Category Archives: Health Care Quality

Annual North Carolina Leadership Dinner

Raleigh, NC

Yesterday evening, I spoke at the North Carolina Leadership Dinner as part of the 2011 Emerging Issues Forum, presented by the Institute for Emerging Issues at North Carolina State University. Each year, the Forum brings together leading thinkers and decision makers to foster bigger and better ideas for innovation and improvement of our state and nation. I have included my remarks below.

I have been working on improving the public’s health for almost 35 years. And as I look out in the audience, I know that many of you have been in the trenches for as long, or longer than I have.

We are fortunate in this state – and especially fortunate in this region – to have access to some of the best medical care this country has to offer. I arrived in this state a little over a decade ago. The decisions that our state’s leaders made long before I arrived, and the teamwork with which they approached the challenge of building modern health care in North Carolina paved the way for all that we enjoy today.

But through the years, there have been several activities that I am especially proud of:

From fluoridating the public water supply in my home town, Birmingham, Alabama, to starting Medicare’s efforts to publish information allowing quality comparisons across the Nation’s hospitals.

From adding “Prevention” to the name of the CDC, and making prevention a practical reality in the Nation’s health system, to creating the NC Institute for Public Health, the outreach and service arm of UNC’s school of public health.

And from building the NC Cancer Hospital to implementing the new University Cancer Research Fund, I am deeply proud to have been involved in each of these efforts – but I am by no means claiming exclusive credit for any of them – they were very much team efforts. These achievements required lots of people, many organizations and institutions, working together to do challenging and important things to improve the public’s health.

For most of these years, I also have been working on reforming the American health care financing and delivery system – beginning with my work as a lower-level White House staffer for President Reagan.

I did the staff work for his health reform package from his State of the Union speech 28 years ago. I am sure you all remember it, right?

No, you don’t, because it did not get enacted.

Many health reform efforts – by many administrations – over many decades – went nowhere.

Of course, last year President Obama and the Democrats in Congress passed the Accountable Care Act. And promptly, the Republicans began the repeal effort.

It is too early to say how all this will turn out – and it is not my purpose this evening to speak in favor of or against the ACA.

Many of you know this, but let me be plainspoken. I have been appointed to political positions by three Republican presidents – Reagan, Bush 41 and Bush 43. At the same time, Nancy-Ann Deparle and Don Berwick – the key people on health reform for President Obama – are close friends of mine.

So I believe I have a reasonably balanced perspective on health reform.

You do not need me to handicap what’s going on in Washington – there are plenty of others who are doing that – take your pick.

But I will make one point – the various activities I mentioned at the beginning of my talk this evening – things I’m proud of being a part of over the years – they were team efforts – made possible by broad-based, bipartisan collaborative work.

We very much need a team effort to fix health care in America – and here in North Carolina.

Of course, there are limitations to what a single state can do, acting alone. But that should not be an excuse for total inaction.

That’s my message this evening – to all of us here convened by Governor Hunt and the Emerging Issues Forum – all of us, consumers and providers, business leaders and elected officials, rural and urban, Republicans and Democrats.

I believe the single biggest thing holding us back from thoroughgoing reform of our health care system is that we each believe that somebody else needs to change, needs to reform. If only they would do it, then all would be well.

I think we are the collective victims of our concerted efforts to blame someone else. Or to believe some things that just aren’t true.

What I am going to do with the remainder of my time this evening is empower us to rethink our long-held assumptions, and to move us from our comfortable, but mistaken, positions. This will guide us toward a team effort to build a much better American health care system, starting here in North Carolina.

So, here is my list of the top things we know for sure about health care – things that are not true.

1. The American health care system is the best in the world.

For all the good it does, it really needs a major overhaul. I believe the oft-reiterated slogan that our country’s system is the “best in the world” is evidence of a desire to keep everything as is. I am an “American exceptionalist” too, and I know that some of you hate international comparisons – but it is simply undeniable that on average, outcomes of care in the US are not as good as average outcomes in many other industrialized countries. This is mostly because of our inability to close the disparity in the health outcomes for certain ethnic or racial minorities.

The international comparisons are not looking at the best each country has. They are comparisons of where things are on average – from top to bottom. And our bottom is what pulls us down. These people spend large parts of their lives outside the health care system. They haven’t seen the inside of a doctor’s office for years. They know only the ER at a hospital as their usual source of care. When it comes to a national average, they get equal billing with those who take advantage of the best we can offer.

2. Everybody eventually gets the care they need.

Repeated studies have shown conclusively that there is a huge cost to American society of “uninsurance” – people seek care later, have worse illnesses and worse outcomes. And we have the crazy quilt of cross subsidies – paying customers pay much more to cover the cost of uncompensated care – for UNC Health Care, which includes Rex Healthcare here in Wake County, that’s $300 million this year.

3. Almost always, the quality of care people get is very good.

Many researchers, especially Dr. Beth McGlynn at RAND, have shown that far too commonly, people do not get the care they need – and others like the Institute of Medicine have shown the harm done in the processes of care because of the lack of attention to patient safety. I chair the board of the National Quality Forum, and we are working with all parties at interest to measure and report results and then to drive vast improvements in care quality.

4. The cost of care in America is not really a problem. It is a clean, non-polluting industry that employs millions of people. And at a time when the economic problem is “jobs, jobs, jobs,” health care is one sector where employment continues to grow.

Health care now represents 17 percent of our economy, which is far more than any other country. At a time when we are worried about our competitive position in the world economy, this has to be a concern. And the Medicare actuary has just said that health reform is going to add to aggregate health spending.

Let me be even more emphatic – proposals for health care reform that do not take cost control seriously should not themselves be taken seriously. Indeed, that is a major shortcoming in last year’s legislation.

5. If you like your care, nothing about it will change

This is a line often used by President Obama. Unfortunately it is one of the most hurtful of these mistaken ideas. Because almost everything about American health care must change if we are to be successful in overhauling it as I am suggesting.

We need to redesign care in fundamental ways, to create coordinated care across primary and specialty doctors and others, so that each of us has a “patient-centered medical home.” As I hope you have heard, that is what we are doing in a very innovative pilot medical office with Blue Cross Blue Shield of North Carolina.

This initiative, if successful, could help avoid putting consumers in the middle of health insurance conflicts.

Let me say a bit more about health reform. The news media focuses on conflict in the health care debate. That focus keeps attention from an emerging Washington consensus on health care. In watching the back and forth between Republicans and Democrats, we pay no attention to what they agree on.

They agree that on the fact that future government will take less of the financial risk attributed to growing health care costs. Yes, they disagree about who should bear the risk instead, and how that risk should be borne. Democrats in Washington prefer solutions that put more risk in the hands of health care providers, and Republicans want individuals to deal with more of the risk themselves. But we should not let this back and forth cloud the reality that both parties are telling us that the government will take less of the risk. Both parties are saying that some parts of the health care system will have to change in the future.

Let me say again – we very much need a team effort to fix health care in America – and we need to do that right here in North Carolina.

I have tried to tell you the truth, about a series of long-held and unfortunately mistaken ideas about health care. You might be sitting there frustrated, and even disappointed with what I have told you.

I am hoping that as I went through some of the myths about our health care system, many of you thought, “Well, Bill, you’re right.”

The problem is that the myths don’t go away. Ours is a free country, and everyone is entitled to believe what he wants. And unfortunately, I think the average North Carolinian is not yet on board to face the challenges ahead.

There is a vast gap between the experts and the public on health care. For example, there is a consensus among those who do research on our health care system that much care that is delivered is unnecessary. But that is not the view of the average American. When surveyed, 67 percent said they do not get the tests and treatment they need. Only 16 percent said they received care that was unnecessary.

This divergence of views has had a powerful impact on what happens when health care experts suggest ideas to politicians about how best to go about dealing with lowering costs. By going along with the experts’ assumption that we have unnecessary care, those politicians created an opportunity for their opponents to reach the 67 percent who think they do not get the tests and treatments they need. And that, I would suggest, is how the term “death panel” gained such potency.

The reason we continue to over-treat is three-fold:

  • Patients demand more
  • Most health care is paid for on a fee-for-service basis, so the more you do the more you make
  • Our medical liability system makes providers reluctant to say no to patients.

Those who expect individual consumers to make more cost aware choices also have reason to be disappointed. Only 22 percent of Americans say they have ever asked about cost when making health care choices.

As someone who has worked very hard to create information that would allow comparisons of health care providers, I find it disheartening to learn that 70 percent of Americans believe there are no big differences across health care providers. If you don’t believe there is a difference, you will never want to look for anything better.

In a free market, the consumer rules. At this point, the consumer is not open to much of what the experts recommend.

As we try to rally the citizens of North Carolina and the nation to take on the challenge of health care overhaul – a major problem is this disconnect between the “experts” and the “average person.” I confess to being a health policy wonk – and we “experts” have long been concerned with the issues on my list above.

But the typical hard working North Carolinian – who today may hold down two jobs and surely wants to be responsible – all too often cannot afford the co-pays and deductibles if he has a sick child, especially one with a chronic illnesses.

That is what real people are worried about. And we owe it to them to come together to work on these real issues with vigor and determination, not just hunkering down with our long-held positions and slogans.

Our state has long had a proud record of innovation and leadership in health and health care. With the ideas and energy that you and the Emerging Issues Forum speakers have brought to this conference, I am very hopeful.

Yes, I mean those words. I am hopeful, but they can surely sound like high-minded platitudes. It is not enough for us simply to say “let’s work together.” We actually have to do it.

There is an old Greek proverb: “A society grows great when old men plant trees whose shade they know they shall never sit in.”

Friends, young or old, let’s go out – together – and plant some trees. With teamwork, we can do great things for North Carolina.

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.

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.

Visiting Machu Picchu

roper-will-machupicchu
Today we went to Machu Picchu.

It is called one of the seven wonders of the modern world — and now I know why.

It was an incredible experience. I am sure it will be the highpoint of our entire trip to Peru.

We took a half hour bus ride, a three hour train ride, then another half hour bus ride to get there.

We spent almost four hours with a guide walking and climbing around Machu Picchu. And then we reversed the trip back.

But it was totally worth it all!

You can Google and get a fuller description of this marvelous place, but here are major points —

About 500 years ago, the Incas built the city of Machu Picchu, high in the mountains. It was a city for the elites of Incan society, and it included houses, public spaces, temples and other buildings.

The Spanish conquered the region shortly thereafter, and ruled it for hundreds of years. But they never discovered Machu Picchu, given its very remote location.

It was not until about a hundred years ago that it was found by Yale archeologist Hiram Bingham. Since that time it has been visited by vast numbers of people, despite how hard it is to get to.

I am about out of superlatives to use to describe it — you simply have to see it to believe it.

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.

Health Reform 2009

It is clear that the new Obama Administration and the Congress are going to have a serious go at health reform this year.

As someone who has been trying to help accomplish a substantial overhaul of our flawed health care financing and delivery system for decades, this is a really interesting and even exciting time. A lot is at stake, but we have a major opportunity to make major improvements in health and health care in America.

Last week, President Obama hosted a health policy summit at the White House that focused primarily on covering the uninsured and cutting costs. He also asserted that now, more than ever, is the time to discuss how we will implement health care in the future. This time is a time for opportunity and evaluation.

In regard to the summit, I spoke with several people about my thoughts. I think we ought to target covering the uninsured, in an efficient manner that controls (and does not add to) costs. There are real opportunities for making progress on implementing electronic health records, doing comparative effectiveness research to guide practice and payment, etc.

The White House Office for Health Reform, headed by my friend Nancy-Ann DeParle, is going to be hosting several regional forums on health reform around the country. One of them will be in Greensboro, North Carolina, on March 31. The others will be in California, Iowa, Michigan and Vermont in March and early April, with the intent of gathering ideas from local communities about how to fix the system.

The problems of the country's and the state's health system are mirrored at UNC Health Care. We're the state's safety net hospital. At UNC, we've seen a dramatic increase in uncompensated care, to unprecedented levels. In some of our clinics, 40 percent of our patients are uninsured now. As North Carolina's unemployment rate worsens (yesterday it was announced as 9.7 percent), this tidal wave of uncompensated care will get much worse, I fear.

I'm pleased that our country and our state are making headway in the discussion of health care policy. I look forward to sharing what we are doing with others at the White House forum in Greensboro.

President Obama said in his speech to the summit attendees on March 5, what better time than now and what better cause for us to take up?”

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.