‘Doc fix’ flies in the face of rewarding quality, not quantity, of treatment

One of the last things that Congress did before finally getting out of town a few days before Christmas was the so-called “doc fix” – finding money to stave off a scheduled cut for Medicare physician payments. But they only did it for two months – meaning lawmakers will come back in January and struggle with it all over again.

The uncertainly, coupled with the prospects of what, on paper at least, could be a 27 percent fee cut, raises questions about whether more physicians will start cutting back on the number of Medicare patients they take, or dropping out of the program altogether.

It’s also worth reflecting on what this Medicare payment system (formally known as the Sustainable Growth Rate or SGR) means – because it reinforces the very heart of fee-for-service medicine at a time when the health reform law, and many large employers and insurers, are supposedly trying to nudge the health care system away from fee-for-service, which encourages volume. The goal is to move toward new models of more coordinated and integrated care that are supposed to promote value.  So the irony is that we’re tying ourselves in knots about SGR – which pays doctors for how much they do – when the focus is supposedly on creating a system that rewards doctors for how well they do. Go figure.

The SGR dates back to one of those sprawling congressional budget deals, back in 1997. It is supposed to link Medicare physician costs to larger economic and population trends. But the formula didn’t work. Everyone in Washington has pretty much agreed on that. But they haven’t agreed on how or when to replace it. There’s been a lot of talk about coming up with a “doc fix” for a couple of years to allow time for a transition to a TBD new system. But that’s a tall order, given that all the parties don’t agree on what a new system should look like, or which of the new payment systems and incentives being tested are going to turn out to work well (and how long it may take to get them working.)

Until 2002, payments under the SGR rose modestly. Then in 2002 physician Medicare fees were cut by 4.8 percent. In subsequent years, Congress (heavily lobbied by physician groups) postponed the cuts called for by the SGR formula, or approved modest fee hikes. Now, the cumulative postponements mean that doctors face a 27 percent cut – and erasing it would cost about $300 billion over a decade. payments have grown very modestly for nearly a decade now. On top of the SGR issue, physicians and all other Medicare providers face a 2 percent cut starting in 2013 under last summer’s deficit-reduction agreement.

The Medicare Payment Advisory Commission, or MedPAC, knows a mess when it sees one.

The system … has failed to restrain volume growth and, in fact, may have exacerbated it,” MedPAC wrote to Congress earlier this year, recommending yet again that the formula be jettisoned. To a certain extent, cutting physician payments for specific services only encourages them to offer more services.  There isn’t an expert consensus on exactly how much or precisely how the SGR system stimulates more volume. But a recent New England Journal of Medicine article found that doctors in some states were digging the SGR hole much deeper than others (Florida, Texas and New York being among the major culprits). And some specialties’ “excess growth” is much more than others (these include internal medicine, cardiology, diagnostic radiology, and family practice - some of which I would not have guessed.) This doesn’t mean that fees should be slashed in some states and not others, or that family practitioners should get a pay freeze while neurosurgeons make even higher incomes. But it does suggest, as the Harvard health policy experts that wrote the NEJM piece note, that new systems, less blunt and less arbitrary, are required.

The congressional focus on short-term “doc fixes” – a decade’s worth now – blunts the momentum for permanent change. “If you are always doing a fire drill, and finding a perpetual one-year patch, it keeps you from confronting the larger mega-reform that’s needed,” Tom Miller of the American Enterprise Institute observed.

The AMA and other physician groups have warned for years that more and more physicians will stop treating Medicare beneficiaries. On an online AMA survey in 2010, one in five doctors overall, and nearly one-third of primary care doctors, said they are already limiting Medicare patients.

So while Congress struggles for a way out, it’s probably a good time to look at what physicians are doing in your state. (This AMA guide to choices doctors can make about Medicare participation may be useful.) I suspect a lot of doctors don’t quite understand what’s going on in Congress (because as we saw during the pre-Christmas impasse, Congress didn’t seem to quite understand what’s going on in Congress.)

• Do physicians think they will actually get a 27 percent cut? (They won’t - but they may not get an increase or only a modest one.)
• Are they preparing to drop Medicare patients or at least take fewer new ones?
• Have they begun to understand why the system is unsustainable, and become increasingly open to alternatives including ACOs, bundling, medical homes, etc?
• Are they coming up with any creative local solutions? Or are they just assuming that somehow the system can keep muddling through indefinitely?

How might retail clinics change health care delivery in your community?

I don’t routinely blog about the work of AHCJ board members (which doesn’t mean you shouldn’t read Charles Ornstein’s latest on Florida’s slow reaction to physicians who treated and prescribed drugs under Medicaid “amid clear signs of possible misconduct.”)

But I’m making an exception to my self-imposed rule for Julie Appleby’s recent Kaiser Health News piece “The Walmart Opportunity: Can Retailers Revamp Primary Care?“

I’ve read other pieces about the future of retail clinics, including their potential for treating chronic disease. But I thought Appleby did a terrific job of asking – and often answering – many interlocking questions about the delivery of primary care, the management of chronic disease, the quality of care and what this all has to do with health reform.

While asking big-picture questions, she also wove in details that gave the story texture and made it a good read. If you saw my tweet, you’ll know I was particularly taken by the bit about how long-distance truckers can pull up in the parking lot of more than 600 centers to get their mandatory federal checkups.

As Appleby noted, the clinics – which sometimes lose money but bring customers into the stores – started with the low-hanging fruit, the “relatively healthy patients looking for convenient, low-cost care for simple problems.” The next stage is to try to start treating more expensive chronic diseases, such as diabetes and heart disease, which are big drivers of health care spending. Treating chronic disease, however, is definitely a problem in search of a primary care solution. As her story said:

“It’s sad that the existing health care establishment has not figured out a way to make primary care affordable and accessible,” says Jerry Avorn, a professor of medicine at Harvard. “We should not be surprised if someone outside of our world comes in and does it for us.”

Some of the retail clinics are already venturing into aspects of chronic care: diabetes management, weight-loss programs. (I think we can safely say that primary care physicians have not solved the U.S. obesity problem). Some employers are using the clinics for wellness and routine screening programs.

The costs tend to be lower. Appleby cited a study in the American Journal of Managed Care that costs are 30 percent to 40 percent lower than in the doctor’s office and 80 percent cheaper than in the emergency department. Consumers like the predictability and transparency of the costs (although insurance can also pay) . They don’t get pricing clarity up front at the doctor’s office or hospital.

Several provisions of the federal health law may further spur interest in the clinics. For instance, small businesses will have incentives to offer worker wellness program. The clinics may help fill in some gaps in primary care which are expected to get worse before they get better because of the pent-up demand for care that may burst out when coverage expands under the health law starting in 2014. The Association of American Medical Colleges estimates a shortfall of 21,000 primary care doctors by 2015. Not everyone agrees that there is an across-the-board shortage, as opposed to a shortage in specific underserved areas.

How clinics make the jump from flu shots and throat cultures to the far more complex task of monitoring chronic disease is not completely clear. Remember that patients, particularly older patients, often have multiple chronic diseases (i.e. diabetes and hypertension and congestive heart failure and arthritis, etc.). Some questions remain: Will the clinics turn out to be good at managing relatively stable patients in the early stage of disease – where the convenient locations and evening and weekend hours may enhance compliance? What about with the more advanced illnesses? Will the retail clinics add to fragmentation and miscommunication? Or will the clinics somehow form relationships with “new, integrated collaborations between doctors, hospitals and insurers?”

I don’t want this post to get longer than Appleby’s article so, when you read it, pay attention to the other issues she raises, and think about how they are playing out in your community:

• Scope of practice. What is the role of nurses/nurse practitioners/physicians assistants versus physicians? Turf battles can produce good sources and good stories.
• Does your state have laws about clinics directly employing physicians?
• Will clinics “skim off” healthy patients from physician practice and leave them with all the sickest and most expensive ones, without greater reimbursement? Or, by taking on some routine medical tasks, will clinics allow physicians to spend more time doctoring?
• Who are the patients? (Other than truck drivers and high school students needing sports physicals.) Are clinics just a convenient way for insured middle-class people to get routine care? (I’ve taken my son in for a throat culture at 7 p.m. when he’s feeling scratchy and I know there’s strep in his class. It’s way better than waiting until the next morning to go to the pediatrician when he might be sicker, and he has to miss school and I have to miss work. And, if he does need antibiotics, I’d have to go the drug store anyway.) Or are the clinics avoiding poorer neighborhoods, meaning the underserved stay underserved?
• Appleby didn’t mention this explicitly but it’s worth adding to the mix: To the extent the clinics are in underserved communities, are they helping low-wage hourly workers who don’t have paid sick leave or the flexibility to take an hour or two off in the middle of the day to get their kid (or their mother-in-law) to the doctor?
• Are any of the clinics – anywhere – starting to share information with patients’ primary care physicians? Or, in the case of diabetes, heart disease, etc., are they sharing information with specialists? It can be as simply as faxing something, sharing electronic medical records or using secure email. If I take my kid for that throat culture, it’s really not a catastrophe if I forget to tell his pediatrician (and I don’t need to bother if it’s negative). But for things like immunizations, or A1C levels for diabetics, or blood pressure spikes or changes in medications - someone needs to keep track of the big picture. Of course, communication isn’t all that great right now between doctors without the clinics but, since health reform has some incentives for improving coordination, where do the retail clinics fit in?

That question about integration, which Appleby raised, doesn’t yet have a clear answer. Could the clinics end up having some kind of relationship with the “medical home” or the “Accountable Care Organization” or other models of integrated care? I am not sure of all the legal or contractual problems. If someone has written about this, please chime in. But I can envision ways that clinics can be brought into the coordinated or accountable care loop. It may turn out to be in everyone’s interest – patient, physician and clinic – to do the looping.

AHCJ asks Supreme Court to permit broadcast of health reform arguments

AHCJ has asked Chief Justice John G. Roberts of the U.S. Supreme Court to permit live audio and video coverage of the oral arguments next March in the case challenging congressional authority to mandate health insurance coverage and other provisions of the Affordable Care Act.

The Court has long permitted print journalists to cover its proceedings and, more recently, began offering time-delayed audio recordings of oral arguments. But AHCJ is pushing for real time audio and video coverage in this case, due to the historic significance of this case and potential impact on millions of Americans.

In the letter to Chief Justice Roberts, AHCJ contends that these provisions are inadequate for such a historic case with potentially sweeping impact on the health care system and millions of Americans.

The Radio Television Digital News Association has filed a similar request with the high court, as has C-SPAN and U.S. Sen. Charles Grassley, R-Iowa. The New York Times weighed in with an editorial last week.

See the AHCJ letter.

Back-to-the-beat resources on health reform

Since so many of us are in storm (or non-storm) what-are-we-going-to-do-with-all-these-batteries cleanup and back-to-school mode, I thought I’d bring some resources and interesting studies to your attention to help bring your focus back on the beat.

Confusion still reigns

You probably saw the Kaiser poll reminding us once again how confused people remain about the health reform law - including the very people who would be most helped by it, the uninsured. It got a lot of coverage but if you missed it, it’s a must read. It ties into the theme of massive national confusion – and the frustration I feel that the confusion persists despite a fair amount of good reporting – that I wrote about in the first post I did for Covering Health. I think a lot of the confusion stems from the mandate . People hear that they will “have” to buy insurance, and they panic or get angry because they can’t afford it. They don’t hear that they may well qualify for subsidies to make it affordable-and they don’t have to be dirt poor to get the subsidies; many middle class people will also benefit.

Most of the coverage of the KFF poll I heard or saw centered on the uninsured, but there is also a related data note looking at knowledge and expectations of people who have employer-sponsored health insurance. Asked what they would be willing to do to lower health care costs, the answer could be summed up as “not much.” They are OK with participating in a wellness program (although not necessarily actually getting “weller”) but didn’t like the idea of more generic drugs, more restrictive networks of doctors, or higher copays and deductibles.

Eating away at the doughnut hole

An AHCJ member found this report by EBRI, the Employee Benefit Research Institute, useful so I’m sharing. It’s about how the health reform law will slowly (over a decade) close the “donut hole” for Medicare drug coverage, and how repealing the health law would create a savings hole for older Americans who use a lot of prescription drugs. (The doughnut hole is the gap after you use up the basic drug benefit but haven’t hit the “catastrophic” level. Beneficiaries pay monthly premiums through the gap, but don’t get benefits until they burn through the gap. ) EBRI studies health care and retirement issues and does periodic issue briefs.

Staff physicians on the rise

The Center for Health System Change has been tracking health care developments in 12 communities and found that hospitals are hiring more staff physicians. In policy circles, the talk has been that the staff-physician model is a tool in creating more clinical integration, care coordination, higher quality and lower cost – but this study found that the hospitals are in it primarily for market share. Physicians like it because it’s fewer hassles. It doesn’t necessarily bring down overall health care costs. Now, this is a snapshot in a fee-for-service world; new payment models being developed by private insurers, and Medicare and Medicaid may change the dynamic. But it’s an attention-worthy snapshot. The HSC Issue Brief, “Rising Hospital Employment of Physicians: Better Quality, Higher Costs?” is available online.

Who applied to be ACOs?

There was a lot of coverage a few months back about all the health systems that were not going to apply to become Medicare Accountable Care Organizations, at least not under the original shared savings model. We aren’t hearing as much about who is applying – worth checking in your community. Medicare also created an alternative, called the pioneer ACO, to attract more plans. We won’t know until around November how many applied to be pioneers, or who they are, but here’s the story of one plan that’s ready to go.

Behind the drug shortage

There was a lot of discussion on the AHCJ electronic discussion list recently about drug shortages, particularly chemotherapy shortages. I was out of town for a few days (helping care for a relative and learning, among other things, that Medicare pays for oxygen concentrators but not for the batteries) and I haven’t caught up with all of the messages, but this essay in the Sunday New York Times a few weeks ago by Ezekiel Emanuel taught me lots I didn’t know about generic chemo drugs, pricing and shortages, and proposed solutions.

Kenen explains why the mandate matters

Usually I blog about topics that that lend themselves to local coverage, that explain health reform in the context of a state or community. But I think it’s worth taking a quick look at the individual mandate, or “shared responsibility,” because it’s so important – as politics and as policy. It’s back in the news after the Aug. 12 ruling. We won’t know its fate until the Supreme Court tells us, but it’s worth noting now:

• Courts have been divided and, on the appeals court level, it hasn’t been all partisan. One Democratic-appointed judge ruled against the mandate as written, and one Republican-appointed judge ruled for it.
• The federal health reform law doesn’t go away if the mandate is struck. But it will look different.
• Even with a mandate, the Affordable Care Act by 2019 would cover about 32 million people – and still leave 23 million uncovered. (That’s the CBO estimate from 2009.)
• The insurance industry’s [reluctant?] support for the Affordable Care Act was contingent on having the mandate. States that have changed the insurance rules – requiring plans to accept people with pre-existing conditions, etc. – without a mandate have seen costs skyrocket, which in turn means fewer, not more, people end up covered.
• There’s a lot of speculation about when the Supreme Court will rule – the timing could affect the presidential elections – but that’s speculation at this point. “If the court upholds the law, the Republican base gets energized four months before the election,” Bradley Joondeph, a Santa Clara University law professor, told the Wall Street Journal. “If it gets struck down, well, there go the guts of the centerpiece of Obama’s domestic agenda.”

I’m going to give you some links that will help follow the legal case, (AKA are we all wheat farmers?) and then highlight articles that have outlined some of the policy alternatives to the mandate – other steps that would encourage, although not require, more people to get covered. Of course, getting any changes through the Republican-controlled House is daunting, but not impossible if it were part of a larger “must-pass” or compromise legislation.

Legal issues

• Health Affairs/RWJF did a recent issue brief.
• The SCOTUS (Supreme Court of the United States) blog – which I suspect most of us health policy types have heard of but don’t actually read – is mandate madness. Seems to be rivaled only by same-sex marriage as the topic of choice.
• Linda Greenhouse (from last December) had an online ‘Opinionator” piece in The New York Times.

Policy Alternatives

• Austin Frakes, of the Incidental Economist blog (a good blog, by the way), recapped some of the main policy alternatives and I looked at a few approaches here for Kaiser Health News. (I don’t usually link to my own work on this blog, but am making an exception today.)
• Paul Starr has been worried about the mandate all along (here and here).
• Julie Rovner of NPR (among others) reported on the history of the mandate, which is generally regarded as a Republican idea when it emerged during the first President Bush’s administration. Republicans now generally oppose it, as this essay at the Heritage Foundation makes clear.

Report explains doctors’ reluctance to adopt EMRs

Writing for the Center for Public Integrity’s iWatch News, Susan Jaffe spent time in the trenches to better understand how government incentives toward the adoption of electronic medical records are (or aren’t) working. She spent time with Cleveland-area small practices and government agencies to understand the real obstacles faced by physicians on the ground. It offers a picture of the reality of EMR today. Some of my favorite tidbits:

• “570 different electronic health systems certified by private organizations for non-hospital settings may be used to qualify for the bonus.”
• “The systems are priced in a way that does not make comparison shopping ‘easy or necessarily valid,’ said Dottie Howe, a spokeswoman for the Ohio regional extension center. There is no basic price because each company offers different components, features, options, and level of technical support.”
• EMR systems can include more than a thousand sometimes-customizeable details, and that’s not including the myriad warnings and cross-checks.
• Compatibility with the systems in the area’s large hospitals is tough to guarantee, yet factors as a major concern for many small practices.
• How early adopters in the field were burned and are wary of getting fooled again.
• When practices adopt EMRs, they typically have to go through a “learning curve,” a period of weeks or months during which they can only see about half as many patients.
• Many major HIT companies don’t guarantee that physicians who adopt their systems will meet the standards for a government HIT bonus.
• The VA’s proven HIT system is available for free, but can’t handle billing and insurance.
• To get the maximum bonus payment, practices must adopt EMRs this year or next.
• Only certified systems can earn bonus payments, yet the second and third stages of certification haven’t even been finalized yet.

An accompanying piece by Emma Schwartz looks at one physician’s concerns.

Potential changes in regulation of medical devices would likely impact health care costs

As the medical device industry ramps up its campaign against further government regulation, Merrill Goozner takes stock of the regulatory and business environment in that arena and explains what is at stake. The key battleground at present is possible modifications to the 1976 law which allows devices to bypass some rigorous testing as long as they’re similar to something that has already been approved for market. The problem? That similarity doesn’t always mean they’re safe, as Goozner points out.

A study published earlier this year in Archives of Internal Medicine found that of 113 major product recalls between 2005 and 2009, only 19 percent had gone through the more rigorous clinical trial testing required for new products, while 71 percent had used the follow-on process. There had been only 49 major recalls in the prior five years.

Despite slipping onto market through the similarity provision, many of these new products claim to be improvements over their predecessors and thus come with commensurately higher price tags. According to Goozner and his sources, this little disconnect has done quite a bit to increase the cost of health care in America.

“Requiring evidence of benefit of effectiveness for patients before device approval would prevent billions of dollars from being spent on technologies that are not helpful for patients and are even harmful,” said Rita Redberg, editor of the Archives of Internal Medicine and a cardiologist at the University of California, San Francisco. “There are many examples, such as vertebroplasty and kyphoplasty for back pain [compression fractures], on which Medicare spends approximately $1 billion annually. After they were FDA-approved, randomized clinical trials showed they were no more effective than a sham procedure in relieving symptoms.”

The device industry, often cited for its red-hot growth rates in the past, now posts numbers that, while huge, still lag behind the health sector at large. That may be why the industry is stepping up political pressure to reduce its regulatory burden and to sidestep a 2.3 percent excise tax that was passed as part of recent health care reform efforts. For more on the money and politics involved, see Goozner’s full piece, which was also published in The Fiscal Times.

Related

• Medical device investigation unearths conflicts, regulatory issues
• House Committee on Oversight and Government Reform hearing: FDA Medical Device Approval: Is There a Better Way?, June 2, 2011

Health reform battle entering a new phase

As I try to figure out what AHCJ members most need as they cover health reform in year two of the Affordable Care Act, I tried to see if I could detect themes at the AHCJ conference in Philadelphia. That unified theory of health reporting plan went out the door as I heard questions ranging from very basic queries about pre-existing conditions to far more technical inquiries about accountable care organizations.

My next plan was to blog about the “reporting on health reform” session.  A conference fellow  beat me to that - (also see the tip sheets Covering health reform issues, Health care reform: Litigation update, Three health reform issues to watch in the states).

The repeal and replace stage of the health wars isn’t over. But I think we are entering another phase. The dominant national discussion topic is the deficit and the debt – and that leads into Medicare, Medicaid and other entitlements.  I’ve done a tip sheet on Medicare and “premium support.” Medicaid is next up.

The proposals in the House-passed version of the budget are not brand new; Medicaid block-grant proposals have been around since at least the Reagan years, and they were definitely part of the Gingrich era. I remember hearing about variants of premium support and/or Medicare vouchers in the late 1990s, and I suspect they were around before that.

We don’t know every detail of what the Ryan plan would do; the budget plan is a federal framework, and the details aren’t filled in. And of course the Ryan budget won’t be accepted by the Democratic-controlled Senate or President Obama.  But this idea isn’t going to go away. We need to watch how it plays into reforms being considered at the state level, and see what kind of steam it picks up (or loses) after 2012.

If your governor or state legislature favors block granting Medicaid, it’s time to start asking questions.

• What would Medicaid look like under a block grant?
• Who would still get it?
• Would there be enrollment caps and waiting lists?
• How much of the costs would be shifted to the beneficiaries and families?
• Would providers get paid less?

States can already get waivers for Medicaid, and that can allow for innovation in red and blue states alike.  States will have a lot more flexibility under some of the ACA provisions in the next few years, including ways of doing a better job caring for people with chronic disease and the “dual eligibles” on Medicaid and Medicare.

Here are a few articles I’ve seen recently that describe some of what the states are already doing – or considering – as they confront rising Medicaid costs today.

Looking at the coverage

Carol M. Ostrom of The Seattle Times had an April 17 piece: “Doctors: State plan to limit Medicaid ER trips risks lives.”

Several of the Florida papers have had pretty good coverage of Gov. Rick Scott’s plans to transform Medicaid. But a solid hour of Googling didn’t net me one good big clear step-back story (it may be out there somewhere … send it if you see it) that tells out-of-state readers the whole story. But I still found work by John Kennedy and Stacey Singer at The Palm Beach Post (here’s one) and Marc Caputo of The Miami Herald (click here - you have to read down a bit to get the state overview) helpful.

The Oregonian has been taking a look at some of Gov. John Kitzhaber’s agenda, which should be worth watching as he has a track record as an innovator (and knows CMS administrator Don Berwick quite well).  And of course we’ve all heard a lot about Arizona.

A lot of the stories I looked at from around the states were written by state capitol reporters, not health beat folks, so they were heavy on process and “Republican said X, Democrat said Y” kind of coverage. They didn’t always do a great job of getting beyond a fusillade of quotes.  I guess if I’ve been Googling for more than an hour and can’t find a really solid health overview story, I should stop here and invite you to send me any you’ve seen (or written).

Don’t forget about Medicaid

Medicare is getting an awful lot of ink – after all, old people vote, and most of us expect to get old someday and need Medicare. We’ve got to look harder at Medicaid which covers poor kids and their parents, some of the disabled and mentally ill, some of the HIV population, and lots of the residents of nursing homes. That isn’t who votes. That isn’t who decides what reporters cover. And it’s certainly not a benefit most of us hope to use someday.

Last comment for today - and you’ll probably hear me return to this theme frequently because, to me, it’s some of the most interesting reporting we’ll be able to do in the coming years:  Remember the Affordable Care Act, the health reform law, isn’t only about coverage and insurance exchanges. It makes countless changes to Medicare and Medicaid - changes that will affect the current fee for service model, changes that affect the private managed care sections of it and changes that will add new dimensions as we explore new ways of delivering care (medical homes, ACOs, a number of Medicaid programs aimed at getting people care in the community, not just nursing homes).

Joanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.

Meeting the challenges of explaining health reform

Editor’s note: Today we introduce Joanne Kenen as AHCJ’s health reform topic leader. She will be writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform.

Health reform, to say the least, is confusing. The Kaiser Family Foundation had a great “data note” recently establishing just how little the American people know about reform. (The lack of knowledge apparently did not correlate with the intensity of political feeling).

So, how did people do? Fewer than one in 100 got all 10 questions right. Only a quarter scored seven or more right – a “C” or above if we were grading.

A third got four or fewer right (F minus, minus?) Two percent didn’t get one single question right. Most were in the low-performing middle, correctly answering 4 to 6.

What killed me (no pun intended) is that only 45 percent knew – after all the zillions of words we’ve written about this – that there are no government panels making life-and-death decisions for older Americans. Can’t you see the tabloid headline: “Zombie Death Panels Refuse To Die.”

Sorting out the details

Why should we, as journalists, care about this non-knowledge – aside from the fact that it’s just depressing? I think it’s a two-fold challenge.

The first challenge is internal. Many health care reporters are juggling several health and science or health and domestic policy beats, or so immersed in local coverage that it’s hard to find time to sort out the 8 gazillion arcane details of the Patient Protection and Affordable Care Act . That’s where I come in – AHCJ has asked me to be its – or rather your – “health reform topic leader.” My task: help you get unconfused. I’ve done one tip sheet on the one-year mark of ACA (which is March 23), with more to come.

The second challenge is external – or maybe existential. We have all reported and reported and reported on this. Some of our work has been very good. But it hasn’t gotten through the noise and buzz and screeching and tweeting of the current media world – or through editors pressing us to write about who is up and who is down politically, rather than about the substance. I don’t have any easy answers on how to fix that – how to make sure that our readers/watchers/listeners (and sometimes our editors) understand and value our credibility – and find time to pay attention.

Find creative ways to tell the story

One tool is to translate the policy locally and sometimes narratively. I am always looking for fresh ways to tell readers about health care, in ways they can come to it anew and understand. A couple of years ago, just before I left Reuters, I did a story about how many college kids were studying health policy – a field that barely existed during the last big national debate in the Clinton years. Another time I wrote a magazine feature about a family with three generations of doctors (plus a 5-year-old carrying his dad’s black bag and talking about aortas). Without loading a lot of overt policy in the piece – which would not have flown in Washingtonian Magazine – I was able to illustrate how this family’s experiences had spanned a half-century of changes in American medicine. If you do stories like that (which are fun by the way) or see great work by colleagues, let me know about them. I’ll be writing for this blog regularly and will share some of your creative approaches.

Another tool – and obligation – is to just understand the policy and the politics and the changing health care system so well that we can break it down and make it clear for our readers. There are a lot of resources out there. I’ll try to bring some of them to your attention, and when you find useful ones, bring them to mine by sending e-mail to joanne@healthjournalism.org.

The sheer amount of resources – issue briefs, timelines, webcasts, transcripts – can be daunting but having so much at our online fingertips is still way easier than it was 15 years ago, when we had to go to events in person, collect stacks of documents, remember where we filed the documents, and then frantically search through the pages when we needed a fact on deadline (unless NPR’s Julie Rovner was within shouting distance of my desk in the Senate press gallery, then I could just ask her … )

Here’s one way to start. Kaiser followed up by putting that pop quiz online. Test yourself. (Or test your editor? Or how about your spouse or partner – unless you really don’t want confirmation of how well they do or do not listen?) And maybe then think about what, if anything, confused you. Or them. And try to end the confusion for someone else.

About me

Joanne Kenen

For those of you who don’t know me – I’ve covered both the politics and policy of health in Washington, D.C., for years, and written about it for numerous kinds of publications. I have been a health-focused Congressional correspondent for Reuters, a Kaiser Media Fellow writing about palliative care, aging and end of life in 2007, a think-tank based blogger, and I have freelanced for everyone from Slate to the AARP to Health Affairs.

I have written about both the cost/coverage side of things, and the delivery system changes, particularly about chronic disease and aging. I’ll be in Philly for Health Journalism 2011, AHCJ’s annual conference, so say hello, and feel free to email me or comment below on how I can help you.

Fact-checking Pawlenty’s health reform claims

In some parts of the country, health care-related posturing for the 2012 election is already in full swing. Over at CJR.org, AHCJ Immediate Past President Trudy Lieberman applauds a forceful bit of health care reform fact-checking by Minnesota Public Radio reporter Lorna Benson. In her piece, Benson carefully picks apart claims made by former Minnesota Governor Tim Pawlenty as he touts his health reform record as a key piece of his 2012 presidential campaign.

Pawlenty’s two big health talking points are his “baskets of care,” or bundled payments for certain procedures, and his pay-for-performance plan. While both sound promising on paper, Benson found that some gaping holes had opened up as soon as the rubber met the road. See Benson’s full piece for the details of how any real change has been difficult to track or, indeed, even to detect at all.

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