Commentary from Dave Durenberger

August 12, 2009

TIME - OUT
Across the world people are taking a break. Congress left Washington last week and President Obama is planning a vacation break as well. I'm spending more time with grandkids and feeling good about being just a week from my 75th birthday. Senators Kay Bailey Hutchinson (R-TX) and Bob Martinez (R-FL) are resigning from the Senate to be replaced before the 2010 election by their GOP governors. In Kay's case she's planning to run against hers for governor.

Senator Chris Dodd, whose been running behind in re-elect polls in CT while chairing the Banking Committee and reporting a health reform bill out of HELP, says he has prostate cancer and will have surgery. The good news is the Senate Ethics Committee gave him only a reprimand for getting a below-market-rate interest mortgage from Angelo Mazillo at Countrywide Financial.

To the extent that the national rate of unemployment or the stock market is an indication of economic optimism, July felt good. Not for everyone. A neighbor and good friend age 54, whose wife just lost her father and whose home has been on the market for a year, called to say he'd just lost his job to the economy's impact on the trucking industry. But he plans to get another and asked me to help. He has managed businesses from $12m yr to over $100m if you want to help me.

The "Cash for Clunkers" program appears to be a big success. The Senate confirmed Federal Judge Sonia Sotomayor as the new justice of the U.S. Supreme Court by more than a two-thirds vote and right on the president's time schedule. The Republican position on the president's health policy reform proposals has been reduced to "shout-down" attacks on members of Congress by "tea party" fanatics sent by right wing radio. Bill Clinton made a quick trip to North Korea a diplomatic and humanitarian success and no one paid him his usual six-figure fee to do it.

TIME TO GO GOLFING
Minnesotans this week host the last of the major golf tournaments and, maybe the best of 2009. Ninty-eight out of 100 of the world's best professional golfers tee off tomorrow at Hazeltine National Golf Course in Chaska, MN. That ties a record set by the 2002 PGA also at Hazeltine. Padraig Harrington and Tiger Woods are paired with Rich Beem in the 8:35 am Thursday start. The golf course is across the highway from the Oak Ridge Conference Center where last year in April, 40 of the top health policy reformers in the country spent a weekend developing advice for the next president of the U.S. to use in approaching health reform. We called it System 2009. At the time, John McCain looked a sure GOP winner and the Clinton-Obama race was a toss-up. Tonight we reunite in Washington D.C. to see how well President Obama is doing.

by Weyant's World

NO TIME-OUT FOR HEALTH POLICY REFORM
When it became clear that congressional reform legislation was becoming a vote-buying contest among Democrats, I counseled the president in an op-ed to postpone his effort until after the 2010 election in order to get real Americans informed and involved. That's not going to happen. We're going to have to take what we can get. The Democratic leadership has the muscle to deliver a bill the president can sign. The Republicans did it in 2003 in the Medicare Modernization Act and the Democrats will by this year's end.

The question they ask in Washington D.C. is how the heck to get a bill that expands coverage and makes health care and health insurance affordable again? Not only did President Obama promise not to raise taxes on anyone earning under $250,000 a year in adjusted gross income, but he also promised to reduce the cost of health insurance premiums to the average American family by $2,500 by the end of his second term. Health industry pledges to take cuts in Medicare payment will not do it. Republican Senate leader Mitch McConnell already has that one pegged: "The Democrats want to cut a half a trillion dollars out of your Medicare benefits."

In order to get to a second term, President Obama will have to prove he's kept his promise on both counts. There are two ways he can get it done. One is to legislate it. That appears now to be highly unlikely. There are ways to get it done, but they divide some powerful Democratic members of Congress from some powerful Democratic members of Congress. The other is to have Congress give authority to get it done to an "independent commission" or to an agency of government. That's why the medical-industrial-Republican congressional complex is fearful of "government run health care." They can't get easily get around this to their congressional allies.

TAKING THE HARD WAY TO THE SUMMIT
Mountaineers who tackle K2 in the Himalayas take on one of the most difficult challenges in the world. The standard route of ascent is the Abruzzi Spur on the southeast ridge of the peak in Pakistan climbed first in 1909. Opposite the Abruzzi Spur is the North Ridge, which ascends the Chinese side and is rarely climbed. . . . I am thinking of this as I watch President Obama try to climb the K2 of health policy reform. I can imagine him, never having climbed it, forced by circumstance into taking the most hazardous route possible to the peak. His chosen guide, Tom Daschle, is forced to check out just as the expedition is being launched. He's never really replaced.

His sherpas' are all experts on the Abruzzi Ridge - liberal congressional veterans who know how to spend money expanding coverage (Abruzzi Ridge), but flummoxed on saving money by payment reform (North Ridge.) He has lots of Republican governors volunteering to replace him claiming they climbed Mt. Health Reform in Minnesota, Massachusetts and Louisiana (but couldn't find K2 if they tried), and Republican members of Congress who've already decided President Obama should have done Everest not K2.

Then there's the mountain itself - a Congress which also acts as the board of directors of the nearly $1 billion a year Medicare and Medicaid programs - who come from every side and every elevation on K2. What they know about reaching the peak depends on whether they've ever gone. And then you have the $2.5 trillion a year health care industry that wants to go to the top but not to have to carry any of the load.

HEALTH POLICY REFORM 2009
Without the American people on his side, no president can take on a $2.5 trillion industry, most of whom fear change more than the unhappy status quo. The only way this president could have been successful was to win over the public before going to the Congress, and he failed to equip himself for that task before launching his commitment to reform.

I must say it is very difficult to watch the president of the United States spending a couple hours on an AARP tele-conference answering older Americans questions like "Am I going to be able to get a wheel chair under your health plan?" He doesn't even have a health plan. If this goes on for another month I can begin to see the presidency as a force for good reform will start to slip. Not just in health policy. This is serious business.

by Jimmy Margulies

WHO WILL ACCEPT HALF A LOAF OF HEALTH REFORM?
Gerald Seib in the Wall Street Journal says that has become the question in Washington. And well said. Democrats want universal coverage and will settle for progress toward. Republicans want cost containment, but will have to settle for the half of universal coverage the Democrats can't finance. The insurance industry hates the idea of having to compete with something called "a public plan," so their half is to require the public plan to negotiate rates with doctors and hospitals just as private insurers do. Hospitals give up half a loaf by agreeing on reduced payments from Medicare and receive a half a loaf in expanded payment coverage for currently uninsured.

The public wants to pay less of their future paychecks for health insurance and will probably have to settle for more people eligible for Medicare and Medicaid, thus taking the burden off the private insurance industry and employers. Because nothing else in the half-loaves is designed to bring down the underlying costs of unnecessary and unnecessarily costly medical goods and services. Meaning the doctors, so far, have given up nothing, because they think they've been accepting under-payment for services right along.

Only the drug, device and diagnostics industry can convert half a loaf into a loaf and a half. Witness: Concessions to the liberals on Medicare prescription drug price negotiations resulted in agreeing to extend the existing patent life of new biologicals (a combo of biology and chemistry) for 12 more years. This is, by far, the most profitable of any part of the medical industry. Assuring 12 more years of protected profit-making for investors in a "health reform bill" is as incredible as having a conservative Republican like George Bush expand the prescription drug coverage at the expense of taxpayers without getting any control over prices in something called "Medicare Modernization." Only in Washington!!

LOW COST, HIGH QUALITY AMERICAN HEALTH CARE
Famous conservative economist Martin Feldstein writes in the Washington Post that President Obama does not have the right answer for health reform. Marty disparages the belief that patients in Minnesota receive better care for much lower costs than patients with like conditions in New York and California. He says, "When I hear that, I wonder whether we (in NY or CA) should cut back on care, as these experts advocate, move to Minnesota, or wish for the genetic stock of Minnesotans."

He ought to compare something simple like C-section rates in New York City (+50 percent) to Minneapolis (14 percent). Marty needs to take the time to find out whether the data showing vast disparity in practice is true, find out whether the care in MN or in NY is better, and then ask what it takes to get NY doctors to change.

On July 21 four eminent physicians and health policy experts brought professional leadership from ten American health care communities to Washington, D.C., to talk about the answer to Feldstein's questions. How do you get higher value for less money? The communities were Sacramento, CA; Cedar Rapids, IA; Portland, ME; Ashville, NC; Sayre, PA; Temple, TX; Richmond, VA; Everett, WA; LaCrosse, WI; and Tallahassee, FL. Not one MN in the ten, Marty.

The physician experts who tested their success on an array of value measures were Dr. Donald Berwick, CEO of the Institute for Healthcare Improvement; Dr. Elliott Fisher of the Center for Evaluative Sciences at Dartmouth College; Dr. Atul Gwande of Brigham and Women's Hospital in Boston; and Dr. Mark McClellan of Brookings Institute who was FDA and CMS administrator under the recent President Bush. You can find John Iglehart's summary of the event at Health Affairs.

WHO IS RUNNING THE MEDICARE PROGRAM?
As long as we've been engaged in reforming the health care system by reforming payment policy, Medicare is the way to get it done. After more than six months in office, President Obama has yet to appoint anyone to run the Centers for Medicare and Medicaid Services (CMS), which direct a trillion dollars a year into the Medicare and Medicaid programs. If you were serious about driving down the cost of health care, you'd give CMS the authority to do it and appoint an administrator who could get it done.

I am betting the White House and Democratic leaders of Congress are near agreement on the authority CMS needs to drive payment policy without having industry groups constantly running circle around it on their way to congressional power centers. This would be in lieu of the IPAC and the MedPAC authority to do the same. CMS could be authorized to make changes in payment policy subject to the so-called "base-closing veto" by Congress…so long as a MedPAC was employed to bring independent expert judgment to bear as it does today, and the chair and ranking of committees of jurisdiction are fully informed of the contemplated actions.

HEALTH REFORM LEGISLATION WILL NOT WIN OR LOSE THE 2010 ELECTION
Only a substantially weakened president will. In 2003 President Bush and Republicans rammed a Medicare Modernization bill through a GOP Congress which spent billions of tax dollars without raising taxes on "a public plan" to create a new prescription drug program and billions of dollars to "give people a choice of private insurance" and were rewarded with a 2004 election victory.

In Massachusetts, a universal coverage bill with individual and employer mandates and without delivery system reform passed the Democratic Legislature with help from Republican Governor Mitt Romney. While the Bush CMS supported the bill, today's Republicans do not. In MA voters did not take it out on the bill's supporters in either the 2006 or 2008 elections. Point is, voters can't follow health policy any better than their representatives, but they expect the latter to know what's best for them since they always claim to.

That's why the White House and Democratic leaders will pass this bill whether guys like me think they "got it right" or not. The problem is with the president. He has had to carry the burden of explaining health system failures and what "his" bill will do to solve them. It's an impossible task. President Obama's frustration with his ability to move the public opinion needle shows. That's not good.

It would be well for him to switch off health reform as cure for the recession and for the potential bankruptcy of entitlement programs, and focus on what most Americans are missing by not living in communities where health care systems help keep us healthy, out of hospitals and out of spending our paychecks on medical care we can't afford and don't need: Providers who play to America's strengths rather than its weaknesses. He can actually take us - rhetorically or in person - to places in America where you can see this strength at work.

PhaRMA: A STEP TOO FAR
Former Democratic and Republican Congressman and PhaRMA exec Billy Tauzin brazenly told the White House that they'd made a deal to contribute $80 billion over 10 years to reducing the cost of health care and it was the White House's job to make sure the Democratic Congress stuck to the deal. Said brazen Billy: "Who is ever going into a deal with the White House again if they don't keep their word? You are just going to duke it out instead."

Within a few short hours, the Democratic leadership in the House told Mr. Tauzin where he could shove his "deal" and they were more than prepared to duke it out with him. Cheers from everyone for the quick put-down - which should have come from the White House, but didn't. Breathes there a man (or woman) with soul so dead that never to him/herself has said, "the drug industry has had health care financing policy to itself forever?" If a Democratic majority in Congress and the White House can't break PhaRMA's lock on America's health and health care spending, then health policy reform is impossible.

OUR NEW SURGEON GENERAL
I've been through a lot of battles over the competency of presidential appointments of surgeons general. But President Obama has selected a primary care doctor from a little town in Alabama who is a giant in every field of her endeavor. Dr. Regina Benjamin has been a friend for eight years and I have grown to marvel at how a person, who knows herself so well, can change other people's lives so effectively simply by being true to herself.

"HARRY AND LOUISE" SWITCH FROM BIG HEALTH INSURANCE TO BIG PHARMA
The policy-making environment in Washington is getting really bad when the promoters of coverage expansion at the expense of the taxpayers rather than the medical industry trot out the infamous Hillary health opponents "Harry and Louise" to promote health care for all. Actually these two actors married each other shortly after helping Chip Kahn and the health insurance industry attract opposition to Hillary Care. They have appeared in four or five other appeals to the grass roots of health care. This time the drug industry will spend $4 million on actors Harry Johnson and Louis Caire Clark to help pass President Obama reform.

NO PATIENT LEFT BEHIND
The MN Dept. of Education this week informed us that 1,048 of 2,303 MN schools are not making adequate progress under the NO CHILD LEFT BEHIND (NCLB) educational achievement guidelines. All schools are listed by shortcomings. Some have suggested a NO PATIENT LEFT BEHIND (NPLB) test for hospitals to ensure that the number of patients who die or are injured because of hospitalization moves quickly to zero. Unlike public education, no one referred to a hospital by their doctor expects to be injured or killed by the hospital. So why not do it? Because patients might very quickly require their doctors to choose only the safest in America hospitals.

As you might expect, the hospital industry wants none of it. Even the "Safest in America" patient industry is reluctant, suggesting that you and I are supposed to ask questions of hospital staff to protect ourselves from error. Just as school administrators, teachers, and school boards who do not perform well attack NCLB, so the hospital industry and docs will attack any effort to make transparent the comparative performance of hospitals - attacking the measures, claiming "every patient is different." Performance measures become "government-controlled or managed-care insurance controlled health care."

98,000 AMERICANS DIE EVERY YEAR
The Institute of Medicine informed Americans that many of us died because of hospital mistakes or negligence during 1999. The number hasn't changed much since then despite efforts by the hospital and the patient safety industry to move the needle. Millions of other mistakes occur. Hospital re-admission rates for the same problem are staggering, and only now are payers like Medicare doing anything to stop paying for "repair jobs."

If you add to the billions of dollars this systemic approach to "market" failures costs all of us what experts agree is about $700 billion a year in unnecessary clinic visits, radiology and other diagnostics, surgery, hospitalization, and specialty care in the last 24 months of life, you've got a really big number!!

The point of the NPLB movement is not blaming the failures. It's rewarding the many successful hospitals and doctors across America. All the delay in dealing with the problem of injured patients and unnecessary care delays the day we have payment systems that reward the successes with new patients and better financing. It delays the day we create a sense of value rather than expectations in medicine. It delays the day we can finance better health and health care from "savings" on unneeded medicine. It's the way every other American industry (except education and health care) works!!

NPLB SHOULD LIST THE HIGH VALUE ACHIEVERS, NOT THE LOSERS
The way every other industry does. Thomson-Reuters rates American hospitals on a few levels of care quality now. HealthEast System in St. Paul was announced this week as one of the Top Ten in America. Allina, Fairview, Mayo and St. Mary's Duluth Clinic were other MN hospitals or systems in Top 100. But that raises another challenge: Do parents or kids have any choice of public schools? Not many. In health care, do patients have a choice of hospitals? Or do doctors make the choices for them? You know the answer is doctors, not patients, and often at the behest of the hospitals where they - not we - have been granted "privileges." Or where they have a financial interest and share in the profits.

THE MEDICAL TECHNOLOGY INDUSTRY ALSO OPPOSES TRANSPARENCY
By far the most profitable sector of the health care industry is drugs, devices and diagnostics - the "medical miracle industry" which also involves medical specialists, surgeons and radiologists with whom it shares the wealth of "innovation." Senator Chuck Grassley (R-IA) seems to be the only policy-maker who "gets" the connection between the industry and the medical decision-makers. He responds to every journalistic exposé of "conflict of interest" with (as in the case of Dr. David Polley and the University of MN) a 142-page questionnaire. Unfortunately, Chuck doesn't seem to be spending as much time working on performance transparency in the Medicare payment side of his job.

The industry has a sound-bite response to every effort to measure new product performance against old products. I think of this every time I see a study telling us how more effective aspirin is against lots of more recent, and more expensive, inventions. It goes "You don't want some government or insurance company bureaucrat determining whether you live or die."

Here's a good one: "Medical technology innovation thrives in a pluralistic, private market where patients can vote with their feet."...Steve Ubl, CEO of AdvaMED, the device industry lobbying association in an otherwise very nice Janet Moore (TRIB) piece on a 40-year old MN boy making good in D.C. How many patients demand Medtronic rather than St. Jude or Boston Scientific stents? The best we can do, as research studies on effectiveness come in long after the manufacturer has recouped investment and marketing costs, is ask our doctor to help us make a choice. We don't own the device in our bodies or the information it produces. Who does? Nobody really knows.

If medical professionals tell us their work cannot or should not be researched, measured and publicly compared, then every time they accuse policy reformers of interfering with "medical markets," ask them "What markets?" Markets do not exist without access to comparative performance information and an informed consumer with a financial and health interest in making informed choices.

FOR ANOTHER TIME
But where is the value on transparency in the health professions education industry? Can anyone tell me the relationship between what it costs a medical student to get an M.D. or specialty training and the quality of the graduate's performance as a result? I suspect the students could, if it was always their money and they had access to No Student Left Behind information on America's medical schools. Compared, say, with European or Asian? More on the fallacy of "medical markets" later.

CHOOSING BETWEEN HEALTH CARE FINANCING REFORM AND DELIVERY REFORM
Uwe Reinhardt argues this week that President Obama needs to make clear his goals for a reformed health system. No one in America should be deprived of necessary medical services because the cost to them makes other necessary living expenses impossible. Everyone in the U.S. health system must do their part to reduce the growth in health care costs.

The first goal can be achieved with health insurance reform and most of the parts to the policy change are on the table - some having been put there by the health insurance industry, so get off their backs. Republicans like me have long resisted the move to mandated insurance coverage unless, as a nation, we can count on everyone's commitment to cost reduction. Uwe argues that it is much too difficult to derive congressional or provider consensus on delivery system reform now, so we must take what we can get, including the president's promise to finish the job in his term.

DOCTOR/GOVERNOR/PRESIDENTIAL CANDIDATE/DNC CHAIR/CITIZEN HOWARD DEAN
…spoke to a crowd of some 200 at Book Passages in San Francisco's Ferry Building recently. He spent an hour signing copies of his book, Howard Dean's Prescription for Real Health Care Reform, and an hour answering questions in the informative and entertaining way that only Howard Dean can pull off. Acknowledging the political make-up of much of his audience, he said, "I know you think Nancy Pelosi's not liberal enough, but..." Actually I found myself wishing President Obama could handle the subject as well as Dean; or that President Obama would ask Dean to become administrator of CMS. If Dean hadn't burned a few Democratic bridges along his political path, he would make an even better Tom Scully than Tom was to Bush II - and that was darned good.

HEALTH FITNESS
One of the most popular ways to reduce health care costs is staying well. CBO finds this one difficult to score as budget savings, but Americans know it works. For example, this from the San Francisco Chronicle:, "Nintendo's Wii Fit became the best selling game over the last 12 months and the most successful console ever introduced designed for women. Nintendo sold more than 7 million copies at $99 each and the game ranks among the top five in the U.S. More importantly, says Billy Pidgeon at Game Changer Research, this is bigger than brain games and could rival and potentially eclipse the music category. Others are quick to enter the field and Nintendo has Wii Fit Plus ready to market this fall."

St. Catherine University
Twin Cities of St. Paul and Minneapolis, MN
Searching for a new leader for Dean of the Henrietta Schmoll School of Health
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