Guest post by Skylanda.
Local newspapers are a funny thing - half pulpy fiber ready-made for the recycling bin, half pure insight into the local ways and goods. When I first moved to Oregon several years back, I picked up the local rag one day, intending to peruse the real estate and rentals section. The front page caught my eye; on it was a lengthy list of medical conditions, some five hundred or so altogether. Somewhere on the list - probably around number three hundred or so - was a line break. I scrutinized it for some time, but couldn’t discern the connotation even behind the accompanying article. It took me several years of pre-clinical and then clinical experience to fully appreciate what I saw on the front page of the paper that day.
The list of medical conditions was the condensed essence of the state Medicaid program, known about town as the Oregon Health Plan (OHP). There is much myth - and much detail - about OHP that is somewhat lost on me, so any Oregonians out there who care to correct me are invited up front to do so. But the gist of it, as I understand it, goes like this.
Years back - before the lean years, when Oregon was still enjoying the spill-over of the tech boom in California - a group of reform-minded physicians and other supporters started a bold experiment in health care reform. The charge was led a lanky, cowboy boot-clad, bolo tie-wearing governor who goes by the name of Kitzhaber. Kitzhaber was an ER doctor in his first incarnation, before he got into politics. This crowd got federal exemption from the standard Medicaid rules, and went about creating a new system on which a model of universal coverage could be built. It was built on a series of assumptions, something like this:
The first premise is that the coverage offered should occur in a hierarchy, and that that hierarchy should be 100% transparent. These folks claimed - boldly, I emphasize again - that all available medical treatments could be given numerical value based on a set of parameters that come down to, essentially, health bang per health buck. There are, for example, cheap treatments that result in major health gained - things like vaccinations and drugs to control diabetes; these things top the list. Then there are cheap treatments for only marginal health gain (oh, let‘s say, acupuncture), and expensive treatments for large health gain (how about: chemotherapy for cancer); these get mixed up in the middle. Finally, there are expensive treatments for little health gain, and these go at the bottom of the list (the most notorious of these was treatment for pancreatic cancer - expensive, painful, almost useless, most people die of the disease no matter what you do for them). You can use health surveillance data to then multiply each list entry by a) the number of people who get that condition each year, and b) how much it costs to treat each one of those people. You can keep a running total in the next column, and if you know your total Medicaid budget for the year, you can draw a line through the list where your running total equals your Medicaid budget. You cover the conditions above the line, deny the conditions below the line, and voila, you have achieved maximum health available per dollars you have to spend.
Although I suspect it involved a little more math than I give credit for, perhaps.
The genius of this tactic is the transparency - that the list was run in the paper every year (maybe still is, I don’t know…Oregonians, want to chime in on that?). Don’t like it? Think it’s heinous that coverage is denied to little Susie just because her condition fell two notches below the line? Fine. Pressure your representatives for more dedicated Medicaid funding from the state and federal pools next year. It’s the opposite of the CIA’s black-line discretionary budget: you know exactly what your tax dollars are buying, and if you don‘t like it, you‘re welcome to involve your own bad self in the political process and push to change it.
The second premise - which you may have already noted above - is that the decisions on which to base the list are to be based in clinically sound data and guidelines. In the parlance of modern medicine, they are to be “evidence based.” This tactic means that the ranking of the list was based on available data, not on what is popular at the moment, what the pharmaceutical reps are pushing, or what is the hottest new experimental procedure. This also caused some consternation - partly because not everything medical people do is evidence-based under the best of circumstance, and partly because no kind of experimental treatment is covered at all (though this is not atypical of any insurance plan). Nevertheless, there it is.
This also leads to the third premise: that the medication formulary associated with this plan should also be evidence based, with a firm emphasis on cost control. Functionally, this means that if two drugs perform the same in trials, the cheaper one goes on the formulary and the more expensive is not covered unless there is some compelling reason why the patient cannot tolerate the cheap one (formularies are usually based on which drug company cut which deal with which insurance company and/or hospital, making them profoundless useless outside of their immediate context). This was among the most useful tools produced by the OHP folks, and doctors here and there around the nation picked up the OHP formulary for informal use in their own practice because it was so pointed and effective in weeding out pharmaceutical advertising from actual evidence. I used it not because I had many OHP patients (by the time I came around, OHP was flailing badly, and most my patients were either privately insured or uninsured), but because it was the easiest way to find a drug in a given class that a poor patient was most likely going to be able to pay for.
The final premise that made OHP such a unique experiment in medical coverage was the role of the list itself. Medicaid is designed to cover poor people (Medicare, remember, is designed to cover retired people); the definition of “poor” often moves to accommodate a given state’s Medicaid budget. In some states, you have to be so dirt poor that if you work so much as a few hours a week, you’re off the Medicaid rolls. The crux of the OHP experiment was to shift the mode of cost control from trimming people from the rolls to trimming the health care package itself. The standard metaphor they used went like this: when your local county elementary education budget gets cut by 10%, no one throws 10% of the kids out of school - they merely cut 10% of services: teachers, aides, school lunches, whatever. It’s not ideal, but even in the worst of circumstances, as a society we agree that you do not cut people out of that particular service; you can cut the service package, but you cut it the same for all parties. And so should be health care: when the inevitable budget crisis comes reaming through your front door, you do not cut people off the Medicaid rolls; you cut services, you cut the package offered, so that the total group of people is still covered.
And this is the place where revolutions happen. Though this is the norm in every other industrialized nation, it is an alien concept here, one that needs metaphors and explanations and justifications. But the crux is this: we take care of ours. Even in lean times, when they’ve trimmed the fat and are now cutting down to bone, we’re all in this equally, together, getting the same goods, receiving the same package, facing the same limitations, even if we‘re just talking about the subset of us on Medicaid. It’s just that little tweak of this thing called justice. It ain’t perfect, but wow, it’s a bold shot, isn’t it?
That was then, back in the mid-1990s or so. I moved to Oregon a couple years after the tech bust, when state budgets on the west coast were doing the rough equivalent of the gymnastics that the mortgage industry is performing now. Whereas providers rushed to sign on OHP patients in the early days, reimbursement for services had fallen so sharply that it had become hard to find providers who weren’t refusing patients at the door. This doesn’t speak well of all providers, but you can’t entirely blame them: you cannot maintain a business pulling in less cash per patient than it costs to rent the building you house your office in for that chunk of time; the world just doesn’t work like that. When I left the state, the program was sinking rapidly and no one was quite sure how to fix it, short of a mass infusion of cash that didn’t seem to be materializing.
Meanwhile, Kitzhaber’s term limits ended his governorship and he left office the year I moved up there; he and his cadre went on to found the Center for Evidence-Based Policy, a think-tank dedicated to continuing the pursuit of the basic values of OHP: cost-effective, health-effective medicine. Medicine, that is, that buys health.
Far from a requiem, the precepts of the OHP should serve as a model for nation-wide reform. Transparency, evidence-based practice, cost-effective choices mandated first when all other parameters are equal. And the move toward policy that gives at least a tiny little nod to that stubborn, hard-to-kill beast we call justice.
Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.
Local newspapers are a funny thing - half pulpy fiber ready-made for the recycling bin, half pure insight into the local ways and goods. When I first moved to Oregon several years back, I picked up the local rag one day, intending to peruse the real estate and rentals section. The front page caught my eye; on it was a lengthy list of medical conditions, some five hundred or so altogether. Somewhere on the list - probably around number three hundred or so - was a line break. I scrutinized it for some time, but couldn’t discern the connotation even behind the accompanying article. It took me several years of pre-clinical and then clinical experience to fully appreciate what I saw on the front page of the paper that day.
The list of medical conditions was the condensed essence of the state Medicaid program, known about town as the Oregon Health Plan (OHP). There is much myth - and much detail - about OHP that is somewhat lost on me, so any Oregonians out there who care to correct me are invited up front to do so. But the gist of it, as I understand it, goes like this.
Years back - before the lean years, when Oregon was still enjoying the spill-over of the tech boom in California - a group of reform-minded physicians and other supporters started a bold experiment in health care reform. The charge was led a lanky, cowboy boot-clad, bolo tie-wearing governor who goes by the name of Kitzhaber. Kitzhaber was an ER doctor in his first incarnation, before he got into politics. This crowd got federal exemption from the standard Medicaid rules, and went about creating a new system on which a model of universal coverage could be built. It was built on a series of assumptions, something like this:
The first premise is that the coverage offered should occur in a hierarchy, and that that hierarchy should be 100% transparent. These folks claimed - boldly, I emphasize again - that all available medical treatments could be given numerical value based on a set of parameters that come down to, essentially, health bang per health buck. There are, for example, cheap treatments that result in major health gained - things like vaccinations and drugs to control diabetes; these things top the list. Then there are cheap treatments for only marginal health gain (oh, let‘s say, acupuncture), and expensive treatments for large health gain (how about: chemotherapy for cancer); these get mixed up in the middle. Finally, there are expensive treatments for little health gain, and these go at the bottom of the list (the most notorious of these was treatment for pancreatic cancer - expensive, painful, almost useless, most people die of the disease no matter what you do for them). You can use health surveillance data to then multiply each list entry by a) the number of people who get that condition each year, and b) how much it costs to treat each one of those people. You can keep a running total in the next column, and if you know your total Medicaid budget for the year, you can draw a line through the list where your running total equals your Medicaid budget. You cover the conditions above the line, deny the conditions below the line, and voila, you have achieved maximum health available per dollars you have to spend.
Although I suspect it involved a little more math than I give credit for, perhaps.
The genius of this tactic is the transparency - that the list was run in the paper every year (maybe still is, I don’t know…Oregonians, want to chime in on that?). Don’t like it? Think it’s heinous that coverage is denied to little Susie just because her condition fell two notches below the line? Fine. Pressure your representatives for more dedicated Medicaid funding from the state and federal pools next year. It’s the opposite of the CIA’s black-line discretionary budget: you know exactly what your tax dollars are buying, and if you don‘t like it, you‘re welcome to involve your own bad self in the political process and push to change it.
The second premise - which you may have already noted above - is that the decisions on which to base the list are to be based in clinically sound data and guidelines. In the parlance of modern medicine, they are to be “evidence based.” This tactic means that the ranking of the list was based on available data, not on what is popular at the moment, what the pharmaceutical reps are pushing, or what is the hottest new experimental procedure. This also caused some consternation - partly because not everything medical people do is evidence-based under the best of circumstance, and partly because no kind of experimental treatment is covered at all (though this is not atypical of any insurance plan). Nevertheless, there it is.
This also leads to the third premise: that the medication formulary associated with this plan should also be evidence based, with a firm emphasis on cost control. Functionally, this means that if two drugs perform the same in trials, the cheaper one goes on the formulary and the more expensive is not covered unless there is some compelling reason why the patient cannot tolerate the cheap one (formularies are usually based on which drug company cut which deal with which insurance company and/or hospital, making them profoundless useless outside of their immediate context). This was among the most useful tools produced by the OHP folks, and doctors here and there around the nation picked up the OHP formulary for informal use in their own practice because it was so pointed and effective in weeding out pharmaceutical advertising from actual evidence. I used it not because I had many OHP patients (by the time I came around, OHP was flailing badly, and most my patients were either privately insured or uninsured), but because it was the easiest way to find a drug in a given class that a poor patient was most likely going to be able to pay for.
The final premise that made OHP such a unique experiment in medical coverage was the role of the list itself. Medicaid is designed to cover poor people (Medicare, remember, is designed to cover retired people); the definition of “poor” often moves to accommodate a given state’s Medicaid budget. In some states, you have to be so dirt poor that if you work so much as a few hours a week, you’re off the Medicaid rolls. The crux of the OHP experiment was to shift the mode of cost control from trimming people from the rolls to trimming the health care package itself. The standard metaphor they used went like this: when your local county elementary education budget gets cut by 10%, no one throws 10% of the kids out of school - they merely cut 10% of services: teachers, aides, school lunches, whatever. It’s not ideal, but even in the worst of circumstances, as a society we agree that you do not cut people out of that particular service; you can cut the service package, but you cut it the same for all parties. And so should be health care: when the inevitable budget crisis comes reaming through your front door, you do not cut people off the Medicaid rolls; you cut services, you cut the package offered, so that the total group of people is still covered.
And this is the place where revolutions happen. Though this is the norm in every other industrialized nation, it is an alien concept here, one that needs metaphors and explanations and justifications. But the crux is this: we take care of ours. Even in lean times, when they’ve trimmed the fat and are now cutting down to bone, we’re all in this equally, together, getting the same goods, receiving the same package, facing the same limitations, even if we‘re just talking about the subset of us on Medicaid. It’s just that little tweak of this thing called justice. It ain’t perfect, but wow, it’s a bold shot, isn’t it?
That was then, back in the mid-1990s or so. I moved to Oregon a couple years after the tech bust, when state budgets on the west coast were doing the rough equivalent of the gymnastics that the mortgage industry is performing now. Whereas providers rushed to sign on OHP patients in the early days, reimbursement for services had fallen so sharply that it had become hard to find providers who weren’t refusing patients at the door. This doesn’t speak well of all providers, but you can’t entirely blame them: you cannot maintain a business pulling in less cash per patient than it costs to rent the building you house your office in for that chunk of time; the world just doesn’t work like that. When I left the state, the program was sinking rapidly and no one was quite sure how to fix it, short of a mass infusion of cash that didn’t seem to be materializing.
Meanwhile, Kitzhaber’s term limits ended his governorship and he left office the year I moved up there; he and his cadre went on to found the Center for Evidence-Based Policy, a think-tank dedicated to continuing the pursuit of the basic values of OHP: cost-effective, health-effective medicine. Medicine, that is, that buys health.
Far from a requiem, the precepts of the OHP should serve as a model for nation-wide reform. Transparency, evidence-based practice, cost-effective choices mandated first when all other parameters are equal. And the move toward policy that gives at least a tiny little nod to that stubborn, hard-to-kill beast we call justice.
Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.