Thursday, May 14, 2015
Adios Germany
I bid a fond fair well to Germany, where at every stop I was received with remarkable hospitality and friendship. I also appreciated the frankness with which my many interviewees spoke about the strengths and weaknesses of their country's healthcare system, especially when it comes to the sensitive and sometimes controversial aspects of access for refugees and the undocumented.
Without doubt, the highlights of my trip were the conversations and conviviality with my German counterparts from Eisenhower Fellowships. Their warmth towards me and my wife made us feel like we were long absent friends. Our discussions were vibrant and, many times, quite personal. I learned a great deal, and was humbled by how these exceptional people took me in as one of their own. I will never forget it.
Now back to the U.S. Over the next weeks I will be posting every Monday about my trip to Germany as I process the information I received and try to connect it with our reality in America. Then, as I draw closer to the second half of my travels, I will discuss my preparation for visiting Mexico.
Tuesday, May 12, 2015
Reaching Out Into the Dark Corners
I had the opportunity to meet with Dr. Rolf Rosenbrock and Sergio Cortés of Der Paritätische Gesamtverbande. It was a broad and freewheeling conversation that took place in German, Spanish and English.
The Paritätische is an association of social movements committed to the idea of social justice: equal opportunities and the right of every human being to live a life of dignity in which they can develop freely. Or, as Dr. Rosenbrock said, "we reach out into the dark corners" and defend the marginalized and disadvantaged in society.
 |
| Dr. Rolf Rosenbrock (left) and Sergio Cortés with the author |
The Paritätische is an association of social movements committed to the idea of social justice: equal opportunities and the right of every human being to live a life of dignity in which they can develop freely. Or, as Dr. Rosenbrock said, "we reach out into the dark corners" and defend the marginalized and disadvantaged in society.
I've mentioned in other posts that the theme of solidarity is one that continues to come up in my interviews. Some have commented that this is a concept which mostly draws lip service today, and I'm sure that must be true in the same way that "American Exceptionalism" is touted by some who have no real interest in being exceptional, but my experience in Germany has been shaped by this idea, and it is certainly central to the work of the Paritätische.
As their website says, the notions of equality and parity characterize the organization’s self-perception. "The Paritätische sees itself as a community of solidarity, uniting different and independent initiatives, organizations and institutions from a broad spectrum of social work." This takes the form of a multiplicity of social services and facilities. But this also includes the premise of helping people to help themselves. Sergio told me that right now there are 190 migrant-member groups working in a variety of areas, notably in health promotion, to help their own communities. The Paritätische supports these groups and other members by making available free expert advice in the fields of social work, law, management and administration. They also help seek funding for projects.
Over the years the Paritätische has been able to earn a unique position among German welfare associations, not only highlighting where things are going wrong but also actively influencing the development of social and economic policy. Dr. Rosenbrock pointed to legislation about to become law that centers around increased resources for disease prevention and the promotion of healthy living. Thanks in part to the work of the Paritatische a provision was included that specifically calls for the allocation of a part of these resources to immigrant communities.
One of the things I found so refreshing about my conversation with Dr. Rosenbrock was his groundedness and sense of humor. He commented that sometimes it can seem like the organization's work is akin to "pissing into the ocean." This feeling seems to come especially from the little attention given by policy makers to the social determinants of health. And of course he is right. We have ample evidence in the United States that public health efforts, however well organized and funded, crash against the shoals of income inequality, poor public education, few job opportunities and unsafe (or non-existent) housing. But Dr. Rosenbrock and Sergio are clearly doing good and have the evidence to prove it. It is an example we should better emulate in the United States.
Changing Focus on Immigration
My wife and I enjoyed a wonderful tour of the Reichstag, courtesy of Beate Hasenjager, who is in charge of all the facilities at the government complex including procurement, and the first woman to ever hold this position. She gave us a behind-the-scenes look at the main chamber where the elected officials meet, a number of the meeting and assembly rooms, and the incredible glass dome that sits atop the building and which is both beautiful and functional, providing light and helping with temperature control.
Germany is a parliamentary democracy. There is a president but he is mostly a figurehead when it comes to enacting laws. The chancellor (currently Angela Merkel) is elected by an absolute majority of the Bundestag (the lower house) for a four-year term and is the head of government. The Bundesrat (the upper house), has 69 seats, with each state having three to six representatives depending on the state's population. The Bundestag has 598 deputies who are elected for four years using a mixed system of proportional representation and direct voting; additional seats are added when a party wins more seats through direct voting than it would have by proportional representation alone. A party must win at least 5% of the vote in order to be represented. Furthermore, Germany is divided into 16 states, each with its own constitution, legislature, and government, which can pass laws on all matters except those - such as defense, foreign affairs, and finance - that are the exclusive right of the federal government.
Over lunch Beate and I discussed health policy and a broader conversation about immigrants. I described to her how the U.S. has tried to legislate immigration and the current movement towards E-Verify. Beate stated that in Germany it is not possible to find work if you are in the country illegally.
That, of course, is how many people in America would have it. But what seems to be lost is the fact that immigration is never, at its essence, about law: it is a political decision, the kind that allowed my parents to legally emigrate and 12 million others not. Immigration law is not the Ten Commandments. It is not composed of immutable truths like "Thou Shalt Not Kill." But unfortunately this conflation of law and political policy can bind us from taking actions that are good for the country.
In a recent New York Times article, for example, Philippe Legrain, a former economic adviser to the president of the European Commission, argues convincingly that immigrants are the "tonic" the EU needs to reverse Europe’s demographic decline and resultant economic stagnation. He also refers to a study by the Organization for Economic Cooperation and Development showing that migrants tend to be net contributors to public finances. Here in the U.S. there is an abundance of similar data (for example, I previously referred to data collected by the St. Louis Mosaic Project).
We can debate over just how immigrant labor fits into the overall economic picture of our country and what are the proper mechanisms (increased numbers of visas, expanded ability to seek asylum, etc.) to manage the flow of immigrants, but we can never get to that point - and fully realize the tremendous benefits of immigration - if the issue is always seen through the prism of law. Let's insist on changing the focus to a policy discussion and have a more productive conversation about immigration.
Thursday, May 7, 2015
Post from Berlin
I've been remiss of late to post on my blog. Lots going on and very detailed interviews that I have to process. I suspect I will be doing a lot of post-trip blogging as I am able to full digest everything that I have seen and heard. In fact, I only have a few minutes now because I'm heading out for a tour of the Reichstag. So here are just a couple of quick things that caught my attention.
I met with Anissa Kirchner and Flaminia Bartolini of MediBuro Berlin. Like MediNetz, they are staffed by a collective of volunteers and refer patients (asylum seekers and undocumented) to a group of about 100 doctors who will privately and confidentially see the patients. MediBuro pre-negotiates prices with the providers and raises funds to help patients out when their treatments are very costly. Also like MediNetz, they have a political operation, although theirs is much more vocal and self-described "leftist." Two things (of many) that struck me during our two hour conversation were medical status and barriers to care for asylum seekers.
Unlike in the U.S. where the only issue for getting insurance (now that pre-existing conditions are off the table) is your ability to pay for it, in Germany your status (worker, student, unemployed, etc.) is directly linked to how you are covered. Anissa described to me how she fell into a gap after she graduated from high school and did not immediately want to enter university. She was no longer a dependent, was not a student, and did not have a job. These are "status portals" (my term) for coverage. Before a law change in 2007, Anissa said, she would have in fact been uninsured. Now, like the ACA, German law requires you to have insurance, so she had to decide between foregoing what she wanted to do (volunteer at an NGO) or paying a very high cost for insurance. An interesting twist from the situation as we know it in America.
Flaminia also talked about how asylum seekers are assigned to a specific area of Germany (the concept is to avoid having any one section of the country overly burdened with caring for migrants), and the healthcare "permit" that they are given is only valid in that area. If they were to, for example, visit relatives in another part of Germany and they got sick, their only option would be emergency care. In addition, even within their home area, asylum seekers must go to a government office and get specific permission to seek care before they can go to a doctor. Flaminia says MediBuro and groups like theirs are advocating on an on-going basis to change the law in these areas.
Sunday, May 3, 2015
An Examination of a Sickness Fund
As mentioned in a previous post, the Sickness Funds, or Statutory Health Insurance companies, are an integral part of the German healthcare system. So, as part of my Eisenhower Fellowship, I met with Thorsten Schonherr, Head of Department for AOK Bremen, and company spokesman Jorn Hons. AOK Bremen is one of eleven Sickness Funds within the AOK corporation. They work primarily within Bremen but also cover people from the state of Lower Saxony.
Thorsten Schonherr and the author
Since the Sickness Funds are for-profit entities, I asked if the Funds compete with each other. Thorsten said that all Sickness Funds are about "95% identical" to each other, but that they do compete on the other 5% by "making your Fund as attractive as possible." That takes the form of, for example, special contracts with psychotherapists and hospitals which go beyond - or offer something different - than is offered by other Funds. Due to the German concept of Solidarity that emerges from the German social code, it is understood and accepted by most Germans that the overall package of benefits is made possible by young healthy people paying premiums that largely pay for those who are sick. I say "most Germans" because about 10% of the population chooses private insurance instead of the Sickness Funds (you must earn more than 50,000 euros per year to be eligible). On the plus side, with private insurance you are not bound by what the Sickness Funds have decided are covered treatments and your premiums are significantly lower. However, these premiums increase with age and only cover the individual (each family member must be covered separately). And should you become severely and/or chronically ill, your premiums can skyrocket.
Cost containment for the Sickness Funds is primarily achieved by annual negotiations around reimbursement rates for any and every treatment and service. Such a situation would be anathema in America, but as Thorsten said, "Social good, that is our Bible." And by having a set rate for all treatments, it creates certainty for stakeholders and makes a realistic budget possible.
Jorn Hons and the author
I asked Thorsten and Jorn specifically about hospital stays and reimbursements, since in the U.S. this is a major driver of costs. They said that until 2003, hospital reimbursement payments were based on the number of days the patient stayed. The result was that patients who, for example, could have been discharged on a Friday were kept hospitalized until Monday. The new system now bases reimbursements on "diagnosis groups." For example, Thorsten said, if someone breaks her leg it will be reimbursed at a set amount regardless of the number of days the patient stays in the hospital.
Unfortunately, a byproduct of this change has been what Jorn called "the bloody discharge," where a patient has not been fully cured or healed but is nevertheless discharged and referred to their primary care physician for follow up. "This is an ongoing discussion for us," Jorn said.
I went on to ask about the German dichotomy between the system that AOK is part of (the Statutory Health Insurance, or Sickness Funds) and the private insurance system. I understood that the premiums for the private system were considerably lower than for the Sickness Funds, but given that premiums for the private system were subject to substantial increases with age and illness, why, I inquired, would people opt for private insurance?
"We have been having this discussion for ages," Jorn responded. "It is often a financial decision," he said, because the premiums are much lower. But there are other factors. Civil servants, he said, get their premiums paid by their employer, and certain trade groups have their own dedicated private insurance. Also, Jorn said, private insurance "pays for everything, and we don't."
Does this mean, I asked, that the private system is potentially subject to unnecessary care? Yes, Thorsten said. One indication they have seen is that while most doctors' patient mix includes only 10% from private insurance, they are deriving 20-30% of their income from those patients.
What about Germany's aging population, I asked? Like the U.S., Germany has a high average age and a birthrate that is below replacement. Is there a concern about exploding medical costs relate to this demographic reality?
"I personally don't think [out of control costs] will happen," Jorn said. He referenced the concept of Solidarity that I discussed in an earlier post. "Our Solidarity system is designed for the sick," Jorn said. Thorsten added that Germany is also focusing much more now on disease prevention through public awareness and programs about nutrition and exercise that will hopefully help produce healthy aging. And in fact, Jorn interjected, "A new law is being adopted that stipulates we have to make a certain amount available for prevention." It doubles the amount spent on exercise and nutrition, including cooperation with gyms where Fund members get special rates, as well as providing medical and dental checkups in schools for children. "We want to be known as a health fund, rather than a Sickness Fund," Jorn stated.
Earlier in the Fellowship I had some private conversations regarding the sharing of personal medical information. I had been told that there was very little sharing, making each patient a "black box" anytime they went to see a physician other than their primary care provider. Thorsten said this was largely the case.
"We have had this discussion for many many years now" to create ways to privately share information, he said. "But this idea has remained an idea only."
So this is a part of the German system that is not working that well, I said. But you are still clearly proud of what has overall been achieved. What works best in German healthcare?
Solidarity, both Jorn and Thorsten answered. Also, Thorsten added, by statute the government "can't tell us how to cover care, they can't take money out of the system. And we have easy and fast access" to care.
Thorsten and Jorn were very generous with their time, which permitted an extensive discussion. I'll have much more to say about it as I process the information and integrate it with other interviews in Germany. For now I have just a few impressions.
One thing that struck me is how right Sigrid Becker-Wirth of MediNetz was: if you are undocumented, you have very few options for care that don't make you highly likely to be deported. The gentlemen from AOK both said several times that the undocumented are "not part of the system." My interpretation is that the Germans leave the undocumented out in the cold for healthcare not due to animus regarding their race or country of origin but because of the German regard for adherence to the system (this interpretation has been reinforced by private conversations with others during my trip). As noted earlier, this regimentation carries excellent benefits in many respects, but makes it very difficult indeed for those who are outside the system. I'd go so far as to say that the undocumented may be better off in the United States because, although the undocumented face severe challenges in America, there is no "duty to denounce," which I've learned not only makes life difficult for the undocumented but also for asylum seekers who fear the required registration by which they can be tracked if their request for asylum is denied.
Many U.S. hospitals are not very fond of the readmission penalty that they can incur under the Affordable Care Act when a patient is hospitalized again within 30 days. And they have a point, to a certain extent. But the results speak for themselves, and I wonder if the "bloody discharge" phenomenon in Germany would not fade if they adopted the same policy.
I think it's pretty clear that the U.S. will not be adopting a Sickness Fund model anytime soon. But one aspect we could and should follow is the public release of data. As Thorsten mentioned, there is a degree of competition between the Sickness Funds, one aspect of which is a ratings guide that provides data on multiple categories. And since 2007, all hospitals have been required to publish results on 27 selected indicators defined by the Federal Office for Quality Assurance. Germans can review this data and use it to change Sickness Funds if the ratings indicate, for example, that your Fund is not well managed or is charging higher premiums for services, and they can readily compare hospitals. Granted, this is not a perfect analogy when it comes to insurance since Americans cannot cross state lines when purchasing insurance, but the idea of greater transparency in performance data about insurers - and providers - is long overdue in the United States.
Since the Sickness Funds are for-profit entities, I asked if the Funds compete with each other. Thorsten said that all Sickness Funds are about "95% identical" to each other, but that they do compete on the other 5% by "making your Fund as attractive as possible." That takes the form of, for example, special contracts with psychotherapists and hospitals which go beyond - or offer something different - than is offered by other Funds. Due to the German concept of Solidarity that emerges from the German social code, it is understood and accepted by most Germans that the overall package of benefits is made possible by young healthy people paying premiums that largely pay for those who are sick. I say "most Germans" because about 10% of the population chooses private insurance instead of the Sickness Funds (you must earn more than 50,000 euros per year to be eligible). On the plus side, with private insurance you are not bound by what the Sickness Funds have decided are covered treatments and your premiums are significantly lower. However, these premiums increase with age and only cover the individual (each family member must be covered separately). And should you become severely and/or chronically ill, your premiums can skyrocket.
Cost containment for the Sickness Funds is primarily achieved by annual negotiations around reimbursement rates for any and every treatment and service. Such a situation would be anathema in America, but as Thorsten said, "Social good, that is our Bible." And by having a set rate for all treatments, it creates certainty for stakeholders and makes a realistic budget possible.
I asked Thorsten and Jorn specifically about hospital stays and reimbursements, since in the U.S. this is a major driver of costs. They said that until 2003, hospital reimbursement payments were based on the number of days the patient stayed. The result was that patients who, for example, could have been discharged on a Friday were kept hospitalized until Monday. The new system now bases reimbursements on "diagnosis groups." For example, Thorsten said, if someone breaks her leg it will be reimbursed at a set amount regardless of the number of days the patient stays in the hospital.
Unfortunately, a byproduct of this change has been what Jorn called "the bloody discharge," where a patient has not been fully cured or healed but is nevertheless discharged and referred to their primary care physician for follow up. "This is an ongoing discussion for us," Jorn said.
I went on to ask about the German dichotomy between the system that AOK is part of (the Statutory Health Insurance, or Sickness Funds) and the private insurance system. I understood that the premiums for the private system were considerably lower than for the Sickness Funds, but given that premiums for the private system were subject to substantial increases with age and illness, why, I inquired, would people opt for private insurance?
"We have been having this discussion for ages," Jorn responded. "It is often a financial decision," he said, because the premiums are much lower. But there are other factors. Civil servants, he said, get their premiums paid by their employer, and certain trade groups have their own dedicated private insurance. Also, Jorn said, private insurance "pays for everything, and we don't."
Does this mean, I asked, that the private system is potentially subject to unnecessary care? Yes, Thorsten said. One indication they have seen is that while most doctors' patient mix includes only 10% from private insurance, they are deriving 20-30% of their income from those patients.
What about Germany's aging population, I asked? Like the U.S., Germany has a high average age and a birthrate that is below replacement. Is there a concern about exploding medical costs relate to this demographic reality?
"I personally don't think [out of control costs] will happen," Jorn said. He referenced the concept of Solidarity that I discussed in an earlier post. "Our Solidarity system is designed for the sick," Jorn said. Thorsten added that Germany is also focusing much more now on disease prevention through public awareness and programs about nutrition and exercise that will hopefully help produce healthy aging. And in fact, Jorn interjected, "A new law is being adopted that stipulates we have to make a certain amount available for prevention." It doubles the amount spent on exercise and nutrition, including cooperation with gyms where Fund members get special rates, as well as providing medical and dental checkups in schools for children. "We want to be known as a health fund, rather than a Sickness Fund," Jorn stated.
Earlier in the Fellowship I had some private conversations regarding the sharing of personal medical information. I had been told that there was very little sharing, making each patient a "black box" anytime they went to see a physician other than their primary care provider. Thorsten said this was largely the case.
"We have had this discussion for many many years now" to create ways to privately share information, he said. "But this idea has remained an idea only."
So this is a part of the German system that is not working that well, I said. But you are still clearly proud of what has overall been achieved. What works best in German healthcare?
Solidarity, both Jorn and Thorsten answered. Also, Thorsten added, by statute the government "can't tell us how to cover care, they can't take money out of the system. And we have easy and fast access" to care.
Thorsten and Jorn were very generous with their time, which permitted an extensive discussion. I'll have much more to say about it as I process the information and integrate it with other interviews in Germany. For now I have just a few impressions.
One thing that struck me is how right Sigrid Becker-Wirth of MediNetz was: if you are undocumented, you have very few options for care that don't make you highly likely to be deported. The gentlemen from AOK both said several times that the undocumented are "not part of the system." My interpretation is that the Germans leave the undocumented out in the cold for healthcare not due to animus regarding their race or country of origin but because of the German regard for adherence to the system (this interpretation has been reinforced by private conversations with others during my trip). As noted earlier, this regimentation carries excellent benefits in many respects, but makes it very difficult indeed for those who are outside the system. I'd go so far as to say that the undocumented may be better off in the United States because, although the undocumented face severe challenges in America, there is no "duty to denounce," which I've learned not only makes life difficult for the undocumented but also for asylum seekers who fear the required registration by which they can be tracked if their request for asylum is denied.
Many U.S. hospitals are not very fond of the readmission penalty that they can incur under the Affordable Care Act when a patient is hospitalized again within 30 days. And they have a point, to a certain extent. But the results speak for themselves, and I wonder if the "bloody discharge" phenomenon in Germany would not fade if they adopted the same policy.
I think it's pretty clear that the U.S. will not be adopting a Sickness Fund model anytime soon. But one aspect we could and should follow is the public release of data. As Thorsten mentioned, there is a degree of competition between the Sickness Funds, one aspect of which is a ratings guide that provides data on multiple categories. And since 2007, all hospitals have been required to publish results on 27 selected indicators defined by the Federal Office for Quality Assurance. Germans can review this data and use it to change Sickness Funds if the ratings indicate, for example, that your Fund is not well managed or is charging higher premiums for services, and they can readily compare hospitals. Granted, this is not a perfect analogy when it comes to insurance since Americans cannot cross state lines when purchasing insurance, but the idea of greater transparency in performance data about insurers - and providers - is long overdue in the United States.
Friday, May 1, 2015
In Search of Solidarity
It's still early in my trip, but my impression so far is that there are many similarities in the issues faced by both the German and U.S. healthcare systems, particularly when it comes to keeping people healthy instead of treating them when they are sick. With regards to America, I'm not optimistic about this changing anytime soon. Just the other day I read an article profiling Mark Bertolini, CEO of Aetna, who said that the future of healthcare was "retail." That might be a good idea if what we mostly care about are markets (and in fairness, Bertolini expressed some good ideas about disease prevention), but what we need to care about is investing in a healthy population.
And that is where there is a big difference between the U.S. and Germany. The Germans have their challenges but they approach them with a different philosophy, one that goes back to at least the time of Bismarck; even today the German statutory insurance companies are called "sickness funds," harking back to when Bismarck instituted a system in which people contributed a portion of their wages so that when they got sick, the funds would replace their earnings until they recovered. Over time, access to care became woven into the social fabric. Germans came to see their economy as a social market economy, that is, one that combines capitalism with the belief that society should protect all its members from economic ruin and social distress. This belief is called solidarity, or Solidarität, and is a key concept of German society. This concept has moved Germany toward a health system that is universal, affordable and accessible. While not ignoring costs, it doesn't make money the primary factor in deciding what treatments to offer. And while not anti-business, it does not allow businesses to unduly influence decisions. (As just one example, pharmaceutical companies are prohibited from advertising their products in the media.)
The U.S. does not have Solidarität, but we do have guiding principles, a moral North Star, as former CMS administrator Don Berwick said. To the extent that our decisions about healthcare reform, in all its aspects, are divorced from those principles, we will continue our stunted starts and stops and half-measure efforts that just plug holes instead of fixing the proverbial dam.
This is true of so many of the issues we are grappling with. Look at climate change. Much of the effort around climate change has been "technocratic," that is, working to create the necessary technology to fix climate. But we know all too well how far that has gotten us. Finding solutions is not enough. The United States has no shortage of very smart people who are adept at solving complex problems. What we are missing is to care about the problem in the first place. President Obama just shared this same sentiment with regards to the events in Baltimore. "If our society really wanted to solve the problem, it would," the president said. "It's just that it would require everyone to say, 'This is important.'"
He is exactly right. When that change takes place, solutions follow. It's as true for healthcare as for any major issue. Until we reach a critical mass of caring, healthcare reform will just be a grandiose version of take two aspirins and call me in the morning.
And that is where there is a big difference between the U.S. and Germany. The Germans have their challenges but they approach them with a different philosophy, one that goes back to at least the time of Bismarck; even today the German statutory insurance companies are called "sickness funds," harking back to when Bismarck instituted a system in which people contributed a portion of their wages so that when they got sick, the funds would replace their earnings until they recovered. Over time, access to care became woven into the social fabric. Germans came to see their economy as a social market economy, that is, one that combines capitalism with the belief that society should protect all its members from economic ruin and social distress. This belief is called solidarity, or Solidarität, and is a key concept of German society. This concept has moved Germany toward a health system that is universal, affordable and accessible. While not ignoring costs, it doesn't make money the primary factor in deciding what treatments to offer. And while not anti-business, it does not allow businesses to unduly influence decisions. (As just one example, pharmaceutical companies are prohibited from advertising their products in the media.)
The U.S. does not have Solidarität, but we do have guiding principles, a moral North Star, as former CMS administrator Don Berwick said. To the extent that our decisions about healthcare reform, in all its aspects, are divorced from those principles, we will continue our stunted starts and stops and half-measure efforts that just plug holes instead of fixing the proverbial dam.
This is true of so many of the issues we are grappling with. Look at climate change. Much of the effort around climate change has been "technocratic," that is, working to create the necessary technology to fix climate. But we know all too well how far that has gotten us. Finding solutions is not enough. The United States has no shortage of very smart people who are adept at solving complex problems. What we are missing is to care about the problem in the first place. President Obama just shared this same sentiment with regards to the events in Baltimore. "If our society really wanted to solve the problem, it would," the president said. "It's just that it would require everyone to say, 'This is important.'"
He is exactly right. When that change takes place, solutions follow. It's as true for healthcare as for any major issue. Until we reach a critical mass of caring, healthcare reform will just be a grandiose version of take two aspirins and call me in the morning.
Subscribe to:
Posts (Atom)