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Health-care experts say Obama can get some reform himself

By David Ignatius
Sunday, January 24, 2010; A17

It's the truism of the week: To surmount his political troubles, President Obama needs to show leadership -- especially on his signature issue of health-care reform. But how can he do that with a Congress that will be even more gridlocked after last Tuesday's election shocker in Massachusetts than it was before?

A simple suggestion: Obama should use his authority as president to start reforming the health care system right now -- without waiting for congressional passage of a behemoth health-financing bill. He should use the existing "public options" -- especially Medicare and Medicaid -- as laboratories for change. This approach would have the benefit of beginning to reduce the costs of delivering care before comprehensive legislation makes the system universal.

This approach, which some medical leaders have been urging for months, would respond to one of the messages that Massachusetts voters were sending. Bay State reporting suggests that voters liked Obama well enough but they rejected the health-care monstrosity that has emerged in Washington after a year of congressional logrolling and special pleading. Judging by anecdotal evidence, people seem worried that the legislation will disrupt their existing care and balloon the deficit -- without really reforming the system.

As is usually the case when the public speaks this loudly, the people are right: The process that has produced the House and Senate bills has been an abomination. The voters sent Obama to Washington to lead, not to engage in endless horse-trading. When Sen. Ben Nelson demanded a tax exemption for his state of Nebraska as the price of his vote, that should have been a sign to the White House that the process had gone haywire. Instead, the administration agreed to similar buy-offs for the insurance industry and labor unions.

So how can Obama show leadership, immediately, without waiting another day for the venom-merchants of Capitol Hill? For an answer, I called my two health-care gurus, Dr. Denis Cortese, a former chief executive of the Mayo Clinic, and Dr. Delos M. Cosgrove, chief executive of the Cleveland Clinic. They outlined some ways the president can break the impasse.

The White House can jump-start this reform process by appointing (at last) an administrator for the Centers for Medicare and Medicaid Services, which oversees the programs. Obama should direct the new CMS chief to manage our existing "public option" systems so that they pay for value.

Last summer, Cortese gave the White House a plan for how these reforms would work. It's still a good blueprint.

First, Medicare should adopt a "value index" that would "reward those who provide safe, high-quality care with excellent service at a reasonable cost." For policy wonks, the equation would be Value equals Quality divided by Cost. Good data exist to measure the variables -- through hospital admissions, readmission rates, emergency department visits, mortality rates and the detailed cost data, region by region, gathered by the Dartmouth Atlas of Health Care.

Second, Medicare should start bundling payments to hospitals, physicians, nursing homes and others so that providers are paid for outcomes, rather than individual procedures. Cortese favors beginning with some common conditions, such as heart failure, lung disease and diabetes, and some common procedures, such as hip and knee operations and open-heart surgery. Medicare began experimenting with such bundling back in 1991; now it needs to get serious: Paying health providers together will force them to work together, too.

The president could begin these reforms immediately, as pilot projects. To make them universal across Medicare would probably require legislation, according to Jeff Korsmo, director of the Mayo Clinic's Health Policy Center.

Insurance reform can come only from Congress, and that's what has gotten bottled up in the nightmare legislative debate. Obama can break that logjam by reaching over the heads of the feuding legislators to the health-care community, where there is a growing consensus that the system must be fixed. "I don't think any of the players are happy with the status quo," says Cosgrove.

America's biggest problem is political dysfunction. The system isn't fixing problems that people care about, such as health care. To become the leader the country needs, Obama needs to bypass this infuriating, enfeebled Congress -- perhaps by convening a health version of a "constitutional congress" that brings together doctors, hospitals, insurance companies and patients. The legislation can come later, once the process of change has begun.

davidignatius@washpost.com

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