Healthy Policy

Good news and bad news

The bad news is that the Senate is moving forward with malpractice reform.  They're fairly typical -- caps on all non-economic damages over $750,000, and $250,000 for individual practitioners.  Refer to my series on the Medical Malpractice Myth for more extensive discussion of the evils of tort reform, but the basics are these:

• The problem isn't lawsuits, but medical malpractice, which injures hundreds of thousands of patients a year, and our current system doesn't do enough to protect against medical error.

• Tort reform, which mostly involves caps on awards, would do nothing to prevent medical error

• Only 3-4% of injured patients sue; there are far fewer lawsuits than we would expect

• Tort reform fails to address this issue as well, and we would expect even fewer patients to receive compensation for their injuries

The good news is the Senate, unlike its radical counterpart, took out clauses preventing medical device and pharmaceutical companies from  punitive damages if their device was approved by the FDA.

While that clause seems logical at first glance, recent problems with Guidant and faulty manufacturing (which is totally separate from whether the device works in the first place), gives more than enough pause.  Also, as pharmaceutical companies haven't been exactly honest in reporting the findings of their clincial trials, the tort system of checks and balances is something that needs preservation.

Conquering the crutches

I'm ready to author a mini round up. I'm not finished yet -- the doctor says it will still be two or three months until I'm completely back to normal.  From here I get tortured by physical therapy and try to erase my limp, but it's all uphill as far as I'm concerned.

It started with this procedure. (look here to see my post-surgery x-ray)  The total cost of my surgery was $21,113, and that doesn't include any of the follow up appointments. 

I stayed in the hospital for two nights, an experience I had managed to avoid since the age of thirteen, but quite valuable as I've continued my foray into health policy.  I wrote a lengthy post describing my experiences, but I'd make these main points: you will see dozens of people, most of whom you don't know, and they will poke and prod you and bug you regardless of whether you're sleeping, going to the bathroom, or bright eyed and bushy tailed.  Also, don't expect to get any rest.  Or have anyone know anything about you besides your procedure.

Once I was released from the hospital, I had a leg brace comprised of straps and hinges at the knee.  It wasn't bad really, and made me feel more like a basketball star or skier who tore a number of ligaments than a girl whose childhood bone disease left her leg requiring some tweaking. 

And then there were the crutches.  Three months of hopping around on two, unable to carry anything for myself (although I did devise some creative hopping patterns to carry small things a few feet).  Three months of fearing steps, refusing escalators, and avoiding wet pavement.  Three months of sore armpits, rambo-esque biceps, and dwindling leg muscles.

Following my foray into two crutchdom, I was introduced to the single crutch.  For the first time in three months I fetched my own coffee.  My single crutch became more of an appendage, or a presentation I took with me everywhere.  Whenever I sat down, I searched out a place to lean it where it wouldn't tumble over.  It fell repeatedly; I learned the only way a crutch doesn't fall over is if you lean it against a brick wall or similarly rough surface, or lay it on the ground.  I flung it into my passenger seat when driving, it fell over with a clang constantly when shopping, and sat as a constant reminder of an annoying friend to be carried everywhere.  But I don't want to complain too much-- it also afforded me the ability to walk semi-normal, my armpit mostly calmed, and it represented progress.

The next step after the single crutch is either more of the same or total freedom.  My appointment, scheduled for six weeks after the move to one crutch, was a source of stress and anxiety -- will I be making enough progress to move on?  Or will I have to endure this awkward way of moving for any number of additional weeks? 

And after 18 weeks, I've finally done it.  My x-ray showed enough improvement to let me walk without assistance.  There was concern early on that my bone wasn't healing and additional efforts might be needed to make it do so (i.e. a bone graft).  So after four and a half months of slow progress, my doctor was as happy to let me go as I was to leave.  I felt like Steve Martin pretending to walk in Dirty Rotten Scoundrels -- ridiculous grin on my face and all. 

I know it's all uphill from here, and that I don't have to fear going back to the doctor and taking a bad x-ray.  My leg feels heavy and unwieldy; I have a small limp and it takes a lot of concentration to try to move as normal as possible. 

But as summer rapidly approaches, I know I'm lucky enough to be released from my body's shortcomings, and I will be able to do whatever I want, barring training for a marathon. 

Now that's progress.

Schtuff

HPites, I have a major check-in with my orthopedic doc this afternoon where I'm hoping to be pared down from one crutch to zero.  (X-rays, etc, to follow later today).

While I'm busy having my bone x-rayed, you should go read some stuff.  First, refer to QandO's post rebutting my Canada post from yesterday, then head over to Ezra's, where he's kindly done the re-rebutting for me. 

Also, stop by Adrienne's for her take-down of the new anti-obesity drug Xenical and the efforts to take it OTC. 

I'll be back in the afternoon!

Mass features reinstated

The Massachusetts legislature voted to override Romney's vetoes on Tuesday.  So the employer assessment of $295 is back (albeit still insufficient).  Other things reinstated include:

• Extension of dental and vision benefits to adult Medicaid beneficiaries and discounts on premiums and copayments for meeting wellness goals;

• A larger, revamped Public Health Council;
• A provision that would require a member of the Massachusetts House and Senate to participate in negotiations with the federal government regarding special Medicaid funding; and
• A provision that prohibits the Governor from making significant changes to mental health benefits without an explanation to the Legislature
  

These vetoed items actually say a fair amount about Romney.   Namely, that he could care less about tooth decay (for an explanation of why it matters to have dental care, go here) and doesn't think public health initiatives matter in the age of bird flu.   Too bad -- besides their disaster-combating aspects, public health initiatives need to play a large role in any reform overhaul, as the current incentives to be healthy are utterly failing. 

Luckily Massachusetts has a democratic legislature which has its priorities in line.

Evidence

And if you want to know why the things I discussed in my last post make me so angry, it's because arugments like those keep us from doing anything about this:

The percentage of moderate-income U.S. adults who do not have health insurance during any part of the year increased to 41% in 2005, up from 28% in 2001, according to a study by the Commonwealth FundAP/Houston Chronicle reports (Agovino, AP/Houston Chronicle, 4/25). For the study, researchers surveyed 4,350 adults, focusing on those ages 19 to 64, using 25-minute telephone interviews between August 2005 and January 2006. According to the study, 41% of adults with annual incomes between $20,000 and $40,000 did not have health insurance for at least part of 2005, compared with 35% in 2003 and 28% in 2001. In addition, the study finds that 18% of adults with annual incomes between $35,000 and $60,000 were uninsured for part of 2005, up from 16% in 2003 and 13% in 2001 (Whitehouse, Dow Jones Newswires, 4/26).

It's getting worse, and instead of coming up with workable, real solutions for reform, we're arguing over waiting lists in Canada. 

Canada, health care reform, and you

A few things in the health care debate have been riling my feathers lately.  The first is yesterday's post by Ezra Klein examining how the folks over at the right-leaning The Corner are busy questioning the definition of "is".    Ramesh Ponnuru writes:

I don't think [universal health care] is possible, actually. If you can't get an operation because your country's national health insurance system has you on a long waiting list, in what sense have you enjoyed "universal coverage"?

Ezra goes on to discuss how one can, in fact, define universal, and that definition is "everyone in the population receiving health insurance". 

Jon Cohn addresses the latter part of Ponnuru's argument over at The New Republic's blog, the Plank, and dug into the stats on waiting lists:

Here's the summary findings from an exhaustive survey by the Organization for Economic Cooperation and Development (OECD):

The health system in France is regarded as delivering high quality services, with freedom of choice and generally no waiting lists for treatments.
--Page 69, sourced to a 2000 study by a trio of academics

And: In Germany, "Waiting lists and explicit rationing decisions are virtually unknown."
--Page 70, citing a World Health Organization study.

If Ramesh knows something the OECD doesn't, I'd love to hear about it.

I'm going to throw myself into the fight here, and debunk another favored myth of the Right, which is that the Canadian health system is so bad, millions of Canadians come here for their health care. 

A 2002 Health Affairs paper examined hospitals near the border, as well as national surveys to tease out how many Canadians actually visit the U.S. to receive elective procedures.

In terms of hospitals along the border offering advanced treatments or special diagnostic technology (i.e. CT scans and MRIs), about 640 Canadians were seen, along with 270 for procedures like cataract surgery. They compare this to about 375,000 and 44,000 similar procedures in the region of Quebec alone during the same period. If you divide the total number of Canadians seeking those treatments in the US, divided by the number in Quebec alone that's about 0.09%.  Not even a tenth of a percent.

But the most striking stats come from the Canadian National Population Health Survey (NPHS).  From the article:

Only 90 of 18,000 respondents to the 1996 Canadian NPHS indicated that they had received care in the United States during the previous twelve months, and only twenty had indicated that they had gone to the United States expressly for the purpose of getting that care.

Only 20 of 18,000 sought care in the United States.  I can't believe how many people are coming over here!  Their system but be truly awful.

But let's give this number some context. We've all heard about seniors getting their prescriptions from Canada. (Hell, even driving to visit my sister at college in rural Kansas, I saw a billboard for "Canada Drug of Topeka!") But how many seniors really do that? Is it exaggerated, like the claims of Canadians coming stateside?

Polling data from 2003 (approximately a year after the Health Affairs article) indicates that 8% answered YES to the following question:

"Have you ever bought prescription drugs from Canada or other countries outside the United States in order to pay a lower price?"

If 8% of the 18,000 Canadians polled in NPHS had expressly sought care in the United States, that would be 1,440. Not 20, as the survey showed.

In other words, we have 72 times the number of Canadians seeking care in the US going to Canada (or at least calling there) to get prescriptions.

What angers me so much about the Right's rhetoric on health care reform is that their arguments are so weak that they're now essential questioning the definition of "is".

Universal health care has been achieved in dozens of nations on this planet.  One of which has some waiting lists, while others have essentially none.  According to surveys, less than 0.1% of Canadians are expressly seeking care in the U.S. 

The bottom line is our health care is twice as expensive, fails to cover 46 million people, has questionable quality, kills around 100,000 people a year from error, and for all this we have worse health indicators (i.e. lower life expectancy, higher infant mortality, etc).  Other countries do it better, and they do it with the help of government to pay for health costs.    

We can at least move to a system where everyone has health insurance. Or, you can believe the folks over at the Corner who are arguing that universal coverage doesn't exist.

What do you want? 

AHP's and the ACS

The American Cancer Society is among the groups protesting Mike Enzi's Association Health Plan Bill.  And they have some sound and not so sound reasons for this:

  In response to the bill, which likely will move to the Senate floor for consideration in May, the American Cancer Society plans to publish print advertisements that warn the legislation could reduce the ability of women to obtain coverage from health insurers for mammograms. Forty-nine states require health insurers to cover mammograms. Dan Smith, vice president of government relations for ACS, said, "Not only would this legislation wipe out guaranteed access to cancer screenings, it would remove coverage guarantees for clinical trials, off-label drug use and smoking cessation services."

The mammogram thing is a great point.  But off-label drug use?  Most Americans don't know what that is or why we should have it, particularly in the case of chemotherapy, and frankly, it's not such a great thing to use a large part of your ad campaign on behavior that is discouraged by the FDA.

Maybe we could talk about prenatal care coverage?  Or any number of other things Americans will immediately understand, that Association Health Plans could wreck?

Mumps and the Midwest

My initial reaction to the Midwest Mumps outbreak story was "Hooray for being vaccinated!"  Then I read this:

Mumps, a viral infection, is usually not serious, and there have been no reports of deaths. The most troubling aspect of the epidemic is that many of the patients had been vaccinated. Does this mean that millions of people who thought they were safe actually are not?

So, uh, considering I live in Kansas, I'm feeling a bit worried...

And then the article goes on to suggest that there might be significance that many of the afflicted are young adults (read: college age), rather than children.  Crap.

Trust, doctors, and race

A new study unearthed evidence that blacks trust physicians less than whites.  The study, from the University of Pennsylvania, found nearly 45% of blacks have low trust levels, compared with 33.5% of whites.

The finding that there is a racial disparity in terms of practitioner trust doesn't surprise me at all.  That's due, in part, to a recent discussion with my long-term pediatrician (who works at an acute care children's hospital) about treatment issues he sees.  We talked about defensive medicine and lawsuits, but the part I found most intriguing was our discussion of racial disparities at the hospital.  He told me that low-income black patients in the metro area just don't trust the doctors, particularly at the ER, and often give false phone numbers and addresses, which makes follow up impossible.

The UPenn study attributed much of the lack of trust to the fact that many blacks are uninsured and seek care in the ER, where the staff changes often.  This makes perfect sense to me -- the experience of medical treatment chiefly through an ER setting, where you wait hours to see anyone, see a different doctor every time, and have an invasive, thorough medical history taken each visit, is quite different than visiting a consistent primary care doc.

What's interesting about the study as well is that the race of the physician didn't impact trust level, as one might expect it would.  And that speaks to grave, structural trust problems between the African American population and medical practitioners.

Latino trust levels were not examined in this study.  My pediatrician didn't believe that Latinos had as many issues with trust, but I wouldn't just take his word for it.  Language barriers and fears of deportation create further hurdles for these families. 

Many low-income patients continue to use the ER for care even when they have insurance (whether it's Medicaid or otherwise).  The question for public health experts and medical practitioners, then, is to figure out how to decrease this utilization, which will lower health costs while building trust and more consistent care. 

The various intracacies of medical devices

This post by Chronic Babe is a great round of up trying to engage in sexual activity while being affixed to medical devices.  Well written, straight forward, and non-apologetic (as it should be)!  Well done, babe.

Grand Rounds

Grand Rounds is up at the Health Business Blog.  Well done, David!

Mixed Messages

A new report commissioned by Charles Grassley (R-IA) and administered by the GAO has found that the FDA's ability to deal with safety problems is, well, problematic. 

Grassley, unlike the other Republicans overseeing the FDA, believes "[the] problems are systemic and cultural, not isolated or easily fixed."  He's also proposed a drug safety bill to kick the FDA into gear. 

More on the report itself later on.

Aspirin, Pharma, and You

The Wall Street Journal took a gander at the number of "aspirin resistance" papers in the last few years and found some peculiar trends.  Namely, that there's been a lot of talk all the sudden about aspirin resistance.

For my fellow non-health care practitioners, aspirin resistance basically means aspirin doesn't lower your blood pressure or prevent clotting like it should, and therefore you must need some other expensive prescription medication.

A dozen papers were published in 2002 alone examining this condition, and many more have followed.  Besides confusion over the correct way to identify patients with aspirin resistance, researchers don't know if these people can actually be helped by other medications either.  And most experts agree that the number of people with such resistance is quite small.

The pharmaceutical industry doesn't see it that way, and has seized the opportunity to promote sales of prescription products like Plavix along with the tests that measure aspirin resistance.  Their efforts, propelled by publicization in medical and trade journals, are working.  Producers of laboratory tests that measure aspirin resistance have seen their sales grow in double digits.  And Medicare ordered 43,000 such tests, twice as many as it did only two years ago. 

Aspirin resistance could be potentially devastating for those it affects, and heart surgery and hospitalization is certainly much more expensive than these tests.  But a doubling of tests for this rare condition in two years is troubling, and points to physician pressuring (and caving), non-disclosure of conflicts of interest, and plain old improper focus of research dollars (see my previous post for a better location). 

Calling Bill and Melinda Gates!

Please donate some money to this:

Researchers are closing in on a breakthrough microbicide gel to help prevent HIV infection in women, scientists said on Monday, but a lack of funding by major pharmaceutical companies is hampering research.

For those of you who won't know, microbicides are gels or creams, usually inserted vaginally, that help prevent sexually transmitted infections.  The chief target of current microbicide research is to prevent HIV infections. 

Microbicides are the ugly stepchild of already poor funding for HIV medications.  That's because the people they'll help the most are women in third world countries who have extremely patriarchal marriage arrangements (read: most of Africa and India).  Many men in these cultures make regular visits to the local prostitute, where they contract HIV and bring it home to their wives, who pass it on to their children.  Because condom use is taboo (especially women requesting that condom use), women have little ability to protect themselves from infection.

The development of a microbicide for HIV would give these women power to protect themselves and their children.  But a successful anti-microbial agent hasn't been developed yet, although a few are in the final stages of clinical trials.

Microbicides would also be significantly cheaper than treatment with HIV medications, which people in third world countries have essentially zero access to. 

Remember me?

Read Graham on a woman with an autobiographical memory.  Now there's certainly things in my life (read: the week following my surgery) I'd prefer not to remember that well, but sign me up for this skill!

Weird America

This man commutes seven hours a day.  And while he claims that it helps him achieve the perfect work/life balance, I'm convinced he's crazy.

More on McGuire

There's new developments related to yesterday's post on United Health Group's CEO, William McGuire (a good discussion is getting going in the comments, as well). 

The Wall Street Journal is reporting that McGuire has called for a suspension of his and other executives' compensation packages.  Despite its unprecedented  nature, this is a noteworthy move as the vast majority of McGuire's compensation package exists in stock options (an estimated $1.6 billion). 

But there's more to the story.  Because of UHG's lax restrictions on when CEO's can choose to receive stock options, it appears that McGuire greatly increased the value of his compensation package.  In fact, a statistical analysis by WSJ found that the chances of McGuire's options attaining their current value, if new options packages were chosen at random, was approximately two hundred million to one. 

The SEC is looking into it, and there's another lawsuit in Minnesota from allegedly wronged shareholders.

Apparently I'm not the only one feeling a bit uncomfortable with that level of compensation...

United Health Group and You

It's anecdotes like these that make me seriously question if profit should be in the health care industry at all.

When William McGuire switched careers in 1986, he was so restless that a pay cut of more than 30% didn't faze him. Health maintenance organizations were booming, and Dr. McGuire wanted to help run one. So he jettisoned a six-figure income as a pulmonologist in favor of an HMO management job that paid about $70,000 a year.

Savvy move. Today, the 58-year-old Dr. McGuire is chief executive officer of UnitedHealth Group Inc., one of the nation's largest health-care companies. He draws $8 million a year in salary plus bonus, enjoying perks such as personal use of the company jet. He also has amassed one of the largest stock-options fortunes of all time.

Unrealized gains on Dr. McGuire's options totaled $1.6 billion, according to UnitedHealth's proxy statement released this month. Even celebrated CEOs such as General Electric Co.'s Jack Welch or International Business Machines Corp.'s Louis Gerstner never were granted so much during their time at the top.

Dr. McGuire's story shows how an elite group of companies is getting rich from the nation's fraying health-care system. Many of them aren't discovering drugs or treating patients. They're middlemen who process the paperwork, fill the pill bottles and otherwise connect the pieces of a $2 trillion industry.

What's come of this $8 million a year, plus an estimated $1.6 billion in stock options?  Think how many extra people could be covered a year with that $1.6 billion.  Especially when the company also did this:

The Arizona Department of Insurance on Friday ordered United Healthcare to pay civil penalties totaling $364,750 — the largest fine in the department's history — for violations of state insurance laws. State regulators said United Healthcare illegally denied more than 63,000 claims by doctors without receiving all of the information needed to accept or deny a claim. The company also failed to follow state laws for promptly notifying doctors and patients about about decisions and appeals, the state said. United also violated a 2002 agreement to correct previous violations, the state said.
 

And the fact that they're doing this while the rest of us see our premiums rise 10%/year (if our employers don't drop coverage, that is):

The "risk" business has been a particular gold mine for UnitedHealth and its rivals in recent years. As health-care inflation eased, insurers still raised premiums at double-digit rates. UnitedHealth's stock price tripled between January 2003 and January 2006, helped by acquisitions, although it has fallen back somewhat since the beginning of this year. UnitedHealth's net income in 2005 totaled $3.3 billion, nearly four times the figure in 2001.

No, this all makes me quite angry, and really puts to question insurer's claims that health care costs are rising so quickly that they can't keep up with them. 

This is the kind of money I'd expect to see from an oil CEO (who are doing similarly well right now).  But in health care, this kind of profit is disgusting.  We have 45 15 (sorry quoted the percent on accident) million uninsured people in this country, we have a health care industry trying it darndest to shift costs to consumers with health savings accounts and high deductible plans, and we have insurance CEO's valued over a billion dollars for their efforts.  Not hospital groups, or entire organizations, but individuals. 

Is this the kind of system that fits with our ideals?  If health care is an expensive necessity, one that we join together to ensure for everyone, should health insurers be making these kinds of profits?

Health Wonk Review #5

Our fifth Health Wonk Review is up over at Envisioning 2.0!  Great job, Fard, I'm especially a fan of the clearly superior acknowledgement, a la Einstein, of us policy wonks' intellectual efforts ;)

Good Read

This WSJ article on how doctors are seeking to improve their primary care practices is an interesting read. 

Get your tests people

From WaPo:

Despite strong evidence that tests like a blood pressure check every two years are worthwhile, barely 50 percent of U.S. adults receive the diagnostic and preventive screenings that many medical experts recommend. Several factors explain why many Americans remain unaware that they have hypertension, colorectal cancer, high cholesterol and other lethal conditions: the proliferation of recommended tests, doubts about the value of some once-standard exams and time demands that keep many doctors from performing systematic screening.

Explain to me how the value of blood pressure cuffs has been questioned? (those drug store things don't count)  If people aren't getting their blood pressure checked every two years, it's because they're not getting/going to check-ups. 

In a study published last year, Duke University physicians suggested why compliance with screening standards is so spotty: "Taken together, the time needed to meet preventive, chronic and acute care requirements vastly exceeds the total time physicians have available for patient care," they said

If the patients don't show up for their physicals, that's one thing, but is it really that tough to screen for the basics -- blood pressure, high cholesterol, and diabetes?  Colorectal cancer is a different story, you have to get an oh-so-pleasant colonoscopy, but surely the others aren't such a problem that primary care docs aren't doing their purported aim -- verifying the general health of their patients. 

Employees take GM/Ford for all they can

So those plans to cut retiree health benefits?  They're backfiring:

The auto industry's efforts to rein in employee health costs is drawing an expensive reaction, as union workers and their spouses hurry to Michigan doctors for knee replacements and other elective procedures before they lose their comprehensive medical benefits.

Hospitals, doctors and insurers have all noticed a surge in demand for elective surgery since last year when Rick Wagoner, the chief executive of General Motors, led a public relations campaign to prepare auto workers for health care cutbacks, and  Delphi, the G.M. parts supplier, filed for bankruptcy protection. Hip, knee and shoulder replacements at the Henry Ford Health System were "up 20 percent in the second half of last year and remain strong," said Robert Riney, chief operating officer of the system, the largest hospital group in the Detroit area.

On the other hand, it remains much cheaper than covering all these workers' benefits for the long term.  And in some weird way, it probably gives the auto industry a sense that they've fulfilled some obligations, if they're able to say,"Listen, we paid for x number of joint replacements and elective procedures before dropping coverage.  And they've got Medicare."

Physical therapy and me

So I've been doing physical therapy the last few weeks.  There's lots of different types of PT offices.  There's the ones that serve mostly athletes or people injured in sports, and the therapists tend to be very fit, A-type personalities, who wear tight shirts (that goes for the men and women) and it's all a glorified in-shape machine.

Then there's my PT office, which is in a medical plaza building that, as far as I can tell, serves mostly old people.  It's probably the smallest PT office I've ever seen; the staff consists of a calm, harmless middle aged man and an intensely religious assistant in her mid twenties.  The other patients are all over fifty, with the exception of one high school age girl who tore her ACL.  The other patients seem to have shoulder/neck injuries, so they spend their appointments stretching their arms or getting massages or anti-inflammation massages with some little microphone thing. 

And what are my exercises?  The newest additions consist of walking around the room sideways and backwards.

But they fooled me at my small old people physical therapy office!  The first day I went they gave me 8 exercises -- mostly 80's exercise video-style leg lifts and a theraband.  But every time I go I get more and more and more.  Now I have like 25 exercises, including the silly walking sideways and backwards, and a variety of other weird things.

The real kicker is I'm not even bearing full weight on my leg yet -- what will they come up with when that happens???

Chef Blogging

Chef Kate was busy Easter morning, so I figured I'd pass on my recipe for my centerpiece, Egg Souffle with Fresh Herbs.  The recipe basis comes from a delicious meal at this bed and breakfast I stayed at in California.  I got the recipe from the owner but lost it, so I recreated it from memory and added a few ingredients.  Below the fold.

Message Control

After Friday's announcement that Medicare would extend the Part D enrollment deadline for low-income beneficiaries, Leslie Norwalk, the Deputy Administrator of CMS, said it is not legally permissible, according to rules set out in the Medicare Modernization Act:

The 2003 Medicare law states that a "special enrollment period" beyond the deadline can be established only for beneficiaries with exceptional circumstances (Freking, AP/St. Paul Pioneer Press, 4/14). CMS earlier this month announced that it will allow "ongoing" enrollment in the Medicare prescription drug benefit for beneficiaries who qualify for a low-income subsidy (Kaiser Daily Health Policy Report, 4/14). Democratic lawmakers and some advocacy groups have been pressing the Bush administration to extend the deadline for all Medicare beneficiaries. However, Norwalk said giving an extension to all 43 million eligible beneficiaries would "undermin[e] what Congress put into place." She added, "Our actuaries tell us 1.6 million fewer people would enroll if we do that. We are not going to push back the deadline." Norwalk also said the deadline encourages people with relatively few drug expenses to enroll, allowing for lower overall costs.

So when you mess around with the enrollment deadline, it does, in fact, discourage people from signing up until the next deadline.  CMS was proposing to extend the deadline indefinitely, which is a truly terrible idea, because those who are not inclined to do so (i.e. those without high drug costs) will definitely not sign up. 

More than that, the problem with this bill is not the deadline, and Democrats (and others) need to stop pretending it is.  The problem is the huge array of "choices", which make it overly difficult to choose a plan, and is therefore acting as a huge barrier to enrollment.  Changing the deadline won't solve that problem, and as Norwalk says, might actually decrease the enrollment. 

But someone in the administration should have figured this out before announcing an enrollment extension. 

Walmart to extend insurance

Maybe they think their new banking scheme will pay for this:

Wal-Mart Stores said today it will relax eligibility requirements for part-time employees who want health insurance, allowing an additional 150,000 workers to gain coverage if they choose.

Until now, the employees have had to work for Wal-Mart for two years to qualify for employer-sponsored insurance. Beginning next month, they will have to work at the company for one. The coverage also will extend to their children.

This addresses part of the problem -- relaxing eligibility rules to one year of employment is fairly significant, and the monthly premiums are quite affordable: purportedly $23 per month, with the option to extend coverage to children for an extra $15 per month. 

But there's a catch: the plans have a $1,000 deductible for individuals, and up to a $3,o00 deductible for families. 

Uwe Reinhardt is well known for discussing health savings accounts in the context of a waitress who makes $30,000 dollars a year.  But let's take your average Wal-Mart employee, makes significantly less than our $30,000 dollar a year waitress.

The average Wal-Mart worker makes $8.23 an hour and typically works less than 24 hours a week. The average Wal-Mart employee working 40 hours a week would earn only $17,118 a year, but a more realistic annual wage for a Wal-Mart worker is about $10,000.

A single parent Wal-Mart employee working part time and electing family coverage would have an annual deductible equal to over 30% of their income.  Let's keep in mind, as well, that a $3,000 family deductible is on the lower end of HDHP/HSA style deductibles, which can run up to $10,000.  (That really makes HDHPs seem like the solution for low income workers, no?)

It's great that Wal-Mart is taking the leap and offering more coverage, and surely some will take advantage of it and enjoy the benefits they deserve.  But when a large percentage of workers elect not to sign up (because they can't afford it), I hope Wal-Mart doesn't claim,"they just don't want it."

Health Wonk Review: Call for Submissions

Fellow wonks,

Fard Johnmar is hosting Health Wonk Review Thursday (April 20th) over at Envisioning 2.0.  Don't forget: submissions are due by tomorrow at 9 am.  You can email them to Fard, or use Health Wonk Review's submissions page. 

Hospital Story Time!

It's Friday, and that means fun story time.

Today's story is not about yours truly, who has managed to stay out of the hospital since surgery, thankyouverymuch.  It's about my mom, who went under for surgery yesterday.

And may I just take a second to remark that it's so much more fun to collect hospital stories as a visitor/friend/advocate than as a patient.  (Here's my impression of my hospital stay back in December)

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

They wheeled my mom into her spacious private hospital room.  She was fairly woozy, but happy to be out of the recovery room, where she told me the other patient had been moaning (a low, growling moan) f0r about an hour.   Within a minute an attractive nurse in bright pink scrubs enters.  She surveys the room, my mom, me and my dad, and picks up the chart. 

She begins to ask my mom the usual "Welcome to the hospital, are you in pain/are you nauseous/do you want ice chips" questions.  Her speech is fairly clear, except for the harder consonants, which are muddled, and I immediately realize: she's deaf.

In my non-patient humble opinion, I think it's fantastic that a deaf person is a nurse.  She reads lips incredibly well.  But for my mom, this isn't the best situation.

Because my mom is also deaf, and she left her hearing aids at home.

My mom has a degenerative disease that affects her hearing.  Because she's been losing it slowly over the last thirty years, she hasn't learned sign language.  She can understand people for the most part, when she has her hearing aids on, but the nurse's muddled consonants confuse her. 

At one point a woman comes in with cleaning supplies and starts disinfecting all the counter tops in the room.  Immediately my mom freaks out and asks for a cloth to put over her nose and mouth (apparently cleaning solvents are very bothersome when you've just left surgery) (Also, I'm quite sure the room should have been cleaned before my mom was actually in it, but I digress).

So my mom is laying there holding the blanket over her mouth, trying to talk to the nurse, who now can't read her lips, and they're both looking at me to interpret.  It's the deaf leading the deaf, except they can't communicate.  This strikes me as a pretty amusing irony.

Aside from the deaf nurse, they had a nifty e-prescribing system, where the tech scans both the patient's hospital bracelet and the medication before administering.  The tech wheels around a little cart with a laptop attached.  It's quite mobile, and I was very impressed. 

And can I just say that ever since I got in to health policy, I'm a total nerd at doctors/hospitals.  I'm like a detective taking note of everything I see, and I get excited by e-prescribing systems.  My family must think I'm crazy...

Messing with Texas

Texas is seeing some unintended consequences:

The number of children enrolled in Texas' SCHIP program fell by more than 9,000 in the beginning of April, marking the fourth straight month of decreased enrollment, state officials announced on Tuesday, the AP/Austin American-Statesman reports. More than 30,000 children have left the program since Dec. 1, 2005, according to the Texas Health and Human Services Commission. About 292,700 children -- the lowest number of beneficiaries since 2001 -- are currently enrolled in the program, according to the AP/American-Statesman. More than half of the children who left the program in the beginning of April were cut because their families did not pay a new enrollment fee of up to $50. The fee, which the state began collecting this year, is based on a family's income and is intended to replace monthly premiums. Families must renew their SCHIP coverage every six months (Austin, AP/Austin American-Statesman, 4/12). According to the Houston Chronicle, the enrollment drop comes "as officials announced a $3 million program to educate families on how to keep their children insured." The state Health and Human Services Commission in May is launching a campaign to explain new application requirements, including proof of income and new enrollment and renewal fees. The enrollment drop "has alarmed children's advocates because Texas has the highest rate of uninsured children in the nation," with about 25% of children without coverage.

This is really unfortunate.  I tend to think it's a bad idea to make people renew coverage every six months, as well.  It's hard enough to get them to sign up in the first place.

And as the rate of the uninsured has been rising, the drop-outs don't reflect a rash of children now with health insurance  from another location. 

Also, it says that children were cut who didn't pay the $50 fee.  I'll bet most of those families had no idea/paid no attention to the fact that this was going on. 

Would-be reformers, take note

Ezra writes:

Among the many reasons I'd prefer not to be a politician, navigating the remarkable confusion of your constituents as to their opinions on public policy issues ranks high up there. They're for abortion, for abortion restrictions; for lax immigration laws, in favor of draconian enforcement; for going through the UN, enamored with acting unilaterally; for tax cuts, for spending increases; and on and on it goes. The phrase "mutually exclusive" is absent from America's political vocabulary, as is the concept of a "tradeoff."

He's right on the mark. That's why we have a war that, if there was a draft, no one would want to fight, a war without any tax increases. This logic extends to health care reform and our quest to fix the system.

Just look at my post from yesterday, where I discussed the ramifications of Gov. Romney vetoing the employer assessment. 

When I attended the National Health Policy conference in February, an entire presentation was devoted to the idiosyncrasies of health policy polling. Sure, the vast, vast majority of Americans are in favor of reform, and a majority will even support a "modest tax increase". But if you name any specific dollar amount of that tax increase, the foundation of support crumbles.

I wish I could say, "This is a cultural problem; let's try and fix it." But the truth is that this is a symptom of democracies -- when you're insulated from making the calls, it's easy to support or protest them. A change in perspective, where people bring themselves to support reform with trade-offs, only occurs in the face of substantial problems and hardship (like premiums reaching $20,000/family in today's dollars).

In the meantime, we should keep talking about all the things that are wrong with the U.S. health system, and all the ways other countries succeed where we fail. That way, when it's time for reform, the foundational message and education will have been laid, and coupled with the public's willingness (if not desperation) to act, efforts will hold strong.   

New York Times Ugh

Sorry for the delay on this pronouncement, I'd been trying to get used to it, but

I HATE THE NY TIMES REDESIGN!!!!!!!

It used to be my favorite site because I thought the layout was the most user-friendly.  You could glance at the page, see all the various headlines, and get a good idea of the news in 20 seconds.  No more, and they have a stupid flowery font (and I'm usually a fan of flowery fonts!) that doesn't befit the NYT.  Now I'm forced to head elsewhere.

Can we change it back, please?

Romney says no to employer assessment

The Boston Globe is reporting that, in a show of his Republican colors, Massachusetts Governor Mitt Romney will sign the new health bill, but veto the employer assessment (you know, the paltry $295?). 

This bill is shaped with the assumption that the vast majority of employers will not drop coverage of their employees.  It does not make plans for what to do (and in particular, how they would pay for it) if that is the case.  $295 is significantly lower than originally proposed, and that number is already causing uneasiness.

Fortunately, there are more than enough Democrats to override Romney's veto.  But it still sends a message that employers shouldn't be punished for not providing insurance.  If you're like me, and you want to uncouple the employer-insurance relationship, that's just fine.  But MA hasn't planned for it, and who knows how they'll handle it if there's an exodus of employers from the system.

It's never good to leave people without a parachute, and if Romney had his way we might see a lot of people crashing to the ground as their insurance is pulled out from under them. 

Johns Hopkins reverses on comestics line

Yesterday I wrote about the revelation that Johns Hopkins will be partnering with Sephora to develop a "Johns Hopkins tested" cosmetics line.  Apparently I wasn't the only one uncomfortable with this announcement, as Hopkins retreated from the partnership today (again, via Health Care Renewal):

After the relationship was publicized and criticized, the Baltimore Sun reported that Johns Hopkins quickly decided to revise it. Johns Hopkins will no longer receive stock or a seat on the board of directors of the cosmetics company. Hopkins asked that company marketers "withdraw all references to JHM (Johns Hopkins Medicine) except for certain limited information - on product packages and in previously printed promotional material - that disclose JHM's consulting role," although so far the Sephora web-site's page for Klinger Advanced Aesthetics Cosmedicine has not been modified (as of April 10, 2006).

I'm with Roy Poses; Hopkins' retraction is a good move. 

More ways to punish the poor

It's come to light that the 2005 spending bill contains a little-publicized new restriction:

Individuals seeking care through Medicaid beginning on July 1 will be required under federal law to show proof of U.S. citizenship -- such as a birth certificate, passport or another form of identification -- the Boston Globe reports. The requirement was included in the Deficit Reduction Act of 2005, which President Bush signed into law earlier this year. The provision's intent is to prevent undocumented immigrants from claiming to be citizens in order to receive benefits only provided to legal residents, according to the Globe.

Can we say Katrina??

It's well known that African Americans, not just "immigrants", often have no birth certificate or proof of citizenship (and they're certainly not using passports to go vacation in Europe).  And certainly recent natural disasters give us pause when considering these kinds of provisions -- imagine how many documents were lost last September. 

This bill is only going to make it harder for the most vulnerable and poor to get health care.  Any money it saves by denying illegal immigrants care will be far outshadowed by the extra pain we're shifting to other Americans, who are the victims of unfortunate circumstance.

Things that don't make sense

From the things that don't make sense to me about Consumer Directed Health Care File, we have this recent news:

CMS likely will reduce Medicare reimbursements to physicians by 4.6% in 2007 because of increased program spending on physician services, Herb Kuhn, director of the Center for Medicare Management at the agency, said on Friday in a letter to Glenn Hackbarth, chair of the Medicare Payment Advisory Commission, CQ HealthBeat reports. 

Cuts were supposed to be 4.4% in 2006 but political forces were able to put them off for a year.  The announcement last year was met with much vehemence -- mostly complaints over the fiscal stability of physician practices.

Now let's take a look at this comment from Matthew Holt's post on health savings accounts from yesterday:

Transparency is a problem... but will not be solved by legislation. People and employers will begin demanding better cost information as time goes on with HDHP. I am not sure what the magic number is in terms of market penetration, but it will occur.

As a practicioner, once all of the insurers post prices online, I no longer need to participate, and I can reduce my overhead expenses by setting prices at levels I deem reasonable. If that idea became widespread, then costs would decrease for most Americans.

First, isn't this comment presupposing the insurer is gone?  Isn't that the case if the physician is doing the underwriting?  And why, exactly, when doctors complain again and again about how salaries have fallen, would they decide that prices should be lower than what the underwriter forces upon them?  But let's suppose that's not what the commenter means, the insurer is still around.  The administrative costs saved from this particular  excisement are quite small, and if you really want to save administrative costs, go single-payer.

But here's my real question: if doctors are rebelling this much against Medicare-led payment rates, and consumer directed health care largely functions on the idea that consumers will force providers to lower payments, why should we expect CDHC to work?  It's not like patients can say, "gee, I guess I won't have that coronary bypass after all..".  The administrative overhead is still in place, because you still go through insurers, you have even more billing because now a good portion is going directly to the patient rather than the insurer.  I just can't understand how this kind of push for price transparency is actually going to bring down prices.  Refer, as well, to Paul Ginsberg on the relatively nontransparent prices for Lasik. 

Or South Africa, where their HSA experiment led to a race to the bottom, and did not, in fact, reduce prices. 

I invite anyone who strongly believes otherwise to try and convince me, because I honestly cannot see how it would work.

Random resource

Talk of the Nation is discussing Massachusetts and health insurance, tune in if you're an NPR nut like me.

Single payer vs. HSA's

Matt Holt has a great conversation going in the comment thread of this post.

Are you obese?

A new study from UNC-Chapel Hills found that only 15% of obese people correctly identified their weight class:

About 90 percent of normal weight adults and 85 percent of overweight and obese adults accurately self-reported their weight and height such that the BMI calculated using those self reports fell in the same category as actual BMI.

That accuracy changed, however, when researchers asked participants about their perceived weight status, that is, if they would consider themselves NOW to be underweight, normal weight, overweight, or obese. Seventy-one percent of normal weight and seventy-three percent of overweight adults classified themselves correctly, compared to only 15 percent of obese adults who correctly considered themselves to be obese.

If you read this Washington Post article, however, it's perfectly understandable where the confusion comes from:

A 5-foot-10-inch adult _ both male and female _ is overweight at 174 pounds and obese at 209, according to the U.S. Centers for Disease Control and Prevention.

Did you know that? (Doctors, you're not allowed to answer).  I definitely didn't, and this is where the disconnect is coming from: messages have been unclear about the point at which we are considered obese.  Sure, there's the BMI calculator, but how many of us actually use it?  Or trust the result?

The sample size of this study was very small (~100), so more research is certainly called for.  But better education efforts need to get going, ASAP.

Also, do most PCP's take your BMI at annual physicals?  If doctors aren't telling their patients that they're obese when they are, that will certainly impact patients' self-image.  It would be an uncomfortable conversation, but if your doctor won't tell you you've reached that dangerous weight point, who will?

Three cheers for Kansas!

My home state of Kansas is undertaking a new health information technology (HIT) program:

A new test program in Wichita may someday lead to the storage of all personal medical records online, easily shared among hospitals and physicians.

Wichita health care providers are helping pioneer a state pilot program that creates a centralized patient database of medical information, setting the framework toward a national exchange of health information.

State officials and their partners plan to publicly announce the project today, although it quietly launched in February to assess viability.

Called the Community Health Record Pilot Project, the demonstration moves Kansas another step forward in creating a unified electronic medical records database.

"We're really interested at the state level in seeking ways to improve the health information exchange that goes on between practitioners and hospitals," said Robert Day, interim executive director of the Kansas Health Policy Authority. "Everybody sees it as a really critical transformative process."

The pilot will use claims data of patients in Kansas Medicaid's HealthWave program, maintained by FirstGuard.

Although there is a delay between when claims are processed and uploaded to the database, historical data going back about two years has already been submitted to Cerner Corp. of Kansas City, Mo., which supplies the online database technology.

The total cost to tax payers is estimated at $750,000 and half of that will come from Medicaid.  A good investment, and one that can hopefully be extended to other health systems in the state in the next few years.

Time for some reevaluating

Via Health Care Renewal, Johns Hopkins is starting a new venture:

The Baltimore Sun and the Wall Street Journal reported (the latter available here via the Pittsburg Post-Gazette) the latest venture by the revered Johns Hopkins University. They are collaborating with a cosmetic company whose products will be labeled as produced "in consultation with Johns Hopkins Medicine."

The Cosmedicine "premium skin-care line," per the Journal, will be sold by Sephora, a unit of LVMH Moet Hennesy Louis Vuitton, and manufactured by Klinger Advanced Aesthetics, a unit of TrueYou.com Inc. According to Dr Edward Miller, Chief Executive of Johns Hopkins Medicine and Dean of the School of Medicine (and also on the board of directors of Bradmer Pharmaceuticals, a Canadian biotechnology company), "We have been pretty clear about our role. We are reporting on the scientific validity of studies done by outside testing agencies." But, according to the Journal, "Johns Hopkins will also work with Klinger to develop clinical 'best practices for the company's chain of spa-clinics." Their offerings include "'light medical' services, such as Botox and Restylane shots...."

The Cosmedicine web-page proclaims,  "Cosmedicine, the only skincare line tested for performance and safety in clinical studies designed and analyzed in consultation with Johns Hopkins Medicine, a world leader in healthcare, education, and research."

For those of you outside Sephora's 13-25 y.o. female target audience, it's a large expensive cosmetics chain that's quite popular.  Mostly they carry a bunch of sparkly eye shadows and lipsticks, but apparently they're moving on to "age-defying" cosmetics. 

But I'm quite troubled that Johns Hopkins, a world renowed academic institution (and arguably the best med school in the U.S.), a top-notch treatment center (anyone remember ABC's "Hopkins 24/7" series from about six years ago?), is partnering with Sephora, aka the home for all things sparkly and cosmetic-y for young women. 

Should there be a differentiation between the institutions that perfect life-saving techniques and disease management with those who perfect cosmetic treatments? 

Aren't those different goals?

More than that; it's not just the testing and "approving" of cosmetic products, it's the promoting and profit sharing.  What's the logical extension of this?  Johns Hopkins approved medical devices? 

Aetna is going to kick some diseased butt

Good news for public health advocates:

Aetna officials on Wednesday announced plans to expand the number of disease management programs offered by the company from six to 30, the Hartford Courant reports. Aetna currently offers disease management programs for asthma, chronic heart failure, coronary artery disease, diabetes, end-stage renal disease and lower back pain. Under the expansion, Aetna will begin to offer disease management programs for conditions such as cancer, HIV, hypertension, migraines, peptic ulcers, rheumatoid arthritis, sickle cell disease and stroke. Aetna will group the disease management programs into categories such as pulmonary, orthopedic, oncology, "neuro" and gastrointestinal under the name Aetna Health Connections.

This makes me very happy.

More on Mass

After reading dozens of opinions and articles on the Mass Health Reform Bill, I want to put in some additional two cents.

I think people are being too harsh on this in general.  So what if Romney is running for president?  As Ezra excerpted (originally from Jon Cohn) over at TAPPED:

And while it will undoubtedly annoy some progressives who don't love the plan or think he's taking credit for an idea (and favorable circumstances) that fell into his lap, they should be thankful for this development.

Thankful, because nationally the most important impact of this new law may be on politics, not policy. Once Romney starts boasting about how he achieved universal health coverage in Massachusetts, it will become that much harder for conservatives to demonize the very concept as "big government." Oh, they'll try--and they'll have at least some success. But now Democrats will have this retort: If a Republican governor and leading presidential contender with strong conservative credentials thinks universal health care is a good idea, how radical an idea can it be?

Progressives are also screaming "follow the money!", which strikes me as ridiculous.  Is coverage only good if it comes from a "pure" place?  Is it more important to have insurers out of the equation NOW, or to get everyone covered affordably?  To me, it's obvious.  In an ideal world, private insurers would be out of the equation.   But this is far from an ideal world, and a world where we can get everyone into insurance without bankrupting ourselves seems good enough for me.  Keep in mind this is a state initiative, and compromises here are much different that what we'd want for a national system.  These reforms are laying the road to universal care, not the building. 

I also disagree with Joe Paduda that there will be a huge rise in demand.  Only 11% of Massasschussetts is uninsured; and they have huge free care pools.  There will probably be a small increase, but no rash of people all of the sudden having tons of elective procedures and crowding specialists.  There just aren't enough people without insurance to do that.

That being said, I have a few concerns:

• There is no dedicated funding source.  This program will absolutely fail if there isn't enough money for it.  State budgets don't have the ability to absorb cycling costs like the Fed.  This could prove problematic.

•  The penalty for not insuring employees is terrible.  It is much, much too low to be any kind of disincentive for dropping insurance.

• It's unclear what will happen with the number of employers dropping care.  This statement over at Ezra's is making me think.  I'm unsure whether we'll see that.  And without a stiffer penalty, we well might.  But taking it a step further -- what happens if employers do drop care?  There's the affordable option being subsidized by the state so they'll still be covered.  But costs to the state will greatly increase unless there's a new source of funding dedicated toward this problem.  It won't work if employers drop coverage and just pocket the money, or funnel it toward other expenditures.  The state won't be getting any more money to deal with the increased cost.

There will be many lessons learned from this experiment.  It's a major change, and it will give much insight into the "right" and "wrong" ways to reform.  I know we'll all be watching eagerly.

Twenty three years ago on this day...

I was born! 

This year has been particularly transformative, as I discovered my endless well of interest in all things health policy, started this blog to help explore my knowledge, and applied for my first real Adult Jobs. 

I also graduated from college, had major surgery, and lived in three different cities (Santa Cruz, Los Angeles, and Kansas City.  I narrowly missed my fourth, Washington D.C., but I'm hoping to get there in about a month).

It's truly a charmed, blessed life I live, and I'm so glad that you continue to come by and read my insignificant thoughts in this little corner of the internets.  The positive feedback I've received here and at TPM Cafe is a fabulous birthday present.

So here's to another year; I hope it brings lots of learning, and I hope we all keep working toward our ultimate goal in our often short-sighted blogging endeavors -- quality, affordable, and accessible health care for all.  Now that would be a great birthday present...

Adults say we can measure quality, but it doesn't really matter

A new survey flushes out opinions on rating health care quality.  According to the poll, forty-nine percent of U.S. adults believe there are "fair and reliable" methods to measure and compare hospitals' and medical groups' quality of care. 

Well, this bodes badly for those pushing substantial reforms based on better information on prices and quality.

But really, your average U.S. adult has no idea what they're talking about on this issue, so I wouldn't take it too much to heart.  And if they think they have such good indicators of quality already, they probably don't really care about actual stats on quality (i.e. the eyes and ears method), and they won't use new resources for doing so.  The real question is how high these adults judge their current quality of care. 

UMDNJ: Very bad people

This extensive reporting by Health Care Renewal of the problems at UMDNJ makes me very sad. 

Hospitals and price transparency

Tony Chen of Hospital Impact has a good list of why price transparency won't bring the earth shattering changes advocates promise:

(1) 10% of folks make up 70% of costs. and most of them won't be subject to financial incentives, so they won't be shopping too much.
(2) lots of folks just won't have time to shop given healthcare's urgency
(3) for a lot of services that would be very "shoppable" (e.g. a nose job), a face-to-face with the doc to get an estimate is necessary, adding too much work to shop
(4) healthcare just isn't that simple; one size does not fit all; price ranges (very big ones) seem appropriate.
(5) well, the cartoon above says it. oh, and one minor detail, what about quality of care?

I think people really underestimate the quality of care issue.  Who among us doesn't want to absolute best care for their loved ones?  This isn't a race to the bottom, and when life and death is concerned, people aren't thinking about which hospital offers the lowest price for the angioplasty that has to be done right now.   Their choices just aren't rational in this situation; it's not like when I call around to five different tailors asking how much a hem is.  You also enter into a personal relationship with your doctor, and the one offering the lowest price might not give you the most confidence. 

Also, we're big fans of cartoons here at Healthy Policy; head over to Tony's and see the great cartoon attached.

More on the MA bill

Ezra has a great round up of the MA bill, with some thoughtful questions and concerns about the bill's funding. 

Also see Leif Wellington Haase over at the Drug Bill Debacle.

Health Wonk Review: Health Business Blog

David Williams hosts this edition of Health Wonk Review!   Great stuff David.  Head over for the fulfillment of all your wonky needs.