died when they got the transplant?” she said.
The public needs to get away from the concept of just going to a doctor when they don’t feel well, Wasserman Schultz said.
The chronically uninsured, she said, are still the most expensive aspect of the system. The failure of reform means we are still left with people coming to emergency rooms, which are high-cost places for treatment.
Shaffer said she’d like to see more personal accountability when it comes to prevention of diseases such as diabetes and some types of cancer.
She said: “More than 60 percent is what we do our selves – life, liberty and the pursuit of happiness – and we’ve gotten out of balance.”