If universal healthcare coverage is adopted by the U.S., it probably will come with a price: cutbacks on the indiscriminate use of world-class medical technology. That is the trade-off foreseen during a July forum focused on the role of markets in medicine, hosted by the Center for American Progress (CAP; Washington) and billing the assembled panelists as “healthcare experts from across the political spectrum.” The panelists, to a person, advocated adoption of universal coverage for the U.S. but also agreed this will mean that Americans will have to reduce their expectations concerning how much med-tech will be available to them in such a system.

Daniel Callahan, PhD, director of international programs at the Hastings Center (Garrison, New York), framed the healthcare issue of the day as balancing “equity on the one hand with personal choice” on the other. An obvious model for this balance is Europe, with Callahan calling that system less than an unmitigated success. “The Europeans are struggling to hang on to universal care,” he said, while the U.S. continues to examine the idea. But he did note that Europeans enjoy a higher life expectancy than Americans and seem relatively satisfied with their healthcare systems.

In his view, universal healthcare in Europe are “far superior” to the delivery patchwork in America, while at the same time acknowledging the need for market mechanisms. The impact of such mechanisms on medical culture, he said, require some compromises, noting parenthetically that healthcare economists are typically more interested in efficiency than ethics.

Citing political elements working against universal coverage, he said these are “most clearly seen in the pages of the Wall Street Journal,” later adding, “I always get annoyed with the Wall Street Journal because it uses Canada as a whipping boy.”

Until the 1960s, the U.S. and Canada handled healthcare in much the same way, Callahan said. However, “Canadians are much more communitarian,” he noted, a characterization driving the nationalization of its healthcare, a notion doesn’t fly in the U.S. where citizens “are much more suspicious of government.” He argued that using Canada’s healthcare system as a bellwether for nationalized healthcare in the U.S. is not valid because Canada, like the UK, finances its healthcare by means of taxes rather than using employer/employee contributions to finance care, as in the Netherlands and France. Universal healthcare requires “carefully introduced market mechanisms,” employed tactically rather than strategically to assemble a comprehensive healthcare system, he said.

However, an improved delivery system for Americans promises to come with a price tag, one likely to be very unpopular. “Somewhere between 40% and 50% of healthcare costs can be traced to new technology or intensive use of existing technology,” Callahan said, arguing that the American appetite for the latest and the greatest is unsustainable. “The most startling paradox is that healthcare [technology] has improved,” with continually rising costs and “no end in sight.” Callahan insisted that Americans would have to be willing to “set some limits on progress” if they obtain universal coverage and that corralling spiraling costs is something that “Europeans need as much as we do.”

Willis Goldbeck, consulting director of global public health policy and government affairs at European pharmaceutical maker UCB (Brussels, Belgium), offered a dim view of prospects for limiting the utilization of med-tech, however, terming the odds “somewhat less than zero.” But he called the current U.S. healthcare delivery system “very sloppy,” and “a medical repair model” rather than a method for reducing illness and disease.

Goldbeck said that “the numbers, the heterogeneity” of the U.S. population make it “impossible to compare” healthcare in the U.S. with that in other nations, calling such attempts “dangerous.” He added: “Choice is the bogus issue of all times.” He said that without meaningful information on outcomes and costs, the consumer of healthcare services cannot possibly make an informed decision on where to spend healthcare dollars.

Jeanne Lambrew, a senior fellow at CAP and an associate professor for health policy at George Washington University (Washington) discussed Callahan’s book, titled Medicine and the Market: Equity v. Choice. She faulted it as being too pessimistic about universal healthcare put in place in the U.S., saying, “It might be [here] sooner than you think.” Lambrew seconded Callahan’s position that Americans are possessed of a “concept of infinity” where medical intervention is concerned. “We really do have this mindset” that infirmity can be evaded indefinitely.

Lambrew told BB&T that she sees two reasons to believe that universal coverage is close on the horizon. “Big business outcry is on the rise,” she said, noting the current distress of the domestic auto industry in financing worker health insurance. Secondly, she noted, as a harbinger, Massachusetts Gov. Mitt Romney’s move to impose mandatory universal coverage in his state. “When one can see the political capital [in proposing universal coverage],” she said, “this is no longer the third rail.”

White paper faults CMS wound care policies

The Advanced Medical Technology Association (AdvaMed; Washington) last month released a white paper on current Medicare coverage and reimbursement policies for the management of chronic and complex wounds, charging that these policies “do not keep pace with the latest technological advances, negatively affecting the delivery of appropriate care to patients.” Titled “Advanced Wound Management: Healing and Restoring Lives,” the white paper outlines the impact of chronic and complex wounds (leg ulcers, pressure ulcers, diabetic foot ulcers and burns) on patients and the nation’s healthcare system, putting the cost of managing and treating these types of wounds in the U.S. at $20 billion annually.

Newer moist-wound healing therapies and other advanced wound care technologies, such as negative pressure wound therapy, bioengineered skin substitutes and low energy ultrasound, have been shown to help wounds heal faster and provide good value. “Unfortunately, current Medicare policies often focus narrowly on a specific unit cost or the cost of wound care at a specific site, while not considering the long-term costs of caring for patients,” AdvaMed said in a statement.

The AdvaMed report explains various challenges facing patients as they seek access to the most appropriate cost-saving wound care. The white paper also describes the challenges that physicians and other healthcare professionals face as they strive to provide care across clinical settings with coverage, coding and reimbursement policies that do not adequately reflect the technological advances in wound care treatment.

“This report highlights the need to modernize Medicare’s payment system so that patients suffering from chronic and complex wounds have access to the most effective treatments available,” said Stephen Ubl, president/CEO of AdvaMed. “Revising Medicare policies to accommodate the latest medical technology innovations will help patients receive better care and improve their lives.”

The paper includes a number of recommendations to improve Medicare’s wound care policies, including a variety of changes in coding and billing practices; updating of the Surgical Dressing Policy’s categories and associated fees, providing Medicare coverage of compression technologies for healed venous ulcers to reduce recurrence rate sand reduce overall treatment costs; and expanding coverage for advanced therapies such as Negative Pressure Wound Therapy, low energy non-contact ultrasound, off-loading devices and support surfaces “to encourage consistent treatment planning as the patient moves through the healthcare system.” It also recommended “a more aggressive” approach to wound care treatment that would allow for earlier treatment of wounds to reduce the overall costs of this therapy.

The white paper is available at www.advamed.org/publicdocs/june2006_woundmanagement.pdf.

Bill fights against imaging cutbacks

Members of the House of Representatives are still examining the impacts of the Deficit Reduction Act of 2005 (DRA), which President George Bush signed into law this past February. In that vein, Rep. Joe Pitts (R-Pennsylvania) introduced H.R. 5704, a bill that would impose a two-year moratorium on reductions in Medicare payments for imaging services.

According to a letter addressed to Speaker of the House Dennis Hastert (R-Illinois) authored by Pitts, the proposed cuts embodied in the DRA would “lead to reimbursement reductions of upwards of 30% to 50% for imaging services that patients and their physicians rely on to properly detect, diagnose and treat life-threatening conditions.” And Pitts argued that a two-year delay would “give Congress a chance to fully understand how cuts of this magnitude could affect Medicare beneficiaries’ access” to such services. The outpatient procedures addressed are those taking place in both doctors’ offices and stand-alone imaging centers.

Pitts also has sent a letter to Hastert charging that Congress did not engage in an “analysis of the impact this change in payment policy will have on Medicare beneficiaries’ access to imaging services,” potentially resulting in “higher co-pays and increased wait times and travel times to receive imaging services.”

H.R. 5407 – titled the Access to Medicare Imaging Act of 2006 – calls for “a budget-neutral, two-year moratorium” by amending section 5102 of the DRA by replacing the year 2007 with the year 2009. Pitts’ bill also calls on the Government Accountability Office (GAO) to conduct “a comprehensive study on patient access and services issues” related to the Medicare payment reductions in question, specifically looking at “rural and medically underserved areas” as well as “the appropriateness of using the hospital outpatient department prospective payment system methodology to set reimbursement under the Medicare program for all imaging services, regardless of the site of service.” If passed H.R. 5704 would require that GAO complete such a study by July 31, 2008.

The co-signers of Pitts’ letter, which includes Reps. Christopher Shays (R-Connecticut) and Charles Boustany (D-Louisiana), make the case that “reduced access to imaging in the physician’s office will increase” wait times experienced by those seeking non-urgent imaging services and will erode the cost savings to beneficiaries by seeking such services outside a hospital. The letter states that a cranial CT scan without contrast typically incurs a co-pay of less than $40 in a free-standing imaging center, but that the cost “doubles to $75” when using a hospital’s outpatient imaging center.

Reaction to the bill has been predictably positive in the provider community. Arl Van Moore, MD, who chairs the board of chancellors for the American College of Radiology (ACR; Reston, Virginia), said that “Congress needs to take a closer look at how the arbitrary cuts in the Deficit Reduction Act will adversely affect access to care nationwide.” Van Moore lauded Pitts and his co-signers, remarking that the GAO study would “allow for the creation of a more thoughtful and ultimately more effective approach to these services which will protect access to care and allows doctors to provide the highest quality care to their patients.”

In a March 1 letter to a number of members of Congress, the Access to Medical Imaging Coalition, spearheaded by ACR and the National Electrical Manufacturers Association (NEMA; Rosslyn, Virginia), said that Congress did not evaluate “the potential impact of this change in payment policy,” and expressed concern that “these cuts will have numerous unintended consequences, including potentially diminishing access to imaging services outside the hospital setting.”

Estimates of the impact of the DRA reduction in imaging spending vary widely. The Congressional Budget Office pegged the savings to Uncle Sam at $2.6 billion over five years, but according to the Society for Interventional Radiology (SIR; Fairfax, Virginia), the reduction in payments could tally up to $6 billion over five years. According to its web site, SIR is “currently assessing these cuts and also working with a broad coalition to determine the impact to SIR members and to patient care.”

Transplant programs faulted

About 20% of federally funded transplant programs do not meet minimum standards set by the Centers for Medicare & Medicaid Services (CMS; Baltimore), according to a recent reporting by the Los Angeles Times. CMS funds most U.S. transplant programs and requires medical centers to perform a minimum number of procedures and maintain a minimum survival rate to receive certification. The Times examined the number of procedures performed by medical centers as part of the 236 federally funded heart, liver and lung transplant programs from 2002 to 2004, as well as survival rates, based on information available to the public on the web sites of the United Network for Organ Sharing and the Scientific Registry of Transplant Recipients.

According to the Times, 48 of the transplant programs continue to operate “despite sometimes glaring and repeated lapses.” Nine lung transplant programs and 36 heart transplant programs did not meet CMS standards. Those 48 transplant programs accounted for 71 more deaths within one year of transplants than normally expected, based on a government analysis of survival rates.

CMS has the authority to revoke the certification of transplant programs that fail to meet agency standards but “rarely does,” the Times reported. CMS has revoked the certification of 11 transplant programs since 2000, but, in “nearly all of those cases, it moved only after the programs had voluntarily ceased operations,” according to the newspaper.

Barry Straube, chief medical officer for CMS, said, “In areas where there is a concern, whether it’s because they are not meeting certain volume standards or outcome standards, at a minimum, that is going to trigger a review of that specific program.” He added that CMS might reduce the number of the minimum number of procedures that transplant centers must perform. However, Michael Acker, a heart transplant surgeon and chief of cardiac surgery at the Hospital of the University of Pennsylvania (Philadelphia), said that heart transplant programs should have to perform more, not fewer, procedures. Acker said, “It’s not just doing the transplant ... There are so many reasons for why you need a vigorous team.”

Chair Chuck Grassley (R-Iowa), chairman of the Senate Finance Committee, sent a letter to federal officials who oversee organ transplant programs asking why they have not taken action against programs that fail to meet federal standards. Grassley previously asked the Government Accountability Office to investigate the organ procurement and transplant system and determine whether federal agencies are able to provide effective oversight. In his letter to the heads of CMS and the Health Resources and Services Administration, Grassley said, “I have been increasingly concerned about the oversight of the organ procurement and transplantation system.” He added that problems uncovered last year at three California programs, which have since closed, “may be indicative of problems at facilities elsewhere.”

CMS Administrator Mark McClellan responded with a statement saying that CMS improved oversight of transplant programs last year after agency officials found serious operational problems at the University of California-Irvine Medical Center. According to McClellan, CMS will take action against transplant programs that fail to respond to a federal safety survey sent in March. “Medicare has been and remains very concerned that beneficiaries have access to a system that is both fair and safe,” he said.

Bill would authorize pilot health courts

Common Good (New York), a bipartisan legal reform coalition, reported that six leaders in patient safety and healthcare quality are calling for pilot projects for special health courts as a way of restoring reliability to medical justice. Both U.S. Senate Majority Leader Bill Frist (R-Tennessee) and the Progressive Policy Institute, known in the 1990s as President Bill Clinton’s “idea mill,” have endorsed the concept. So have hundreds of leaders in American healthcare and law.

Special health courts would be devoted exclusively to healthcare issues, much as existing specialized courts focus on other areas of law: admiralty courts, tax courts, drug courts, bankruptcy courts, and administrative tribunals in areas ranging from workers’ compensation to vaccine liability.

The six calling for the pilot projects are Dennis O’Leary, MD, president, Joint Commission on Accreditation of Healthcare Organizations; Margaret O’Kane, president, National Committee for Quality Assurance; Susan Sheridan, co-founder and president, Consumers Advancing Patient Safety; Martin Hatlie, president, Partnership for Patient Safety; David Kendall, senior fellow for health policy, Progressive Policy Institute; and John Rother, director of policy and strategy, AARP.

O’Kane said, “America’s legal system today impedes efforts to enhance patient safety. As a nation, we should experiment with new approaches to resolving medical injury disputes – such as health court pilot projects – that would better compensate patients, improve efficiencies and promote patient safety.”

“The unreliability of medical justice today has infected healthcare with a debilitating distrust,” said Philip Howard, chair of Common Good. “These consumer and patient safety leaders understand that a reliable system of justice is needed to align incentives towards patient safety and avoiding wasteful practices.”

Last month, six hospitals and academic medical centers announced their interest in serving as pilot projects for special health courts. They include Duke University School of Medicine and Health System (Durham, North Carolina); Emory Healthcare (At-lanta); Jackson Health System/University of Miami Leonard M. Miller School of Medicine (Miami); Johns Hopkins School of Medicine (Baltimore); New York-Presbyterian, the University Hospital of Columbia and Cornell (New York); and Yale-New Haven Hospital/Yale Medical Group (New Haven, Connecticut).

Health courts would feature full-time judges trained in healthcare issues to define and interpret standards of care in malpractice cases, relying on neutral experts paid by the court and setting precedent. A key goal of these courts is to avoid a key controversy of compensations – that they seem to benefit lawyers as much as, or more than, plaintiffs.

Common Good is leading the effort to develop models for health courts in partnership with the Harvard School of Public Health, with funding from the Robert Wood Johnson Foundation.