Matt Masiello, M.D., MPH

Category: Public Health

  • Local experts weigh in on health-care reform

    20120517-164136.jpgLocal medical leaders are closely watching health-care reform legislation developing in Washington. While most agree with the importance of providing affordable options to the estimated 45 million to 50 million uninsured Americans, they have different views on how the insurance should be structured and what additional changes should be addressed.

    “The question is: How are we going to pay for that expanded coverage?” said Scott Becker, president and chief executive officer of Conemaugh Health System. “The real interesting debate is going to be how far do they go with this public option. The key is how the benefits package is shaped.” Answers to those questions could change the structure of how health insurance is delivered in the United States, Becker said.

    The public option, or government-sponsored health care plan, would be available as an option along with private insurance company plans, Democratic Sen. Robert P. Casey Jr. said during a teleconference announcing one of the bills had been approved by committee and sent to the full Senate.

    In the Health, Education, Labor and Pension committee’s bill, the public option is a gateway to getting access, Casey said, adding it is expected many would move on to traditional private plans. But the public option is crucial to controlling costs. “I believe big, powerful insurance companies need to be held accountable.” Casey said. Under the committee’s bill, the gateway program would be launched with federal money but managed by a nonprofit cooperative, he said. “It’s meant to be a self-sustaining entity that can be competitive in the marketplace,” Casey said.

    While any government-funded health insurance is meeting stiff opposition from Republicans, none of the local experts interviewed was ready to totally dismiss the idea. “I think the good thing is we are trying to develop coverage for 45 million people who don’t have insurance”, Becker said. “It is going to create a level playing field, but you are not going to get that for nothing.”

    The final structure of a new public option will be developed after both the House and Senate pass bills and they are sent for reconciliation. Until then, Conemaugh is taking a wait-and-see attitude. “As they say: The devil is in the details,” he said. Lack of details has many in the insurance industry worried, Highmark spokesman Michael Weinstein said. Government insurance plans such as Medicare and Medicaid have traditionally paid physicians and hospitals less than private companies.

    “There is a natural advantage to government-run plans: They dictate the payments to doctors and hospitals,” Weinstein said. “It is going to drive up the cost.” If the government-funded plan does not pay enough to cover expenses for hospitals and doctors, he said, the medical organizations will shift those costs to private plans such as Highmark. As those rates go up, insurance companies fear more employers will drop private plans and put their workers into the government plan. Bringing down costs must be part of any plan. Highmark supports a plan that would base payments more on outcomes, Weinstein said. “We haven’t seen enough debate on this: How doctors and hospitals are paid,” he said. “The way Medicare works, the more tests a patient has, the higher the cost. It doesn’t guarantee better outcomes.”

    Some local preventive medicine advocates agreed that reform should include restructuring the way doctors and hospitals are reimbursed. “The good thing about the discussion is we are going to look at policy change,” Dr. Matthew Masiello, chief wellness officer, said from Windber Research Institute. “It opens up the doors with universal health care to look at policy we have not dared address in a serious way before. ”Smoking, obesity and nutrition can be addressed by adding financial incentives for physicians who direct patients into programs that help them overcome unhealthy habits”. Although Casey said his committee’s bill addresses preventive medicine and wellness, Masiello says all the proposed reform falls short.

    “I see very little in there to support developing a substantial health-promotion, disease-prevention infrastructure,” Masiello said. “For that reason we are going to see higher cost of health care until we develop significant infrastructure.” Adding 45 million to 50 million people to the insured “pool” will be expensive, especially because many of those uninsured have chronic conditions that may be undiagnosed because they haven’t been seeing doctors.

    Windber Research Institute is part of a study using electronic medical records to identify patients with unhealthy behavior and direct them into intervention programs. “Those kind of things should be on the front burner,” Masiello said. “Down the road you are going to get the results that will allow a reduction in the cost of health care.” The research institute’s top dog is more blunt. “This isn’t health-care reform,” said Tom Kurtz, Windber’s president and chief executive officer. “It is misnamed. They are going after an insurance product.” The 45 million or more people are just a symptom of a larger issue, he said. “It addresses nothing of the underlying problems of the health-care system.” Kurtz said, adding it might even be time to ask why the U.S. health insurance structure is based on employers. Recent layoffs highlighted the issue. “They need to revamp the system,” Kurtz said. “No one has even addressed the basic questions: Is health care a right? Is it an entitlement? What should be covered?”

    Other countries have addressed many of these issues successfully, he said, adding “Japan is a good example.” But it’s tough to legislate behavior, Becker warns. Insurance companies could, however, charge higher premiums for those with greater health risks.

    For now, Congress and the health-care industry should look at focusing on improving access to primary care doctors, Becker said. The current system pushes more money toward specialists, but family physicians are the front line of prevention. “It’s a cultural challenge we face now,” Becker said. “We need to open up roads and create incentives for more physicians to go into primary care.” Like his former Windber colleagues, health-care consultant F. Nicholas Jacobs believes the reform does not go far enough. “Tort reform, intelligent efforts toward stemming the continued surge of illegal aliens, a wellness rather than a sickness reimbursement system, acceptance of hospice and palliative care for end-of-life care, electronic medical records and new efforts to bolster our medical school attendance are just a few of the changes needed to allow health-care reform to gain meaningful traction,” Jacobs said in a statement.

    The former president and chief executive officer of both Windber Research Institute and Windber Medical Center worries that current proposals have been watered down too much to appease conservatives and others. “Health reform is critical,” Jacobs wrote.
    “But meaningful, ethical leadership is much more critical and both seem to have been on life support for a very long time.”

    **This article was published in the Tribune Democrat on July 19, 2009

    http://tribune-democrat.com/local/x914502174/Local-experts-weigh-in-on-health-care-reform

  • JAMA Commentary Promotes Investment in Disease Prevention

    http://www.rwjf.org/publichealth/product.jsp?id=38452

  • World Health Organization and Health Promotion – Why?

    20120518-174532.jpgIn 2009, international health experts arrived at Windber, PA, to lend us some of their expertise. We heard and discussed how we as a community; how we in our hospital systems can improve the health outcomes of our citizens and community. Those in attendance were clinicians, nurses, academicians, scientists, managed care executives, information technology specialists and an executive pharmaceutical team from NY. The one comment most of these folks made as the session was winding down and finally came to an end was how exhausted they were. Can you imagine having your world turned upside down on such issues as universal health care? Or this new terminology called clinical health promotion serving as the proven, evidence based approach to not only improving the health of our patients, but assuring us of better chance of getting out of the hospital quicker and with fewer complications.

    The easy answer to the why the WHO came to town is that it is an organization having a 20 year track record in hospital based health promotion, the new lingo in the vocabulary of US politicians. In the U.S. we pay more for our health care then any of the other developed countries and have poor health outcomes as a result. It is time we look outside of our borders for help. Taiwan did it and several other countries are doing pretty well with their health care. In my twenty years as a hospital based physician I have experienced numerous hospital consultants, regulatory and health award groups entering a hospital environment to either announce the great things we are doing as hospitals or how to lay claim to better patient care. Thousands and millions of dollars are spent on such questionable practices. And how has all of this improved the health of out communities, our nation? We have seen the result, a fragmented and broken health care system. Millions are uninsured; more under insured and bankruptcy, due to health insurance bills, in now all too common for thousands of U.S families. I have to wonder whether international health experts, with a proven track record, were invited to the recently held presidential forums to offer advice on health care reform. Most likely not and the same politicians or health care leaders that have gotten us into this situation were again touting their expertise or referring to their best selling novels.

    Another message we received from our visiting international experts is that our patients must ask some additional questions of their physicians or surgeons as they are preparing for surgery or a hospitalization. A physician telling you, the patient, of his specialty or his or her many years of experience should not be enough to assure us of the best outcome. Doctor, what evidence is there to support your decision? This is the question we need to now ask as we rise to that next level of health education.

    Dr. Tim Neuman from Germany summed it up well during the panel discussion at the University of Pittsburgh at Johnstown. “You are a bizarre country,” when he described the many concerning issues we have in this country, but “for this event I see solidarity.” Some thing we need to see more of at the grass root s level. A thank you to the community, our partner, the University of Pittsburgh at Johnstown; our sponsors; and the fine folks at the Windber Research Institute and Medical Center. Oh, and by the way, the cost to the hospital for this WHO consultation was around $400, which is expected to be reimbursed once all the other bills are paid. Not bad, and probably difficult to comprehend.

  • Bullying – yes, a lot of talk, but action

    When the media does get involved in an informed manner they are able to successfully make that statement to inform the public of where we are and where we should be regarding that “social issue.” Thomas Sowell, from the Hoover Institute based in Stamford, California and a frequent contributor to the Tribune Democrat national newspaper system did that for us in his April 25th piece on bullying, “A lot of talk about bullying, but little action.” In many ways he is correct. Politicians, alone or educators, alone, often have less then adequate results in any singular attempt to reduce bullying in our schools. What will work and what has been demonstrated to work is a public health approach to the issue. Bullying is a complex social epidemic. First, there should be no question that it is at epidemic proportions when upwards of 30% of our children are involved in bullying on any given school day. Also, the health and legal issues related to bullying adds another layer of activity to that epidemic. It costs all of us when that child is seen in the physician’s office or emergency room with a health issue, small or significant, related to bullying or when we can now document increased criminal activity in adulthood when a child becomes a bully in his youth.

    It is not only the politicians, media or educators that need to step up to the plate and act. Our managed care organizations and health care providers must appreciate the health consequences of bullying beyond that of the school based bullying event. Health care reform needs to involve all the players at many levels. The Academy of Pediatrics and similar national organizations must appreciate the “evidence” of evidence based programs. Though not having their origins in the United States these internationally recognized initiatives have been evaluated over the decades and to now hold these programs to another level of ill defined evaluation allows us never to get out of the gate to do something about the issue. Judges and lawyers need to imbed a “public health” foundation into their unfunded policy mandates and not just require, reprimand or punish the student or school. Monitored, evidence based programs need to be part of the equation.

    It is a complex issue requiring the theories and practices of public health science to implement that evidence based program with the highest of fidelity, monitor and evaluate the effort and, lastly, but most importantly, enable and empower those educators, politicians, health care providers, etc to sustain the initiative beyond the initial funding or programmatic activity.

    An example of this public health approach and the only such example in the United States is what has occurred in Pennsylvania. The Highmark Foundation, in partnership with their health care organization, Highmark, Inc, and in realizing the health and social consequences of school based bulling, developed a coalition of educators, public health professionals, program specialists and other key partners to strategically address the issue. This five year effort has resulted in the largest U.S. implementation and evaluation of an internationally recognized bullying prevention initiative. The $ 9 million dollars did not come from the government, CDC or some other nationally recognized organization, but from a regional foundation that wanted to develop that program to assist their clients. Along the way they developed a national model – – action, not talk. In this coalition driven initiative involving approximately 250,000 children, 400 schools and thousands of teachers, parents, school bus drivers, and lunch room monitors bullying rates have decreased along with increased adult and bystander involvement. We are now reporting out on these positive findings as well as demonstrating the cost benefit to the health care system, the educational system and society. Thus, the action taking place in western Pennsylvania resulted in a comprehensive public health initiative involving an evidence based program; a large population; program implementation with high fidelity; extensive monitoring and evaluation to the point of evaluating not only a decline in bullying rates but other behavioral and health enhancements as well as a cost benefit to many segments of our society. It is certainly a confirmed call to action.