The Blue Ridge Academic Health Group Report 8 October 2004 CONVERGING ON CONSENSUS? Planning the Future of Health and Health Care Mission: T he Blue Ridge Academic Health Group seeks to take a societal view of health and health care needs and to identify recommenda- tions for academic health centers (AHCs) to help create greater value for society. The Blue Ridge Group also recommends public policies to enable AHCs to accomplish these ends. Report 8 • October 2004 The Blue Ridge Academic Health Group CONVERGING ON CONSENSUS? Planning the Future of Health and Health Care Members and participants Members Invited Participants Enriqueta C. Bond, PhD, President, John T. Fox Burroughs Wellcome Fund President and CEO Roger J. Bulger, MD Emory Healthcare, Emory University President, Association of Academic Arthur M. Kellerman, MD, Chairman, Health Centers Department of Emergency Medicine, Catherine DeAngelis, MD, Editor in Chief, Emory University School of Medicine Journal of the American Medical Association Thomas Lawley, MD Haile T. Debas, MD, Executive Director, Dean, Emory University School of Medicine Global Health Sciences Institute Kenneth E. Thorpe, PhD University of California, San Francisco Robert W. Woodruff Professor and *Don E. Detmer, MD, President and CEO, Chairman, Department of Health Policy American Medical Informatics Association; and Management, Rollins School of Professor Emeritus and Professor of Medical Public Health, Emory University Education, University of Virginia Arthur Garson, Jr. M.D., M.P.H., S t a ff Vice President and Dean, School of Medicine, Janet Waidner, Executive Administrative University of Virginia Assistant, Woodruff Health Sciences Center, Michael A. Geheb, MD, Emory University Senior Vice President for Clinical Programs, Oregon Health Sciences University Editors *Michael M.E. Johns, MD, Executive Vice Ron Sauder, Director, Media Relations, President for Health Affairs; CEO, Woodruff Health Sciences Center, The Robert W. Woodruff Health Sciences Emory University Center; Chairman of the Board, Emory Healthcare, Emory University Jon Saxton, JD, Policy Analyst Jeffrey Koplan, MD, MPH, Vice President for Academic Health Affairs, Emory University Lawrence Lewin, Executive Consultant Steven Lipstein, President and CEO, BJC HealthCare, St. Louis Arthur Rubenstein, MBBCH, Dean and Executive Vice President, University of Pennsylvania School of Medicine George F. Sheldon, MD, Professor of Surgery and Social Medicine, Chair Emeritus, Dept of surgery. UNC-Chapel Hill, Editor-in-Chief American College of Surgeons *Co-Chairs Contents Report 8: Converging on Consensus? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Section 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 The Problem: History and Situational Analysis Section 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Convergence: Value-Driven Health Care IOM Five Basic Principles for Reaching Universal Coverage (Exhibit 1) 8 Converging on Universal Coverage 9 The Bush Administration Proposal 9 The Kerry Proposal 12 Converging on Characteristics of a New Health System 13 Four Goals for HHS Effort to bring Health Care into the Information Age over the Next Decade (Exhibit 2) 14 The National Coalition on Health Care: Principles for Reform (Exhibit 3) 16 Section 3: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 The Future of Health Policy: Convergence or Continued Conflict? The Role of Academic Health Centers in Furthering Consensus for a STEEEP Health Care System 18 Time to Take the Offensive 18 AHCs As Innovators in Employee Health 18 The AHC as Partner with Private Sector and Local and State Government in Defining and Rewarding Appropriate Care: The University of Virginia 19 The AHC in Partnership for Adopting Common Electronic Data Standards by Connecting For Health 20 The AHC as a Partner in Major Nationwide e-Health Initiative 20 The AHC as Partner with Private Industry for Disease Management: The University of Michigan, GM and Ford 22 The AHCs as Catalysts of Change and Progress 22 Recommendations . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Appendix 1. Principles Developed by IOM Committee by which to Evaluate Proposals for Universal or Near-universal Access to Affordable Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Appendix 2. Leadership and Innovation for the Future of Health Care . . . . . . . . . . . . . . . . . . . . . . . .25 Reproductions of this document may be made with written permission of The Robert W. Woodruff Health Sciences Center by contacting Nicole Price, Woodruff Health Sciences Center, Emory University, 1440 Clifton Road, Suite 400, Atlanta, GA 30322. Phone: 404-778-3500. Fax: 404-778-3100. E-mail: blueridge@emory.edu. CONVERGING ON CONSENSUS? Planning the Future of Health and Health Care is eighth in a series of reports produced by the Blue Ridge Academic Health Group. The recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not official positions of Emory University. This report is not intended to be relied on as a substitute for specific legal and business advice. For questions about this report, contact Michael M.E. Johns at the address listed above. Copyright 2004 by Emory University. The Blue Ridge Academic Health Group Report 8 The Blue Ridge Academic Health Group (Blue Ridge Group) has been concerned with the imperative for health care reform since our Group’s inception in 1997. Our second report, entitled, Promoting Value and Expanded Coverage: Good Health is Good Business, advocated the establishment of a “value-driven” and “evidence-based” health care system, one that “. . . promotes the health of individuals and the population by providing incentives to health care providers, payers, communities and states to improve population health status and reward cost-effective health management” (BRAHG 1998a). In the intervening years, some progress has been made and a great deal has been learned on the subject of national health care reform based upon these and related principles. Nevertheless, as a nation, we have yet to achieve anything approaching effective, system-wide reform. We have yet to bridge the chasm between the reality and the promise of our health care system. In this, our 8th report, the Blue Ridge Group reviews the progress of and prospects for comprehensive health system reform and provides an academic health center (AHC) leader- ship agenda for reaching this critical goal. ■ We describe a promising convergence of consensus on both the need and goals for health care reform. ■ We describe the major remaining roadblock to successful reform. ■ We present a “to do” list of models, initiatives and policy recommendations that AHCs can pursue to lead our nation to a health care system worthy of the name. 4 Section 1: were without health insurance coverage in The Problem: History and 2003, and cost pressures have caused most Situational Analysis insurance sponsors (for instance, employers) to reduce and limit benefits, and/or to The 20th Century saw great strides increase premiums, co-pays and related finan- in medicine and the public’s health. cial obligations of the insured (U.S. Census Bureau 2004). ■ Starting early in the century, health care Several times during the 20th Century, developed a robust scientific, and increas- efforts were undertaken to comprehensively ingly technological, foundation. Public address cost and coverage issues by attempt- health measures enhanced the overall health ing to enact nationwide insurance coverage of the population and medical care became for health care. This included major efforts increasingly effective. by Presidents Franklin D. Roosevelt, Truman, ■ Mid-century, the establishment of the Nixon and Clinton. The Clinton effort was National Institutes of Health (NIH) initiated targeted as much towards reining in health a national commitment to the support and care spending (which had grown to over 14 advancement of biomedical science, which percent of the nation’s gross domestic prod- has endured. This commitment spurred uct), as towards ensuring near-universal cov- unprecedented discovery and innovation in erage and access to quality health care. This basic and clinical science, and the ever- effort, like those before it, was not successful. increasing promise of greater medical success. The ensuing growth of what is generally ■ After the Second World War, in the light of referred to as “managed care” is credited with nationwide wage freezes, employer-sponsored reducing the rate of growth of health expen- health and retirement benefits became a ditures for several years (though not without standard mechanism for access to health engendering heated debate about rationing of insurance, while enhancing employee com- health care access and services). But by the pensation, and equitably spreading costs and year 2000, health care costs had resumed their risks through large insurance pools. rapid growth (Reinhardt, et. al. 2004). ■ With the enactment of the Medicare and The most recent effort at reform, the Medicaid programs in the mid 1960’s, the Medicare Prescription Drug Improvement, nation committed to enhancing access to and Modernization Act of 2003 (Medicare medical care and services by the very poor Modernization Act) sponsored and passed by and the elderly. These programs created the Bush Administration, surprisingly did not publicly financed health care plans for pop- prioritize cost reduction (U.S. Congress ulations that the private sector could not 2003). Despite being hailed in some quarters profitably or effectively insure, while as the most important reform since the enact- attempting to equitably distribute the costs. ment of Medicare itself, the final bill, includ- However, these national commitments ing the manner in which it was passed in the came at a high cost and still left millions of Congress, was extremely controversial. The Americans without access to affordable health implementation of many of the Medicare care. Annual Gross Domestic Product (GDP) Modernization Act’s provisions is not set to attributable to health care spending grew begin until the year 2006 and there are wide from 5.1 percent of GDP in 1960 to over differences of opinion on how the bill will 13 percent in 1999 (Chernew et al., 2003), affect the future of Medicare and the health with projections that it will grow to 18.4 per- care system as a whole. But, while agreeing on cent by 2013 (Heffler, et al 2004). 15.6 percent little else about its potential impact, with costs of the U.S. population, or 45.0 million people, estimated at well above $500 billion, most 5 analysts agree that the bill will result in even sures as a result of our graying population. higher health system costs (Butler 2003). Emerging infectious diseases (EIDs). As Despite this latest infusion of billions of SARS has recently reminded us, from the third dollars into health care, the house of American world to the first, new pathogens can emerge medicine remains severely distressed, plagued and spread quickly, threatening global health by a host of structural problems. while severely taxing our economies and over- As late as the mid-1960’s the health care whelming our health systems. Further, the con- system was a modest bungalow based on a tinuing spread of preventable diseases, such as professional model of the solo practitioner AIDS, in much of the world signals that real and community hospital woven into the fabric control and eradication requires a greater of household and community life. It has since response from governments and health profes- metastasized into what is now a vast and sionals than has been forthcoming to date. unwieldy structure plagued by archaic financ- The threat of bioterrorism. Along with ing systems, perverse financial incentives, EIDs, the heightened threat of bioterrorism is endemic inefficiencies, significant variations driving new demand for readiness and research. in quality, and a host of related deficits in We face major gaps in funding and prepared- administrative, service, accountability, safety, ness in our public health infrastructure. outcomes and information systems. The result Irrational provider payment systems. The is that, while excellent care is available to current payment and reimbursement systems many people, the U.S. also has the widest for health services are extraordinarily complex health disparities based on income level, and and inefficient. In many cases, for patients and has the lowest overall health status, of any providers alike, payment systems create per- other industrialized country in such funda- verse incentives that result in over-, under-, or mental areas as life expectancy and infant mis-utilization of health care. mortality. For example, the most recent Medical malpractice and patient safety. Organization of Economic Cooperation and Tort reform and patient safety remain major Development (OECD) projections of life problems. Rising premium costs have become expectancy show the U.S. 22nd for males and a significant burden to health professionals, 26th for females among all industrialized provider organizations, drug and device man- countries (OECD 2004). On top of this, we ufacturers and others. At the same time, now suffer from the recently identified public patient safety and quality assurance remain health epidemic of obesity (Burros 2004). serious issues that have not been adequately Our nation already pays far more per addressed by the provider, pharmaceutical, or capita for health care than any other industri- insurance communities. alized country (approximately 1.5 times the The burden of uninsurance. Approximately per capita spending of Canada, which is sec- 45 million Americans were uninsured in 2003. ond to the U.S. in health spending) (Glied A three-year study by the Institute of Medicine’s 1997,5). Simply investing even more money is Committee on the Consequences of Uninsur- clearly not the key to effective reform. ance found that widespread “uninsurance” has Putting more pressure on this wobbly significant society-wide consequences: structure are many factors: ■ Uninsured children and adults do not Demographic trends. Our aging society is receive the care they need. Consequently, trending toward a more complex and more they suffer from poorer health and develop- costly disease burden. Though the genomic ment and are more likely to die prematurely revolution suggests the possibility of someday than those with coverage; 18,000 unneces- practicing regenerative and reparative medi- sary deaths are attributable to lack of health cine, we will experience escalating cost pres- coverage every year. 6 ■ Even one uninsured person in a family can The Blue Ridge Group has long main- put the financial stability and health of the tained that if the right actions are taken, e.g., whole family at risk. relentlessly pursuing only necessary, appropri- ■ A community’s high rate of uninsurance can ate and effective services with an effective adversely affect the overall health status of information and communications infrastruc- the community, the financial stability of its ture, a “value-driven” health care system can health care institutions and providers, and emerge (BRAHG 1998a). the access of its residents to certain services, A value-driven health system would uti- such as emergency departments and trauma lize performance-based incentives and bal- centers (IOM 2003a). anced competition in achieving national The “market cure.” The efforts over the health goals. It would develop incentives to last decade to impose market discipline on the improve the health of both individuals and health care sector have led to an era described populations, while achieving the highest pos- by the Institute of Medicine as one of sible value for the dollars invested and spent. “Brownian motion” — of “mergers, acquisi- A national health information infrastructure tions and affiliations,” rather than of real would allow secure communication of rele- progress in securing lasting savings or vant data for diagnosis, treatment and out- improvements in delivery systems and health comes tracking by those with a right and need outcomes for the population (IOM 2001:3). to know. In the face of this constellation of existing However, such an incentivized, value- and emerging challenges, the question is driven health system would work if, and only whether we might soon reach a “tipping if, the entire population is in the system. point” where the distressed house of health Having all people included means ensuring care will come tumbling down, no longer able that everyone has sufficient insurance and to accommodate the endless cobbling-togeth- access to basic health services, which could be er of partial and disparate systems, structures, provided competitively by government pro- and reforms. grams or the private sector, or, better, through a combination of both. Universal health insur- ance coverage, therefore, is one essential pre- Section 2: condition to an effective and efficient U.S. Convergence: Value-Driven health care system. In a major advance in Health Care public policy over the last decade, this premise has been widely accepted, even across tradi- With so much at stake for the health and tionally partisan lines. well-being of individuals, communities and Recently, the Institute of Medicine spon- the nation overall, health care reform has sored a series of landmark studies that sur- remained a perennial priority on our nation’s veyed the full range of research and proposals domestic agenda. This priority has been rec- on the topic of achieving a United States ognized and championed by a cross-section health care system worthy of the name. From of health sector and public policy leaders and the base of fact and analysis reported from organizations. At every level, from the local to these studies, the IOM can be seen as having the national, and in both public and private proposed the adoption of two fundamental initiatives, change and innovation continues. national health policy goals that are critical to Many individuals and organizations have effective health care reform. contributed significant research and policy The first urges that our nation should development to this effort. provide “health insurance that will promote 7 Exhibit 1: IOM Five basic principles for reaching universal coverage. 1. Health care coverage should 4. The health insurance strategy be universal. should be affordable and sustainable ■ Being uninsured can damage the health of for society. individuals and families. Uninsured children ■ Politics and economics will determine what and adults use medical and dental services less society can afford. Any major reform proposal often than insured people and are less likely will need mechanisms to control inflation to receive high quality care, as well as preven- and encourage use of efficacious, cost-effec- tive and chronic care services. tive services. ■ Uninsured children risk abnormal long-term ■ Everyone should contribute financially –– development if they do not receive routine through taxes, premiums, and cost sharing –– care; uninsured adults have worse outcomes because all members of society will benefit for chronic conditions such as diabetes, from universal health insurance coverage. cardiovascular disease, end-stage renal disease ■ The reform strategy should strive for efficien- and HIV. cy and simplicity by eliminating complex eligi- ■ “Universal” means what it says. Everyone bility rules, underwriting, billing procedures living in the United States should have and regulatory requirements. health insurance. 5. Health insurance should enhance 2. Health care coverage should health and well-being by promoting be continuous. access to high-quality care that is effec- ■ Continuous coverage is more likely to lead to tive, efficient, safe, timely, patient-cen- improved health outcomes; conversely, gaps in tered, and equitable. coverage can result in diminished health. ■ Insurance should be designed to enhance the ■ Achieving coverage well before the onset of quality of the health care system by meeting an illness can lead to a better health outcome, the six aims recommended by the IOM since the chance of detecting disease early in Committee on Quality of Health Care in its course is enhanced. America (see list below). ■ Interruptions in coverage interfere with ongo- ■ Basic benefit packages should include preven- ing therapeutic relationships, contribute to tive and screening services, outpatient missed preventive services for children, and prescription drugs, and specialty mental result in inadequate chronic illness care. health care, as well as outpatient and hospital services. 3. Health care coverage should be ■ Variations in patient cost sharing could be affordable to individuals and families. used as an incentive for appropriate service ■ The main reason people give for being unin- use because this is known to influence patient sured is the high cost of coverage. Lower- behavior (IOM 2004). income families have little leeway in their budget for health expenditures, so financial assistance will be necessary for them to obtain coverage. 8 better overall health by providing financial Converging on Universal Coverage access for everyone to necessary, appropriate and effective health services” (IOM 2001a). The 2004 presidential election cycle provides The second IOM national health policy a useful lens through which to view both the goal urges that our nation should transform policy convergence and the primary roadblock its health care system so that it will be: to effective reform. The leading Republican ■ Safe – avoiding injuries to patients from the and Democratic proposals for health care care that is intended to help them. illustrate both the opportunities and the ■ Timely – reducing waits and harmful delays remaining obstacles to effective reform. for both those who receive and those who give care. The Bush Administration Proposals ■ Effective – Providing services based on sci- The Medicare Modernization Act of 2003 was entific knowledge to all who could benefit arguably the most important opportunity in and refraining from providing services to decades to move the health coverage and those not likely to benefit (avoiding under- reform consensus forward. Proponents pro- utilization and over-utilization, respectively). moted the legislation, in part, as a means to ■ Efficient – avoiding waste, including waste add a pharmaceutical benefit to the coverage of equipment, supplies, ideas, and energy. for the Medicare popula- ■ Equitable – proving care that does not vary Yet, after years tion and to set the stage in quality because of personal characteristics for the entry of private of growing such as gender, ethnicity, geographic location, sector insurance plans as and socio-economic status. bipartisan con- an alternative for seniors ■ Patient-centered – providing care that is sensus for a in the Medicare market respectful and responsive to individual Medicare drug place. Yet, after years of patient preferences, needs and values and benefit and a growing bipartisan con- ensuring that patient values guide all clinical sensus for a Medicare drug commitment to decisions (IOM 2001, 41-42). benefit and a commitment The Blue Ridge Group believes that the find at least to find at least $400 billion goals of universal coverage and a health care $400 billion to to provide one, the bill system that is safe, timely, effective, equitable, provide one, the devolved into a highly par- efficient, and patient-centered (hereinafter, bill devolved into tisan and controversial STEEEP) reflect societal aspirations for our measure. nation’s health care system around which it a highly partisan Proponents, primarily is now possible to discern a convergence of and controversial Congressional Republicans consensus. This convergence presents an measure. and President Bush, her- unprecedented opportunity for leadership alded the addition of a efforts that could effectively reform the new drug benefit and the beginning of the U.S. health care system. transformation and modernization of the A review of leading proposals for health Medicare program. Cheaper and better overall care reform shows that there is reason to health insurance coverage would result from a believe that significant progress can be made. new prescription drug benefit tied to incen- The opportunity is to build upon commonali- tives to private sector insurers to offer new ties, create the processes needed to resolve the coverage for seniors. Private sector and market remaining obstacles, and marshal the effort to innovation would catalyze quality improve- restructure our health care system. ments that empower individuals and families to become better consumers and lead to lower 9 Table 1: Summary of Leading Proposals for Health Care Reform Plan Additional Lives Covered Cost Proponents Karen Davis 39 million (if mandatory) $70 billion/yr Commonwealth Fund & Cathy Schoen1 33 million (if allow opt-out) National Coalition Universal coverage N/A 94 public and private organi- for Health Care zations representing 100 mil- Reform2 lion persons President Bush3 2.1 – 2.4 million $90 billion (2005-2014) Bush Administration Republican Party Senator Kerry4 27 million (resulting in 95 percent cover- $653 billion (2005-2014) [net Democratic Party age rate) costs inclusive of savings] PATHOS5 (Pathways to Universal coverage within 5 years N/A Paul Ellwood, Jackson Hole Healthy Outcomes) Group Center for Health N/A N/A Speaker Newt Gingrich and Transformation6 others 1. Davis & Schoen 2. NCHC 2004 3. Thorpe 2004 4. Thorpe 2004 5. Ellwood 2003 6. Gingrich, et al. 2003 10 Funding/Savings Mechanisms Key Features - Efficiency gains from switch to CHP - Congressional Health Plan (for self-employed, small businesses, - Savings from electronic administration long-term uninsured) - Cost incentives in reinsurance trust fund - Tax credits for uninsured - Federal costs for CHP premium assistance; - Medicare Part E (for uninsured 60-64, disabled in 2-yr waiting period, CHP reinsurance; Medicare premiums and Medicare dependents) COBRA; Medicare Part E; expansion of Medicaid - State Family Health Insurance Program open to everyone below 150 percent of poverty line Reduce estimated waste of $300 - $500 billion/ yr: - Health insurance for all savings through effective cost containment can - Improve quality “more than offset” the cost of universal coverage - Control total costs, stop cost shifting - Finance the system more equitably - Simplify administration Federally funded - Refundable income tax credit for those under 65 not covered by employee-sponsored insurance or public health plan - Tax deductions for premiums paid in high-deductible plans - Association health plans for small businesses and associations All costs of expansion federally funded - Medicaid and SCHIP for children under 300 percent of poverty Substantial savings from: - Medicaid and SCHIP for parents under 200 percent of poverty - Drug spending slowed: HHS negotiates costs of - Medicaid for childless couples and single adults in poverty drugs for Medicare recipients - Small businesses, adults 55-64 and those between jobs can enroll - Administrative overhead: move all transactions in new insurance pools based on FEHB from paper to electronic platform - Employers meeting criteria eligible for reinsurance coverage - Promote disease management in both private - Federal stop-loss pool reimburses health plans for 75 percent and public plans (esp. for congestive heart failure, of catastrophic cases diabetes, hypertension) - Electronic information systems required - Substantial drop in uncompensated care burden - Reduce costs of malpractice - Federal stop-loss pool reduces variances in claims, achieve 10 percent reduction in cost to insurers Based on Wyden-Hatch proposal: a Citizens - Overhaul health system (electronic health records, prevention and treatment Health Care Working Group would be appointed guidelines, health information pathways between physicians and con- to frame and conduct a national debate, with sumers, and outcomes measurement and management technology) hearings, on how to provide access to affordable - “Agreement on Responsibility” with severable contract between physician coverage for all Americans, and to make recom- and patient mendations to the Congress within 3 years - Institute for Medical Practice and Consumer Technology - Reduce inefficiencies Create a “21st century Intelligent Health System” with following features: - Improve ROI through promoting better technolo- - Information-rich health savings accounts gies and solutions - Electronic health records with expert systems to minimize errors, maximize care - New system of health justice - Create a transparent buyer’s market for prescription and OTC drugs - Create a system for capturing and promoting better solutions with superior outcomes - Develop real-time research database – make cancer a chronic disease by 2015 - Create “virtual” electronic public health network and bioshield for defense against outbreaks and attacks 11 costs for insurance and care, enabling far more The Bush Administration is committed to Americans to afford insurance and to get the significantly expanding coverage and improv- care they need (Antos and Calfee 2004). ing our systems of care through mechanisms Opponents, including most Congressional and incentives that can empower the private Democrats, saw a deeply flawed drug benefit sector to take the leadership in achieving these and large subsidies to private insurers – all goals through a vigorous marketplace. designed to hobble the Medicare program and so lead seniors into an insurance marketplace The Kerry Proposal likely to be confusing at best and treacherous Nine Democratic contenders began the race for at worst (Families USA 2004). the Democratic nomination in 2003. By the In addition to the Medicare legislation, the time of the writing of this report, Massachusetts Bush Administration has submitted to Congress Senator John Kerry is the Democratic Party several proposals designed to address the prob- nominee. A comprehensive analysis of all lem of uninsurance. The three main proposals of the Democratic contenders’ health care in President Bush’s 2005 budget are built reform proposals was maintained by the around tax policies that the Administration Commonwealth Fund claims would make health insurance more Kerry’s plan also (See: Collins, et al, 2003). affordable and hence increase coverage. These proposes a feder- Senator John Kerry’s include subsidies for individuals and families to ally funded pre- proposals for expanding help cover the cost of purchasing non-group mium rebate health insurance coverage health insurance, including a tax credit for and improving our sys- pool designed to lower-income people and a new tax deduction tems of care build on for premiums for non-group health insurance protect individu- existing private and public policies with high-deductibles. The President als, families and insurance programs and has also supported association health plans firms from finan- also add a new federal cat- (AHPs), which allow small businesses and asso- astrophic insurance pro- cial devastation ciations to purchase health insurance through gram design to reduce the large purchasing pools. The plans would be reg- in the case of cost of private insurance. ulated under federal rather than state insurance catastrophic ill- The plan would laws and would be exempt from benefit man- ness or injury. expand Medicaid and dates, and other state regulations not required SCHIP eligibility to under federal rules (Thorpe 2004a). include both children currently eligible for Despite the scope of the Bush Medicaid through 300 percent of poverty and Administration legislation, and the stated also parents of Medicaid and SCHIP kids objectives of significantly increasing coverage through 200 percent of poverty; and it would and access and lower costs, independent analy- make eligible single adults and childless cou- sis shows that none of these objectives is likely ples in poverty. New costs would be fully paid to be reached in the short or medium terms. by the federal government and states would During the early years of the plan, the three receive bonus payments during the first three programs in combination would extend cover- years of the program to enroll both those cur- age to 2.4 million uninsured. However, since rently uninsured and those newly eligible. the dollar value of the refundable credits To deal with the large number of people declines over time, the number of uninsured employed by small firms that currently cannot covered under the plan will also decline. By the afford to offer employee health care coverage, year 2014, the plan would extend coverage to Kerry would make the Federal Employees approximately 2.1 million otherwise uninsured Health Benefit Plan (FEHBP) available to those at a cost of $90.5 billion (ibid). in firms with 50 or fewer workers and unin- 12 sured individuals (including workers between Converging on Characteristics jobs). Workers between jobs, and individuals of a New Health System without access to employer-sponsored insur- ance (and not eligible for public plans), could In addition to the converging consensus on purchase insurance through the plan, with achieving universal insurance coverage, there subsidies provided based on income. is also a clear convergence on the need to Employers would contribute at least half the reform the structure and functioning of the premium and would receive a 25 percent health care system itself. The evidence of con- refundable tax credit for all workers under vergence on a creating STEEEP health care 150 percent of poverty, phasing out at system is everywhere to be found. 300 percent of poverty. President Bush has endorsed proposals to Senator Kerry’s plan also proposes a fed- improve and standardize medical record keep- erally funded premium rebate pool designed ing, billing, and information systems that to protect individuals, families and firms from would enable the development of more effi- financial devastation in the case of catastroph- cient and effective administrative and quality ic illness or injury. control programs in line with the IOM Federal costs under the Kerry plans are STEEEP aims. In April 2004, President Bush estimated to be $895 billion over ten years, called for the majority of Americans to have extending insurance to 26.7 million persons interoperable electronic who are currently not covered. This includes health records within In addition to the approximately $230 billion in federal spend- 10 years, and in doing ing for the reinsurance pool that targets those converging con- so signed an Executive with health insurance and $665 billion for sensus on achiev- Order establishing the programs targeting the uninsured (Thorpe ing universal position of the National 2004). Coordinator for Health insurance cover- Table 1 summarizes the Bush and Kerry Information Technology. and several other leading reform proposals age, there is also In May 2004, Dr. David that target achieving universal or near-univer- a clear conver- Brailer was appointed the sal health insurance coverage. In addition, gence on the nation’s first health care The Economic and Social Research Institute need to reform information technology (ESRI) has analyzed almost two dozen more “Czar.” He was charged the structure and proposals for expanded coverage and compre- with developing, main- hensive health care reform developed by a functioning of the taining, and overseeing broad cross-section of thought-leaders in health care sys- a strategic plan to guide health policy. These can be reviewed on the tem itself. nationwide adoption of ESRI website, available at http://www.esre- health information tech- search.org/covering_america.php. The ability nology in both the public and private sectors. to evaluate how these and any other proposals Secretary of Health and Human Services might succeed in achieving universal coverage Tommy Thompson and Dr. Brailer subse- has been advanced significantly by a frame- quently unveiled four goals and related work developed by the IOM Committee on strategies for bringing health care into the the Uninsured. The IOM framework is sum- information age over the next decade. marized in Appendix 1. 13 Four Goals for HHS Effort to bring Health Care into the Exhibit 2: Information Age over the Next Decade Goal 1: Inform Clinical Practice. will be interoperable and consistent with the Strategy 1. Provide incentives for Electronic national health information network. Health Record EHR adoption. The transition to safe, more consumer-friendly and regionally Goal 3: Personalize Care. integrated care delivery will require shared Strategy 1. Encourage use of Personal Health investments in information tools and changes Records. Consumers are increasingly seeking infor- to current clinical practice. mation about their care as a means of getting better control over their health care experience, Strategy 2. Reduce risk of EHR investment. and PHRs that provide customized facts and guid- Clinicians who purchase EHRs and who attempt to ance to them are needed. change their clinical practices and office opera- tions face a variety of risks that make this decision Strategy 2. Enhance informed consumer choice. unduly challenging. Low-cost support systems that Consumers should have the ability to select clini- reduce risk, failure, and partial use of EHRs are cians and institutions based on what they value needed. and the information to guide their choice, includ- ing the quality of care providers deliver. Strategy 3. Promote EHR diffusion in rural and underserved areas. Practices and hospitals in rural Strategy 3. Promote use of telehealth systems. and other underserved areas lag in EHR adoption. The use of telehealth — remote communication Technology transfer and other support efforts are technologies — can provide access to health serv- needed to ensure widespread adoption. ices for consumers and clinicians in rural and underserved areas. Goal 2: Interconnect Clinicians. Strategy 1. Regional collaborations. Local over- Goal 4: Improve Population Health. sight of health information exchange that reflects Strategy 1. Unify public health surveillance archi- the needs and goals of a population should be tectures. An interoperable public health surveil- developed. lance system is needed that will allow exchange of information, consistent with privacy laws, to Strategy 2. Develop a national health information better protect against disease. network. A set of common intercommunication tools such as mobile authentication, Web services Strategy 2. Streamline quality and health status architecture, and security technologies are need- monitoring. Many different state and local organ- ed to support data movement that is inexpensive izations collect subsets of data for specific purpos- and secure. A national health information net- es and use it in different ways. A streamlined work that can provide low-cost and secure data quality-monitoring infrastructure that will allow a movement is needed, along with a public-private complete look at quality and other issues in real- oversight or management function to ensure time and at the point of care is needed. adherence to public policy objectives. Strategy 3. Accelerate research and dissemination Strategy 3. Coordinate federal health information of evidence. Information tools are needed that systems. There is a need for federal health infor- can accelerate scientific discoveries and their mation systems to be interoperable and to translation into clinically useful products, applica- exchange data so that federal care delivery, reim- tions, and knowledge (Thompson and Brailer bursement, and oversight are more efficient and 2004). cost-effective. Federal health information systems 14 In addition, the Department of Defense, In addition, a number of bills are in the the VHA and the Department of Health and Congress from both sides of the aisle that Human Services have been major drivers of are focused on improving the communica- the electronic health information effort, tions and IT infrastructure, although it is through the Consolidated Health Informatics unlikely that they will move forward during Initiative. Key supporting roles have been this session. played by agencies such as the National Over the last two decades, a host of associ- Institute for Standards and Technology ations and philanthropic organizations have (NIST) of the Department of Commerce and undertaken major efforts to understand and the Agency for Healthcare Research and address one or more of the IOM aims. Quality (AHRQ). HHS Secretary Tommy Sponsors of these efforts include The Thompson announced in March 2003 that the Commonwealth Fund, The Robert Wood government had developed the first set of uni- Johnson Fund, The form coding standards to be used across all The Blue Ridge Pew Charitable Trusts, agencies (U.S. DHHS 2003). Group believes that The Kaiser Foundation, John Kerry would also enhance informa- all of these efforts The W.K. Kellogg tion and quality systems. His health care demonstrate what is Foundation, the reform proposal calls for: Association of ■ Providing financial incentives to help now a broad policy Academic Health providers and purchasers invest in quality convergence on the Centers (AHC) and improvement; imperative to solve many more. In addi- ■ Rewarding health care organizations and tion, many new and the problem of the physicians that invest in modern informa- non-traditional organi- uninsured and to tion systems, especially electronic medical zations have stepped records, patient registries, and reminder sys- comprehensively forward to promote one tems that improve the quality of care and reform our health or more of the six aims, help eliminate wasteful spending - with system to achieve a including The Jackson financial incentives; Hole Group, The health system that ■ Providing economic incentives to computer- Leapfrog Group, and ize prescribing systems. Such systems can adequately addresses The National Business reduce medication errors by 80 percent or the STEEEP criteria. Coalition on Health, more, and yet most hospitals and clinics do The National Coalition not use them; on Health Care (NCHC) (See Exhibit 1), and ■ Ensuring that all Americans have secure, others. Federal and State agencies too have private electronic medical records by the stepped-up their focus on the six aims, includ- year 2008; assure federal government adopts ing the Agency for Health Care Research and modern computerized methods for health Quality (AHRQ), the Medicare program, the care transactions that are widely used in Medicaid program through the State Children’s other industries; and Health Improvement Project (SCHIP), and a ■ Requiring private sector insurers to use variety of state-initiated programs. advanced systems. Private insurers would The Blue Ridge Group believes that all of have to use this simplified technology these efforts demonstrate what is now a broad standard as a condition of doing business policy convergence on the imperative to solve with the federal government (Medicare, the problem of the uninsured and to compre- Medicaid, and the federal employees health hensively reform our health system to achieve benefit program) to make health care trans- a health system that adequately addresses the actions less costly (Kerry 2004). STEEEP criteria. 15 Exhibit 3: The National Coalition on Health Care Reform Principles The National Coalition on Health Care (NCHC) has developed perhaps the most compre- hensive and broadly endorsed health reform proposal. The NCHC is the nation’s largest and broadest alliance working for the achievement of comprehensive health care reform, representing nearly one hundred of America’s largest businesses, unions, health care providers, associations of religious congregations, pension and health funds, insur- ers, and groups representing patients and consumers. The Coalition’s proposal advances five principles: 1. Health Care Coverage for All ■ urgent need for cost relief requires short-term ■ to be achieved within two to three years after constraints: the passage of legislation • rates for reimbursing providers for care ■ defined core benefit package encompassed ■ employers and individuals able to purchase sup- • only after those rates take effect, limits on plemental coverage beyond core package increases in insurance premiums for cover- age defined by that package ■ options for insuring all Americans include • employer mandates (supplemented with ■ to facilitate comparisons, insurers required to individual mandates as necessary) set premiums separately for core benefit pack- • expansion of existing public programs age and supplemental coverage that cover subsets of the uninsured • creation of new programs targeted at 3. Improvement of Health Care Quality subsets of the uninsured and Safety • establishment of a universal publicly ■ accelerated development of an integrated financed program national information technology infrastructure ■ mandatory participation for health care, including: ■ subsidies for less affluent • protocols for electronic patient records, prescription ordering, and billing 2. Cost Management • standards to protect privacy ■ within five years, bring increases in the costs and • mechanisms to incentivize and provide premiums associated with the core benefit pack- capital for the upfront investments neces- age into alignment with increases in per capita sary to build the infrastructure gross domestic product ■ measures of process and outcomes quality to ■ increase the value for patients that is generated improve accountability and help payers and by any given level of health care spending patients make better choices ■ measures include: ■ independent national board, with members • providing more and better information drawn equally from public and private sectors, for patients, providers, and purchasers to coordinate public and private efforts to • improving quality and outcomes of care and improve quality of care reducing amount of unnecessary and injuri- ■ board also responsible for coordinating develop- ous care ment of national practice guidelines • building national information technology • guidelines to be based on reviews, by panels infrastructure for health care of leading health care professionals, of • modernizing and simplifying administration research on impacts of technologies and procedures 16 Section 3: TheFuture of Health Policy: Convergence or Continued Conflict? With the goals for national health reform well defined and widely shared, the remain- ing challenge is to address the major remaining roadblock to comprehensive health care reform: As a nation, we have been unable to resolve the place of health care in our national life. As a nation, we have enacted discreet policies and programs (like Medicare and • guidelines could be cited in malpractice cases Medicaid) that treat affordable health care as as evidence of best medical practice a basic necessity. But we also continue to ■ board to update core benefit package to reflect treat health care as if it were a utility or changes in practice guidelines service to be turned on As a nation, we 4. Equitable Financing or off, like water or have been unable heat, depending on the ■ measures to reduce or eliminate cost-shifting across categories of insurance programs and payers to resolve the place individual’s ability to ■ mechanisms or sources that could be used, individually of health care in pay. Our inability as a nation to resolve the or in combination, to fund program costs include: our national life. • general revenues place of health care in • earmarked taxes and/or fees our national life is partly due to some prac- • contributions required from employers tical (primarily economic) issues and partly • contributions required from individuals and due to political (and ideological) issues. families On the practical side, there are two sig- ■ financial obligations to be adjusted, or subsidies nificant issues. The first issue is that health provided, based on relative ability to pay for less care can be expensive. Providing and paying affluent individuals, families, and employers for universal health care requires wide agree- ment (or at least acquiescence) concerning 5. Simplified Administration the need to find the means to pay for it. A ■ assurance of coverage for all Americans and estab- second practical roadblock to health care lishment of core benefit package to create consis- reform is the fact that any proposed change tent set of ground rules and reduce variations that in public policy with respect to the health now draw time and resources away from protection system affects the economic interests of many and advancement of health powerful stakeholders. Every level of govern- ■ creation of an integrated national information ment, from the local through the federal, is technology infrastructure – including electronic implicated in service, regulation, administra- patient records, prescription ordering, and billing tion and/or care delivery. The total workforce • to reduce administrative complexity, costs, and involved in health care is estimated to be medical errors about 20 million, or about 14 percent of the ■ national practice guidelines to reduce variability of workforce (U.S. BLS 2004). Total spending is care and billing and improve quality of care (NCHC estimated at $1.5 trillion, or 16 percent of 2004). GDP (Heffler, et al 2004). Consequently, designing effective reforms is a complex and high-stakes challenge. The political “capital” 17 necessary to effect significant reform is often ship must come, in largest part, from the well beyond the threshold that many policy health professions themselves. Academic health makers are willing to risk or invest. center leaders and leaders throughout medi- On the political and ideological side, there cine and the health professions must come is an ongoing standoff principally between together and step forward to provide the kind those who believe that the government and of decisive leadership that is so desperately public sector must be involved in any success- needed to advance a consensus agenda for ful comprehensive solutions to our health national health care reform. system problems and those who believe that government should have little or no role in The Role of Academic Health Centers providing access to and in allocating health in Furthering Consensus for a STEEEP insurance and services and that these responsi- Health Care System bilities should be transferred to the private Providing this decisive leadership will not be sector and the competitive market place. As easy. Over the last two decades, AHCs have any observer of American politics knows, the been among the most vulnerable of the major proposal to treat health care as a right or to health care system stakeholders, which include provide for universal access in the U.S. has, in public and private payors and providers, health every instance, been met with vigorous care professionals, and employers, among oth- resistance from influen- ers. AHCs have had to demonstrate their Where are the solu- tial individuals and capacity for change and leadership in a new institutions who believe health care environment. The Blue Ridge tions and the leader- that strengthening or Group itself was formed in large part to help ship that can resolve broadening governmen- enable AHC success in the new environment; these remaining tal health services moves and our past reports have addressed changes political and practical America towards and innovations both required of and pio- roadblocks to health “socialized medicine.” neered by some AHCs over the last decade. This ongoing ideo- To date, most AHCs have been successful in care reform? logical divide, appears adapting to the competitive market place and to have deepened in in preserving critical sources of support. recent years. Where are the solutions and the They have accomplished significant reforms leadership that can resolve these remaining throughout their missions and operations. political and practical roadblocks to health They are starting to focus on leading a new care reform? Is there any hope of resolving the century of advances in health and healing, place of health care in American life? through pioneering work in genomics, The Blue Ridge Group believes that there nano-medicine, prospective medicine, and is hope. Public policy consensus continues to evidence-based care. grow in favor of a STEEEP health care system; and this growing consensus continues to push Time to Take the Offensive both state and federal policy makers to find The challenge now for leaders in the AHCs and better solutions. However, the “tipping point” in the health professions is to emerge from an has not yet been reached where it is possible to era of intense inward-looking focus on their overcome the ongoing practical and political own institutional challenges and to take the next barriers to significant reform. To reach this tip- steps in leading STEEEP health care reform. ping point will require courageous leadership AHCs and their leaders, and other leaders that can galvanize and leverage the broadest in medicine, are now poised to move from the constituency of stakeholders around the neces- defensive to an offensive posture. sity of STEEEP health care reform. This leader- AHCs must take the lead in modeling 18 and developing STEEEP approaches to—and and is being studied at other AHCs (Landro, WSJ, systems of—care that can demonstrate proof 2004). Duke is offering the plan to 31,000 of concept in the widest possible array of employees, along with its partners Physician populations, disease states and settings. At the WebLink, the Duke Center for Integrative same time, leaders in the medical and other Medicine, and PrimaHealth IA Physicians. health professions must take the lead in advo- Duke University Health System is moving cating for better systems of care and a national progressively across several fronts to show how focus on better health and better public health an academic medical center can be both a preparedness. research-intensive creator of future-oriented Through our own innovations and approaches to health care, as well as a major demonstrations and in partnership with the employer that administers its own medicine to public and private sectors, we must demon- employees. In 2003, Duke and The Center for the strate and advocate for the vast improvements Advancement of Genomics (TCAG) announced in health services and population status that that they would collaborate to create “genomic- are possible in a system that is STEEEP and based prospective medicine,” keyed to the spe- accessible to all. cific genetic profile and risk factors of individual A prime opportunity for AHCs is to focus patients. The collaboration is focused on on what no STEEEP system can do without: a research in cardiovascular, hematologic, and basic set of necessary, appropriate and effec- infectious diseases, to determine whether tive health services, built on a sound base of genomic predictors could support interventions science, practice and policy. Policy advocates in defined patient populations to prevent dis- have circled around the concept of ‘minimal ease or begin treating it earlier in its course. essential services’ for years but no group has The Blue Ridge Group applauds this and been either courageous or committed enough other such efforts. Never has the ancient maxim to comprehensively address this crucial issue. seemed more apropos: Physician, heal thyself. In Vital elements and precursors and many major urban areas. AHCs are both among examples of such necessary, appropriate and the largest private employers, and the owners of effective health services can be found in pilot the largest and most comprehensive healthcare initiatives and models that have been and are systems. We can use and evaluate emerging being sponsored by and with AHCs in techniques of health promotion, disease preven- localities and states throughout the nation. tion and management, and increasingly, restora- A number of prime examples follow: tive or regenerative medicine to manage costs and improve health in our own employee popu- AHCs As Innovators in Employee Health lations, with our own doctors and treatment In January 2004, Duke University Health System facilities. (See: http://www.dukemednews.org/mediakits/ unveiled a new employee health plan, detail.php?id=7388#summary) Prospective Health Care, which will create indi- vidualized profiles of health status and health The AHC as Partner with Private Sector and risk, targeted to early detection and prevention Local and State Government in Defining and of diseases and conditions. Participants will Rewarding Appropriate Care: The University receive an individual health plan and health of Virginia (See: Garson 2004a) coaching, and persons who are at highest risk The Institute of Medicine has recommended that will be assigned to nurse care managers. Duke's state models be developed as demonstration program was acclaimed as "pioneering" by The building-blocks for nationwide health care reform Wall Street Journal, which noted that similar (IOM 2004). Working at the state level, it is possi- work is underway in some managed care groups ble to create specific programs and models to (such as the Group Health cooperative in Seattle) expand access, decrease cost and improve quality. 19 In Charlottesville, Virginia, The University of more than 100 agencies and organizations from Virginia Medical Center (UVMC) is working in both the private and public sectors, launched in partnership with Anthem Health Care to signifi- 2002. The project has a goal of speeding adop- cantly improve Medicaid patient care and out- tion of common electronic data standards, while comes. The University of Virginia has created a protecting privacy and security, in order to free proposal and is working with Anthem and the health care system from dependence on Medicaid on a reimbursement system with an paper and realize all the economic and quality incentive to physicians that is rooted in practice advantages of a system based on electronic guidelines created by medical specialty societies health records. Along with representatives of and tied to quality-based reimbursement. major government agencies such as CDC, the The proposal is based on the understanding FDA, the Veterans Health Administration, and that attainment of the STEEEP aims must be the Office of Disease Prevention and Health based in providing the most appropriate care Promotion, and HHS, Connecting for Health’s possible. Such care can be informed by practice steering group has representation from the guidelines that are carefully developed by repre- AAMC, Partners Healthcare, Cleveland Clinic, New sentative groups of physicians and professional York-Presbyterian, and scores of other private as societies, and based on evidence. Despite the well as public groups. A demonstration project widespread development of guidelines, physician called the Healthcare Collaborative Network joins practice does not always match the guidelines, New York Presbyterian Hospitals, Vanderbilt and there is wide variation across the country. University Medical Center, and Wishard Memorial While practice guidelines do not completely Hospital, among others. In this initiative, data define appropriate care for every individual, from certain laboratory tests and other proce- in most cases, practice guidelines provide the dures at participating hospitals will be shared best information for the individual patient. To with the CDC (for infectious disease surveillance), improve physician compliance with guidelines, with the FDA (for tracking adverse reactions to the UVMC partnership with Anthem and medications), and with CMS (for quality of care Medicaid proposes to reward physicians for com- tracking of Medicare beneficiaries). pliance with guidelines and achievement of year- Most recently, the Robert Wood Johnson ly performance measures centered on the top ten Foundation joined with the Markle Foundation Medicaid diagnoses. Additionally, where relevant to support the next phase of this work, which guidelines do not indicate a particular test or includes an incremental “road map” of specific treatment is not indicated, that test or treatment action steps to be taken going forward. will not be reimbursed. The entire program is built on the participation of all relevant profes- The AHC as a Partner in Major Nationwide sional associations and nationally recognized e-HEALTH INITIATIVE guidelines maintained by the AHRQ National (See: www.ehealthinitiative.org) Guideline Clearing House and professional Also representing the combined efforts of some societies. A fuller outline of this proposal is 100 organizations, the The eHealth Initiative and presented in Appendix 2. the Foundation for eHealth Initiative, launched in 2001, are working to promote the development The AHC in Partnership for Adopting and adoption of interoperable electronic health Common Electronic Data Standards by CON- records with appropriate levels of access by con- NECTING FOR HEALTH sumers, providers, payers, and public health (See: http://www.connectingforhealth.org) agencies. The adoption of modern information Sponsored by the Markle Foundation with technology holds great promise for reducing initial funding of $2 million, Connecting for errors, improving the quality of care delivered, Health is a significant collaborative effort of reducing costs, and empowering patients and 20 families to better understand and address their within communities who are using IT and own health care needs. The ability to fulfill this health information exchange to address quali- promise is hindered by the proliferation of com- ty, safety and efficiency goals. This program peting and incompatible information and will demonstrate value and evaluate impact records systems and the failure to develop and of IT and further the development of strategies adopt nationwide clinical data standards. The and tools to facilitate an electronic health mission of the eHealth Initiative and the information infrastructure. Foundation for eHealth Initiative is to drive improvement in the quality, safety, and efficiency ■ The EHR Collaborative. This is a consortium of of healthcare through information and informa- health care information technology-related tion technology by engaging hospitals and other associations working together to achieve com- healthcare organizations, clinician groups, mon goals related to the adoption of standards employers and purchasers, health plans, health- across the healthcare community. care information technology organizations, manufacturers, public health agencies, academic ■ The Healthcare Collaborative Network. This and research institutions, and public sector network has launched a national demonstra- stakeholders. tion project involving large hospitals, leading Sponsoring organizations include a number healthcare technology leaders, and three feder- of academic medical centers, including New York al agencies, which is designed to demonstrate Presbyterian Hospital, the University Hospitals of both the feasibility and value of an electronic Columbia and Cornell, East Carolina University, model of standardized data interchange to Georgetown University Medical Center, The support public health, quality and safety goals. Johns Hopkins University Medical Center, Duke University Health System, and the universities of ■ Investing in America’s Health. This project is a Pittsburgh, Tennessee, Texas, and Virginia. Public large-scale communications campaign designed sector partners include the AHRQ, Department to raise national awareness of the role of of Defense, National Library of Medicine, and information technology in addressing quality, many leading corporations, professional societies safety and efficiency challenges in the U.S. and health advocacy organizations. healthcare system. The eHealth Initiative is addressing these problems through advocacy, education and other ■ The Leadership in Global Health Technology informational activities. Programs supported Initiative is facilitating an international dia- by the eHealth Initiative and Foundation for logue among both industrialized and develop- eHealth Initiative include: ing countries regarding policies and methods to implement a health information infrastruc- ■ Accelerating the Adoption of Computerized ture to support common quality, safety, and Prescribing in the Ambulatory Environment. efficiency goals. This initiative engages stakeholders from across every sector of the prescribing chain to develop ■ Through a coordinated Outreach to Employers, design, implementation and incentives recom- the eHealth Initiative has employers in a dia- mendations that will facilitate the effective logue to foster and support employer and and rapid adoption of electronic prescribing purchaser efforts to advance the safety, quality in the ambulatory environment. and efficiency of healthcare through the adop- tion of an interconnected, electronic health ■ Connecting Communities for Better Health information infrastructure. Representatives Program. This program provides seed funding from sixteen large private employers came to and support to multi-stakeholder collaboratives Washington D.C. in July 2003; to begin laying 21 the foundation for a long-standing, collabora- likely that most of this good work remains tive relationship between eHI and employers. unknown to the public or even to policy experts or other interested parties who are not ■ The Public-Private Sector Collaboration for directly involved in it. Even as and when one Public Health. This initiative has engaged multi- or another effort gains some public exposure, ple stakeholders across every sector of health- it is seldom linked to other similar or comple- care to develop strategies and methods for mentary efforts. leveraging standards-based information AHCs and others are truly pioneering systems to support public health surveillance, tomorrow’s health and health care systems. management and response. But traditional academic and other local “own- ership” boundaries contribute to a lack of The AHC as Partner with Private Industry common knowledge, coordination or other for Disease Management: The University of timely, systematic and structured sharing of Michigan, GM and Ford methods and outcomes among these many (See: http://www.med.umich.edu/partnershiphealth/ efforts. This means that they fail to play the and http://conferences.mc.duke.edu/2002dpsc.nsf/ role that they could and should in promoting contentsnum/bh.) the health policy convergence and in moving Since 1997, the University of Michigan has public policy past the remaining political and worked in a pioneering partnership with both practical roadblocks to significant health sys- the Ford Motor Company and with General tem reform and health status improvement. Motors to develop and implement innovative Overwhelmingly, this is because each of our employee health plans featuring high intensity centers has operated as if they were castles medical and disease management. Current UMHS in separate nation-states rather than being programs include Partnership Health, a collabora- national resources facing and addressing tion with Ford, and Activecare, a collaboration common problems and opportunities. with GM. John E. Billi, M.D., Associate Dean for AHCs and their partners have the capacity Clinical Affairs of the University of Michigan to change this. The Blue Ridge Group believes Medical School, and Associate Vice President for that the time has come to dramatically increase Medical Affairs of the University of Michigan, and improve the coordination, sharing and serves as co-chair of two regional evidence-based cooperation between and among AHCs. At quality improvement initiatives including the present there are several associations that play Southeast Michigan Quality Forum and the important roles in coordinating common areas Michigan Quality Improvement Consortium. of policy and advocacy. But their agendas historically have not accommodated the degree The AHCs as Catalysts of Change of collaboration we feel is needed. and Progress The Blue Ridge Group recommends that The foregoing is a just a sample of the hun- the following steps be taken to focus AHCs dreds of vitally important programs and initia- and their professional and other human tives being pursued and modeled by AHCs and resources on realizing the goal of achieving a their public and private partners. They are STEEEP health system, accessible and afford- doing their part in the national challenge to able to all. create a STEEEP health care system. Yet, it is 22 Recommendations 1. All AHCs should formally adopt the goal of achieving a reformed health system and proceed to develop the research and educational agenda needed to assure that our nation provides: a. health insurance that will promote better overall health by providing financial access for every- one to necessary, appropriate and effective health services, and b. a health care system that is safe, timely, effective, efficient, equitable and patient-centered (STEEEP). 2. This implies that AHCs identify and adopt in each of their missions best practices that lead to promotion of universal coverage and each of the IOM’s STEEEP aims. This includes programs that promote these goals and values in programs involving: a. student and resident education and training b. patient education c. community outreach and partnerships d. clinical services e. the conduct of translational research and development 3. AHCs should adopt the IOM’s STEEEP aims in their roles as employers. a. Many AHCs have some of the largest and most comprehensive health care delivery systems and are among the largest private employers in their regions. Both as employers and as health care providers, AHCs have a special opportunity and responsibility to be leaders in health promotion and chronic disease management with their own their employees. 4. AHCs have a responsibility to be both leaders and partners in the adoption and improvement of IT systems in education, clinical care and research for their regions. 5. AHC and professional leaders can be seen to have a special responsibility to sustain and promote achievement of a STEEEP health system not just at the local and state levels, but at the national level as well. National-level leadership from those at the highest levels of practice, administration, and innovation is indispensable to bringing about meaningful and lasting change. With respect to recommendation #5, the Blue Ridge Group believes that AHC and professional and academic leaders should take a further, unprecedented step. AHC and professional and academic lead- ers must, as a group, move to a more cooperative and common agenda for national health reform. They must align and coordinate resources and agendas so that, as a group, they can act as the major leader- ship force that the AHC and medical community must be in determining the future of the health care system. While many AHCs are quite different from others, all share the difficulties of achieving best practices in health care, education and research within the current environment. AHCs should build on their commonalities to develop a much more shared sense of vision and collaboration. 6. The Blue Ridge Group recommends an AHC STEEEP Leadership Summit. The objective of the plan- ning process for the summit, its agenda, and ultimate execution will be to create the policy consen- sus and the resource and organizational capabilities to make the AHC and health professions com- munity a major leadership force for the future of the American national health care reform. a. We propose the following as a roadmap for this process: 1. AHC STEEEP Leadership Congresses should be designed to bring together AHC and health professions leaders, on an 18 month timeline, in regional and/or in other relevant groupings to define a common leadership vision and agenda for American health care for 2020. 2. These Congresses should establish requisite working groups with timelines to develop a consensus vision, agenda and proposed action plans and required resources over a period of 12 months. 23 3. Out of these Regional congresses a leadership steering committee should be formed to plan for an AHC STEEEP Reform Leadership Summit. The STEEEP Steering Committee would be charged with defining a consensus vision and an action plan, and to plan the Summit, perhaps by forming an executive planning committee. 4. An AHC STEEEP Reform Leadership Summit would be convened where the vision, plans and resource requirements would be presented, refined and ratified. Out of this process, the goal would be for the AHC community to develop the resources, struc- tures and/or organizational and institutional capability to be a major leadership force for future of the American health care system. This proposal contemplates that the existing organizations that represent various aspects of the AHC will be significant actors in this effort, including the AAMC, the AHC, the AMA and many other provider and professional organizations. The call for a Summit is in no way meant to suggest that one or another or some combination of existing organizations might not be identified as the right and best organization or entity through which to organize and coordinate the STEEEP Reform Summit. But it is to say that our current coordination and leadership capabilities and mindsets are not nearly sufficient to what is required of us. Either one or more of our existing organizations must be vastly strengthened and resource-enhanced, or else combined – or we must find the new organizational form or nexus with which we can become the pro-active and effective leadership force that is required. The convergence of public and policy consensus around the need for universal health insurance coverage and a health system that is safe, timely, effective, efficient, equitable, and patient-centered is at risk of devolving into a new era of partisan dysfunction. Achieving the promise of a healthy future requires the leadership that only a strong, visionary and unified AHC community of leadership can provide. It is time to step up and provide that leadership. Principles Developed by IOM Committee by which to Evaluate Appendix 1. Proposals for Universal or Near-universal Access to Affordable Health Coverage. Four Prototype Reform Strategies In its final report, the IOM Committee on the Uninsured made a bold attempt to address this road- block. It developed a model approach that stakeholders could adopt in evaluating how well different approaches to health care reform might address the problem of uninsurance. The Committee ana- lyzed the range of health care reform proposals and divided them into four basic approaches. It then applied its five basic principles for health care reform (see Exhibit 1 above) to each in order to begin to characterize how each approach might perform with respect to each principle. The IOM committee’s approach illustrates the possibilities for systematically evaluating the ability of particular reform proposals to achieve universal or near-universal insurance coverage and the “six aims.” Each of the four prototypes would require system change, ranging from least to most. Prototype 1: Major public program expansion and new tax credit The current favorable tax treatment for employment-based private insurance would remain. Employers would not be required to offer coverage. Medicaid and SCHIP would be combined; Medicare would be extended to 55 year olds who pay a premium. A tax credit would be provided for moderate-income individuals to purchase private insurance; the tax credit would be both refundable if a person owes no taxes and available as a credit when the policy is purchased. 24 Prototype 2: Employer mandate, premium subsidy, and individual mandate Employers would be required to offer coverage and contribute to their workers’ premiums, although a federal premium subsidy would be available for employers of low-wage workers. Medicaid and SCHIP would be merged, and Medicare would remain as it is. Individuals would be required to obtain cover- age through work, through enrollment in a public program, or through individual purchase. Prototype 3: Individual mandate and tax credit It would be the responsibility of individuals to provide health insurance for themselves and their families through the private market. Each person would become eligible for an advance, refundable tax credit. The federal government would administer the tax credit. However, insurance regulation would remain at the state level. Medicaid and SCHIP would be eliminated, but Medicare would remain as is. Prototype 4: Single payer Everyone would be enrolled in a single, comprehensive benefit package, but persons could pur- chase supplemental policies for non-covered services. This approach would be administered and funded federally but would use contractors and private health plans to review claims and process payments, much as Medicare does now. A “global budget” would help control aggregate health care spending. Medicaid and SCHIP would be eliminated; those currently eligible for Medicare could be folded into the single payer model. Assessing Reform Strategies Using the Principles Each prototype meets some principles better than others. For example: ■ Universality. Universal coverage is more likely to be reached through any model with mandated coverage, compared to the voluntary approach of Prototype 1. ■ Continuity. Continuity and portability of coverage remain issues for Proto-types 1 and 2, particularly when a person changes jobs or family relationships change. The single payer model, Prototype 4, would most successfully eliminate gaps in coverage. ■ Affordability and Sustainability. Affordability of any plan to individuals, families, and the country would depend on the size of subsidies or tax credits and cost sharing requirements. Tax credits going to low and moderate income individuals would be more progressive and equitable than current tax exemptions for employment-based coverage. One value of a tax credit is that the federal income tax is a relatively sustainable source of revenue compared to current funding sources. ■ Enhancing Access to High Quality Care. There would be more federal leverage in designing a comprehensive benefit package in Prototypes 3 and 4. Single payer models, much like Medicare, are generally considered to have substantially lower administrative costs than private insurance plans, since the need for advertising, underwriting, and much eligibility and billing work disappears. Implementation of comprehensive reform based on any of these four prototypes could more nearly achieve each principle than does the current hodgepodge of insurance mechanisms. 25 Appendix 2. Leadership and Innovation for the Future of Health Care The University of Virginia: AHC as Partner with Private Sector and Local and State Government IMPROVING QUALITY OF CARE: A PARTNERSHIP OF MEDICAID WITH PHYSICIANS The dimensions of “quality” have been defined by the Institute of Medicine as effectiveness, efficiency, safety, timeliness, patient-centeredness and equity. Many of these can be improved by providing the most appropriate care possible; such care can be informed by practice guidelines that are developed by representative groups of physicians, and based on evidence. Most certainly, practice guidelines do not completely define appropriate care since patients are individuals and care must fit the patient. Nonetheless, in more cases than not, practice guidelines provide the best information for the individual patient. Despite the presence of guidelines, physician practice does not always match the guidelines, and there is wide variation across the country. Numerous attempts have been made to improve physician compliance with guidelines, including chart reminders, preprinted orders, patient reminders and visits with physicians from known experts. It has been hypothesized that payment may be a stimulus that could lead to better compliance. The Institute of Medicine has endorsed this practice, recognizing that care may not be permitted to fall below a certain standard, but that it would be appropriate to pay for quality above that standard. Accordingly, this proposal is made in which payment will be tied to practice guidelines. To incent positive use of the guidelines, performance measures derived from national guidelines will be the benchmark, and after a lower limit of performance is chosen, payment will be made for measures above this level (e.g. after acute myocardial infarction, 85% of patients receive beta blockers). Additionally, to incent the reduction in waste, if a national organization has recom- mended that a test or treatment is not indicated, this test or treatment will not be reimbursed. METHODS 1. To make the greatest impact, the 30 most costly Medicaid diagnoses in Virginia (10 highest inpatient, outpatient and emergency room) were tabulated. 2. These diagnoses were submitted to the US Agency for Healthcare Research and Quality Guidelines Clearing House, and 10 diagnoses were chosen that had national guidelines and performance measures that were based on data as much as possible and that had the most consistent guidelines across different organizations preparing them. The diagnoses were: 1. Asthma 2. Congestive heart failure 3. Acute respiratory failure—adult 4. Pneumonia 5. Chronic renal failure 6. Sickle cell disease with crisis 7. Newborn respiratory distress syndrome 8. Neonatal jaundice 9. Schizophrenic disorders 10. Dementia 26 3. Since these guidelines will now be used for payment, it will be important to be certain the performance measures and non-reimbursed tests and procedures are current and that experts from Virginia validate these as applicable. a. The president of the physician specialty society in Virginia that is most closely allied with the diagnosis will be contacted. i. Willingness to participate in a session of “vetting” the guideline in their area of expert- ise will be assessed. b. For those willing to participate, the guidelines and performance measures will be sent to 6 specialists in the field chosen by the president; additionally, 4 generalists will be asked to participate, from Virginians nominated by the American Academy of Family Practice, American College of Physicians, and American Academy of Pediatrics. i. Individuals will be asked initially to choose 5 performance measures for positive reinforcement and 5 tests/treatments for non-reimbursement. 1. For the initial pilots, inpatient measures may be more efficient to measure and report 2. They will be asked to choose those performance measures that, in their opinion, are not being done consistently; and for non-reimbursed tests/treatments, those that are being performed, but should not be. 3. For drugs, an evidence-based formulary (based on guidelines) will be needed for pharmacists; the percent of a physician’s prescriptions for a given condition that meet the evidence-based criteria could serve as one of the performance measures 4. A telephone conference call will then be held and a modified-Delphi approach will be used to achieve consensus on between 3-5 measures in each category. 4. Three diagnoses will then be piloted. The cardiologists have agreed to pilot congestive heart failure. a. Methodology for the following will need to be developed: i. Data collection and analysis—must be HIPAA compliant 1. For performance measures, an aggregate will be required at the end of the year. This is be collected by either a. physician self-report, or b. concurrent data transmission. a. Physician self-report i. There would be no pre-approvals. ii. Physicians are paid through the year for each patient. iii. Software would be developed and provided by Medicaid. This would contain a form that would list applicable performance measures as well as Class III indications. For each patient on the list, physician (or staff) would mark applicable performance measures (e.g. patient had ventricu- lar function test during the year, etc). If the patient had a Class III indi- cation, the physician could indicate a reason for an exception (why this should be paid). Otherwise, Class III would not be paid (and would result in a need for reimbursement to Medicaid). iv. The physician’s office would keep the record concurrently with each patient visit. v. At the end of each year, Medicaid would send each physician/physician group a list of patients with the diagnosis from ICD-9 codes. Those patients would be downloaded from the software. 27 1. Return of the form would trigger a payment by Medicaid for the time taken to collect the data (“payment for structure”). 2. Payment would also be made for the aggregate performance meas- ures. Any non-payment for Class III would be deducted. At least in the first year of the program, if the deductions for Class III exceeded positives for performance measures, the physician would not be asked to repay. 3. Physicians choosing not to participate would not be required to do so. b. Concurrent data transmission i. Electronic methods could be available to tie a test/treatment to a guideline electronically (e.g. a test would require coupling to a diagnosis). 1. Concurrent review using electronic methodology could be developed related to practice guidelines. 2. A methodology for dealing with exceptions will need to be devel- oped. Certain patients do not fit the guidelines and exceptions must be granted. The medical director would ultimately grant these excep- tions using the guidelines developed by the physician advisory com- mittee for that condition. 3. This could be done by a web-based tool using a screen similar to current preapproval screens, but where the physician could log the exception on the web. In any event, exceptions must be noted in the chart (ie, the reason that the patient does not fit the guideline). —Note: enhanced FMAP is available for Medicaid Information Technology c. For either method, random audits would be performed i. Auditing could be done by telephone after a letter/email was sent with the names of the charts to be audited. 2. Pilot physician groups will be chosen (3). The adherence to guide- lines will be measured in those groups before and after the program goes into effect. 3. Payment amount and methodology. It is recommended that for posi- tive change, a 10% premium is needed for CPT codes involved in performance measures. 4. Calculation of cost of the program and both financial benefit as well as medical effectiveness. 5. Communication with physicians about the program. These pilots will last for one year, following which other physician groups and diagnoses will be added. 28 References Chernew, M.E., Hirth, R.A., Cutler, D.M. 2003. Increased Spending on Health Care: How Much Can the United States Afford? Health Affairs. Vol. 22 no. 4, Antos, J and Calfee, J.E. 2004 Of Sausage-Making and 15. Medicare. American Enterprise Institute (AEI) Online Health Policy Outlook. Available online at: Collins, S.R., Davis, K., Lambrew, J.M. 2003. Health http://www.aei.org/research/health/publications/pubI Care Reform Returns to the National Agenda: 2004 D.19765,projectID.8/pub_detail.asp. Accessed 10/5/04. Presidential Candidates’ Proposals. Washington D.C.: The Commonwealth Fund. Association of American Medical Colleges. 2002. AAMC Graduation Questionnaire: All Schools Davis, K. and Schoen, C. 2003. Creating Consensus Report, 2002. Washington DC:, Association of on Coverage Choices. Health Affairs Web Exclusive. American Medical Colleges. http://www.healthaffairs.org/webexclusives/. Accessed 10/4/04. Blue Ridge Academic Health Group (BRAHG). 1998. Academic Health Centers: Getting Down to Business. Detmer, D.E. 2003. Building the National Health Washington, D.C.: Cap Gemini Ernst & Young U.S., LLC. Information Infrastructure for Personal Health, Health Care Services, Public Health, and Research. Blue Ridge Academic Health Group. 1998a. BMC Medical Informatics and Decision Making 3, no. Promoting Value and Expanded Coverage: Good Health 1. 1472. is Good Business. Washington, D.C.: Cap Gemini Ernst & Young U.S., LLC. Ellwood, P.M. 2003. Crossing the Health Policy Chasm: Pathways to Health Outcomes. Jackson Hole Blue Ridge Academic Health Group. 2000. Into the Group Policy Paper. 21st Century: Academic Health Centers as Knowledge Leaders. Washington, D.C.: Cap Gemini Ernst & Enthoven, A.C. 2003. Employment-Based Health Young U.S., LLC. Insurance is Failing: Now What? Health Affairs Web Exclusive. Available online at: http://www.healthaf- Blue Ridge Academic Health Group. 2000a. In Pursuit fairs.org/webexclusives/hadley_web_excl_052803.htm. of Greater Value: Stronger Leadership in and by Accessed 10/4/04. Academic Health Centers. Washington, D.C.: Cap Gemini Ernst & Young U.S., LLC. Families USA. 2004 The Health Care Crisis In America: Facing Problems, Finding Solutions. July Blue Ridge Academic Health Group. 2001. e-health 2004 Issues Brief. Available Online at: and the Academic Health Center in a Value-driven http://www.familiesusa.org/site/PageServer?page- Health Care System. Washington, D.C.: Cap Gemini name=Health_Issues_2004. Accessed 10/5/04. Ernst & Young U.S., LLC. Garson, A. 2004. U.S. Healthcare: The Intertwined Blue Ridge Academic Health Group. 2001a. Creating Caduceus of Physicians, Coverage, Quality and Cost. J. a Value-driven Culture and Organization in the Am. Col. Cardiology. Vol 43, no.1: 1-5. Academic Health Center. Washington, D.C.: Cap Gemini Ernst & Young U.S., LLC. Garson, A. 2004a. Health Care for all of U.S.: Start with the States. Harvard Health Policy Review. Vol 5, Blue Ridge Academic Health Group. 2003. Reforming no. 1 Spring 2004:47. Medical Education: Urgent Priority for the Academic Health Center in the New Century. Atlanta, GA: Gingrich, N., Pavey, D., Woodbury, A. 2003. Saving Emory University. Lives & Saving Money. Washington, D.C. Alexis de Tocqueville Institution. Blumenthal, D. 1997. The future of quality measure- ment and management in a transforming health care Glied, S. 1997. Chronic Condition: Why Health Reform system. JAMA 278 (19):1622-25. Fails. Cambridge, MA: Harvard University Press. Burros, M. 2004. New Approach to Childhood Hadley, J. and Holahan, J. 2003. Covering the Obesity Urged. New York Times. October 1, 2004. Uninsured: How Much Would It Cost? Health Affairs Web Exclusive. Available online at: Butler, S.M. 2003. The Medicare Drug Bill: An http://www.healthaffiars.org/webexclusives/hadley_we Impending Disaster for All Americans. Online. b_excl_060403.htm. Accessed 10/4/04. Heritage Foundation June 13, 2003 (Executive Memorandum #885). Accessed Online 10/4/04. Heffler, S., Smith, S, Keehan, S., Clemens, M. K., Available at: http://www.heritage.org/Research/ Zezza, M., Truffer, C. 2004. Health Spending HealthCare/bg1636.cfm. Projections Through 2013. Web Exclusives, A Supplement to Health Affairs, January to June 2004. 29 Institute of Medicine, 1999. To Err Is Human: #397. Available online: http://www.heritage.org/ Building A Safer Health System. Washington, D.C.: Research/HealthCare/wm397.cfm. Accessed 10/4/04. National Academy Press. Moffit, R.E. 2004. Lessons of Success: What Congress Institute of Medicine, 2001. Crossing the Quality Can Learn from the Federal Employees Program. Chasm: A New health System for the 21st Century. Heritage Foundation WebMemo #565. Available Washington, DC: National Academy Press. online at: http://www.heritage.org/Research/ HealthCare/wm565.cfm. Accessed 10/4/04. Institute of Medicine, 2001a. Coverage Matters: Insurance and Health Care. Washington, D.C.: National Coalition on Health Care (NCHC). 2004. National Academy Press. Building a Better Health Care System: Specifications for Reform. Washington, D.C. Available Online at: Institute of Medicine, 2002. Care Without Coverage: http://www.nchc.org. Too Little, Too Late. Washington, D.C.: National Academy Press. Newhouse, J.P. and Reischauer, R.D. 2004. The Institute of Medicine Committee’s Clarion Call for Institute of Medicine, 2002a. Health Insurance is a Universal Coverage. Health Affairs Web Exclusive Family Matter. Washington, D.C.: Supplement, January to June 2004. National Academy Press. Oberlander, J. 2003. The Politics Of Health Reform: Institute of Medicine, 2003. Health Professions Why Do Bad Things Happen To Good Plans? Health Education: A Bridge to Quality. Washington, D.C: Affairs Web Exclusive. Available at: National Academy Press. http://content.healthaffairs.org/cgi/content/full/hlthaff. w3.391v1/DC1. Accessed 10/4/04. Institute of Medicine, 2003a. A Shared Destiny: Community Effects of Uninsurance on Individuals, Oliver, T.R., Lee, P.R., Lipton, H.L. 2004. A Political Families and Communities. Washington, D.C.: History of Medicare Prescription Drug Coverage. The National Academy Press. Milbank Quarterly. Vol. 82, No. 2:283-354. Institute of Medicine, 2003b. Hidden Costs, Value Owcharenko, N. and Moffit, R.E. 2003. How the Lost: Uninsurance in America. Washington, D.C.: President’s Health Care Plan Would Expand Insurance National Academy Press. Coverage to the Uninsured. Heritage Foundation Backgrounder #1636 March 11, 2003. Accessed Online Institute of Medicine, 2004. Insuring America’s 10/4/04. Available at: http://www.heritage.org/ Health: Principles and Recommendations. Washington, Research/HealthCare/bg1636.cfm. D.C.: National Academy Press. Reinhardt, U.E., Hussey, P.S., Anderson, G.F. 2004. Institute of Medicine, 2004a. Academic Health U.S. Health Care Spending in An International Centers: Leading Change in the 21st Century. Context. Health Affairs Vol. 23, no. 3 Washington, D.C: National Academy Press. Rubin, E.R.R. and Schappert. 2003. Meeting Health Johnson, H. and Broder, D. S. 1997. The System: The Needs of the 21st Century. Washington D.C. American Way of Politics at the Breaking Point. Boston, Association of Academic Health Centers. MA: Little, Brown and Company. Stoline, A.M. and Weiner, J.P. 1993. The New Medical Kerry, J. 2004. John Kerry’s Plan To Make Health Care Marketplace: A Physician’s Guide to The Health Care Affordable To Every American, JohnKerry.com. System in the 1990’s. Baltimore, MD: The Johns Available online at: http://www.johnkerry.com/issues/ Hopkins University Press. health_care/health_care.html. Accessed 10/5/04. Thompson, T. and Brailer, D. 2004. The Decade of Ludmerer, K. 1999. Time to Heal: American Medical Health Information Technology: Delivering Education from the Turn of the Century to the Era of Consumer-centric and Information-Rich Health Care, Managed Care. New York; Oxford U. Press. Framework for Strategic Action. Presentation to The Secretarial Summit on Health Information Technology, Miller, W., Vigdor, E.R., Manning, W.G. 2004. July 21, 2004, Washington, D.C. Available online: http:// Covering the Uninsured: What is it Worth? Bethesda, www.hsrnet.net/nhii/materials.htm. Accessed 10/5/04. MD. Web Exclusives, A Supplement to Health Affairs, January to June 2004. Thorpe, K.E. 2004. Federal Costs and Savings Associated with Senator Kerry’s Health Care Plan. Moffit, R., Owcharenko, N., Hunter, D. 2004. The Available Online: http://www.sph.emory.edu/ State of Health Care. Heritage Foundation WebMemo hphpm.html. Accessed 10/4/04. 30 Thorpe, K.E. 2004a. Federal Costs and Newly Insured U.S. Census Bureau. 2004. Income, Poverty, and under President Bush’s Health Insurance Proposals. Health Insurance Coverage in the United States: 2003. Available Online: http://www.sph.emory.edu/ Washington D.C., U.S. Department of Commerce. hphpm.html. Accessed 10/4/04. U.S. Congress. 2003. H.R. 1: Medicare Prescription Thorpe, K.E., Florence, C.S., Joski, P. 2004. Which Drug, Improvement and Modernization Act of 2003. Medical Conditions Account For The Rise In Health Washington D.C. Gov. Printing Office. Care Spending? Health Affairs Web Exclusive. Available online at: http://content.healthaffairs.org/cgi/ U.S. Department of Health and Human Services content/full/hlthaff.w4.437/DC1. (U.S. DHHS). 2003. Federal Government Announces First Federal Egov Health Information Exchange U.S. Bureau of Labor Statistics (U.S. BLS). 2004. Standards. Press Release. Available Online at: Employment Situation Summary: August 2004. http://www.hhs.gov/news/press/2003pres/20030321a.h Washington D.C. Available Online at: tml. Accessed 10/5/04. http://www.bls.gov/news.release/empsit.nr0.htm. Accessed 10/05/04. Notes 31 Blue Ridge Academic Health Group Report ORDERING INFORMATION If you would like to order copies of this publication—or any of the others listed below—please contact Nicole Price Woodruff Health Sciences Center Emory University 1440 Clifton Road, Suite 400 Atlanta, GA 30322 Phone: 404-778-3500 Fax: 404-778-3100 blueridge@emory.edu When requesting publications, please refer to the report number and title and provide your full name, organization name, business address, city, state, zip, telephone, and email. Report 8: CONVERGING ON CONSENSUS? Planning the Future of Health and Health Care Report 7: Reforming Medical Education: Urgent Priority for the Academic Health Center in the New Century Report 6: Creating a Value-driven Culture and Organization in the Academic Health Center Report 5: e-Health and the Academic Health Center in a Value-driven Health Care System Report 4: In Pursuit of Great Value: Stronger Leadership in and by Academic Health Centers Report 3: Into the 21st Century: Academic Health Centers as Knowledge Leaders Report 2: Promoting Value and Expanded Coverage: Good Health Is Good Business Report 1: Academic Health Centers: Getting Down to Business 32 IBC1 BC1