Healthy Policy

ED's and the uninsured

The percentage of uninsured patients visiting emergency departments is apparently in sync with the general population:

Most emergency department patients have health insurance and regular primary care physicians, according to a study published on Wednesday by the American College of Emergency Physicians, the Los Angeles Times reports.  For the study, researchers from the Robert Wood Johnson Foundation and the University of California-San Francisco surveyed 32,669 households in the U.S. in 2001. According to the study, respondents without health insurance accounted for about 15% of ED visits. In addition, the study finds that about 84% of respondents who visited EDs four or more times annually had health insurance and that 81% had access to primary care through a physician or a clinic. About half of respondents who visited EDs four or more times annually were enrolled in public health insurance programs such as Medicaid or Medicare, and one-third had private coverage, the study finds. The study estimates that about 45 million U.S. adults made a total of 80 million visits to EDs between July 2000 and June 2001. Some experts said that the study indicates an expansion of health insurance alone would not significantly help EDs address problems with overcrowding, which they said results in large part because patients cannot obtain appointments with their physicians or must wait for hospital beds (Yi, Los Angeles Times, 3/29).

As 15% of the population is uninsured, this makes sense.  What's more interesting here is the realization that 45 million adults made 80 million visits -- which means that several patients (the majority being insured) are visiting the ED too often.  I've been a patient in the ER maybe twice in my life; several of these patients are going almost twice a year (and others certainly more). 

But I think most ED docs could tell you that an expansion of insurance alone would be insufficient to fix our emergency problems.

190 subpoenas for pharma

Bad news for pharma:

The Federal Trade Commission on Wednesday announced that it plans to subpoena 190 drug companies in an investigation of possible anti-competitive practices in the pharmaceutical industry, the AP/Los Angeles Times reports. The subpoenas, which require approval from the Office of Management and Budget, would be part of a probe into whether pharmaceutical companies are suppressing competition by releasing authorized generic versions of their own brand-name drugs to coincide with the introduction of products from generic drug makers. Under federal law, after a generic pharmaceutical company successfully challenges a patent held by a brand-name manufacturer, it has six months of exclusivity to sell the drug in the generic market by itself. However, a loophole allows brand-name manufacturers to authorize their own generic versions, which increasingly are entering the market at the beginning of the six-month exclusivity period. Generic drug manufacturers depend on that exclusivity period to recover their costs and make a profit, but with authorized generics entering the generic market sooner, profit margins are falling for generic manufacturers.

If definitely appears that this is an industry-wide practice, given that such a large number of firms are receiving subpoenas.

And now for everyone's favorite subject!

Booze!

A new study on drinking Red Bull with alcohol finds that.....you're still just as drunk!  You just don't feel like it!

Well, duh.  Obviously if we'd discovered a substance that makes you sober up to the point that your BAC slips back below 0.08, it'd be all over the place.

Since I am party to this trend, a few observations:

• I kinda like the taste of Red Bull, so every once and awhile I'll get one for that reason

• I'll get Red Bull/vodka when I go out if I'm really tired (and don't tell me I should just stay home in that case -- that's just silly sensical thinking)

• No one I know drinks RB/V and believes this makes their BAC go down and therefore enables them to drive home.  Really, people, you'd have to be pretty stupid to believe that. 

• Also, RB/V is a very expensive mixed drink (usually $3 more than standard vodka tonic)

Why do you need a study when you've got me, huh?

Hat tip to Medpundit

Teddy bears cause autism

This is a great graphic from Grand Rounds:

Health disparities, revisted

Matthew Holt has an interesting editorial from Brian Smedley on the recent health disparities study:

This view, however, squarely contradicts what the vast majority of research studies have found for decades – that some patients, most notably African Americans, Latinos, those who don't speak English well, and in some cases, women – receive a lower quality of health care than their counterparts, even when they have similar health insurance and are treated for the same health conditions in the same hospitals. This applies across the gamut of health care, ranging from basic services such as screening and immunization, to primary care, to more expensive, high-tech, specialty procedures.

 

These are the conclusions of literally hundreds of studies published in peer-reviewed journals over the last two decades.  And while a few studies, such as the Asch study, find that disparities are diminishing or that all groups receive equal (albeit poor) treatment, their findings must be considered relative to the massive volume of evidence to the contrary. Even the U.S. Department of Health and Human Services' National Healthcare Disparities Report, released in January and which represents the most comprehensive survey of its kind, finds that, despite some areas of improvement, racial and ethnic healthcare disparities persist, and are worsening in some areas.   For example, the NHDR found that Latino patients with diabetes are receiving poorer quality care today than they were even a few years ago. 

Smedely doesn't discuss where the research disparity comes from, but clearly there's something to think about here.  Asch's study may very well be abberration, but the bottom line is that quality of care is poor, and everything else tells us it's even worse for the actual poor.   Also, remember again that Asch's study only looked at what happens after patients get to the hopsital -- it says nothing about those who can't afford care. 

psst...I have a life!

HPites,

Your fearless leader is heading to DC later today for job interviews and will be there the rest of the week.  She will attempt to continue providing the usual content, but will mostly likely fall short of doing so, so keep this in mind when you swing by and she's conspicuously absent. 

Thanks

La Grand Rounds

Seriously, it's that time again?  Apparently.

Grand Rounds is up at the NHS Blog Doctor

When care harms

This post about two cancer patients' last months of life, one through the medical system, one with no medical care, is worth a read.

Pecking at nothing

Apparently Medicaid is now requiring all nursing homes to return "left over" medications:

CMS has ordered state Medicaid programs to require nursing homes to return unused medications to pharmacies and to ensure Medicaid is repaid for unused treatments when nursing home patients die, are discharged or have their prescriptions changed, according to a March 22 letter, the Atlanta Journal-Constitution reports. In the letter, Dennis Smith, director of the Center for Medicaid and State Operations at CMS, also wrote that state Medicaid programs should limit the amount of medications provided to nursing homes at one time to "help to curtail prescription drug waste."

It's not that anything is particularly wrong with with this program, but honestly, this is how we're going to cut back on waste in health care?  By ordering nursing homes to return medications? 

How much money will this actually save anyways?  Particularly once you factor in the administrative costs of such a program. 

It's just such a backward way of controlling costs.  Random comparison: my home state of Kansas recently legalized concealed weapons.   Some advocates claim that concealed weapons actually make people safer because "criminals" will be less likely to draw guns or use force because the person they're trying to rob/kill might have a concealed weapon.   Well, I guess on some weird planet that logic makes sense.  But not compared to simply much tighter gun control laws to get guns out of people's hands, period. 

Reinhardt responds to Salgo

Everybody's favorite health care economist, Uwe Reinhardt, sent in a letter to the editor responding to Peter Salgo's New York Times Op-Ed "The Doctor Will See You for Exactly Seven Minutes".  Reinhardt takes issue with the blame game:

Dr. Salgo also says that "publicly traded H.M.O.'s, for example, began restricting doctors to an average seven-minute 'encounter' with each customer." I defy him, or any doctor, to produce a memorandum from an H.M.O. to that effect.

During the 1990's, H.M.O.'s did extract discounts from doctors. To keep their income at previous levels, doctors voluntarily shortened visits. The H.M.O.'s were not to blame.

Finally, the average length of hospital stays started declining in the mid-1980's, after Medicare began paying hospitals a flat fee for each admission. Hospitals found it profitable to voluntarily reduce the length of stays.

Another letter echoes part of these sentiments -- that it's not up to patients to enact change, but that doctors need to take more responsibility for the deterioration of the doctor-patient relationship, because they didn't do enough to stop changes in the first place.

UPDATE:  Roy Poses of Health Care Renewal offered some thoughtful comments:

With all due respect, Prof. Reinhardt is quibbling.
Clearly managed care (and Medicare) have periodically either cut reimbursement for office visits, or have failed to raise reimbursement to keep up with inflation. Also, they have imposed ever greater bureaucratic burdens on office practitioners that increase their overhead...See this article that shows that primary care physicians' charges (reflective of patient volume) have increased much faster than their compensation, which has failed to keep up with inflation:
http://www.ama-assn.org/amednews/site/free/bil10920.htm
For Reinhard to call physicians' responses to managed care and government practices "volunary" is sophistry.  Furthermore, I wonder if perhaps Prof Reinhardt's thinking is being influenced by his conflicts of interest?

Depression and pharmaceutical effectiveness

Sad news from the largest ever study on depression:

Antidepressants fail to cure the symptoms of major depression in half of all patients with the disease even if they receive the best possible care, according to a definitive government study released yesterday.

Significant numbers of patients continue to experience symptoms such as sadness, low energy and hopelessness after intensive treatment, even as about an equal number report an end to such problems -- a result that quickly lent itself to interpretations that the glass was either half empty or half full.

The $35 million taxpayer-funded study was the largest trial of its kind ever conducted. It provided what industry-sponsored trials have rarely captured: Rather than merely ask whether patients are getting better, the study asked what patients most care about -- whether depression can be made to disappear altogether.

The study only examined the effectiveness of drugs, not therapy, so it's unclear how many people continue to suffer.  But it's still disheartening.  I can picture those "Depression Hurts" commercials -- and it hurts more than we know when you can't fully recover. 

Docs and Charity

This Kaiser Daily  report on docs and the amount of charity care they provide is pretty interesting.

What the new numbers say

(cross-posted from tpm)

The Administration released a new report yesterday that it enrolled an additional 1.9 million beneficiaries in Medicare Part D last month, bringing the total number of enrollees to around 27 million.  But the many mechanisms through which seniors receive prescription drugs is deceiving, so I'm going to flush out the numbers a bit further.  (I'm mostly working from this Kaiser issue brief, refer to it if you want to get really in depth.)  Because while 27 million enrollees receive coverage somehow, only 7.2 million of the 22.9 million eligible to voluntarily sign up for coverage have now done so.  And of the 27 million HHs is citing, only 26% of the enrollees  have voluntarily signed up for stand-alone coverage.  Further, the polling on Part D is getting worse.

The first thing you need to know to put these numbers in context is that there are 43 million people eligible for drug coverage under Medicare Part D.  So with the current enrollment numbers, around 63% of Medicare enrollees now have prescription drug coverage coming from somewhere.*
(*somewhere is key here -- 11.1 million enrollees get their drug coverage from a source other than Medicare.)

Next, you have the "dual eligibles" (those enrolled in both Medicare and Medicaid), who were automatically enrolled in a plan.  There are 5.8 million dual eligibles.

Health Wonk Review #3

As health policy wonks, we often find ourselves in unfortunate positions.  Medical practitioners don’t trust us because we don’t have a practitioner’s education.  Lay people have no clue what we’re talking about (we can be a little heavy on the acronyms).  Our posts get buried in Grand Rounds because they’re not about the magic of healing.  Our sites, full of thoughtful commentary and hard work, will never attain the traffic of straight political blogs.  Worse still, we don’t even have good health policy wonk jokes!

   

And thus Health Wonk Review was born.  Our fearless leaders put their massive brains together and decided the best way to get more attention to our wonky undertakings was to showcase them apart from other medical writings in their own biweekly review.

I’ll be your hostess this time around, and as such I’m claiming my prerogative and and putting in my two cents.  Using blogging as a forum for exploring health policy ideas is absolutely invaluable.  It simulates the experience of being an academic or working in a health policy organization, while forcing you to develop a distinct voice, a coherent philosophy, and a wide net of knowledge.  And as a general rookie, blogging allowed me to learn in six months what would have taken years without it.

But I didn’t go it alone, and without the individuals showcased here, no one would have ever heard of me, read me, cared about what I said, or critiqued me when I made  mistakes.  Would that everyone had their ideas so challenged every day.  Basically, if you haven’t started a blog but you’re thinking about it – DO IT! 

Enough, about me, onto you!

HEALTH WONK REVIEW: 3RD EDITION

Reform: What’s the definition of “is” edition

A few wonks wrote about health care reform and the debates surrounding change.

Matthew Holt writing at Spot-on got pretty upset with some libertarians accusing foreigners of rationing care without acknowledging that it happens here too and in a much more unfair manner. Of course the libertarians didn't rest easy and it all degenerated into a whole set of comments at THCB about what's the real meaning of the bogeyman called "socialized medicine".

Ezra Klein of the eponymous blog takes issues with a recent Michael Kinsley column and concludes that instead of taking a probing look into single payer proposals, the columnist chooses to misrepresent Paul Krugman’s recent New York Review of Books article.

Marcus Newberry of Fixin' Healthcare looks at state health initiatives that were discussed at the Forum on Healthy America during the winter meeting of the National Governors Association. Marcus was invited to participate by Governor Sanford of South Carolina. See the second post here.

Changes are A’ Comin

A few bloggers surveyed the changing landscape and offered their thoughts.

Tony Chen of Hospital Impact asks what physician practices need to do to prepare for consumer-driven healthcare.

Dmitriy Kruglyak of The Medical Blog Network  reviews  a contentious debate on the progress of health IT progress, touched off my Intel Chairman's speech at HIMSS. As seen through the eyes of Modern Healthcare readers.

Dale Hunscher, a self-proclaimed clinical research informatics geek, looks at the World Health Organization's International Clinical Trial Registry Platform, which if implemented will make most if not all clinical trials worldwide - and their results data - accessible to the world's population through a Web portal that will link to all registries everywhere. It's a great idea, but will it happen?

Medicine and Health Policy

Other writers (some of them M.D.s) examined the clinical implications of policy

Graham Walker of Over My Med Body  asks:  How much of medical care is wasted expense, just because we're impatient?

Fard Johnmar at Envisioning 2.0  writes about the recent New England Journal of Medicine (NEJM) study focusing on healthcare quality.  In his post, he summarizes reaction to the study and features exclusive commentary on the report from Dr. Richard Allen Williams  Dr. Williams, founder of the Association Of Black Cardiologists, says that conservatives should "take no comfort" from the study results. 

Roy Poses of Health Care Renewal examines a recent Health Affairs study about oncologists' decision making that received a lot of press as evidence that personal financial concerns and conflicts of interests influence physicians' relationships with drug companies.  Furthermore, the senior author is a director of Aetna, Inc., the large, for-profit managed care organization, which was not acknowledged in the publication.  Also check out the comments.

Kevin Keith of Sufficient Scruples writes a thoughtful post about yet another way HHS is dragging its feet on long-ago promised changes regarding genetic testing.  Also check out this excellent post  where he asks why ethicists continue to believe that docs don’t respond to economic incentives. (Pay for performance, anyone?)

From the Unbeaten Health Blogosphere Path

In terms of health policy blogging, authors taking a libertarian or free market perspective are in the minority.  This group of posts takes a look at health care from that angle.

Adrienne Aldredge (the only other woman submittee!) of the ‘Dredge Report submitted a series of posts that started with Jane Galt’s examination of what a single payer system in the U.S. would look like and asks what the goals for a health care system should be in the first place.  See Will Wilkinson’s response  as well as Adrienne’s rejoinder.

Bob Vineyard of Insure Blog has a different take on the recent 60 minutes story on the uninsured. InsureBlog explores just how much hospitals write off treating such folks, and explodes some of the myths about "the uninsured."

Jared M. Rhoads submitted The Lucidicus Project, a small but focused new undertaking that regularly publishes news and views from a philosophical and rights-based perspective.  They give away free copies  of Atlas Shrugged and other materials to any medical student who is genuinely interested in learning about the moral and economic case for capitalism.

Trapier Michael at Hayek, MD takes a look  at two parts of the Bush Administration’s health care proposals.   (The first centered on Health Savings Accounts. The second promises to feature a push for price transparency.)

At the Free Canada Blog, Evian discusses the recent news about the Canadian Supreme Court’s decision to allow privatized health care. 

To close the show:

Two bloggers delved into the health costs/employment angle

John Coppelman of Workers' Comp Insider examines how the increasing numbers of uninsured can translate to higher workers compensation costs for employers - specifically because untreated workers may pose a greater health and safety risk.

Joe Paduda of Managed Care Matters takes a look at ways employers are saving money on health care.  Which isn’t by jacking up copays, implementing CDHPs, or slashing benefits.  They are using data mining to identify the high-performing physicians; helping employees and dependents make better decisions, and sharing information about health care quality.  And, these radical ideas are resulting in premium increases averaging 3% per year over the past two years. 

And our lone wolf, economic analysis from Jason Shafrin, of the Health Care Economist.  His post examines Baumol’s cost disease. 

----------------------------------------------

It’s been fun kids.  Please refer to our Health Wonk Review website, created with ample support from the superbly talented Shahid Shah. From now on you will be able to submit your post using a new database on that site. 

Next edition’s host is Health Business Blog on April 6th. 

Equally Terrible

I've been meaning to post on this for awhile, but hadn't really figured out the direction to take.  A new research project by RAND found that regardless of race, age, or income, patients in the U.S. receive equal care once they get to the doctors office.

But, about that care.  It's pretty bad.  In fact, according to the study, patients receive the correct care about 55% of the time.  The glaring comparison that enters my brain is school (a year ago at this time I was in college, taking exams and such).  If I'd done 55% of my work on average, I never would have made out with my degree. 

But there are some major limitations to this study.   It doesn't investigate the effect of a 55% appropriate care level on patient outcomes.  So we don't know if the care grade should be an F or an automatic expulsion. 

Further, and this is key, the study only examined what happens once patients make it to the doctor:

Certainly some people have better access to healthcare than others, and previous studies have shown that people without health insurance get sicker and die younger than those with insurance. But this study wasn't about access to care. It was about what happens after people reach a hospital or doctor's office.

Once they're in the door, regardless of how long it took to get there, they get what they need about half the time, regardless of who they are or even whether or how they're insured, the study found. Recommended care included things that have been scientifically shown to be medically effective and are accepted as the best standard for various conditions. The researchers looked at 439 such measures of quality for 30 common medical conditions and preventive care.

That throws a wrench in things, and explains the multitude of studies showing racial and income health disparities.  Patients need to get into treatment on a regular basis, and use those incomes, to have a true comparison. 

The good?  Patients are given equal treatment and this study found no evidence of bias based on population characteristics.  Considering things like residual (and actual) racism, xenophobia, etc, it's quite impressive that our medical system treats everyone the same.  That's truly something to be proud of.

Now if we could just get them to treat everyone the same, but more accurately, we'd be golden. 

Small businesses and AHPs

More on AHPs from Business Week:

This week, for the first time, the Senate Committee on Health Education Labor and Pensions passed the Health Insurance Marketplace Modernization and Affordability Act. The bill -- which had passed the House several times, but had been stalled at the Senate until now -- allows for the creation of Small Business Health Plans, or SBHPs. Such plans would give small-business owners the opportunity to take advantage of economies of scale by banding together across state lines, and through trade and professional organizations, to garner savings with insurance policies.

With the Senate Committee passage, it appears that small businesses are one step closer to affordable health care.

Ignoring the key critique of AHPs (that insurers will offer paltry benefits and there will be a race to the bottom), there's another elephant in the room. 

Let's say insurers band together and buy insurance.  How many more years will they be able to afford this insurance, as premiums rise across the board?  In this case, getting it is not half the battle, as premiums could quickly become unaffordable. 

One part of the article perplexes me.  If the following is true (and I've no reason to believe it isn't),

In 1998, Butler made the decision to go with an outsourcing company that would provide her employees with benefits. Butler-Burgher has an employee-leasing arrangement with Gevity, a Bradenton, Fla.-based human resources firm, which has a network of hundreds of thousands of staffers.

Here's how it works: Butler pays a fee to Gevity (in this case, $950 per employee per year), and Gevity technically becomes Bulter's employer. Under that arrangement, Gevity handles all of Butler's human resources, payroll, and legal issues. By taking advantage of the economies of scale, Butler's employees receive a menu of health and other benefits, such as 401(k) plans. "We went to a model that was able to provide Fortune 500 benefits at a reasonable cost," says Butler, who estimates that her company saves 20% to 25% on health coverage as a result of the arrangement.

Isn't this a fairly compelling argument against AHPs?  This employer has already found a way around regulation and has been completely able (and seeminlgy satisified with the arrangement) to provide insurance with a company across state lines.

Docs and Religion

From Forbes:

When the man arrived at the emergency room, it was clear to Dr. Dana King that he was having a heart attack -- and that he was terrified.

"I could see the look on his face," said King, a family physician and a professor of family medicine at the Medical University of South Carolina in Charleston.

King took immediate medical steps to help the man. But he also did something a bit unexpected. "I took his hand and attempted to comfort him. I asked him, 'Are you a religious person?'" King said.

"He looked at me like he was looking at me for the first time," King recalled. "A wave of relief came over him. He could see that I was making a connection on a different level. We prayed together, right in the middle of the emergency room. It was a short prayer, but it was just a way to touch someone intimately."

The patient, in his late 40s, survived. King doesn't think it was just the prayer that saved the man's life. Without the life-saving medical treatment, he wouldn't have lived.

I'm not a particularly religious person, but I see nothing wrong with doctors asking patients if they're religious, and then offering to pray with them.  Because while the effect of prayer on health status is unclear, one thing isn't: optimistic people live longer, and if you're feeling confident and connected with your doctor, you're probably feeling a little optimistic.  Stress and fear harm the body, surely it's better to avoid these feelings and give patients a deeper sense of safety and security.

Further, I'm not sure why this is surprising or newsworthy:

Curlin and his fellow researchers surveyed 1,260 practicing physicians in the United States. They found that 76 percent of the doctors believe in God, and 59 percent believe in some sort of afterlife. The researchers also found that 90 percent of the doctors attend religious services at least occasionally, compared to 81 percent of adults in the general population. And 55 percent said their religious beliefs influence how they practice medicine.

If you take Americans as a whole, 81% identify themselves with a specific religion, and 76% identify themselves as Christian.  So doctors are like the rest of the nation. 

Bird Flu: Oh no

Via Medpundit, there's some Very Bad News on the bird flu front:

The H5N1 virus responsible for the current virulent strain of bird flu has evolved into two genetically distinct strains, US scientists have confirmed.

...Back in 2003 we only had one genetically distinct population of H5N1 with the potential to cause a human pandemic. Now we have two

Prior to 2005 every known human case of bird flu had been caused by a particular subtype of the H5N1 virus, which infected people in Vietnam, Cambodia and Thailand.

But the latest analysis by the US Centers for Disease Control and Prevention identified a genetically distinct variant which appears to have emerged last year, infecting people in Indonesia.

So now there's two possibilities of virus strain mutations into human flu pandemics.  Not be alarmist about this, but doesn't that mean that it's now twice as likely that the bird flu could become a human pandemic?

Teacher! Who's this funny man?!

This story about a childless ER doc visiting a third grade classroom is pretty cute.

Words of Wisdom

Everyone knows Paul Ginsberg is just freaking awesome.  Hop over to the Health Care Blog and read his testimony on price transparency and consumer directed health care. 

Grand Rounds

The weeks continue to fly by, as evidenced by another edition of Grand Rounds.

This week it's hosted by Elisa of Healthy Concerns, and she's put together a sound, logically compiled compendium. 

In other news, the deadline for Health Wonk Review submissions is tomorrow morning at 9 am EST.  I've only received five folks so get with it!

Exactly what price transparency isn't going to do

From the opening paragraph of this WaPo article:

Hospital bills are about to become less mysterious. Within a few weeks, the Bush administration plans to publish the prices Medicare pays for common medical procedures, a move that advocates for the poor say will pressure hospitals to give uninsured patients the discounts provided to people with insurance.

I hate to get all nit-picky on this, but I have to.

First of all, this is not going to make hospital bills less mysterious AT ALL.  There will still be five million billing codes, five million acronyms and foreign phrases, and lists and lists of things patients are charged for.  No, this has nothing to do with simplifying bills.

What it does do is list the price Medicare pays for certain procedures. 

But I'd like to see just exactly how, especially in the light of Medicare Part D, this listing is going to "give uninsured patients the discounts provided to people with insurance."

Really though, in the interest of fairness, let's look at how hospitals work with insurance companies.  The insurance company agrees to cover services at a given hospital, and the hospital agrees to charge discounted prices because of the guarantee of patients. 

What happens when an individual comes to the hospital?  They have no contract with the hospital.  If they're uninsured, they have no guarantee (nor can they make one) that they will return to the hospital for further business.  And lastly, if they're poor and uneducated, they have no access to these price lists, have never heard of these price lists, and certainly have no clue how to use price lists to leverage their payment.

That being said, Medicare, with its huge bargaining power, should have control over how much it pays for services, and use that as general tool to influence more uniform pricing.  Price transparency is generally a good thing, and something that we could certainly use more of.

But let's not be naive about what price transparency will accomplish. 

Association Health Plan Primer

cross-posted from tpm

The Senate Health, Education, Labor and Pensions Committee on Wednesday voted along party lines to approve an association health plan (AHP) bill.  President Bush pointed to AHP’s in his state of the union address as one of many reforms to help individuals attain health insurance.  But AHP’s expose individuals to another frontier of risk, where their health benefits are paltry, uncertain, and expensive. 

The key complaint driving the creation of AHP’s is that state regulation bars insurers from offering affordable health plans.  If insurers could offer plans on a national market, bypassing any state regulations, more plans would be offered and more individuals would become insured. Unfortunately, this type of thinking isn’t supported by reality.

Bare-bones plans have been offered for years, and people don’t want them.  But more than that, Ezra Klein takes a look at why we have state regulations in the first place:

The reason states mandate that insurers cover certain procedures is so insurers can't price folks who are likely to need those treatments out of the market. Insuring young women, if you didn't need to cover anything related to pregnancy, would be relatively cheap. Pricing the pregnancy package through the roof would be relatively easy. And denying the claims of those who bought the base package and then got pregnant would be trivial -- and would save you a ton of money. So almost all states mandate that you cover maternal care. And this goes across the board, from procedures the old use but the young don't need to packages that target specific lifestyles. If you allow the insurance companies to subdivide the market by treatment needs, what you'll have is bargain-basement pricing for the young and healthy coupled with unbelievable premiums for their less-lucky friends.

But this statement from Committee Chair Mike Enzi (R-WY) on the purpose of AHPs is the most revealing:

Let us put the power in the hands of small employers and family-owned businesses, rather than in the hands of insurance companies or the government. Let the consumers band together to drive the change that we want to see happen

Enzi is completely wrong about where the power in this situation is going.  It’s funneled directly to the insurers!  They’ll be offering bare-bones plans to these small businesses, who will have no ability to negotiate higher benefits.  Why?  Because there’s nothing barring them from trying to negotiate plans with insurers now.  Insurers simply aren’t interesting in offering an affordable but comprehensive product to small businesses. 

But why trust history?  Enzi wants consumers to band together and force doctors/ hospitals/ insurers/ employers to provide them with cheaper health care.  Because they surely haven’t had enough time to do so the last forty years. 

The bill has already passed committee.  If it passes the Senate, it will only continue to weaken health insurance as we know it.  The way to solve our health insurance problems isn't by cutting benefits, it's by fixing our fragmented system that costs twice as much as our more generous international counterparts.

More employers to offer HSA's

Via Kaiser, a recent survey  of mid-size to large employers found that 30% are currently offering high deductible health plans.  This is a significant increase over the previous year.

Keep in mind here, though, that a high deductible plan is not necessarily coupled with a Health Savings Account. 

I'll be interested to see what the pick-up rate is (i.e. how many employees choose these plans), and how many of those employees stay in the plans after a year. 

Holt and Reinhardt

Matthew Holt is quite enamored with Uwe Reinhardt's discussion of HSA's at a recent KFF event.  Matt pasted the transcript over at THCB, but the gist is that using HSA's as a way of controlling costs actually shifts the responsibility of cutting back on health services principally on the backs of the lower third of the U.S. income bracket.  It's well put and worth reading if you have a few minutes.

Uwe Reinhardt also spoke at the National Health Policy Conference in February.  He's a fantastic, engaging speaker.  I don't think I've ever seen someone able to make health policy so funny.  Any Democratic candidate with health reform on the brain would be genius to just bring him along on campaign stops to go after HSA's.  He's damn convincing.

Distinctions

There seems to be a problem here.  For some reason, people are having a hard time getting it through their heads that there is more than one way to do government sponsored health care. 

In today's edition is Michael Kinsley.  Ezra notes:

The usually good Michael Kinsley ignored his better angels yesterday and turned in a truly muddled effortmanifesto (full disclosure: I'm mentioned in the piece). Kinsley's article is sold as a defense of "modest reform" against "single-payer," which he achieves by ignoring the range of single-payer systems and, like so many others, stereotyping single-payer as Canada. His main complaint is that he fears rationing and, moreover, the inability of rich people to escape it, and thus demands that private money be allowed in purchasing health treatments, and fears that it won't be within the Kurgman-Wells, which is to say single-payer, context.

Kinsley, usually a purveyor of progressive ideas, takes a strange turn here.  He's fallen into the trap of equation government involved health care to mean "Canada". 

Take a gander at Ezra Klein's The Health of Nations series which examines five countries and their health systems for just a glimpse at the different ways good health care is structured in this world. 

There is nothing inherent in government involvement that bars private involvement.  In fact, I'd shudder to see the U.S. in a system that does just that.  There are ways to insulate against all the fears Kinsley lays out in his column.  By making a place for the private market, the richest can buy as much health care as they desire.

And don't give me any more of this rationing talk.  We already ration.  It's just buy ability pay.  Allowing supplementary private insurance in a new system allows for individuals to surpass waiting lists. 

Last week I wrote about France and their private/public hybrid, a great system for the U.S. to take a deeper look at.  I don't know if Kinsley is truly ignorant of health care in these countries or if he's just ignoring it.  But with such a prominent stage in which to voice his opinions, I wish he'd take the time to examine all the options.  He makes the case again and again for modest reforms.  But with our system costing more than twice as much per person as other countries, who have better health outcomes, better equity of care, and much cheaper health systems, I've yet to see an argument for modest reform that promises to bring us up to par with them.

Directions for Health Wonk Review

Alright health policy bloggers, it's that time again.

I'll be hosting the Health Wonk Review next Thursday, March 23rd.  Remember, Health Wonk Review is supposed to showcase policy writings of the last two weeks.  Medical practitioners are welcome to contribute as well, as long as the post suggests something about policy.  Various hosts have made up rules, you can certainly follow those because I have only two requests:

Please have your submission to me by 9 am EST on Wednesday, March 22nd. 

Please put "Health Wonk Review" or "HWR" in the title of your email

My email address is ksteadman at gmail dot com

Everyone's post will be included, but if you have any egregious errors I might be compelled to comment on your submission.  If you have any questions, feel free to email me. 

Kate Update

I had my fourth post-op appointment yesterday, and progress is finally being made (if you're new to the site and haven't been keeping up with my surgery, my original post on it is here.)  My bone is showing some healing, so my doctor graduated me to one crutch.  This was the first morning in 13 weeks I got my own coffee and carried it to my desk.  I have one free hand and use the crutch essentially as a cane.  I also don't have to wear my basketball star brace anymore.

A few notes this far out: do not believe the amount of time WebMD says it will take to heal.  If it took me, a healthy 22 year old, 13 weeks to move to one crutch, it is taking your average person with this procedure (usually individuals in their sixties) as long, if not longer.  WebMD says 10-12 weeks for full weight (i.e. no walking assistance).  Interrogate your doctor more -- I thought at 12 weeks I'd be high-tailin' it out of Kansas City and on to Washington, D.C.  I have another six weeks before I'm well enough to move to a whole new place. 

Don't get me wrong -- progress is progress.  My leg will get strong quickly now that I'm walking on it; I can carry things, and it's a marketed improvement from before I went into the doctor.  Every time I see my doctor he schedules my next appointment for six weeks -- this was (and continues to be) unexpected.  Ask how far apart your appointments will be; that will give you an idea of what your progress will be like.  Sorry I don't have my current x-ray to post, but rest assured it's still looking fairly similar to this.

Out and About

HPites, I've had a hectic morning and I'm heading off to the orthopedic doc this afternoon, so I apologize for the lack of content.  I'll try to put something up later today.

What I meant was...

Go read this.

Concientious Objectors?

Shadowfax has a great post examining the ethics of refusing care:

I do not see how pharmacists, who I generally respect as health care professionals, get off carving out a 'conscientous objector' exemption to providing care to certain persons of whom they disapprove.

Perhaps it is my own background that makes me so sensitive to this issue. I am compelled, both ethically and legally, to provide care to a great many persons whom I dislike or disapprove of. I have cared for Neo-nazis, drug users, spousal abusers, child abusers, felons great and petty; I have cared for individuals who have insulted me and assaulted and injured my staff; I have cared for individuals whose behavior I found deeply immoral and objectionable. I have no legal exemption to refuse to provide them with health care, nor would I claim such a right were it a legal option for me. Because it would be wrong.

Pharmacists have been refusing to dispense a medication that is only birth control pills, that IS NOT an abortion, vs. being required to care for child abusers?  Really, where do they get off?

There are plenty of people that all of us have deal with/help in our everyday life that we'd rather not.  But that's life!  There are plenty of things people do I believe are morally reprehensible, but when your professional calling is to give people medical care, you do it. 

We all know what happens to children that aren't wanted -- they grow up to become the individuals Shadowfax describes in his post. 

Skin in the game?

Ezra continues on his health care beat with an examination of "skin in the game":

This "skin in the game" phraseology has emerged the leading trope of the HSA-movement, so much so that it was a running joke throughout a recent health policy conference I attended. But its weirdness transcends its linguistically resemblance to George Allen's politics-as-football-metaphors language. In health care, all your skin is in the game. If you don't seek out the right care from competent professionals in sanitary environments, you...die. And if the threat of death, or illness, or amputation (as seen in the negligent self-care of many diabetes-sufferers) doesn't put your "skin in the game," Huckabee thinks moderate financial exposure will?

Something else I've been pondering is the flawed way HSAs are being introduced into the market.  If they're supposed to introduce more risk then the employee should feel like it's their money they will have to spend in order to get care.  But if their employer is putting in money up to the deductible (in the case of several companies), doesn't that erase the incentive to be "cost-conscious"?  Isn't their skin not really in the game?

Speculation aside, how much skin should people have in the game?  Many compare the cost of insuring your car, or your house, to insuring your health.  But let's play a game.  Let's say you take away the insurance --- how much is your car or your house?  A house is really a one-time expense, something that you pay for over decades.  With health care you continue to rack up costs.  I, for example, am only 22, but I've racked up well over $200,000 worth of health care costs at this point in my life.  The ability for me to pay for that expense, versus my ability to pay for a house over the course of my lifetime are quite different.  You simply can't have the same amount of skin in the game as you would with houses or cars. 

So what is the right level?  What is the moral level?  Right now there are positions in the great health care debate that advocate for extreme personal responsibility.  Under these kinds of Utopian spending arrangements, I would have a fraction of the care I've received. 

Underlying all these arguments needs to be the recognition that, for the most part, individuals don't choose their health status.  They get a terrible illness, have a costly genetic defect, are hit by drunk drivers.  Conversely, we choose how fancy a car, how big a house we will buy.  When it comes to health decisions, the amount we're able to choose, regardless of whether that's in a libertarian Utopian way (between prices for procedures) or whether we get procedures at all, is quite limited.  Theoretically we could choose not to have cancer treatment, or not to have pacemakers, but no one should have to make that choice. 

So I ask again, as Americans, how much skin do we think people should have in the game?

Sin City Song

If you're like me, you saw the trailer for Sin City last year and were totally mesmerized by the song.  Well, really, by a combination of Jessica Alba and the song (I can dance just like that...really).  Anyways, as time went on, you forgot about that song.  Then one day you decided to see if you could find it on itunes, but no dice. It's not on the Sin City soundtrack (and you can't buy individual songs from it even if it was). 

At this point, I figured out the name of the song and did some googling.  I found the song, albeit with lyrics (the lyrics are pretty ok) for FREE.  And since I'm always thinking of my loyal readers, I'm passing on the link: Cells by The Servant's Servant

Enjoy!

Defensive Medicine Revisited

Well, we're back to the defensive medicine argument.

Ezra's weighed in this time, calling the whole discussion of DM a red herring:

One of my least favorite detours in the health policy debate is the inevitable stroll down Defensive Medicine Avenue. The trajectory is something like this: Conservative Bob brings up malpractice suits. Communist Klein notes that the entire costs of medical malpractice -- lawyer fees, settlements, insurance premiums, everything -- are .46 of one percent of health spending in this country. Ouch. ConservaBob, reeling, throws his hail mary: defensive medicine.

Defensive medicine, henceforth DM, denotes otherwise useless procedures ordered by doctors afraid of lawsuits. Health wonk Kate Steadman, who thinks it bull, reviews the literature here.    Health professional Shadowfax argues the other side here.  Young physician Graham Walker stakes out the middle ground here.  I fall closest to Kate, but I think the whole conversation is a red herring.

DM exists, to be sure, but it's not caused by lawsuits. It's caused by patients. If you define DM as procedures that wouldn't be ordered in a perfectly logical world, there's plenty of it. But the reason most of these tests are run has little to do with the abstract possibility of a lawsuit that the doctor is insured against anyway. They're done in order convert probabilistic diagnoses into virtual certainties.

I generally agree with Ezra; the real issue isn't defensive medicine at all, it's correcting a tort system that doesn't award injured patients properly or do enough to prevent medical error. 

Be sure to check out the comment thread over at Ezra's.  Another dimension here is clearly patient preference, and that even when tests are unnecessary patients will ask for them anyways, to ease their mind.  Shadowfax also weighs in with some thoughtful comments. 

Grand Rounds 2:25

The next Grand Rounds is up at Geek Nurse, with a glass half-full/half-empty theme.  Yours truly did not abide by the theme at all, but my policy writings usually don't mix into the medical practitioner atmosphere of Grand Rounds (hence the advent of Health Wonk Review, which yours truly hosts next and plays nice in).  But no complaints with GR -- the hosts always include my wonky self. 

Anyways, sorry for that digression.  Geek Nurse does a great job, go check it out.

Hungry?

So that sleeping medicine Ambien?  Apparently it does funny things to you:

The sleeping pill Ambien seems to unlock a primitive desire to eat in some patients, according to emerging medical case studies that describe how the drug's users sometimes sleepwalk into their kitchens, claw through their refrigerators like animals and consume calories ranging into the thousands.

The next morning, the night eaters remember nothing about their foraging. But they wake up to find telltale clues: mouthfuls of peanut butter, Tostitos in their beds, kitchen counters overflowing with flour, missing food, and even lighted ovens and stoves. Some are so embarrassed, they delay telling anyone, even as they gain weight.

The reactions range from fairly benign sleepwalking episodes to hallucinations, violent outbursts and, most troubling of all, driving while asleep

Pharma and medication compliance

This article from the New York Times is a good read.  Drug companies have realized that non-compliance with medication regimens represents billions in lost profits every year as prescriptions aren't refilled on a regular schedule (if they're refilled at all).

Two things come to mind:

It really is better for patients to take their medication as prescribed.  The article cites a blood pressure med commercial that urges patients to take their med as directed.  And they should -- it's tough on your heart and downright dangerous to let your blood pressure skip around.

But the recent reduction in health spending came, in large part, from less utilization of prescription drugs.  If drug company informational campaigns are successful, we can expect to see those savings reversed. 

Two sides to every coin, indeed. 

Unsales reps

One of the proposals from Jerry Avorn's book Powerful Medicines is coming into existence:

The Wall Street Journal on Monday examined a state-funded program in Pennsylvania that sends "unsales representatives" to physician offices to encourage the use of generic and other medications that cost less than brand-name treatments. The program is based on the research of Jerry Avorn, a professor of medicine at Harvard University, who has established a system called "academic detailing," which seeks to encourage physicians to make prescription decisions based on scientific evidence rather than promotions from pharmaceutical company sales representatives. In Pennsylvania, the state Department of Aging through a contractor will pay $3 million to a foundation led by Avorn over three years to implement an "unsales" force to counter promotions by pharmaceutical companies and reduce medication costs for the state. Members of the unsales force visit physician offices and discuss alternatives to brand-name medications, such as generic and over-the-counter treatments or behavioral modifications (Hensley, Wall Street Journal, 3/13).

The key thing here will be if this program can help enact systematic changes.  It doesn't work very well for the state to keep sending "unsales reps" year after year at a hefty price tag.  But if the practice can help change prescribing culture after a few years, it will pay for itself. 

HSAs and Wendy's

Yesterday the Washington Post featured an article examining whether HSAs are working for employers adopting them and employees trying them.  The most interesting tidbit was this:

Last year, Wendy's eliminated its old insurance plan for about 9,000 managers and administrators and offered them only an HSA instead. The company has not offered such a plan to its hamburger cooks and the rest of its front-line crew, most of whom do not work enough hours or are not in the right parts of the country to qualify for health insurance -- and tend not to buy it, even if they qualify.

Jeffrey Cava, Wendy's executive vice president of human resources and administration, said the company now insures about one-third of its U.S. workforce, the same as it did before. And although insurance premiums for its HSAs rose much less than the company's old insurance would have done, Wendy's still spent more money overall on health benefits during its first year with health savings accounts than the year before.

First, Wendy's switch to HSAs obviously isn't insuring more workers.  This is something to keep in mind, because if HSAs aren't going to lead to more people being covered, that should really be the key argument against them.   What good is a revolutionary new type of insurance if it's only covering the same people?

Next, it's quite shocking that Wendy's ended up spending more this year than before.  If premiums are lower and it's insuring the same amount of people, where is that discrepancy from?  It's important to look at these actual cases, rather than the theories of HSAs, to see how they're working.  In Wendy's experience, they most likely had a ton of employees dip into their deductibles, costing the company money beyond the former higher premium.

Why we need reform in eleven easy sentences

Joe Paduda makes a strong case for health reform (not that we need a new one, but his is particularly well-put):

"This isn't only about us," said Bruce Peters, a flight technician ... This is a nationwide problem with medical care." Peters notes that any wage increases the workers have been offered will be consumed by insurance costs - - the additional copays, co-insurance, and employee premium contributions contained in the company's latest contract offer.

Peters personalizes the national disparity between wage growth and employees' personal health care costs.  Premiums for employer-sponsored health care have grown five times faster than wages since 2000. 

In 2004, the average family's insurance premiums came within an x-ray charge of $10,000.  In contrast, median family income in 2004 was slightly over $43,000.  Yes, you read that right - health insurance costs came to 23% of family earnings. 

And yes, things have gotten worse since the sunny days of 2004; predictions are that 2006 will see the average family's insurance costs hitting $14,500 per year. 

A survey of smaller employers in California indicates that more than half will not be offering health insurance to their workers this year.  This despite their optimism about growth and increased revenues in 2006.

Joe is also the founder of Health Wonk Review.  He's a great commenter with a wealth of knowledge about policy (and apparently managed care), so if you've never been by I recommend making him a regular read.

O'Neill weighs in

Via Kaiser, former Treasury Secrety Paul O'Neill weighed in on health reform on Wednesday:

According to O'Neill, Congress should pass legislation that would require all U.S. residents with annual incomes of more than $30,000 to purchase catastrophic health insurance for themselves and their families. The federal government would use general revenue funds to purchase health insurance for U.S. residents with lower annual incomes, O'Neill said. He added that Congress also should pass legislation to establish a commission to examine problems with health care prices and reimbursement practices and to require the federal government to develop national performance measures for health care facilities to help reduce medical errors. In addition, O'Neill said that the use of tax credits to address problems in the health care system is inadequate. "When you use tax credits and deductions, unless they are refundable ... they're very inequitable, because the value of the credit or deduction depends on the level of income or wealth accumulation an individual has," he said in a telephone interview (Reston, Pittsburgh Post-Gazette, 3/9).

A major component of any reform needs to be an insurance mandate.  It simply is too expensive for everyone and too risky for health care providers (not to mention the uninsured themselves) to continue allowing people to be uninsured.  What concerns me here, though, is that O'Neill doesn't specify any new avenues to do this.  You can't just mandate insurance when there are clearly not enough affordable options for people to buy into. 

But O'Neill is quite right about using tax credits and deductions to solve our health problems.  Forget inequities, they're an incredibly inefficient way to go about paying for health care and a waste of tax dollars. 

Hospital Challenges

Hospital Impact has an interesting take on the top five challenges identified as major threats to U.S. hospitals.  I'll leave the commentary up to Tony, with the exception of a point on medical malpractice.  Tony writes:

The average malpractice settlement more than tripled from $95,000 in 1986 to $320,000 in 2002. (can't argue with this one either, though we have to remember that inflation alone would bring the $95k to ~$180k. and on the whole, what % of a hospital's budget is dedicated to malpractice insurance/risk management processes?)

Standard inflation adds a certain amount, but the vast majority of the increase you're seeing there is technology.   Lifesaving advances are much much more expensive than they were in 1986, especially when you factor in scanning and imaging devices.  If you need extensive surgery or medical care due to medical injury, that care is simply much more expensive now than it was twenty years ago.

More Blog Awards

Unbeknowst to me, I've been nominated for "Best New Blog" in the Koufax awards.  Now, these awards tend to be more than a little sparse when including such wonky disciplines like health policy.  So even if you don't think I'm the best new blog, but you think health policy blogs are generally a Good Thing, feel free to vote for me on that pretense.  But if you think health policy blogging is totally dull (which it can be, from time to time) I recommend you vote for Battlepanda because Ezra says so, and he knows political blogs a lot better than me. 

Go vote.

It's the specialists!

Matt Holt has an excellent post about the supply of doctors in the U.S. and the inefficiency they create:

Today in Health Affairs (or you can read the potted version in Forbes), Dartmouth researcher David Goodman and his team (including Wennberg) cry bullshit on the “we need more doctors” meme. While the big academic centers which get the money from training them would love to have more residents, by examining one type of intensive medical process — caring for patients at the end of life in ICUs — Goodman et al shows pretty logically that many major academic centers use far too many physician resources. In other words we could provide equally good (or probably better) care while using many many fewer physician “inputs”. Hence overall we need fewer physicians, more efficiently used.

But what Matt fails to address is the number of specialists.  Obviously if many Americans have unfettered access to specialists, the number of tests and procedures will be much larger.  So while in an ideal world we would just scrap a large number of doctors and med school spots, that's clearly not going to happen.  One thing that can change in terms of expensive supply, however, is providing greater incentives to encourage more newly minted M.D.'s to head into internal medicine or become general practitioners. 

That requires fee and reimbursement adjustments, but Medicare could easily lead the way.  As it is, doctors get paid more when they order things.  Increasing payment for good health status or  for general visits that don't involve ordering tests (i.e. I have a fever and need antibiotics) would encourage more doctors to become GPs.  We could even go so far as to substantially discount tuition for doctors that promise to become internists. 

Or you can go another route, which involves greater responsibilities for Nurse Practitioners and Physicians Assistants.  Their labor is cheaper and plenty capable for general check ups. 

Ladies and Gentelmen, I give you France

(cross posted from tpm)

A substantive debate has been circulating tpmcafe and other corners of the web among us health policy wonks and what we deem to be the Right Way to go about fixing our health system.

But there appears to be some discrepancy among the policy wonks when using the term “single payer”.  Some mean pure single payer, or a Canadian or UK style way of delivering care, where there is no or a very small role for the private sector.  Others are making “single payer” synonymous with “universal care”, which is a different issue indeed.

Although some have argued otherwise, I think the one thing nearly all (>95%) progressives agree on that we need to have universal health insurance.  Not that all health insurance and health care services should be funneled through the government, but every single person in the United States should have health insurance, and if necessary the government should step in to fill in the gaps.  That is the baseline of agreement.

From there, you get any number of ways to achieve it.  Hence the quibbling among PPI and Kevin Drum about incrementalism.  Then there's the question of whether or not we should adopt a true single-payer system.  On that front, Leif Wellington Haase wrote an excellent meditation on why we should be cautious with single payer, and today Ezra Klein has a good look at why Canadian-style health care should not be our goal in the United States.

Instead, a better model for the U.S. would be a public-private hybrid that provides a floor of care and universal coverage for everyone, along with varying levels of benefit packages offered by the private sector. 

But what would this kind of system look like, and does it work?  France is one nation with quality results within a public-private framework, and a look at this system is a sound place to start.   

Everyone in France has a basic level of publicly-funded insurance.  This insurance covers everything and makes no demands on physician choice (or the number of tests or visits).  These public funds cover 75% of health costs, with the rest of the cost split between out of pocket payments and private insurance.  85% of the population has a form of supplementary insurance to cover the rest.  All doctors in France take either public or private insurance, so there’s no migration of doctors toward one avenue or the other.

There’s a few things about the French system that address single payer concerns Leif laid out:

• Because of the allowance for a private sector, the development and adoption of technology won’t be stifled

• Private insurers will stay around because they’ll still have “skin in the game”, thus avoiding a complete administrative disaster

Again, the most important goal is to cover everyone.  Once a plan allows for that, we need to examine the ways it can hold down costs. In the case of France, that’s done in many different ways.  Two of the main controls:

• Because the majority of health spending is directly financed by the government, it has great bargaining power to ensure lower prices (think the right way to do Medicare Part D)

• The state plans hospital locations, ensuring a uniformity of available care

And the French system was given the number one rating by the World Health Organization in 2000.  Where did the United States stand? Number 37. 

As Leif said, there are many ways to Rome.  But France represents a well-traveled and smoothly paved avenue.