AMA Pulls Back on Meaningful Use

Meaningful Use Stage 2 is coming to a theater near you.

A brief history: in 2008-2009 two acts created the incentive program for implementation of EHR that resulted in the Meaningful Use requirements:  HITECH (Health Information Technology for Economic and Clinical Health), and ARRA (American Recovery and Reinvestment Act).  The idea was that doctors who billed Medicare and Medicaid could get financial incentives to help them install EHRs in their practices, but only if the EHR and the doctor both ensured CMS that the EHR had “meaningful use”, i.e, that it did what CMS wanted it to do. It was supposed to be a phased-in process, and stage 2 requirements are more stringent than stage 1.

AMA board chair Steven Stack says that the AMA “has provided ongoing input since the inception of the EHR incentive program and has urged greater flexibility to make the program more reasonable and achievable for physicians.” This is sort of true.  On March 15, 2010 AMA executive vice president and CEO Michael Maves wrote a letter to then-head of Health and Human Services Kathleen Sibelius.  In it he said the following:

“On behalf of the physician and medical student members of the American Medical Association (AMA), I appreciate the opportunity to provide comments on the Department ofHealth and Human Services’ (HHS) interim final rule (IFR) on an initial set of standards, implementation specifications, and certification criteria for electronic health records (EHRs).  The AMA recognizes that an initial set of EHR standards, implementation specifications, and certification criteria are required to ensure that certified EHR technology is capable of supporting the achievement of meaningful use by physicians and other eligible professionals(EPs), as specified under the Medicare and Medicaid EHR incentive programs, beginning in 2011.”

Translation: Yeah, yeah, yeah, we understand you need to make sure you’re getting what you’re paying for.  We don’t like it, but we get it.

Then Maves goes on to the next sentence:

“Not only must EHR technology be “certified” to meet the meaningful use incentive requirements, but EHRs must also adequately meet a practice’s specific workflow and clinical needs.”

A still, small voice, as the Bible says.  Translation: “But…what about us?”  This particular sentence seems to have gotten lost in the political soup.

Last week, the American Hospital Association and the American Medical Association sent a joint letter to HHS Secretary Kathleen Sebelius asking for greater flexibility in the requirements of the meaningful use program:

“We appreciate the Department of Health and Human Services’ (HHS) decision to extend Meaningful Use Stage 1 through 2014.  Physicans and hospitals have made significant investments in health information technology (IT), which is evidenced by the increasing numbers of providers who are using EHRs and attesting to Meaningful Use.  We also share the administration’s commitment that no providers – or the patients they serve – are left behind as we proceed to Stage 2.  However, our members, and the vendors they work with, report growing concerns that the rapidly approaching start date for Stage 2 is on a trajectory that will not provide enough time or adequate flexibility for a safe and orderly transition unless certain changes are made.”

Translation: The beatings will continue until morale improves.

The AMA has created a new framework for usability.  At least, they’re calling it new.  The rest of us have known this stuff for years.  Things like this:

1. Poor EHR design gets in the way of face-to-face interaction with patients because physicians are forced to spend more time documenting required information of questionable value. Features such as pop-up reminders, cumbersome menus and poor user interfaces can make EHRs far more time consuming than paper charts.  Amen.

2. Current technology often requires physicians to enter data or perform tasks that other team members should be empowered to complete.  No kidding.

3. Transitioning patient care can be a challenge without full EHR interoperability and robust tracking. Yup.

4. Few EHR systems are built to accommodate physicians’ practice patterns and work flows, which vary depending on size, specialty and setting.  Preach it!

5. Although physicians spend significant time navigating their EHR systems, many physicians say that the quality of the clinical narrative in paper charts is more succinct and reflective of the pertinent clinical information. A lack of context and overly structured data capture requirements, meanwhile, can make interpretation difficult.  Yes.

6. Data “lock in” is a common problem. EHR systems should facilitate connected health care across care settings and enable both exporting data and properly incorporating data from other systems. The end result should be a coherent longitudinal patient record that is built from various sources and can be accessed in real time.  Bring it to me Lord!

7. The meaningful use program requires physicians to use certified EHR technology, but many of these products have performed poorly in real-world practice settings.  Ya think?

“Physicians believe it is a national imperative to reframe policy around the desired future capabilities of this technology and emphasize clinical care improvements as the primary focus,” says Dr. Stack.  What would have been nice is if the AMA had pushed harder back in 2008 for regulations regarding usability and opposed regulation regarding meaningful use a little more.

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UnitedHealthCare in Massachusetts

We all want the advantage.  We put our kids in special pre-schools so they have the advantage.  We work 100 hours a week so our kids can do 8 activities and get the advantage. Tall people have an advantage, we’re told.  Poor people are “dis-advantaged”.  Well folks, there are a whole bunch of senior citizens in Massachusetts who are about to get dis-advantaged starting September 1.

Yesterday the Boston Globe told me that UnitedHealthcare will be cutting 700 doctors, or 2-4% of it’s providers (it has 18,600in MA), from it’s Medicare Advantage plans. UnitedHealthCare is a mammoth national insurance company, and one of the main things it does is provide Medicare Advantage programs.  In fact, it’s the largest provider of such private Medicare plans in the country.  UHC has done this in 11 other states as well, and in some cases has dropped whole hospitals from it’s roster.  Why?  Company spokespeople say “they hope that streamlining the pool of doctors will not just save money but ultimately improve the quality of patient care…”.  They do not specify how quality of patient care will be improved by abruptly removing peoples’ doctors from their insurance plans.  But it will definitely save money.  And why does UHC feel it has to save money?  Because there has been a gradual reduction in the federal reimbursements to private Medicare contractors.

Why, you may ask, is the government using private, for-profit companies to provide Medicare services, and paying up to 14% more for the identical services provided by government-administered Medicare?  Excellent question.  Medicare Advantage, so called because these plans generally cover more services, like eyeglasses and prescriptions, was created after private insurers insisted that not only could they meet the medical needs of senior citizens and the disabled more cost effectively than the government, they could do so and still make a profit. (Thank you to Wendell Potter for that explanation.)  It became part of the Balanced Budget Act of 1997, but such plans have been available since the 1970s.  Well, it turned out that the claims were not true, and many of the private companies that participated dropped out when they lost money.  So the government essentially paid the companies to stay. Hence the 14% overpayment.

So.  Lot’s of money to be made.  15 million people are in Medicare Advantage plans, with payments from the government of $156 billion dollars, or 30% of all Medicare spending.  But you make more money for your shareholders if your patients don’t go to the doctor.  UHC cleared $1.1 billion dollars last year and increased it’s shareholder dividends by 30%.  So last week UHC informed a bunch of doctors in Massachusetts that they’ve been booted from the plan.  They’ll tell the patients this week. Oh, and the changes go into effect Sept 1 but you can’t change your plan until the next open enrollment period, which isn’t until October.

When UHC tried this in Connecticut, county Medical Associations filed a lawsuit and got a temporary injunction from a judge to stop UHC from dropping 2,200 doctors.  Here’s what UHC had to say about this ruling, according to Arielle Becker in the CT Mirror:

“In its statement, UnitedHealthcare said the ruling would ‘create unnecessary and harmful confusion and disruption to Medicare beneficiaries in Connecticut.  We continue to have a broad network of doctors that is designed to encourage higher quality, affordable health care coverage,’ the statement said. ‘We know that these changes can be concerning for some doctors and customers, and supporting our customers is our highest priority.'”

Right.  Because there’s no unnecessary and harmful confusion or disruption when you eliminate peoples’ doctors.

 

 

Mental Health Loses Funding As Government Continues Shutdown

In the months leading up to World Mental Health Day, DC has been shaken by a series of violent events that ended with innocent lives lost and our country’s mental health services called into question. During this same time period, Washington, DC has been consumed by a government shutdown, with lawmakers and policymakers trying to determine how to rein in our country’s financial burdens and overspending. Unfortunately, as federal and state governments look to cut budgets at every turn, mental and behavioral health services are often on the chopping block first. Financial cuts, compounded with US stigma often applied to mental health troubles and disparate access to services across the county, mean that those who need services most are often those left without proper care.

August though October brought DC into the spotlight for many reasons, the saddest of which is the violence that was covered by mass media as two shootings occurred. In one case, Aaron Alexis, a 34-year-old, perpetrated a mass shooting that left 12 people dead, in Washington’s Navy Yard. Previous to the shooting, it was reported that Mr. Alexis was treated at the VA for mental health issues including sleep disorders and paranoia, but had not lost clearance.

Miriam Carey, also 34, reportedly had an unhealthy obsession with the White House when she drove her car into the White House gates and led police on a chase around DC before being killed. Although she had no reported psychosis or supposed violent intent, it was noted in the months leading up to the incident she believed that the President had beenstalking her and might have suffered from postpartum depression. When killed by authorities on Pennsylvania Avenue, she had her 18-month-old child in the car.

Budget Cuts

Although societal stigma and knowledge of where to access behavioral and mental services are often barriers to care, budget cuts continue to make seeking care more difficult. Whether this be through decreases in available services, lack of providers due to poor reimbursements or less preventative actions in communities, the impact of mental health funding shortages is great. According to the National Alliance on Mental Illness, “increasingly, emergency rooms, homeless shelters and jails are struggling with the effects of people falling through the cracks due to lack of needed mental health services and supports.”

In the last five years, significant budget cuts have befallen mental health programs and services. From 2009 to 2011, states cut mental health budgets by a combined $4 billion- the largest single combined reduction to mental health spending since de-institutionalization in the 1970s. In Chicago alone, state budget cuts combined with reductions in county and city mental health services led to shutting six of the city’s 12 mental health clinics. These closures, along with other public and private center closures in Chicago, have eliminated vitally needed services, especially on the south and west sides where they are indispensable.

Threats of sequestration in 2013 had a significant impact on people’s ability to access mental health services and programs, including children’s mental health services, suicide prevention programs, homeless outreach programs, substance abuse treatment programs, housing and employment assistance, health research, and virtually every type of public mental health support. The Substance Abuse and Mental Health Services Administration(SAMHSA) claimed it alone would be cutting $168 million from its 2013 spending, including areduction of $83.1 million in grants for substance abuse treatment programs.

Consequences

Despite the need to balance budget and make all health care services more efficient, many argue that society has better long-term outcomes if more federal and state dollars are allocated to mental and behavioral health care. This includes preventative services as well as mental health testing and treatment.

Because individuals with untreated mental illness often find themselves in emergency rooms, homeless shelters and prisons, the societal cost of prevention and treatment may be exponentially less than funding those other outlets and catchment areas. This is especially true in the case of children, who face cycling in and out of the system throughout their lives if left untreated.

These costs can be exceptionally large over the lifetime given that the National Institute of Mental Health (NIMH) estimates that two-thirds of children with lifetime mental health problems never receive treatment. This takes substantial emotional and financial tolls on individuals and families, as well as the broader society. However, programs that address the mental health needs and provide services for youth show better outcomes in health and education that carry over the lifetime. For example, in the University of Chicago’s Crime Lab, therapy is being used to curb youth violence, especially amongst those with behavioral and mental health care needs.

Additionally staining on the mental health care system is that during times of recession and budget cuts the caseload for mental health actually increases. It has been estimated that during this most recent recession, the caseload of community mental health services alone has increased almost 50 percent. This increase has most notably been seen in the Native American community, where suicide prevention is an essential part of the cultural health care demands.

Everyone Benefits

The NIMH contends that one in 17 people suffer from a “seriously debilitating mental illness,” we as a society are accountable for ensuring that those in need have resources for care. Not only does access to quality mental and behavioral health care ensure that individuals are being properly treated, but that America as a whole saves money and resources caring for those in need in other, more expensive settings. It may further prevent violent acts like those in DC from happing.

On this World Mental Health day think about the ways in which access to and support of mental and behavioral health care can be improved in your community.

 

President Obama Fails To Explain Tech Glitches And Solutions In ACA Speech

Monday at 11:30am EST, President Obama spoke in the Rose Garden about the recent troubles with health insurance exchange enrollment and websites. With a team of young people standing behind him and Janice Baker at his side, the first person in the state of Delaware to successfully enroll in the exchange, President Obama said he was speaking to every American wanting to get affordable health insurance. He claimed that in the last three weeks, despite the horrific technological problems with the websites, that “half a million consumers across the country have submitted application through federal and state marketplaces.” He further touted that the “federal site alone has been visited 20,000,000 times” in the last three weeks. Unfortunately for those American’s who are really interested in signing up on the exchange sites, he glossed over the depth and breadth of the current troubles, giving a speech that sounded more like a State of the Union address with small-business examples and reading letters written to the White House.

President Obama also alleged that no one wants to see the exchange sites improve more than the federal government, noting that, “the website has been to slow, and people have been getting stuck during the process.” He also said that it is the mission of the administration to make them “more better,” with visible cringing from the audience, but claimed failures were due to response rates. He said the public response was “overwhelming, which has aggravated the underlying problems.”

However, he failed to go any further to explain what those other underlying problems were or when specifically they will be fixed. He did say that while HHS and contractors such as CGI Federal are working out the “kinks,” American’s should be patient. He claimed that “if the product is good, [American people] are willing to be patient,” suggesting that there will not be a delay for the individual mandate.

Nevertheless, he followed this by assuring the public that unlike Black Friday sales, the insurance plans will not run out like purchasing a new PlayStation – adding to the list of items the administration has compared exchange sites to, including iPhones and travel websites.

Despite his promises of improvements and putting the “best and brightest” on the job, CNN and other sites have insisted that the inherent technological and platform problems with Healthcare.gov will not be resolved anytime soon. This begs the question, that if the federal government is now searching for the best and brightest to correct the estimated 5,000-5,000,000+ lines of coding that need to be fixed on the federal site alone, who was working on the original platforms?

As he continued his speech, the President reminded the American public that although the websites for enrollment are not as, “quick, consistent or efficient as we want,” that the exchange sites are far more than “just a website.” He noted that many pieces of the Affordable Care Act (ACA) are already in place and being utilized by millions of Americans. He addressed pre-existing conditions, youth under the age of 26 and several other provisions that are already being rolled out by federal law, and the successes they have seen there.

He noted more examples of ACA triumph in Oregon, where he maintained that the exchange, “has cut the number of uninsured people by 10% in three week,” which is about “56,000 more Americans” with health insurance coverage.

During the speech, President Obama also tried to clarify the exchanges or marketplaces by describing them to the public as becoming part of a “big group plan… that bargains on your behalf for the best deal in health care.” He said that by doing so, insurance companies have created new products and options that strengthen market forces, leading to better deals.

He went on to say that without a doubt, “prices have come down,” further claiming that “when you add the next tax credits (those not yet implemented)… then the prices come down even further.”

The President rounded out his talk by noting the Republican party’s opposition to the ACA and how willing they were to “shut down the global economy” to fight against the ACA. A move, he claimed, that shows just how unwilling Republicans are to negotiate on legislation intended to, “free families from the pervasive fear that one illness one injury will cost you everything.”

While that may be the goal of the Affordable Care Act, the underlying technological and coding problems may prove to make that impossible.

 

As They Age: Women Know What They Do Not Know

The need for health care varies greatly over a lifespan, with older adults having significantly more health-related needs and costs than younger individuals. Women, in particular, often face a myriad of health problems as they transition through menopause. Sadly, despite the fact that every woman will go through menopause, very little is understood about the physical and mental changes that occur during this period of life. In addition, women may struggle to find pharmaceutical solutions, which can safely provide proven relief without the worry that those available will increase their likelihood of other health and mental complications.

Much is misunderstood about menopause and the changes that are associated with the hormonal fluctuations. This is largely due to the fact this inevitable transition is rarely apart of the conversation, particularly in the context of health care. Further, menopause is expected to be merely “bothersome”; not something one could attribute real health problems to. Although maternity care and issues related to younger women are required in the Affordable Care Act as essential health benefits, nothing of legislative note will improve the knowledge and acceptance of this natural life progression.

Most insurance companies do not even cover basic mediations associated with menopausal symptoms, and conflicting research has women scared about the potential long-term effects associated with hormone replacement therapy. Negative press, little medical literature and low financial assistance often leaves women to suffer through menopause silently, many of whom worry constantly about memory deficits they experience and potential long term changes.

A recent study focused on the memory complaints of midlife women has been receiving a lot of attention. The study, conducted at the University of Illinois- at Chicago (UIC), attempted to determine if women who are experiencing hot flushes during menopause were able to accurately predict their own memory performance.

According to the principal author, Lauren Drogos, “We found that a one-item question: ‘How would you rate your memory in terms of the kinds of problems that you have?’ was the best predictor of verbal memory performance on a list-learning task. We also found that many complaints were related to mood symptoms.”

In the US, the average woman becomes postmenopausal around the age of 51. Common symptoms that occur include hot flushes, sleep disturbances, mood changes and memory problems. However, until recently it was believed that women were unable to accurately describe the current state of their memory and the changes they experience as they progress through menopause.

Despite the difficulty in being taken seriously about the physical and mental challenges that menopause presents, this recent study from Drogos, along with other research, shows that woman are able to accurately describe their current memory abilities. Specifically, a group of sixty-eight women performed a series of memory tests and were then asked, to detail the types of memory problems they were experiencing. The study concluded that women were able to accurately rank themselves on a scale from no memory problems to severe problems.

Using recall of a short story, the deficits seen in memory did not indicate that women were suffering from dementia, nor were they experiencing shortfalls in memory that were impacting daily life. Instead, it was simply indicative that women who experienced memory deficits often recognized the changes occurring.

Previous research focusing on women’s transitions through menopause also found that hot flushes during the nighttime were the best predictors of memory performance in women. This leads researchers within the Women’s Mental Health Research Program at UIC, to believe that sleep disturbances and stress hormones may play integral roles in memory and hot flushes.

The good news for women concerned about the transition through menopause is that the cognitive decline that occurs appears to only be temporary, with performance rebounding early into post-menopause. Further, for those who want to keep both their minds and bodies at peak performance, research indicates that leading a non-sedentary lifestyle, keeping mentally active, and having a healthy diet can be the best preventers of cognitive decline.

 

Medicare’s Sustainability and Disproportionate Impact on Women

In light of the recent election and the number of monumental decisions elected officials, government agencies, policymakers and health care providers have to make around health care reform, the Medicare program hasn’t been receiving much attention. However, given the sheer number of Americans covered by the program and the fiscal disaster looming for aging citizens, it is important to examine the state of the country’s care for the elderly and disabled.

In the United States, older women rely on the Medicare program disproportionality and significantly more than men. Not only do women make up more than half of the Medicare beneficiaries, they comprise about 70 percent of the oldest (over 85 years old) beneficiaries and are more likely to have multiple chronic conditions as they age. In 2010, the program, which is administered by the Centers for Medicare & Medicaid Services (CMS), covered 47 million elderly (age 65 and over) and disabled beneficiaries. Unfortunately for beneficiaries, the US Government Accountability Office (GAO) has designated Medicare a high-risk program due to its fiscally unsustainable path.

Because women have a greater likelihood of living longer than men, more health care conditions will accumulate and more health care costs accrue. This means that as women age increased cost sharing and out-of-pocket expenses directly impact them more. Therefore, given the importance of Medicare’s cost sharing with seniors, and its quickly dwindling resources, it is important to revisit how vital the program is to the elderly, especially older women.

Facts about older women on Medicare:

• In 2010, the average American woman over the age of 65 had an annual income of less than $15,072 (compared to male counterparts at $25,704)
• Women over the age of 80 made up 62% of all individuals with Medicare in 2010
• In 2011, older women paid an average of $115 for the Medicare Part B premium, plus deductibles that range from $162 to $1132 before their benefits kicked in
• In 2007, the average American women spent an estimated 18.7 percent of her income on out-of-pocket health care costs, with percentages increasing throughout the recession
• Nationally, 49% of women with Medicare report having three or more chronic conditions (compared to just 38% of men)
• Despite cost sharing measures, Medicare does not cover many common and costly health care needs such as eyeglasses, hearing aids and long-term care

Current approaches to prolonging the Medicare program include:

• Capping provider, hospital, devise and pharmaceutical reimbursement payments at 2012 levels
• Reducing Medicare reimbursement rates for health care providers to previous levels
• Raising the age of Medicare eligibility progressively from 65 to 67, or even higher, as people are living and working longer
• Replace Medicare as it currently functions with a Voucher system (also known as a Premium Support Model)
• Restructuring beneficiaries cost-sharing

 

IPAB

Contrary to the title, the IPAB is not a new Apple product. Rather, it is the “Independent Payment Advisory Board” created by the Affordable Care Act to solve the problem of ever-increasing Medicare spending. In people’s worst nightmares, the IPAB is a death panel that will make decisions about how to ration health care for the elderly and disabled. Images of 15 people sitting in a room handing out death sentences flash through the minds of the anti-government crowd. Of course, nothing could be further from the truth, as the IPAB has no authority to limit benefits, increase beneficiaries’ out-of-pocket costs, or otherwise alter the Medicare program in any way that would “ration” care.

So, what can the IPAB actually do to promote slower spending growth in Medicare? They can suggest legislation, that’s what. Legislation that, for example, would reduce or alter the way in which payments are made to providers. It’s debatable if the recommendations from IPAB will work to actually control spending. What’s not up for debate is whether action will be taken, and that’s what I’m most pleased about.

You see, I hear often from family and friends about how Congress “never does anything” and how we should “vote the whole sorry bunch out and start from scratch.” It doesn’t seem to matter which party is in power, either. Congressional disapproval knows no party affiliations. And this isn’t just a trend among my social circle. Americans generally disapprove of the job Congress is doing. The IPAB puts an end to that, and here’s how:

Starting in 2013, the chief actuary of the Centers for Medicare and Medicaid Services (CMS) will report both a projected and a target Medicare growth rate for the next five years. If the projected growth rate exceeds the target growth rate, IPAB is tasked with making recommendations to bring things in line. These recommendations are formally submitted to Congress as proposed legislation. In the past, this is where progress ceased to occur, but no longer.

With the ball in Congress’ court, the options are straightforward. Congress may either enact the legislation recommended by IPAB, introduce and enact its own legislation that achieves the same cost savings as the recommendations from IPAB, or fail to act. If Congress fails to act, however, the secretary of the Department of Health and Human Services must implement IPAB’s recommendations, which cannot be overruled by either the executive or the judicial branches. In short, when Medicare spending increases too rapidly, something will be done to address it, even if Congress fails to act.

 

ObamaCare Keeps Working

When the Census Bureau released the latest numbers on insurance coverage, I wrote a post to highlight that nearly 500,000 young adults went from being uninsured to having insurance. An excerpt from that post actually got picked up by Jonathan Cohn at TNR. Now there’s more evidence that ObamaCare is working for both young and old Americans. The Department of Health and Human Services recently announced that, in fact, more than 2.5 million Americans between the ages of 19 and 25 were covered by their parents’ health insurance in the first half of 2011. That’s not surprising given that the Affordable Care Act included a provision that allows those under age 26 to remain on their parents’ coverage.

And the good news isn’t just for twenty-somethings. Early data show that America’s seniors are also benefiting from the Affordable Care Act. How you ask? Well, one of the first provisions enacted targeted the Medicare Part D “donut hole.” Part D is the program that provides prescription drug coverage for Medicare beneficiaries, and it was designed with a giant gap in coverage right where people needed it most. (As an aside, that was done for purely political reasons, to keep the price tag a little lower on the legislation when it was being debated on Capitol Hill.) Well, ObamaCare didn’t completely eliminate the donut hole, but it did shrink it, by reducing the proportion of costs the beneficiary is responsible for. The result? Nearly 2.7 million older Americans saved an average of $569 each on their prescription drugs through October 2011. Moreover, some 24 million Medicare beneficiaries received free preventive care. This is good news served with a side of good news.

It’s true that health reform is still very much in the process of being implemented. My glasses are not so rose-colored as to expect that every element of the law will be a success. Some things won’t work, and will need to be retooled or abandoned. But some things, as these developments underscore, will be successful, and when that happens, it should be roundly acknowledged.

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Using Medicare Data to Rate Physician Quality

Last week, the federal government announced that it would allow Medicare claims data to be used for the purpose of disseminating physician quality information to the public. What’s news is not that there will be attempts at creating so-called quality “report cards”–attempts at those have been around for some time–rather it’s that the Centers for Medicare & Medicaid Services (CMS) has finally agreed to let a wide range of folks access Medicare claims data for the purpose, which hasn’t happened before on this level.

But what are we to make of this new development? Is it a good thing or not? Giving the “consumer” more information on which to base their selection of a physician and their use of health care services seems like a good thing. After all, it’s essentially central to the idea of a well-functioning free market. As any health economist will tell you, the information asymmetry between consumers and providers leads to all sorts of peculiarities that cause the health care market not to behave like the market for other goods and services. This could then conceivably be a step in the direction of correcting some of those peculiarities.

The real question, though, is how good will this information be? Or, said another way, is poor information preferable to no information? Now, that doesn’t mean that there’s not a lot of excellent potential in these Medicare claims data. On the contrary, there’s much to be learned here. Of course, the realization of that potential is a function of the empirical rigor of the analyses researchers like myself undertake. No, the real worry I have is how this translates to the lay public without grossly oversimplifying things.

Let’s say a system is devised that, in true “report card” fashion, assigns physicians a grade ranging from “A” for outstanding to “F” for visit at your own risk. The public would certainly understand such a grading system, and people would be expected to show a clear preference for “A”-rated physicians over “F”-rated ones, but what about the bulk of physicians in the “B” and “C” range? It’s entirely possible, depending on the rating algorithm used, that a physician who excels in one particular area nevertheless gets a “C” rating. Would the public do its homework, or would it avoid doctor “C”? I worry that the latter may be the most likely outcome.

Again, I’m not saying that efforts to monitor quality and report that information publicly are a bad idea. Far from it. I’m merely suggesting that we must be extremely thoughtful in how we engage in such efforts, because the potential for significant unintended consequences is quite real. We must figure out how to approach these data using the most sophisticated of techniques, all the while with an eye on translating what we find in a manner that is accessible to the public without being “watered down” or less than accurate. The risks and the rewards are great.

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When Medicare Wasn’t Popular

People aren’t too happy these days, and I can understand why. After all, the economy’s still a mess, unemployment is incredibly high, and the government doesn’t seem to be doing anything about it–unless you count blaming each other. But history can be pretty instructive in times like these. Let’s start with one fairly standard event: The President’s approval rating is almost always highest when he/she gets elected, and declines over his/her time in office. There are some exceptions, but generally this is the way it goes, and it really is based on what statisticians call “regression to the mean”–what you might think of as the “nowhere to go but down” phenomenon.

The person who wins the election is the one people like. After all, who would vote for someone they didn’t like? Now, it’s an uphill battle that those who didn’t like the person to begin with are actually going to be convinced that they are doing a wonderful job and they were originally mistaken in not voting for them to begin with. Case in point, you won’t find too many McCain supporters out there who love what Obama’s doing. At the same time, the people who liked the person and voted for them already have high expectations. If the President does a great job, those expectations can be met, and the approval rating can stay high, but it isn’t likely to increase–for the reasons just mentioned. Yet people who originally voted for the President can find that their expectations aren’t met, and their support for the President will go down. This is just the way it goes, and the longer you’re in office, the more chances you have to let someone down.

The exception has very little to do with the President and more to do with circumstances, like the economy. Like it or not, the President is not the sole–or even the greatest–determinant of the state of our economy. However, that doesn’t stop us from wanting someone to blame when things aren’t going well–or reward when things are going great. History bears that out, too. Obama will probably lose the 2012 election–but it will most likely be because of a stagnant economy rather than anything else. That’s why we keep voting for “change.” Things were getting bad during the Bush presidency, so America voted for “change.” The Obama administration hasn’t magically fixed the economy, so in the midterms America voted for “change.” In 2012, if things haven’t improved, we’ll vote for “change” again. Nevermind that in a two-party system, two “change” cycles get you right back where you started. If the economy’s bad, why not vote for the Texas governor who was actually toying with the idea of his state succeeding from the Union?

But that’s just one example of how history repeats itself without us paying it much mind. The second, and my focus today, is Medicare and what it should tell us about the Affordable Care Act. You see, Medicare wasn’t popular when it was enacted. Ezra Klein mentions this briefly here. You can read more about the history here. Yes, even the actor–about to turn politician–Ronald Reagan went on record calling Medicare “socialized medicine” on behalf of the AMA. (As an aside, the funny thing about that is that Medicare is actually much closer to socialized medicine than anything contained in the Affordable Care Act.) Today, however, people love Medicare. In fact, they love it so much that they protest with signs telling the government to keep its hands off the program. They have seemingly forgotten that Medicare is one of the largest government programs in the country. This happened over time, but it is instructive.

The sentiments the public originally felt toward Medicare seem strikingly similar to the sentiments that much of the public currently feels toward the Affordable Care Act. Now, it is entirely possible that that sentiment will persist, that the ACA will be repealed after the GOP sweeps the 2012 elections, and the similarities with Medicare will end right there. However, it is also possible that the Democrats will retain enough seats to block repeal, that the public will slowly come to understand and appreciate the ACA, and that when Congress tries to pass a health reform law in 2060, people will be out in the streets holding signs that say “Keep the Government’s Hands Off the Exchange!” If that sounds highly unlikely to you, all I can say is, it may be, but pretty much that exact scenario has happened before. It isn’t likely to change your feelings about the law one way or another right now, but it is worth thinking about.

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