HCCD Report Vermont 05045

TRANSITION PROJECT GROUP SUBMISSION ⁱ

Sixteen Vermont and New Hampshire residents met December 30, 2008, in West Fairlee, VT as a “Health Care Community Discussion Group” to discuss the health care crisis and the Obama-Biden Transition Project’s approach to that crisis. The group consisted of retirees (among them two physicians, a minister, two former teachers, an economist, writer and advocate, and a banker) and currently employed persons (a physician, paramedic, part-time professor and a teacher). The meeting was co-chaired by Rev. Aery, acting as moderator, and James, MD, MPH, acting as recorder.
Responding to the Project’s request for compelling personal stories, the following vignettes were discussed.
- A self-employed, single-parenting father with limited savings whose acute leukemia was aggressively treated, which temporarily remitted, and which ultimately proved fatal
- A politically conservative retired banker whose lymphoma went into a decade of remission thanks in large part to Medicare financing
- A knee disorder responding to an alternative medicine approach financed out-of-pocket
- An eating disorder complicated by insurance-driven early discharges from psychiatric hospitalization
- The Paramedic in our group reported using friends within the medical community to prescribe medication for her family, by-passing formal office visit documentation and charges.
- One family member reported on the “staggering” medical and continuing care expenses for her 93 year-old mother who had “spent down” to become eligible for both Medicare and Medicaid services.
- Others reported huge volumes of health care billing forms. [A universal coverage system would help rationalize this flood of paperwork. Ed.]
The group did not strictly follow the Project’s proposed format. Synthesizing from less directive discussion, the following observations can be made.
1. The biggest problem in the health care system is the absence of universal coverage.
2. In this rural area the choice is between the Dartmouth Hitchcock Medical Center, with its stellar cast of specialty services and its constantly changing cast of primary care providers, vs. a more rural solo or small group practice with somewhat tenuous connections to academia. Word of mouth dictates choice. Quality should be addressed by documentation of evidence-based best practices and by patient satisfaction. Continuity of out-patient care should be assessed and rewarded.
3. The group acknowledged the merit of employer-based health insurance but noted these adverse attributes of the present employer-based system
  - “Job lock”, i.e. the hazard of losing insurance which an employee faces when considering moving to a better job, and the concurrent cost to society whenever job skills cannot be optimally utilized.
  - The employer’s latitude in changing insurer annually with resultant discontinuity in care patterns
  - The inequity of funding employee’s health insurance with tax-exempt dollars when self-employed citizens enjoy no such tax-break
  - The adverse impact on prevention whenever multiple competing carriers are in the market and the insured population frequently changes carrier. This is a classic example of mal-alignment of incentives. For example, suppose disease “X” has a prevention lead time of about five years. Stated another way, if preventive measure “Y” is applied today, the benefit of the intervention will first become apparent five years hence. Now, if insurer “A” knows that condition “X” is being prevented by A’s dollars, but the condition prevented will likely occur “on the watch” of competing insurer “B”, “C”, or “D”, why spend those dollars?
  - To be rational as a vehicle for prevention, i.e. to enjoy the appropriate alignment of incentives, enrollment must be for a lifetime as is the case in the Veterans Administration health care system.
4. Optional, supplementary private medical care, whether insured or fee-for-service, should be allowable, in a manner analogous to the situation of optional private schooling. In both cases, a solid governmentally underwritten public system should be paid for by all and open to all, with private care (or schooling) being a family’s private, discretionary expense.
5. Exact dollar amounts were not discussed. [The pay-check is nonetheless a rational place for collecting the contribution of an employee to a universal health care system. This is the system employed for funding Social Security and Medicare. For those who are unemployed or self-employed, the income tax system can provide an alternative collecting system. Ed]
6. The group believes in and wishes to support prevention, especially prevention linked to health literacy. Global budgeting would encourage prevention by aligning incentives. When physicians and hospitals can make money by preventing disease (not just by preventing in-patient days) disease will be prevented, and the least skilled agents for prevention will be employed. Example: orthopedists and their hospitals which today make money by fixing fractured hips will encourage carpenters to install bath-tub handrails so they can make money by preventing fractured hips.
7. The government can promote healthier lifestyles through aligning incentives. Behavior is a reflection of community norms. Changing norms may take generations and the application of pressure at many pressure points. [For example, as a physician, if I realize that every case of adolescent sexually-transmitted disease (STD) costs me money, I will be more interested in working with my school system and community at large to encourage STD prevention strategies. And again, prevention will only be fully supported if insurance lasts a lifetime. Ed.]
Participant Survey. Our group did not formally use the survey. These answers are synthesized from remarks recorded on 15 flip charts.
1. Q. What do you perceive is the biggest problem in the health system?
  A. The absence of universality. We need “everybody in; nobody out”.
  The cost of health services is an issue, but not the paramount issue in our group composed primarily of retired professionals.
  [The cost of uninsured health services is driven not just by providers. It is also driven by the perverse incentives of competing health insurers and by the cost shifting which is inherent to such an environment. Ed.]
2. Q. What do you think is the best way for policy makers to develop a plan to address the health systems problems?
  A. The group liked this format and especially appreciated the opportunity it presents for multiple voices to be heard from multiple quarters. There was an early consensus in the group, evoked by a recently released Dartmouth study by the Wennberg/Fisher team, that "only the Federal government" is in a position to move toward substantial change. (Subsequent discussion emphasized that differences between communities and states would require some flexibility in any over-arching federal plan.) Another interesting moment came when the Moderator tested Medicare and Medicaid as possible building blocks for the new national plan. The group immediately suggested “REVISED Medicare and Medicaid”. (Specific “revisions” were not detailed.)
  [There were those in the group committed to Single Payer. The format of this discussion did not favor exploration of that concept. This is unfortunate. We believe that it is incumbent on us—we members of the public—to say what we want, i.e. “Single Payer”, and not be forced into endorsing a sub-optimal system on the grounds that only a sub-optimal system can pass into law. Politicians may be forced to compromise, but they should not expect “we the people” to compromise first. Ed.]
3. Q. After this discussion, what additional input and information would best help you continue to participate in this great debate?
  A. More information on solutions for health reform. [Single Payer advocates want you to be brave enough to present single payer as an option to be discussed. Ed.]

Summary: This group regards universal coverage as the sine qua non of reform. Other issues may approximate but not surpass the importance of universal coverage. We specifically acknowledge that this is a difficult problem in system design, with many forces interacting. We want special attention paid to

mental illness
flexibility in accepting alternative care modes
increased health awareness (“health literacy”)
shared decision-making
patient responsibility
advocacy for special populations, e.g. homeless, poorly educated and un-motivated
an element of local control and acknowledgement of community differences
evidence-based medicine
patient satisfaction as a core aspect of quality
school curricular attention, e.g., meals and exercise
private-public partnerships
a base core of benefits with optional addenda
alignment of reimbursement incentives

James, Recorder
December 31, 2008

ⁱ These notes are prepared by the recorder, James R. Hughes. When brackets appear, they represent the recorder’s (“Ed’s”) personal addition to the dialog which took place.
ⁱⁱ An Agenda for Change. Improving Quality and Curbing Health Care Spending: Opportunities for the Congress and the Obama Administration. http://tdi.dartmouth.edu/press_releases/Policy%20Paper%20E-vfnl.pdf