Last Tuesday "This HCR Bill: 45,000,000 Get CHC-Single-Payer Vermont Health Care" made the REC List.
Bernie Sanders and Ben Cardin got HCR money to expand to 14,000 FQHC clinics. Moving ahead, VHA technology can be applied during this expansion to gets control of skyrocketing chronic care costs.
Save as much as $500-billion dollars a year.
Get better patient outcomes.
Kennedy CHC clinics are 1/5th as expensive as using an ER, 3/5th as expensive as private care for chronic care office visits. Management standards can be implemented top-down.
In contrast, chronic care through private offices presents broadly as an example of unmanaged and inept patient exploitation.
Private patients with multiple CC conditions get bounced to 12 different doctors a year and have 50 different prescriptions thrown at them..
Kennedy CHCs are non-profit. Strong management will make all the difference.
Nationwide, today:
Find A Health Center
There's 4,000 Kennedy-CHC clinics -- 1,200 full service.
MBTF :::
"The facts, ma'am. Nothing but the facts."
-- Dragnet, a cop show
HERE is the link -- to the first diary.
This HCR Bill: 45,000,000 Get CHC-Single-Payer Vermont Health Care.
This first diary identified a heretofore little-appreciated provision in the new HCR Patient Protection and Affordable Care Act. $14-billion is committed to expand the Kennedy-CHC clinic system.
The overall expansion is quite remarkable:
-- 14,000 nationwide Community Health Clinics in 10,000 different municipalities
-- Expand CHC to match VHA technology
-- 45,000,000 people served; possibly 60,000,000 with feature enhancements
-- Budget to attract 20,000 primary care physicians, nurses, etc.
-- Drugs at the lower VHA prices
-- Dental care on-site
-- Patient billing scaled to income
This is starting to look like a Veterans Health Administration for civilians.
The current Kennedy CHC system includes 2800 "satellite" offices that provide reduced or part-time services. Many of these smaller offices will be upgraded, along with more than doubling the total sites.
The upgrades are not well-defined at this point. However, VHA underwent a major re-engineering effort from the mid-1990s to today. VHA is an enormous operation: the hospitals and clinics get $45-billion a year from a total budget at $60-billion.
Moving ahead, CHC and VHA have been poorly coordinated, especially at upper management. For one example, there is no coordination at procurement. This "stovepipe" phenomenon limits knowledge transfers. These same "stovepipes" have again and again prevented direct technology transfers.
CHC and VHA are parallel Federal programs.
VHA has advanced integrate systems. The Kennedy CHCs can't get there.
Anybody here like paying tax dollars twice for the same work ???
We're going to beat this concept pretty hard: chronic care is where the money is, not acute care.
Nationally, 75% of all health care costs go to treating chronic care patients.
Move CC patients over to Kennedy CHCs with a VHA-style management system, you save 50%+ on costs and get better outcomes.
The most of the saving is Medicare/Medicade.
This diary will address the particulars of CHC health care with reference to the VHA management resources. Then we'll return to focus on how VHA and a proposal to make the Kennedy CHC expansion to 14,000 sites doubly valuable.
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American health care is so bad, so expensive, because chronic care is carried on without adult supervision.
There is no management system. There is no governing technology in place in American medicine to govern these CC processes.
Chronic Care: $1,500,000,000,000-a-year and no management.
That's a trillion and a half. Insurance companies deny claims, but that disaster of a SNAFU of a momzer is random acts of criminality with connection to management.
Whatever passes for medical oversight is as bad at regulating chronic care as the S.E.C. was at doing whatever it was they didn't do to regulate Bernie Madoff.
(Please, slow down. Read the last four sentences again.... The CC pin ball machine chews up $1.5-trillion-a-year. Does crappy work. And we know how to do all of the CC treatment regimes better than what happens. Now, I'll prove it....)
To begin with, let's start with medical school. Doctors working on their basic M.D. programs are not trained to manage chronic illnesses. They rarely see a chronic care patient, except on the street.
Acute care gets the attention.
Michael Lockshin, M.D. at NY Hospital for Special Surgery, "At no point in medical school are physicians exposed to patients with chronic illnesses, except for acute episodes leading to hospitalization."
The details for managing the major chronic illnesses are not part of the curriculum. What patients get is the pin ball machine.
Chronic disease exploitation.
What else ??? It didn't take Karl Marx to get the word "exploitation" invented.
Single disease patients get bounced among three doctors a year, plus getting seven drugs thrown at them.
Multiple disease patients get bounced among a dozen doctors -- on average -- and see an astonishing 50 scrips.
Drug interactions and side-effects are also uncontrolled.
We are the worst in the world. Our private system, that is.
VHA doesn't look like this. Not at all. The overall VHA system is what treats the CC patients. Not a school of referral-driven sharks.
In the VHA system, all drug prescriptions for every patient are controlled, cross-checked, managed, and limited through one centralized computer system. Drug cost per coronary disease patient, for example, runs at $1,800 a year and you get to roughly twice that for overall treatment. About a 1/3d of private care.
VHA has better outcomes for these patients, too. No surprise.
Out there in the exploitation environment, you see this most common chronic disease -- coronary disease -- at 17-million patients and $165-billion cost. $10,000 a year per patient.
Here's the overall hit:
Considering the averages for private care vs. what we know about VHA standard procedures -- that 75% could be reduced immediately by a third by adopting the VHA procedures. That is a saving of $500-billion dollars every year.
Getting 100% adoption is likely impossible.
One can imagine the lobbying effort, if such changes and reductions to high incomes were proposed as new laws.
The eventual saving, however, with full VHA management and corrections back to VHA salary structures and VHA materiel costs -- that has to be more like one-half.
VHA regularly treats CC patients for 1/2 to 1/3 the cost of private systems. The CC outcomes for VHA are better than the averages for CC patients treated at private operations.
VHA never allows too many chefs to stir a patient-pot.
One big change with Reid's HCR Act gets the VHA price list for drugs available for the Kennedy CHC clinics.
Sure thing, that's not reimportation from Canada. Same difference....
Chronic care has been the top problem for several decades. VHA put its money to CC cases when the re-engineering work got underway mid-1990s.
There are some heroes. People who know the medical economics. People who are not awed by lobbyists. Nancy Whitelaw at National Council on Aging says that chronic care is the key to "skyrocketing" costs.
Stanford's Chronic Disease Self-Management Program has been around since 1992. The numbers back up a payback at $500-per-patient per year for adopting CDSEMP.
$500-a-year times 133,000,000 CC patients =EQ= $66,500,000,000-a-year for potential savings.
Get with the program for 100% of the chronic care and the patients live better, plus saving as much as we can of this $66-billion-a-year. CDSMP is all over the place. CD patients can find it. But there is no solid institutional force -- nothing like a VHA -- out there pushing it.
Kennedy CHC's can replicate the VHA flavor of CDSMP program.
Don't underestimate VHA.
We're looking at a $60-billion-a-year operation. "239,000 staff at over 1,400 sites, including hospitals, clinics, nursing homes, domiciliaries, and Readjustment Counseling Centers. In addition, VHA is the Nation's largest provider of graduate medical education and a major contributor to medical research." (VHA's web site: va.gov.)
By comparison, the Kennedy CHC system is small potatoes.
The 4,000 CHC sites are clinics and "satellite" shops. There's not a full hospital in the lot, though Vermont has cobbled together 8 "Center" operations that approximate hospital services. Federally Qualified Health Centers are non-profits that fit into this structure. From what I read, there are 1,200 FQHC's. Total manpower runs somewhere around 25,000 slots at full-time equivalency. (Don't hold me to that. Its a guesstimate.)
What has mattered most about this Kennedy CHC system is that 20,000,000 people a year have been using it. That number exploded from 2000-2008. The direct cause for this expansion was that private-sector primary care physicians went to being a scarcity item, particularly for rural and inner city areas.
Now, however, the Kennedy CHC system is going to go to 14,000 sites with a scaling trend toward full clinics in place of part-time, partial service "satellites."
Bernie Sanders says this gets to an expected usage to 45,000,000 people.
We do a scaling program on the expected footprint, this expansion could reach 60,000,000 patients. That is what these clinics could serve using the VHA management model.
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I do not know to what extent remote medicine capabilities are on the table. However, remote medicine is a large factor in Asia. The major cities are clogged beyond normal travel limits, so they move diagnostic equipment around in the evening. Lab techs and nurses do the test work during the day. You do have to schedule ahead for access.
Here in America, our rural areas are up against the same levels of prohibitive travel delays. Getting remote medicine to the rural CHCs -- perfect.
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The first statement at sanders.senate.gov has the growth at another 25,000,000 patients. That makes a total of 45,000,000 patients. But when we run the math, doing the sites and the expansions, this has to be more like a capacity at 60,000,000 patients a year.
This Reid/Pelosi HCR Act has the money for the expansions. Once the expansions are up and running, these Kennedy CHC clinics pretty much pay for themselves -- apart from fractional support to make up shortfalls with MediCare/MediCade payments, the usual Insurance Wars, and more shortfalls with uninsureds.
If you think you like the idea of single-payer, here is 80% of it:
What this give the walk-in, uninsured slob is an environment where there is no profit motive.
The doctors do not own testing laboratories on the side. Getting you a cure on the first visit doesn't cut their slice of the pay-out. And beginning next year some time, you'll get drugs on the VHA price list where there's a pharmacy (and possibly for by-mail prescriptions as with VHA.)
-- We had a typical situation where $1100 in ER cost would have been $200 at the local CHC.
-- Another one, a $950 bill from ER for a 10-stitches cut... that would have been $59 and a $30 prescription at the CHC. The ER couldn't resist tagging on an MRI for the cut thumb.
-- Last time I got teeth cleaned, the neighborhood dentist found a way to bill $800. His assistant did the work in under an hour.
The more Kennedy CHC sites there are, the less we'll get hit with bill-padding nonsense.
Statistical analysis of the CHC system shows that treating chronic care is running 40% cheaper for CHCs overall than for typical private alternatives. That sounds good.
We can do better than 40% improvement. One key is to involve CC patients, so they can help matters out with self-management techniques. Good self-management systems have been available since the early 1990s.
As well, the VHA computer system automatically eliminates the "pin ball" craziness.
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Apply the VHA computer system to the CHCs.
One major difference between CHC and VHA for patients is that VHA has all the patient records and medical actions on the central computer. That can be built up over time, for CHC patients.
This consolidation will assure that a specific diagnosis will receive an appropriate treatment regime.
Full automation cuts refresh time for doctors and eliminates lost records. The VHA system never, ever loses records. (Patients, well sure....)
Handing out the wrong medicines has also been reduced. For non-VHA hospitals the risk of a meaningful dosage error is estimated at 20% for each hospital stay. For VHA hospitals that error rate has been reduced to 0.03% per hospitalization.
These benefits can be carried over to CHC by the simple expedient of having the VHA system do the computer work for the CHC sites.
Only a Fool pays twice for the same item.
The industry lobbyists have an amazing line to throw out -- that VHA does not exist. That 15 years of data are invisible. Here's the recasting from AHIP, quoting a CBO letter out of context:
The Congressional Budget Office (CBO) recently released a letter to Senate Budget Committee Chairman Don Nickles discounting the prospects for estimated cost savings from disease management programs in Medicare. Importantly, CBO did not find that disease management programs don't work. Instead, CBO's review of published research concluded that there was insufficient evidence to indicate that disease management programs could generally reduce overall health spending. Therefore, CBO remains reluctant to estimate or "score" Medicare savings from new or expanded disease management initiatives in its official cost estimates.
AHIP admits that they are shills. This business of involving CBO went the other way for the recent scorings -- CBO got off the AHIP bus.
NCQA weighed in differently:
National Committee for Quality Assurance (NCQA), whose health care system certification standards are respected by insurers and payers, a patient-centered medical home is characterized by four basic criteria:
• First contact care, which examines the manner in which patients make initial contact with the medical care system for emerging health problems;
• Longitudinality, which captures the ability to maintain a relationship with a patient over time, thereby heightening the value of that relationship;
• Comprehensiveness, which relates to the ability of the provider, through a patient care team, to provide, arrange for, or refer to, the full range of needs, not only those that can be appropriately carried out within the "four walls" of a primary care practice;
• Coordination, which encompasses the ability of the primary care provider to integrate its activities with those across different health care settings and providers, and across all of the patient’s conditions.
A typical discussion in the professional non-lobbyist world illustrates where the conversation has been going:
FINANCING COMMUNITY HEALTH CENTERS -- from George Washington University
• First, health centers struggle to balance their resources between offering basic primary health care to all community residents, including both uninsured and seriously underinsured patients, and investments aimed at improving health care quality and efficiency. Community health centers that serve a high volume of uninsured patients are expected to encounter resource-based barriers to health care quality improvement. As the recent experience of health centers in Massachusetts highlights, even as the statewide number of uninsured dropped sharply, health centers became even more important as safety net providers for the remaining uninsured.
• Second, like other health care providers, health centers respond to payment incentives. Thus, when formulating payment reform, it is important to focus on changes to the Medicare and Medicaid FQHC payment systems that would help align payment and quality by augmenting basic reimbursement with quality improvement incentives. For instance, the special incentives for HIT adoption offered under Medicaid under the recent American Recovery and Reinvestment Act (ARRA) encourage health centers to invest in new technology....
• Third, it will be important to assure that recent investments like those under ARRA are sustainable over the long term. Using payment reforms to maintain and enhance recent quality improvement investments will be critical. ARRA provides a substantial amount of new funding from 2009 through 2011 in order to strengthen and upgrade health centers, especially to develop infrastructure and health information technology.
HERE for the GWU piece.
In contrast to twaddle about finishing computer programs some day, VHA spent the core money for HIT back in the 1990s. Then in the 2000-2005 period the databases were upgraded and applications were transferred to a centralized Identity Management structure. VHA has all the usual conveniences of Application Server J2EE environments.
VHA makes most of its HIT software available as freeware.
VHA's HIT has been around for years and years. One integrated system runs everything. There are no mysteries.
So... ta-da... have the VHA IT department do the computer work for the whole of the CHC system.
One simple approach to get rolling is to replicate the VHA computer system. Backup technology will do a mirror implementation as a matter of course.
Then your tasks for re-programming are limited to modifying the skins/titles/constants, doing security work, and tailoring various PC Java code. Loading up existing files is a standard data warehouse ETL project -- one for each group of CHC shops.
The reader may well notice another benefit -- patients at either the VHA clinics or the CHC clinics could be switched over to a closer-to-home facility. Tales of crippled veterans having to be driven hundreds of miles for simple care ??? -- soon a thing of the past.
How hard can that be ???
VHA has about 1,000 clinics of one description or another.
For veterans, especially in rural areas, free access to the CHC system clinics with VHA technical support -- when there are 14,000 of the CHCs -- that will make some of these lives easier and longer.
Knocking down bureaucratic "stovepipes" is the problem. There's several groups that have "colonized" pieces of the budget pie for CHC software and operations. ("Colonized" is the right word. Its like paper bees getting into your attic.) One assumes that this type of problem is why President Obama brought Rahm Emanuel on board.
Get health care at VHA levels for civilians -- that should be the management goal for changing the Kennedy CHC system.
This project to revolutionize CC management could be the Left's Holy Grail for domestic politics. You want government to work, here's a place to dig in.
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And BTW: Look at DKOS and we're paying attention to wild attacks on the HCR Act, digs at our professionals such as Harry Reid and Nancy Pelosi, and slander at White House surrogates and at President Obama.
Let's leave that crap to the teabaggers.
Zillions of words about this amateur, Jane Hamsher ??? Orly's cuz ? Who'd believe for an instant that Rahm Emanuel can give orders to Treasury ?
Crazy people have a natural home. Its called the GOP.
There's 133,000,00 Americans with chronic illnesses. The worst of laissez faire capitalism is being inflicted on them -- with no legal oversight and little help from America's Left.
Almost a third of these CC patients live with daily pain.
We at DKOS could use some focus. Though I do have to admit that Jane and Orly are funnier than watching a freezing rain.