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At big moment, President Obama goes small

By BEN SMITH | 7/23/09

…The president’s remarks on his chosen subject, health care, were cautious and choreographed, hemmed in on one side by the calculations of his professional wordsmiths, on the other by the delicacy of negotiations with two houses of Congress.

He never detailed his own plan or named a single victim of America’s broken system, and he spoke largely in the abstractions of blue pills, red pills and legislative processes. It’s not easy to turn delivery system reform into a rallying cry for change, but at times, it was as if Obama wasn’t even trying…


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Take the red pill, Mr. President

By: David Freddoso

… Last night, President Obama appeared to have taken the blue pill before his press conference. How else could he convince himself, the Congressional Budget Office’s numbers notwithstanding, that his health care reform bill will not increase both health care costs and the federal deficit? How else can he continue to make the argument that a massive expansion of government spending on health care will solve rather than exacerbate the current problems? How can he repeatedly express such absolute certainty that such a measure will easily pay for itself several times over in the long run? Why can he not at least acknowledge the possibility that it will become a costly and useless trillion-dollar boondoggle that follows in the footsteps of his stimulus package?

With his example of the red and blue pills, and another about whether a child’s hypothetical tonsils should be removed, President Obama unwittingly presents the real problem with his plan for reform….

… The Mayo Clinic which President Obama praised in his speech last night is the same Mayo Clinic whose president signed onto a letter to Congress yesterday, expressing fears that a government-option health care plan Obama wants to establish will do more of this cost-shifting. The letter states:

Under the current Medicare system, a majority of doctors and hospitals that care for Medicare patients are paid substantially less than it costs to treat them. Many providers are therefore already approaching a point where they can not afford to see Medicare patients. Expansion of a Medicare-type plan without a method to define, measure, and pay for healthy outcomes for patients will move many doctors and hospitals across this threshold, and ultimately hurt the patients who seek our care. We should not put more Americans into the current unsustainable system.

President Obama brushed off this concern last night near the end of his press conference, citing a hopeful but very vague blog post on Mayo’s website that went up a day before the letter was sent. In addition to ignoring budgetary and medical concerns, he repeated his dubious promise that his plan will not force millions of Americans out of health insurance plans they already have and like. He had no comforting words to convince anyone of the wisdom of creating two new taxes on employers — one of them a tax that punishes small businesses with a higher tax rate if they create more jobs — in the middle of a recession…


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FACT CHECK: Obama’s health care claims adrift?

By CALVIN WOODWARD and JIM KUHNHENN,

OBAMA: “We already have rough agreement” on some aspects of what a health care overhaul should involve, and one is: “It will keep government out of health care decisions, giving you the option to keep your insurance if you’re happy with it.”

THE FACTS: In House legislation, a commission appointed by the government would determine what is and isn’t covered by insurance plans offered in a new purchasing pool, including a plan sponsored by the government. The bill also holds out the possibility that, over time, those standards could be imposed on all private insurance plans, not just the ones in the pool.

Indeed, Obama went on to lay out other principles of reform that plainly show the government making key decisions in health care. He said insurance companies would be barred from dropping coverage when someone gets too sick, limits would be set on out-of-pocket expenses, and preventive care such as checkups and mammograms would be covered.

It’s true that people would not be forced to give up a private plan and go with a public one. The question is whether all of those private plans would still be in place if the government entered the marketplace in a bigger way.

He addressed some of the nuances under questioning. “Can I guarantee that there are going to be no changes in the health care delivery system?” he said. “No. The whole point of this is to try to encourage changes that work for the American people and make them healthier.”

He acknowledged then that the “government already is making some of these decisions.”

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OBAMA: “I have also pledged that health insurance reform will not add to our deficit over the next decade, and I mean it.”

THE FACTS: The president has said repeatedly that he wants “deficit-neutral” health care legislation, meaning that every dollar increase in cost is met with a dollar of new revenue or a dollar of savings. But some things are more neutral than others. White House Budget Director Peter Orszag told reporters this week that the promise does not apply to proposed spending of about $245 billion over the next decade to increase fees for doctors serving Medicare patients. Democrats and the Obama administration argue that the extra payment, designed to prevent a scheduled cut of about 21 percent in doctor fees, already was part of the administration’s policy, with or without a health care overhaul.

Beyond that, budget experts have warned about various accounting gimmicks that can mask true burdens on the deficit. The bipartisan Committee for a Responsible Federal Budget lists a variety of them, including back-loading the heaviest costs at the end of the 10-year period and beyond.

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OBAMA: “You haven’t seen me out there blaming the Republicans.”

THE FACTS: Obama did so in his opening statement, saying, “I’ve heard that one Republican strategist told his party that even though they may want to compromise, it’s better politics to ‘go for the kill.’ Another Republican senator said that defeating health reform is about ‘breaking’ me.”

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OBAMA: “I don’t know, not having been there and not seeing all the facts, what role race played in that. But I think it’s fair to say, number one, any of us would be pretty angry; number two, that the Cambridge police acted stupidly in arresting somebody when there was already proof that they were in their own home, and, number three, what I think we know separate and apart from this incident is that there’s a long history in this country of African-Americans and Latinos being stopped by law enforcement disproportionately.”

THE FACTS: The facts are in dispute between black scholar Henry Louis Gates Jr. and the white police sergeant who arrested him at his Cambridge, Mass., home when officers went there to investigate a reported break-in. But this much is clear: Gates wasn’t arrested for being in his own home, as Obama implies, but for allegedly being belligerent when the sergeant demanded his identification. The president did mention that the professor was charged with disorderly conduct. Charges were dropped.

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OBAMA: “If we had done nothing, if you had the same old budget as opposed to the changes we made in our budget, you’d have a $9.3 trillion deficit over the next 10 years. Because of the changes we’ve made, it’s going to be $7.1 trillion.”

THE FACTS: Obama’s numbers are based on figures compiled by his own budget office. But they rely on assumptions about economic growth that some economists find too optimistic. The nonpartisan Congressional Budget Office, in its own analysis of the president’s budget numbers, concluded that the cumulative deficit over the next decade would be $9.1 trillion.


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Memo to President Obama: America’s doctors are neither stupid nor dishonest

By Stephanie Gutmann

As I write this the polls are not yet in on how many Americans actually watched President Obama’s press conference on Wednesday night or if the 55-minute exercise helped sell his ideas for health care overhaul. But there’s one group he clearly didn’t help himself with: America’s hardworking, generally honest, generally top-notch doctors.

Already radio talk shows like Bill Bennett’s “Morning in America” report being deluged by calls from doctors who are furious about what they heard. And who can blame them? The president used incredibly condescending language, implying over and over again that there is waste in the system, not because of over-regulation and fear of lawsuits, but because doctors are lazy or informed or – shudder! – “out for profit.”

Asked if Americans are going to have to “give anything up to make this [sweeping overhaul including coverage of the entire population] happen”, the president replied sunnily: “They’re going to have to give up paying for things that don’t make them healthier. And I – speaking as an American – I think that’s the kind of change you want.”


THE HEALTH CARE BLOG

Op-Ed: Healthcare Reform Lessons From Mayo Clinic

By LEONARD L. BERRY and KENT D. SELTMAN

mayoThree goals underscore our nation’s ongoing healthcare reform debate:1) insurance for the uninsured, 2) improved quality, and 3) reduced cost.  Mayo Clinic serves as a model for higher quality healthcare at a lower cost.

President Obama, after referencing Mayo Clinic and Cleveland Clinic, advised, “We should learn from their successes and promote the best practices, not the most expensive ones.”  Atul Gawande writes in The New Yorker, “Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country-$6,688 per enrollee in 2006.”

Two pivotal lessons from our recent in-depth study of Mayo Clinic demonstrate cost efficiency and clinical effectiveness.

1. Patient-first medicine.  Throughout its 140-year history, Mayo Clinic has never put money first but lives its primary value:  the needs of the patient come first.  Mayo doctors, as all employees, are on salary.  No doctor earns more by ordering an extra test or procedure.  No doctor earns less by referring a patient to another Mayo physician with more expertise.

Core values guide organizational behavior, and Mayo Clinic’s patient-first core value guides the more than 43,000 employees.  For instance, the head of transfusion medicine noticed a day-shift technician working at 2:00 a.m. as he dealt with an emergency.  The technician explained that she was redoing a test to correct an earlier mistake.  “Why not repeat it the next day?” she was asked. She replied, “I can’t have patients at Mayo Clinic waiting an extra day in the hospital because I fouled up a test.”

Dr. Robert Waller, who retired as Mayo Clinic CEO in 1999, remembers a conversation with a cardiologist whose patient needed a pacemaker. Option A: a Medicare-approved model requiring relatively involved surgery and several days of postoperative hospitalization.  Option B: a new model that could be implanted more simply with only one day of hospitalization.  Option B was not yet Medicare-approved and meant no
reimbursement to Mayo.  Dr. Waller recalls:  “This was a no-brainer – use the pacemaker that is best for the patient.”

Healthcare is a sacred service.  The patient’s quality of life – and life itself – is at stake.  The needs of the patient must be at the center of healthcare reform. This will require, among other steps, revamping doctors’ compensation to encourage efficient and effective care that truly serves patients.  Until we pay doctors for better care, rather than for more care, we cannot successfully reform healthcare.

2. Team medicine.  Mayo Clinic does not have a monopoly on highly capable doctors and nurses, but it has a competitive advantage because its highly capable clinicians pool their knowledge.  When clinicians truly work together, as at Mayo, the result is more efficiency, less duplication of effort, and a greater likelihood of correctly diagnosing and effectively treating a patient earlier in the process.

Medical care in America is highly fragmented, impeding both efficiency and effectiveness.  Patients with multiple or complex illnesses are often treated by physicians from different medical practices who may not communicate with one another.  Not so at Mayo Clinic, which functions like a medical department store with staff experts for each medical specialty.  Working in an organizational culture that demands teamwork and using tools such as an electronic medical record and a sophisticated communication system, Mayo clinicians collaborate to provide the specific expertise needed by the individual patient.

Consider the case of “Don,” who endured an undiagnosed tumor on the base of his tongue for two years.  Both his dentist and an ENT physician told him the discomfort in his mouth was not clinically significant.  When another ENT doctor diagnosed cancer and recommended immediate surgery (that would end Don’s ability to speak), Don contacted Mayo Clinic.  Two weeks later he met his Mayo team of three physicians (ENT, medical oncology, and radiation oncology specialists).  The team dismissed surgery and recommended radiation and chemotherapy instead.  Today, five years after Don’s initial cancer diagnosis, he is cancer-free and living a normal life.  He still sees his initial physician team at six-month’s check-ups. Don’s story illustrates Mayo Clinic at its best.

Teamwork is vital to improving medical efficiency and effectiveness, and health reform must include bold investments that encourage and enable it.  Encouraging medical practices, financially and otherwise, to coordinate a patient’s healthcare over time (called “patient-centered medical homes”) should be in the health reform blueprint.  So should the transformation from proprietary paper medical records to universal electronic records available as needed by treating clinicians.

A time to learn.  Few organizations survive for more than 100 years, much less thrive like Mayo Clinic. Mayo Clinic is not perfect.  Its integrated, multispecialty medical model works wonderfully — most of the time.  Stories like Don’s occur each day at Mayo, but the Clinic cannot help every patient.  Nor is Mayo Clinic the only medical institution that merits consideration in healthcare reform discussions.

Yet, the way Mayo conducts its business, governs itself, and sustains focus on its core values of patient-first needs and collaborative medicine is deeply instructive.  Never have such lessons been more important to our nation’s healthcare.

Leonard L. Berry and Kent D. Seltman, authors of Management Lessons from Mayo Clinic (McGraw Hill, 2008).  Berry holds the M.B. Zale Chair in Retailing and Marketing Leadership in the Mays Business School, Texas A&M University.  Seltman retired from Mayo Clinic in 2008 after serving as director of marketing from 1992 through 2006.

More on the Mayo Clinic:


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The Smoking Gun:  Henry Louis Gates, Jr. Police Report

The New Yorker:  The Cost Conundrum

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