Responding to your comments and questions

imageI got some great comments and questions about my first Thrive post earlier this week. Below are the comments/questions and my answers to them. Keep your thoughts and ideas coming. This is an incredibly important time in health care and it will take all of our voices, opinions and efforts to make sure we get the health care system we all need and deserve.



Ginny Miller wrote:

Dr Mandell,

Thank you for adding your perspective from a variety of vantage points. As a parent of a son with both medical and mental health issues, I know that advocating for the best medical care has been my job for over a decade. I have also spent several years traveling to Washington to express concerns about access to care in our own state. We have had to leave our state for my son to get appropriate care for both his medical and mental health needs. The concern I have with National care is the Congress trying to implement plans that may overlook specific chronic complex health conditions. We already have had to fight for our son’s care in an ongoing basis. Finding ways to provide fiscally sound means is perfectly logical. These means should not be at the cost of people with chronic health conditions.

In my state there are people who are turned away from the only care center for epilepsy. These people have nowhere to turn if they have state insurance. We were fortunate to be able to have insurance that allowed us to come to Children’s of Boston when we had nowhere else to turn in our state.

Advocating for care of my son has been a full time endeavor. My concern is, the complexity of the task before the Congress is extremely large. If solving the Social Security crisis has been beyond previous members, perhaps universal health care is as well.

First, let me thank you for your courage and determination to not only fight for your own child’s health, but your advocacy on behalf of all children. The fact that families must cross state lines to get adequate care for their children with chronic conditions makes an already difficult situation even harder for parents. We are pushing hard to make sure that state to state, coverage and access to health care for children meets reasonable minimum standards.

Keep advocating and we’ll continue to add our voices so our kid’s needs don’t get lost in the larger debate about health care reform.

– Jim

Diane Dion wrote:
Dr. Mandell–

Thank you for articulating your concerns about the “short-term political rhetoric” that dominates today’s health care reform debate. Many of us share your views, especially as they relate to how undervalued and underfunded pediatric services are (oral health to mental health). The reauthorization of the Children’s Health Insurance Program (CHIP) in early 2009 did not seem to have sweeping impact. On behalf of the millions of kids who remain uninsured, keep wearing those three hats.

Dear Diane
I completely agree with you that it is now and will always be unacceptable for any child anywhere in this country to go without health coverage. That being said, there are a couple of things worth noting about the CHIP program and its reauthorization that we and others have fought so hard for.

First, working with the  New England Alliance for Child Health, we have been able to develop a set of messages and proposals about key issues in child health that have resonated across the country.

Second, it is pretty hard to judge the full impact of the  CHIP reauthorization given the incredible recession we have experienced. Perhaps we can take some comfort in the fact that most states have not cut children’s coverage during this period. This New York Times article gives a good overview.

Lastly, there are some very positive investments in quality improvement that may pay dividends in  the long run. These efforts include measure development (see my earlier post), as well as initiative in obesity and the development of “medical  homes” for children.

Thanks so much for your thoughts.

Too Stevens wrote:

I’m concerned that physicians are paid per procedure at many hospitals. How do you think physicians’ pay structure should work in an ideal world? I think it’s great that your hospital is being so transparent.

Thanks for the question. The so called “fee for service” payment system for providers when uncoupled from equally important quality metrics has and will provide perverse incentives. For example, as a pediatric urologist, I always tell parents that not having an operation is better than having a great operation if there is a reasonable chance of spontaneous improvement. Yet, under a pure fee-for-service plan, I might be financially incentivized to perform the procedure rather than seeing if the condition gets better on its own.

Equally as problematic as fee for service, however, were the capitation and payment control systems implemented in Massachusetts in the 1990s, where primary care groups acted as gate keepers. I think a more logical approach would be for health care providers, including hospitals, to be paid for outcomes over episodes of care, and for efficiency and quality of service delivery. Much work needs to be done to achieve this however, since we would need reliable and meaningful metrics, the ability to reward performance and integrated health systems to provide longitudinal care. This is especially true in pediatrics because so much of the development of quality improvement metrics has occurred in the adult care world. If you look, for example, at many of the things reported on government report cards, they focus on adult conditions like cardiac care, stroke, hypertension, etc. All of this will take time, but that is not an excuse for inaction.

I think we should all (consumers, providers, insurers and government) decide how to do this better and move away from much of the short-term political rhetoric.

– Jim

Brian Katulis wrote:

I’m a senior fellow at the Center for American Progress, a think tank in Washington DC. Though health care is not my specialty, it’s an issue that touches all of our lives.

My biggest concern about health care reform is that it won’t happen – that we’ll have a repeat of the 1990s again. I think it’s shameful that we have 46 million or so Americans uninsured – about 15 percent of our population. We as a country can do better.

My three main questions – first, what are you planning to do to shape the debate at the local, state, regional, and national levels?

Second, and this is not my area of expertise, but what do you think about this recent New Yorker magazine article about health care. Toward the end of the article there are some reference to the health care reform efforts in Massachusetts – the first state to adopt universal health coverage for its residents. As a resident and a leader in health care in that state, what are your views on those efforts? What are the pros and cons?

Lastly, in a second more recent article, the same author analyzes a town in Texas that is one of the most expensive health care markets in the country and finds that a major problem are the incentive structures for medical professionals, particularly in physician-owned hospitals. Again, this is not my area of expertise (I do foreign policy), but this passage seemed important to me.

Do you agree or disagree with the conclusions of this article?

All of us have a stake in health care reform. The question is not whether, but how. By focusing on the quality of care provided as well as cost efficiency, we are more likely to achieve the improvements in health care outcomes we deserve.

Dr. Gawande, who is clearly one of the thought leaders in this field, has continued to raise important issues about access to care, quality of outcomes and variation in practice and cost. I couldn’t agree more.

One of the interesting aspects of pediatric care is that the network of health care providers is very differently organized in terms of primary care, specialists and facilities. Most of the care is increasingly becoming regionalized. For example, in Massachusetts, half of the hospitals don’t even have pediatric beds. I mention this to suggest that additional thought will need to be given to the care of children in light of the overall reform process.

Completely nationalized health care systems have many of their own drawbacks, so working to improve our current system I believe is the best approach.

Massachusetts has made great strides in providing better coverage for our residents. Our current system is however a work in progress and all of us have a stake in continuing to reduce our cost structures without stifling the innovation and cutting edge improvements in outcomes embedded in our health care industry culture.

Thanks very much for your comment.
– Jim