Jun 28, 2012

Health care law survives largely unscathed - unbelievable but true!

I'm still waiting for the news to sink in. The Supreme Court has upheld the controversial Affordable Care Act.

"ObamaCare" promises to be a focal point of the November presidential elections. But more importantly, it allows the goverment to continue implementing the health care law leading up to 2014, when the law fully takes effect.

It was a close call. A 5-4 ruling. The most controversial provision of the law- the individual mandate- was deemed by the Court as constitutional.

The ruling preserves key child health provisions, including the law's protections against pre-existing condition exclusions.

I think back to the time that I met a family who had lost health insurance coverage because the mother lost her job. The family stretched their resources to buy expensive continuation coverage. The parents faced the painstaking task of deciding which family members to buy insurance for. In the end the family chose to continue coverage for their two little girls with congenital heart disease. The father, a small business owner, could not afford to purchase health insurance for himself.

When I met this family in my clinic, they were crumpling under the stress of high out-of-pocket medical costs and the fear of what would happen if the father had a medical catastrophe.

No family should face such a decision.

Improving access to affordable and stable health care for everyone should never have been a partisan issue in the first place. But given just how polarizing the issue turned out to be, all I can say is - it's about time.

- Ulfat Shaikh

Jun 24, 2012

A possibly dismembered health care law - and what's at stake

We are on the eve of the Supreme Court's decision on the 2010 health care law. If the law passes, it will be the most transformative health care law in the U.S. since 1965, the year Medicaid and Medicare were enacted.

A looming question is whether the individual mandate - which requires most Americans to purchase health insurance or pay a penalty - will be overturned. And if it is overturned, what other parts of the health care law will it take down with it?

Two key aspects of insurance reform - a ban on denial of coverage based on pre-existing conditions and charging variable rates based on health status, heavily depend upon the individual mandate to offset costs.

But even if the individual mandate is invalidated, other important elements of the bill not associated with the mandate will be important gains. The ruling should not affect health coverage to the uninsured through the expansion of Medicaid, the establishment of state-run health insurance exchanges, and federal subsidies for the purchase of private insurance plans on exchanges.

Fervor about the law has risen to a fever pitch. According to a recent poll, over two-thirds of Americans hope that the Supreme Court overturns part or all of the law. Marketing has played a disturbingly key role in framing the debate. Over the last two years, over $200 million was spent on advertising opposing the law. In contrast, just $69 million was spent on ads supporting the law, with only $700,000 of that money coming from the Obama campaign.

Whatever plays out this week, I am reminded of Uwe Reinhardt's words in T.R. Reid's book, The Healing of America - "Every nation's health care system reflects that nation's basic moral values. Once a nation decides that it has a moral obligation to provide health care for everybody, then it can build a system to meet that obligation".

If this is so, then what essentially is at stake is our nation's moral compass.

- Ulfat Shaikh

Jun 20, 2012

Is health insurance all you need?

Is health insurance all you need to access health care? A study published this month in the New England Journal of Medicine, shows that where you live matters. There is very significant geographic variation in access to care and health care quality, even among those with health insurance.

One explanation is that some insured people may delay needed health services due to high out-of-pocket costs and insurance premiums.

There is also wide local variation in access to primary care, even among the insured. Communities with the poorest access to health care - located in Florida, Georgia, Louisiana, Mississippi, Oklahoma, Texas, and California - also have the lowest quality care.

Another troubling fact - a high number of uninsured people within a community pulls down the overall quality of health care for both insured and uninsured residents alike.

The Affordable Care Act will increase access to basic services and improve health care quality by strengthening primary care. However the lesson learnt here is that clinicians and other stakeholders still need to leverage these resources locally.

- Ulfat Shaikh

Jun 8, 2012

Transparency as a quality improvement tool

I watched Paul Levy's interview on the IHI website this week about how he used transparency as a management tool to improve care. While Levy was CEO and President of Beth Israel Deaconess Medical Center in Boston, he wrote an extremely popular blog called Running a Hospital (he has since retired from this position, and his blog is now called, Not Running a Hospital).

I watched transfixed as Levy described how, as CEO, he shared real-time clinical outcome data for his hospital on his blog, in the process changing his hospital's culture, accelerating improvement, reducing harm, and making transparency the norm.

Turns out that others have implemented this concept with success. Earlier this year, a study published in Health Affairs, looked at more than 400 primary care clinics in Wisconsin to see how well they delivered care for diabetes. The researchers found that a focus on publicly-reported quality data combined with participation in quality improvement projects, improved care for diabetes. Clinics involved in this study were more likely to contribute to patient registries, implement prompts for clinicians about recommended clinical practices, and utilize patient reminders.

A few years ago, The Annals of Internal Medicine published a systematic review, The Evidence That Publishing Patient Care Performance Data Improves Quality of Care. This review showed that public reporting of performance data stimulates quality improvement activity at the hospital level.

Watch Paul Levy's interview, Using a Blog to Improve Health Care, and see why I found it inspiring:
- Ulfat Shaikh

Jun 2, 2012

Providing care in medical offices today- Strengths and challenges

A new report from the Medical Office Survey on Patient Safety Culture shows that teamwork and follow-up of patients are strengths of medical offices. The survey however identifies that work pressure and pace are areas for improvement.
The medical office survey is conducted by the Agency for Healthcare Research and Quality and looks at approximately 24,000 staff from more than 900 U.S. medical offices. The survey is designed to measure the culture of patient safety in medical offices from the perspective of clinicians and staff.

The majority (84%) of respondents who were surveyed reported good teamwork among staff and clinicians. They also reported high follow-up rates with patients (82%). However, only 46% were positive about the work pressure and pace in their offices.

Being a pediatrician, I found it especially interesting that medical offices that only specialized in pediatrics had the highest average overall rating on quality and patient safety. OB/GYN had the lowest average overall rating.

- Ulfat Shaikh