Category Archives: Health Care Finance

Debate over mammograms reveals need for confidence in health care

This week we have had a disquieting reminder of one of the challenges we face in overhauling health care in America the public are deeply distrustful of experts.

The US Preventive Services Task Force an appointed body of leading clinicians and scientists issued a new recommendation of when women ought to have mammograms. Because it differed from what had previously been the advice, and especially because it differed from what millions of people thought they knew to be true the new guidelines were roundly criticized and scorned. By week's end, the USPSTF had tried to clarify what they were saying, and then the US Secretary of Health and Human Services asked the American people to disregard the recommendations altogether.

Not a pretty sight, especially for those who believe that we can improve care and make it more efficient and effective by carefully targeting what is done for individual patients.

I am one of those true believers in health services research and guidelines for the delivery of care comparative effectiveness research, as it is called these days.

I don't know what the right advice is for women regarding mammograms. But one thing I do know if this whole effort is going to work, we have to get to a place where the public has confidence in the experts else we might as well quit trying.

Maybe this is all due to our American individualism or maybe it is because so many of us learned to question authority. Whatever the explanation, it is not helpful to our efforts to construct a more rational health care system, guided by rigorous research and the consensus of the leading scientists and clinicians.

Until we solve this conundrum, we might want to slow down on our promises of health cost savings from comparative effectiveness research.

Edward M. Kennedy a Personal Reflection

Today the news is filled with stories about the passing of Senator Edward Kennedy of Massachusetts from an incurable brain tumor. kennedy

During his almost fifty years in the Congress, Senator Kennedy has been a dominant leader in so many areas of our national life health and health care, education, civil rights, and on and on.

Twenty years ago, in the summer of 1989, as a mid-level member of President George H. W. Bush's White House staff, I was tapped to be the Administration's negotiator with the Congress for what came to be known as the Americans with Disabilities Act.

My chief counterpart in those negotiations was a person on Senator Kennedy's staff and across that summer I had many, many long meetings up on Capitol Hill. Some of those sessions included our bosses and there I was privileged to meet and get to know Senator Kennedy a bit.

I grew to admire him a great deal for his earnest commitment and tireless energy and focus. He was, and we were, ultimately successful, and the ADA is now the law of the land.

Of all the activities I have been involved with, across a number of government jobs, I am proudest of my work on the ADA.

Today I recall proudly and fondly my time twenty years ago and how I intersected briefly and in a small way with Senator Edward Kennedy.

He will be greatly missed.

Health Reform – an Update

Several people have asked me in the past few days for my perspective on what's happening to health reform in Washington.

For what it's worth, here goes

Congress is in recess until Labor Day, and they are back home having lots of meetings with their constituents. President Obama is also hosting events almost daily to discuss health reform with the American people.

We have a governmental system that is chaotic and messy at times and this is surely one of them. Remember the quote about making laws is like making sausage ¦

Several points I'd make

1. Although President Obama won handily (53 percent to McCain's 47 percent), there are a lot of Americans who did not vote for him. So it should be no surprise that many of them are showing up at events and town hall meetings and voicing their opposition to whatever the Democrats and the Obama Administration are working toward. The fact that politics has intruded is shocking to some people, I know, but that's the American way.

2. We still badly need to reform the American health care system and as hard as this public policy and political process is, we need to press ahead as a nation.

3. As we deal with the all too familiar problems of the cost of health care, the lack of access due to uninsurance, and the quality and safety of health care in America, a lot is up for grabs. A few weeks ago it seemed like the Congressional leadership were just going to steamroll the process and enact thoroughgoing reform of the entire system. Now the sheer magnitude of all this is scaring a lot of people, especially at a time of such great economic uncertainty.

4. Proposed reform that does not take seriously the need to constrain cost growth should not itself be taken seriously. And as much as I support prevention (and I do, I put Prevention in the name of the CDC), it likely will not reduce health care expenditures though it will make us all healthier. And as much as I support Health Information Technology (and I do, very much), it is likely to add to costs for the foreseeable future, not save.

5. We need to have a serious discussion as a nation about end of life care and we are beginning that conversation now. We waste (yes, that's the right word) a huge amount of resources there. But we as a nation don't want the government making these decisions like taking your mother off the respirator. My sister and brothers and I had some tough decisions to make as our mother and father were gravely ill, and we made them. But not the government.

6. But critics of the President are crassly scaring the American public with this issue and we need to counter their fears with an honest conversation about the limits of medical care, and help patients and families with those tough decisions.

7. There are some things the government does right and the Medicare program is one of them. We should be proud of it. And I am proud to say that for several years in the 1980s I was responsible for administering it. But it is not a model for the rest of the health care system it is outmoded and frozen in time, tied to a payment system of fee for service that does not make sense for doctors or patients.

8. That is one of the risks of the public plan option that is being debated right now can a government plan innovate and be creative over time?

9. Also, Medicare pays rates to doctors and hospitals that are below the actual costs of delivering that care. A new public plan, if linked to Medicare, would have tremendous clout in the market place institutions like ours would almost certainly have to take whatever rates they offered, even if greatly below our costs, which would surely worsen the crazy quilt of cross subsidization that we now have in health care finance in our country.

10. One of the ironies right now is that many in Congress are insisting on the public plan option because of their faith in the government's ability to run the program, yet many of the same Members are urging that a new independent body MedPAC enhanced be set up to make decisions and oversee the entire system, because they don't trust the regular governmental agencies (like HHS and CMS) and processes (like the Congress) to manage things well.

11. So ¦ where are we? I think the Senate Finance Committee proposal, which is yet to be completed, will be the plan that ultimately holds sway. Yes, there will be some who say it is too conservative, and others will say that it is too liberal (whatever those words mean in this complicated area). But I believe it is likely to pass this fall, surely amended many times. The political stakes are just too high for the President and the Congress they cannot allow failure.

12. So I'd suggest you keep your eye on Senator Baucus and his colleagues on the Senate Finance Committee, and try not to get too distracted by the sound and fury around the whole process.

13. Will such legislation be good for the country? I very much believe so. But this is woefully complicated and it needs to be done right. So taking a little more time is not a bad thing.

14. And what will such legislation mean for UNC Health Care? It's way too soon to answer that question with any finality, but given our huge problems with the uninsured, we would have to be better off, at least in the short and medium term, if those now uninsured are covered. The longer run is harder to predict because the risk is as costs rise, and they inevitably will, will our payments be cut so much that we end up worse off? Time will tell.

15. And in the meantime, we have recently launched an effort to redesign how we deliver care, so that we can be one of the places that people point to as an institution that delivers top quality care in an efficient manner, with lower overall costs. I very much believe that is do-able, but it won't be easy. It will stretch us as an institution, requiring our doctors and hospitals and others to work together in creative ways that we haven't even begun to try yet. But we must I want us to be a part of the solution, not a part of the problem.

More to come ¦ stay tuned.

Sunday trip to Sacred Valley of the Incas

Today (Sunday) we took a tour of the “Sacred Valley of the Incas,” one of the prime collections of sites in the Americas. It was an all day bus tour, but was well worth it.

We visited the Sunday market at Pisac, and had a great time looking and did some buying — beautiful handmade things. Then we went on to Ollantaytambo, and saw incredible hillside Incan terraces, buildings and many other things. It was my favorite site of the day.

We concluded by going to Chinchero, and saw a demonstration of the hand preparation of dyes and then the dyeing, spinning and weaving processes. Very interesting.

It is winter here — and got quite chilly during part of the day when it was raining.

Tomorrow is the main event — Machu Picchu. We are really looking forward to it, despite the fact that we have to get up at 5am to catch the train there!

Health reform is integral to the economy

I have applauded President Obama's actions in making health care reform a prominent issue, and I was very glad to see that he mentioned health care, and science, repeatedly during his press conference Tuesday night.

The purpose for the press conference was to address the economy, and I think this is the context in which health reform belongs. Indeed, these tough economic times highlight the need for reform as unemployment, and costs, continue to rise. Unfortunately, our state of North Carolina recently received the dubious claim of having the highest rate of unemployment. We feel this as a very real pinch in the UNC Health Care System, but, more importantly, we feel for our patients and the people of the state.

I urge President Obama to seize this opportunity to make fundamental, meaningful, lasting changes that make health care more economical, and that provides high-quality coverage for everyone.

We do not need a more expensive health care system, we need to use the resources we now have more wisely.

Tomorrow I'll have the pleasure of speaking with the health care providers of the Mountain Area Health Education Center in Asheville, N.C., about our the state of North Carolina's health care system.

On March 31, 2009, in Greensboro, N.C., I hope to have the opportunity to raise some of these critical issues at President Obama's Regional Forum on Health Reform.

I go into a little detail in this video, recorded yesterday with one of our staff at UNC. I hope you will watch, and let me know your thoughts.

Obama appoints Sebelius and DeParle

Yesterday President Obama announced his nomination of Kansas Governor Kathleen Sebelius as Secretary of Health and Human Services, and his appointment of Nancy-Ann DeParle as Counselor to the President and Director of the White House Office for Health Reform.

Governor Sebelius is an experienced state leader, with a proven track record in health matters. Before her election as governor, she served eight years as Kansas' insurance commissioner. In both roles she has had extensive involvement in health insurance issues.

HHS is the largest cabinet department, and it is a huge management and leadership challenge. In the 80s and 90s, I headed two of the agencies within HHS first, the Health Care Financing Administration (now called the Centers for Medicare and Medicaid Services), and later the Centers for Disease Control and Prevention. HHS also includes the National Institutes for Health and the Food and Drug Administration, and others.

Nancy-Ann DeParle is a proven leader in health and health care. I am pleased to say she is a close personal friend of mine.

She served with distinction as a Tennessee state government cabinet head, a senior official in the federal Office of Management and Budget, and then she also headed the Health Care Financing Administration.

Over the past eight years, she has been a very successful leader in the health business community. I have served with her on two corporate boards, and we are also on the board of trustees of the Robert Wood Johnson Foundation.

I believe President Obama has made very wise choices with these two appointments. The country very much needs for them to be successful in their important tasks.

Council for Entrepreneurial Development’s Biotech 2009 Conference

A few days ago, I participated in a panel discussion at Biotech 2009, a conference in Raleigh, put on by the Council for Entrepreneurial Development.

My fellow panelists included Dennis Gillings of Quintiles, Victor Dzau, of Duke, Maureen Kelley O'Connor, of Blue Cross, and Michael Baldock, of Quattro Partners. We were asked to talk about what the new Obama Administration and the Congress mean for the biotech industry and for health care in general.

I said that the Obama Administration is still likely to make a major push for health care reform, despite not having Senator Tom Daschle to lead the effort. I remain rather hopeful but the challenges got much more difficult when he dropped out.

I also said that the new FDA is likely to be much more skeptical toward the pharma and biotech industries than has been the case in recent years.

And I also talked about the push toward investment in comparative effectiveness, including more than a billion dollars in the just enacted stimulus package. I am a great believer in the importance of producing more information on what works in medical practice, and how to compare therapies. I said that this will be a major challenge to the drug industry, as it will require much more rigorous demonstration of the worthiness of new therapies.

The new landscape presents many opportunities and challenges. I very much hope we do take advantage of the new leadership in Washington to make major improvements in health care financing and delivery. It will be VERY difficult, but our current system has tremendous problems.

Interview with UAB School of Medicine’s quarterly publication

I recently discussed my thoughts on health policy issues the new president should address with my alma mater, the University of Alabama Birmingham School of Medicine, for its alumni newsletter. I talked about health insurance, budget needs for federal health programs and the possible reorganization of the Department of Health and Human Services. To read the Fall 2008 issue, click here.

To Our Employees

As you may know, UNC Health Care has undertaken an initiative to improve access for patients who face financial difficulties. We began this effort in response to concerns raised by the community about how we meet the needs of our patients. Some of the underlying issues we addressed result from the irrational and sometimes immoral system of health care financing we operate under. Some of the issues stem from our own flawed policies and practices regarding financial support and assistance.

I want to take this opportunity to share with you directly the important improvements we've made to our existing policies and the new initiatives we've created to assure access to our health care system and improve our financial assistance programs. It is only through your collective efforts that we will ensure these changes take hold through the institution.

A detailed summary of our recent changes has been published in a community white paper that is available to you, and all citizens, at I encourage you to read it to learn more about our progress.

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UNC Health Care’s Pre-payment Policy and our Public Commitment

As North Carolina's safety-net health care system, UNC Health Care proudly serves all North Carolinians, regardless of their ability to pay. To fulfill this mission, we constantly manage the finances of this institution to ensure we can meet the increasing demands on our charity care program while also educating the next generation of physicians and conducting leading medical research. It is a careful balance that forces us to face new challenges in how we collect payment for the services we provide and how we provide that care to the under- and uninsured.

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