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 righteous money to expand from 4,000 to 14,000 non-profit Kennedy CHC clinics.
VHA technology and management procedures are readily available to upgrade Kennedy CHCs.
Begin to rein in America's skyrocketing $1.5-trillion-a-year chronic care (CC) costs:
-- Save $500- to $750-billion a year.
-- Get better patient treatment, outcomes and satisfaction.
The best of acute care facilities -- the univerity hospitals -- have determined through their HIMSS Davies Awards that top-level EMR goes with excellence. Full VHA implementation is Level 4 or 5 with the strongest medication controls.
In contrast, private walk-in offices present as a low-tech, uncoordinated disaster. Referral cascades produce destructive "pin ball machines."
On average:
-- Multiple-diagnosis CC patients get bounced to 12 different private doctors a year and have 50 different prescriptions thrown at them..
Never, ever at VHA.
Justification for 50,000 first-rate Kennedy CHCs ==> BTF :::
************* UPDATE: *****************************
HERE is Where to Find a Health Center -- for Kennedy CHC clinics by ZIPCODE
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"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.
This expansion is remarkable:
-- 14,000 nationwide Community Health Clinics in 10,000 different municipalities
-- Expand CHC to match VHA medical technology
-- 45,000,000 people served; possibly 60,000,000 if remote medical capabilities are adopted
-- 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.
The upgrades are not well-defined at this point. However, VHA underwent major re-engineering efforts from the mid-1990s to today. VHA is an enormous operation: the hospitals and clinics get $45-billion a year from a total VHA budget at $60-billion.
CHC and VHA are parallel Federal programs. There is no reason to "stovepipe" their EMR and analytical assets.
VHA has advanced Level 5 EMR integrated computer systems. The Kennedy CHCs can't seems to get anywhere close. As non-profits, these Kennedy CHC FQHCs simply do not have the money. Their favorite software companies are not in the league with what has been done at VHA.
There is an obvious solution to the situation.... Anybody here like paying tax dollars twice for the same work ???
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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.
This diary will address the particulars of chronic care in America. This care can be done very well indeed:
-- VHA does it right. Medical providers are paid salaries, incentives are in place to encourage primary care, the EMR records everything, staff work as a coordinated team, there are also 900+ clinics.
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 governance. If you want to "fire" a bad doctor, you have to get a state medical board to pull his license.
-- There is no technology in place to enable direct analysis of what is happening. Its pretty much smoke.
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 no connection to coordinated 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 the VHA's CC treatment regimes are better.
Now, I'll show you....)
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 VHA's 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 the most common chronic disease -- coronary disease -- at 17-million patients and $165-billion cost. $10,000 a year per patient. That is typical.
Here's the overall hit:
Considering the averages for private care vs. what we know about VHA standard procedures -- that the CC 75% of total cost could be reduced immediately by a third by adopting the VHA procedures. That is a saving of $500-billion dollars every year.
We did specific disease by disease analysis. Not on everything, didn't have all the data. But it looks like giving everything to VHA and VHA-style controls could save $500- to $750-billion-a-year.
Getting 100% adoption is likely impossible.
This also means war. Open war with the specialists running these shops.
The goal is to chop the bogus referrals.
One can imagine the lobbying effort, if such changes and reductions to high incomes were proposed as new laws.
The eventual target for savings should combine two strategies:
-- Get treatment done under solid management controls. Full VHA-level management; and,
-- Corrections back to VHA salary structures and VHA materiel costs. Approximation with Kennedy CHC non-profits will do that perfectly well.
The overall savings would target more like one-half today's CC pot.
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 100,000,000 CC patients =EQ= $50-billion-a-year for potential savings.
Insurance companies do try to encourage these programs.
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 -- Bernie Sanders Be Praised ! -- 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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We do not know to what extent remote medicine capabilities are on the table. However, remote medicine is a large factor for clinic systems in Asia. The major cities -- e.g., Seoul and Kuala Lampur -- 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 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.
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The industry lobbyists have an amazing line to throw out -- that VHA does not exist. That 15 years of data are invisible. They have had allies in the Hill. Here's the recasting from AHIP, quoting a CBO letter out of context:
The Congressional Budget Office (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.
For everybody else in the world, UHCs, AHA, VHA, this isn't a question.
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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.
Have the Kennedy CHCs adopt the VHA system, you get there ASAP.
And there's no question of how to do it. You're not there first adopter outside of VHA.
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In contrast to never-ending 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. Operations as small as a single hospital in Texas have implemented the core suite.
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 ??? -- For many older vets, a thing of the past.
How hard can that be ???
VHA has almost 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 -- will make for better quality of life.
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.
133,000,000 CC patients =EQ= 133,000,000 voters.
And they got families. And they're older so you're going after the GOPer core.
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. Plus the likes of "Ass Clowns" and Jane the Teabagger.
Crazy people do, indeed, have a natural home. Its called the GOP.
We at DKOS could use some focus. Jane and Orly are barely funnier than watching a freezing rain.