Last week’s U.S. Supreme Court arguments about the Affordable Care Act created uncertainty over health reform’s immediate future. But the debate about the “individual mandate”—the law’s requirement that everyone get health coverage—strengthened my conviction: To solve our health care system’s cost, quality, and access problems, we must ultimately bring all Americans into that system.

Group Health has embraced the idea that “we’re all in this together” since the Cooperative was established in 1947. Our founders understood the basic principle of insurance: No one can predict when illness or injury may strike, so everyone (young, old, sick, or well) needs to participate to ensure that coverage and care are available and affordable for anyone who needs it. They knew that some would need more care than others. But over time, the population would spread the risk, and everyone would get their fair share from the system.

Group Health didn’t even raise rates with age until the 1980s, when the market forced the issue. Without this change, Group Health would have attracted so many old and sick people that everyone’s rates would have become unaffordable.

The sick may include those few unlucky, uninsured youths who suddenly need treatment for a broken arm, appendicitis, or that rare, unfathomable case of cancer. Or it may be people with existing illnesses who have been denied coverage. The uninsured often get care through emergency rooms, which are required by law to take all comers.

And ultimately, we all pay for their care through higher taxes and increasing insurance premiums. The new law attempts to deal with this problem by expanding coverage through Medicaid and state health-benefit exchanges for individuals and small businesses.

Group Health has always stood for universal health coverage—not only because it’s the “right thing”, but also because it’s the most cost-efficient way to provide quality care. That’s the challenge our country faces today. Ensuring coverage only for subgroups—say, folks over 65, or the employed—just doesn’t work.

As journalist John Cassidy wrote in The New Yorker last week, “Opting out of the health care market is about as realistic as opting out of dying.”

Weeks may pass before the Supreme Court rules. Meanwhile, leading experts continue to call for reforms to the current fee-for-service payment system—a key driver of rising costs.

One is Stanford’s Victor Fuchs, PhD—our country’s most prominent health economist and author of Who Shall Live, a book that has long defined how economics and social choice effect health.

Last week he told the New York Times: “If we solve our health care spending, practically all of our fiscal problems will go away.” And if we don’t, “almost anything else we do will not solve our fiscal problems.”

Dr. Fuchs is not optimistic that health care can change itself. Rather, it will require “revolutionary” changes that unsettle established interest groups, he believes. But “American history is studded with examples of things that were not politically feasible until they were,” like the emancipation of slaves and a trillion-dollar bailout of the financial industry, he said.

“Major changes in health care policy usually occur because of something outside of health policy—large scale civil unrest, a depression,” he added. One catalyst could be a decision by China to stop buying the American bonds that finance Medicare and Medicaid debt, he explained.

But whether change is triggered by forces inside or outside the broken fee-for-service system that dominates our nation’s health care system, we at Group Health must aspire to demonstrate a successful alternative. Ours is a model born 65 years ago from our founders’ desire “to serve the greatest number”—a mantra that fits health reform today.

As citizens and patients, as health care professionals and researchers, we each have a stake in health care’s future; our place at Group Health gives us a front-row seat to history in the making. More importantly, we have an opportunity to work for positive transformation. Let’s not be spectators, but doers.

Attend 2012 Birnbaum Endowed Lecture on April 30. Dr. Don Berwick, senior fellow at Center for American Progress, and former administrator of Centers for Medicare & Medicaid Services, will describe the important role health professionals play in health care reform. Then Group Health, Geisinger Health System, and HealthPartners leaders will discuss the development of integrated health organizations as learning health care systems.

To learn more:

• Read March 6 New York Times interview with Stanford health economist Victor Fuchs.

• Read March 30 Rolling Stone interview with Dr. Don Berwick on “The Fate of Obamacare.”

• Hear key moments of and commentary on Supreme Court debate over Affordable Care Act on Kaiser Health News.

• Follow ongoing coverage of important health reform developments on Kaiser Family Foundation’s health reform blog.

• Read Group Health’s statement of principles for health care reform.

• Read Center for American Progress on why establishing insurance coverage for people with pre-existing conditions requires enacting an individual mandate.

This article first appeared in the Group Health Research Insitute’s online Research News webpage.

The index measures how equitably large, private-sector businesses in the United States treat their lesbian, gay, bisexual, and transgender (LGBT) employees, consumers, and investors.

The perfect score in 2012 is attributed to the addition of Group Health’s LGBT & Allies Staff Resource Group, along with the improved transgender benefits that went into effect in 2011.

The organization was able to achieve a perfect score despite the fact that the HRC has implemented more stringent criteria standards for the designation, Group Health said.

A total of 636 participating employers were rated this year, and only 190 of them received the top rating of 100 percent.

Group Health’s Score:

POLICIES AND BENEFITS

		Policy Description		Rating
		Non-discrimination policy includes sexual orientation		+ 15
		Non-discrimination policy includes gender identity and/or expression		+ 15
		Company-provided domestic partner health insurance (including parity in spousal and partner COBRA, dental, vision and domestic partners legal dependent coverage)		+ 15
		Parity in spousal/partner soft benefits (bereavement leave; supplemental life insurance; relocation assistance; adoption assistance; joint/survivor annuity; pre-retirement survivor annuity; retiree healthcare benefits; employee discounts)		+ 10
		Offers equal health coverage for transgender individuals without exclusion for medically necessary care		+ 10
		Organizational LGBT cultural competency (diversity trainings, resources or accountability measures)		+ 10
		Company-supported LGBT employee resource group or firm-wide diversity council that includes LGBT issues, OR would support a LGBT employee resource group with company resources if employees expressed an interest		+ 10
		Engages in appropriate and respectful advertising and marketing or sponsors LGBT community events, organizations, or legislative efforts		+ 15
		Engages in action that would undermine the goal of LGBT equality		0
		Final Rating		100

Candidates must receive their medical coverage through Group Health in order to be eligible.

The Board of Trustees is an 11-member consumer governing body that sets the strategy, direction, and policy for GHC, a nonprofit enterprise with $3.3 billion in annual revenues.

Individuals with the experience and range of skills necessary to help lead GHC’s consumer-governed health care system are encouraged to apply.

Trustees serve a three-year term.

Applications deadline is Monday, April 9th, 2012, and the election will be held in October.

To apply:

• Go to member ghc.org (www.member.ghc.org) and search for “Board application.”

• For additional information call 206-448-2073 in Seattle, or toll-free 1-800-252-3305, extension 21.

By Mary Agnes Carey

Care management programs, which combine information technology, patient-centered nursing and care coordination, have helped Alliance of Community Health Plan (AHCP) members cut costs and improve patient care, the group said in a report released Wednesday.

For example, the Group Health Cooperative in Seattle has reported more than $2.5 million in cost savings during the first seven months of this year for its 8,224 patients in complex case management and 1,831 patients in regular case management.

Tufts Health Plan in Massachusetts and Rhode Island found that every $1 spent on obstetrical case management for women at high risk for preterm delivery saved $4.50, and on-site and telephone review of hospital utilization saved $4.80 per dollar spent.

The group represents 22 not-for-profit, community-based and regional health plans and provider organizations. The ACHP report says the case management techniques the plans have used included helping patients and caregivers manage medical conditions and psychosocial problems more effectively, coordinating care, reducing duplication of services and reducing the need for expensive medical services.

“Complex, chronically ill patients have traditionally been the most expensive and difficult to treat; almost half of all health care spending in the United States goes to only five percent of patients, many of whom have multiple health conditions as well as social, environmental or financial barriers to good health,” AHCP President and CEO Patricia P. Smith notes in the report. ‘

“Such patients often need and benefit from personalized care, tailored to their individual needs; care management nurses, many of whom work in partnership with social workers, nutritionists, pharmacists and other staff, can step in to supplement the care patients are receiving at their physicians’ offices.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Photo: Steve Woods

By Jordan Rau
This story was produced in collaboration with 

Medicare has begun publishing patient safety ratings for thousands of hospitals as the first step toward paying less to institutions with high rates of surgical complications, infections, mishaps and potentially avoidable deaths.

The new data, available starting last week on Medicare’s Hospital Compare website, evaluate hospitals on how often their patients suffer complications such as a collapsed lung, a blood clot after surgery or an accidental cut or tear during treatment.

The measures also include specific death rates for patients who had breathing problems after surgery, had an operation to repair a weakness in the abdominal aorta or had a treatable complication after an operation.

In addition, Hospital Compare is evaluating rates of some specific medical errors, such as giving patients the wrong type of blood, leaving surgical implements in patients’ bodies during surgery and falls that occur during their stay.

Survey of Patients’ Hospital Experiences

About the survey: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national survey that asks patients about their experiences during a recent hospital stay. Use the results shown here to compare hospitals based on ten important hospital quality topics. Read more information about the survey of patients’ hospital experiences.

The evaluations are part of Medicare’s broad move from paying hospitals a set amount for each procedure. That change was directed by last year’s health care law, which set up new “value-based purchasing program” that will begin in October 2012.

Over time, hospitals with the lowest quality—as judged by a variety of metrics, not just the new patient safety measures—will be at risk to lose up to 2 percent of their regular Medicare reimbursements under the health law.

The new data on patient safety moves Medicare further along toward its ultimate goal, which is to base payments on the actual medical outcomes for patients. To rate hospitals, Medicare is comparing them to the national rates for medical complications and hospital acquired conditions.

For instance, on average, 2.1 out of every 1,000 patients discharged suffered an accidental cut and tear from medical treatment. Out of 100 patients, 4.4 on average died after surgery to repair a weakness in their abdominal aorta.

By looking at how a hospital compares to the national average on this and other complication statistics, Medicare has come up with overall evaluations of how good hospitals are at avoiding complications and hospital-acquired conditions. Medicare is aiming to incorporate the new patient safety data into payments in the second year of the program.

Making this information public has been long favored by patient safety advocates. “This is pulling the curtain back on preventable health care harm to older Americans,” said Rosemary Gibson, co-author of “The Treatment Trap” and editor of a series of articles on overtreatment in the Archives of Internal Medicine. “These are really good things to know. We are really getting into the meat of what can happen to patients in hospitals.”

But the latest data is intensifying objections from the hospital industry and some academic researchers that Medicare is using dubious and unfair measurements in ways that will hurt some hospitals, particularly those with sicker patients. The data is based on billing claims that hospitals submit to the government, not clinical medical records.

One concern held by hospitals and researchers is that hospitals categorize the same things differently when billing Medicare, skewing comparisons.

“Medicare claims data is the thing a lot of people judge from, but it’s a large database and frankly I’ve always wondered if apples and oranges are being mixed,” said Dr. Gerald Healy, a senior fellow at the Institute for Healthcare Improvement, a Massachusetts nonprofit, and past president of the American College of Surgeons.

Hospital officials said their initial review of the new data has exacerbated their concerns that Medicare’s calculations do not fully take into account the fact that some hospitals do more surgeries or treat sicker patients.

“We believe the data is fairly seriously flawed in the way it’s calculated,” said Nancy Foster, a vice president at the American Hospital Association. “When inaccurate data is out there, it both misleads the public and generates a lot of activity that is unproductive in the hospital.”

Atul Grover, head of advocacy for the Association of American Medical Colleges that represents teaching hospitals, said some of Medicare’s measures also make teaching hospitals look worse.

“If you’re not appropriately risk-adjusting on this, you’re already selecting a patient population that’s more likely to die,” he said. “That’s why they come to us, because other people are reluctant to operate on those complex cases.”

Officials at the Agency for Healthcare Research and Quality, which designed many of the measures, referred questions to Medicare. Officials there were not immediately available to discuss the new measures. Dr. Patrick Romano, a professor at the University of California, Davis School of Medicine who helped the government design the measures, said the measures do take the sickness levels of patients into account, although not as thoroughly as Hospital Compare’s existing evaluations of readmissions and hospital-wide mortality rates.

Still, he said the measures were a good addition to the overall view of how well hospitals are doing. “We’re trying to understand a large animal like an elephant or a whale,” he said. “To do that, we take pictures from a variety of perspectives, with different cameras and different techniques.”

Hospital Compare was originally designed to be a helpful consumer tool, but to date it has not been widely used by patients choosing hospitals. Experts caution about drawing dire conclusions from the raw rates of hospitals, as some of the measures are complex and differences not statistically significant.

For some of the measures, Hospital Compare categorizes most hospitals simply as “average,” “above” or “below” the national norm, which experts say is a better way for consumers to know whether a hospital is an outlier.

To find a hospital on the site, type in the city and state, click on the hospital name and then select the “Patient Safety Measures” tab at the left. Hospital Compare also gives patients the option of choosing several hospitals at once. The new data covers the period between October 2008 and June 2010.

Medicare last week also announced 18 more measures it is considering for inclusion in the value-based purchasing program.  Many of these measures look at how hospitals handle stroke patients and what steps they take to protect patients from blood clots. Others are intended to address two bacterial infections that can spread through hospitals: Clostridium difficile and Methicillin-resistant Staphylococcus aureus.

Illustration: Steve Woods Photography

Contact Jordan Rau: jrau@kff.org

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.