I’ve been on vacation since a few days before Christmas, and am taking a break from writing the blog. I hope you’ve enjoyed the posts I wrote and scheduled to go up all this week, but the next week or so are going to be marked by radio silence. I’m actually contemplating a move to a different blogging platform for the new year. Stay tuned for details and enjoy the rest of 2011 and the start of 2012!
Monthly Archives: December 2011
Ryan-Wyden Reflective of Western Approach to Medicine
By now, it’s old news that Republican Congressman Paul Ryan has worked with Democratic Senator Ron Wyden to draft a bipartisan plan to “fix” the Medicare program. What is being proposed, essentially, is a system of “premium support”–the federal government would make fixed contributions to offset the costs of seniors purchasing insurance from an exchange of private plans, while the traditional Medicare fee-for-service program would remain an option for those who wanted to remain in it.
If this sounds a lot like the Affordable Care Act with a public option included, it’s because it is. If that didn’t fly before, why would it be seen as the ideal way forward for saving Medicare? It’s simple, the Democrats envisioned such a plan as a way of moving the health care system towards a system of managed competition or even single payer, while the GOP sees this as a way of moving Medicare away from single payer to a system of managed competition or even traditional private coverage. The problem is that, while it may mask some of the problem, it won’t solve it.
In Western medicine, there seems to be much more emphasis on treating symptoms rather than preventing or curing disease, and this, in my opinion, is the same approach taken by Ryan-Wyden. In theory, injecting competition into the Medicare market should treat the symptom of high health care costs. The problem, however, is that it won’t work. The symptom is a result of the underlying design of the health care system, by which I mean “fee-for-service reimbursement by third-party payers.” There is a mountain of evidence pointing to the fact that a single-payer system, in which the payer has no intention of generating a profit, is the least expensive option for the design of a health care system. Moreover, there is ample evidence that capitation or global budgeting is far less costly than fee-for-service. Those are the elements that need to be introduced into the health care system to start cutting health care costs. Moving Medicare from single-payer towards an exchange of private payers will make it more, not less, difficult to make those changes. Without addressing the underlying “disease,” we will have no choice but to seek out new compromises in an attempt to treat the “symptoms” or else be left to suffer with them.
When will we ever be free of the dreaded “R” word in health care? Will we ever accept that we can’t have our cake and eat it too? I’ve written about rationing many times before. Today, I want to share with you the words of Dr. Don Berwick, outgoing director of the Centers for Medicare and Medicaid Services. In a speech at the Institute for Healthcare Improvement National Forum on December 7, 2011, Dr. Berwick had this to say:
“Inscribed on the wall of the great hall at the entrance to the Hubert Humphrey Building, the HHS Headquarters in Washington where my office was, is a quotation from Senator Humphrey at the building’s dedication ceremony on November 4, 1977. It says: ‘The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.’
I believe that. Indeed, I think that Senator Humphrey described the moral test, not just of government, but of a nation. This is a time of great strain in America; uncertainty abounds. With uncertainty comes fear, and with fear comes withdrawal. We can climb into our bunkers, each separately, and bar the door. But, remember, millions of Americans don’t have a bunker to climb into–they have no place to hide. For many of them, indeed, the crisis of economic security that we all dread now is no crisis at all–it is their status quo. The Great Recession is just their normal life….
Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys….If you really want to talk about ‘death panels,’ let’s think about what happens if we cut back programs of needed, life-saving care for Medicaid beneficiaries and other poor people in America. What happens in a nation willing to say to a senior citizen of marginal income, ‘I am sorry you cannot afford your medicines, but you are on your own?’ What happens if we choose to defund our nation’s investments in preventive medicine and community health, condemning a generation to avoidable risks and unseen toxins? Maybe a real death panel is a group of people who tell health care insurers that it is OK to take insurance away from people because they are sick or are at risk for becoming sick….
And, while we are at it, what about ‘rationing?’ The distorted and demagogic use of that term is another travesty in our public debate….The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry ‘foul’ about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people–elders, the poor, the disabled–who are least able to bear them. When the 17 million American children who live in poverty cannot get the immunizations and blood tests they need, that is rationing. When disabled Americans lack the help to keep them out of institutions and in their homes and living independently, that is rationing. When tens of thousands of Medicaid beneficiaries are thrown out of coverage, and when millions of seniors are threatened with the withdrawal of preventive care or cannot afford their medications, and when every single one of us lives under the Sword of Damocles that, if we get sick, we lose health insurance, that is rationing. And it is beneath us as a great nation to allow that to happen.”
Why don’t you ponder that over the next few days, and have a Merry Christmas!
Last Health Wonk Review of 2011
The last Health Wonk Review of 2011 is up at the blog “Health News Watchdog.” It’s their first time hosting, and they did a great job. (And I’m not just saying that because my post is included.) Here’s the link.
ObamaCare Keeps Working
When the Census Bureau released the latest numbers on insurance coverage, I wrote a post to highlight that nearly 500,000 young adults went from being uninsured to having insurance. An excerpt from that post actually got picked up by Jonathan Cohn at TNR. Now there’s more evidence that ObamaCare is working for both young and old Americans. The Department of Health and Human Services recently announced that, in fact, more than 2.5 million Americans between the ages of 19 and 25 were covered by their parents’ health insurance in the first half of 2011. That’s not surprising given that the Affordable Care Act included a provision that allows those under age 26 to remain on their parents’ coverage.
And the good news isn’t just for twenty-somethings. Early data show that America’s seniors are also benefiting from the Affordable Care Act. How you ask? Well, one of the first provisions enacted targeted the Medicare Part D “donut hole.” Part D is the program that provides prescription drug coverage for Medicare beneficiaries, and it was designed with a giant gap in coverage right where people needed it most. (As an aside, that was done for purely political reasons, to keep the price tag a little lower on the legislation when it was being debated on Capitol Hill.) Well, ObamaCare didn’t completely eliminate the donut hole, but it did shrink it, by reducing the proportion of costs the beneficiary is responsible for. The result? Nearly 2.7 million older Americans saved an average of $569 each on their prescription drugs through October 2011. Moreover, some 24 million Medicare beneficiaries received free preventive care. This is good news served with a side of good news.
It’s true that health reform is still very much in the process of being implemented. My glasses are not so rose-colored as to expect that every element of the law will be a success. Some things won’t work, and will need to be retooled or abandoned. But some things, as these developments underscore, will be successful, and when that happens, it should be roundly acknowledged.
Americans Must Be Bad With Fractions
Americans seem to have a problem with fractions. As in, they don’t appear to grasp how they work. That’s the conclusion I’ve finally reached after noticing a striking trend among public opinion polls in which Americans like the parts of something, but dislike the whole. The only way that one can hold such a position, it seems to me, is if one is unclear that the parts together compose the whole. With fractions, we understand that 2/8 + 1/4 + 1/2 = 1, but the logic doesn’t appear to hold elsewhere.
For example, consider the Affordable Care Act. When polled, the public strongly supported the individual components of the law. Asked to consider the law as a whole, though, and supported dropped off significantly. It’s a bit confusing, isn’t it? They might as well say “I love crust, cheese, tomato sauce, and pepperoni, but don’t you go putting it all together and trying to shove a slice of pizza down my throat.”
We see the same hard to reconcile pattern in Congressional approval ratings. The current approval rating for Congress is the lowest it’s ever been at an abysmal 13%. Asked to consider whether most incumbents deserved to be re-elected, the answer was another all-time-low: 20% said yes. In other words, very few of us approve of Congress as a whole. But the parts? Well that’s a different story. Asked to consider whether the incumbent in their district deserved to be re-elected, the answer was much higher: 53% said yes. Folks, those numbers just don’t add up. It’s time we realized that it’s impossible for everyone to be above average.
The parts necessarily make up the whole. That’s why fractions have denominators. If you, and more than half of everyone else, thinks that your (or their) member of Congress deserves to be re-elected, then the chances are pretty good that they will be. This explains why we keep voting the same people to another term, and yet we act surprised when the result is more polarization and less progress. It’s why we like all of the provisions of health reform, but oppose the law that would implement them, and then wonder why we continue to pay more and more for our health care. We need to understand the part we play in the way things are. If we don’t like the big picture, we need to stop assuming that we’re not the problem, and start figuring out how to fix it.
Wasting Money At the End of Life?
Peter Bach is a physician with a recent op-ed appearing in the New York Times. Dr. Bach’s piece about whether or not end-of-life health care spending is wasteful is compelling. I recommend you read his essay, but I want to hit some of the high points.
The first is that we may be making an error based on hindsight. Precisely because hindsight is 20/20, we can fall into the trap of evaluating health care decisions after the outcome is known, which is not how health care decisions are actually made. So, as Dr. Bach stresses, a tremendous amount of health care spending may be deemed warranted if it saves the life of the patient, but the same spending would be labeled wasteful if the patient dies. This is an excellent point.
Other points Dr. Bach makes relate to supposed sources of bias. For example, sick people need more health care (which costs more money) and are also more likely to die. Ergo, the link between health care spending and death is likely to be positive, but the reality is that health status is the common denominator. He also laments the fact that data on end-of-life spending is much more readily available than data on other types of health care spending. That’s also a pretty accurate assertion.
It’s in his concluding remarks that Dr. Bach gets to the real matter at hand: We don’t know who is going to benefit and who isn’t. In his essay, he describes how he saved someone’s life. As it turns out, the condition that person had is fatal in about 1 of every 8 cases. In other words, paying to intervene for that condition seems like a good bet. If, on the other hand, only 1 out of 8 people with the condition survived, it might be a tougher sell. Of course, what that scenario underscores is that the overall costs and benefits are important to understand, but so are the individual risks and benefits. For example, if you have the condition, you are probably hoping that you are the 1 person who will survive after receiving the intervention, not counting on your being 1 of the other 7.
Research that can help us understand not only which procedures are generally more effective than others, but also who the 1 person who loses or benefits (given the two scenarios above) will be, are the next frontier in improving the health care system–cutting costs without harming quality. Of course, this type of research will bring accusations of “death panels” back out of the woodwork. I just hope few people will actually take such things seriously, so that the necessary work can proceed. Without it, I’m not sure that there’s much hope.
Using Medicare Data to Rate Physician Quality
Last week, the federal government announced that it would allow Medicare claims data to be used for the purpose of disseminating physician quality information to the public. What’s news is not that there will be attempts at creating so-called quality “report cards”–attempts at those have been around for some time–rather it’s that the Centers for Medicare & Medicaid Services (CMS) has finally agreed to let a wide range of folks access Medicare claims data for the purpose, which hasn’t happened before on this level.
But what are we to make of this new development? Is it a good thing or not? Giving the “consumer” more information on which to base their selection of a physician and their use of health care services seems like a good thing. After all, it’s essentially central to the idea of a well-functioning free market. As any health economist will tell you, the information asymmetry between consumers and providers leads to all sorts of peculiarities that cause the health care market not to behave like the market for other goods and services. This could then conceivably be a step in the direction of correcting some of those peculiarities.
The real question, though, is how good will this information be? Or, said another way, is poor information preferable to no information? Now, that doesn’t mean that there’s not a lot of excellent potential in these Medicare claims data. On the contrary, there’s much to be learned here. Of course, the realization of that potential is a function of the empirical rigor of the analyses researchers like myself undertake. No, the real worry I have is how this translates to the lay public without grossly oversimplifying things.
Let’s say a system is devised that, in true “report card” fashion, assigns physicians a grade ranging from “A” for outstanding to “F” for visit at your own risk. The public would certainly understand such a grading system, and people would be expected to show a clear preference for “A”-rated physicians over “F”-rated ones, but what about the bulk of physicians in the “B” and “C” range? It’s entirely possible, depending on the rating algorithm used, that a physician who excels in one particular area nevertheless gets a “C” rating. Would the public do its homework, or would it avoid doctor “C”? I worry that the latter may be the most likely outcome.
Again, I’m not saying that efforts to monitor quality and report that information publicly are a bad idea. Far from it. I’m merely suggesting that we must be extremely thoughtful in how we engage in such efforts, because the potential for significant unintended consequences is quite real. We must figure out how to approach these data using the most sophisticated of techniques, all the while with an eye on translating what we find in a manner that is accessible to the public without being “watered down” or less than accurate. The risks and the rewards are great.
Health Wonk Review: Holiday Shopping Guide
At the Wal-Mart in Seekonk, Massachusetts near my home, the Christmas decorations went up before the last of the Halloween candy was sold. It was almost as if they’d forgotten about Thanksgiving altogether. Then “Black Friday” came, and it was clear that the significance of Thanksgiving was to delineate the pre-game warm-up from the official start of the holiday shopping season. People camped out in advance for the best bargains, mobbed each other before sunrise, and proudly carried home their treasure. Then, no sooner than Black Friday was over, we had “Small Business Saturday” and “Cyber Monday” on its heels, encouraging us to “buy local” and “buy online,” respectively. But, if you’re like me, you still have loads of shopping left to do, and we all know that it can be extremely difficult to find the perfect gift for that special someone on your list. In that spirit, I’ve taken it upon myself to create the Health Wonk Review Holiday Shopping Guide. With the best of the health policy blogosphere represented, you’re sure to find something for everyone on your list, from your drunk uncle to your wonk-in-law.
First off, just about everyone on your list is bound to be concerned with the topic of Maggie Mahar’s post “How Health Care Reform Can Create Jobs and Cut Costs.” She explains how health care reform provides funding for nurse practitioners,community health workers, nurse mid-wives and other health care professionals who are very well-trained to do some of the things that doctors do–at a lower cost. In fact, she highlights some research suggesting that such a shift has the potential to improve quality as well. (As an aside, Maggie recently left The Century Foundation, and is no longer writing HealthBeat, though she continues to write about healthcare on other websites.)
Of course, many of you know somebody who wants nothing more than for the Affordable Care Act to be repealed by Congress or overturned by the Supreme Court. I’d recommend that you send them Joe Paduda’s article “Repealing Health Reform 20-20-20” from the Managed Care Matters blog which explains what will happen without reform. Newsflash: It ain’t good. If health reform is overturned, 20% of Americans may be without coverage in 2020, yet we’ll be spending 20% of our GDP on health care.
If reform does go forward as planned, the Colorado Health Insurance Insider’s Louise wonders if large self-insured groups will restructure their benefits to steer unhealthy employees into the health insurance exchanges. If that happens, it could lead to a death spiral that unravels the entire system. It’s hard to tell the future, but for the person on your list who enjoys reading suspenseful novels or happens to suffer from an anxiety disorder, they could have a lot of fun with this post.
President Obama’s job is pretty tough, so I’m sure he’d appreciate a little something from you this time of year. Especially after receiving the open letter “Dear Mr. President” from Dr. Kerry Willis who gives the President some suggestions on how to save money and increase the value to the system of providing medical care at the Healthcare Talent Transformation blog.
You’re going to want to impress your boss, so why not send them some research and commentary from the fine folks at Health Affairs? In “Implementing Bundled Payment: No Pain, No Gain?”, author Emma Dolan describes the progress that has been made in overcoming challenges to implementing bundled payment arrangements. Her post responds to a November Health Affairs journal article by researchers from RAND and Harvard that highlighted some of the difficulties encountered in implementing the Prometheus bundled payment initiative of the Health Care Incentives Imrprovement Institute.
If you have family or friends in Florida (and who doesn’t?), they might like to know about supporters and opponents of Florida’s push to control its opioid problem, which Jon Coppelman of Workers’ Comp Insider talks about in the post “Opioid Abuse in Florida: Who Controls Controlled Substances?”
For the sports fan on your list, there’s Gary Schwitzer’s article at the Health News Watchdog blog. Schwitzer
And what’s health care without corruption? At Health Care Renewal, Roy Poses writes about an ecological country-level analysis that showed that perceived corruption levels predict country’s levels of child (under age 5) mortality, controlled for other known mortality predictors. Health care and other forms of corruption may kill, at least indirectly. Poses uses the study to highlight the need for true health reform to enable research on, education about, and advocacy against health care corruption, instead of dismissing it as just recent unpleasantness. If you have a beloved cynic on your list, send them to Roy’s post on how “Corruption Kills.”
Lastly, for the skeptic on your list, who–despite your sending them the “We’re #37” video repeatedly–thinks that the American health care system is the best there is, why not send them John Goodman’s latest piece “Do We Really Spend More and Get Less?” from the National Center for Policy Analysis? While I can’t say I agree, Goodman lays out an interesting argument that suggests that the U.S. isn’t really doing that bad vis-a-vis other developed nations. And, if that doesn’t do it for them, then might I suggest Avik Roy’s carefully reasoned explanation of “The Myth of Americans’ Poor Life Expectancy,” which I do tend to agree with.
Well, that’s it for now. There will only be three shopping days ’til Christmas when Gary Schwitzer hosts the next edition of Health Wonk Review over at the Health News Review Blog. Until then, best of luck finding something for everyone on your list!
Will We Get to Watch the Supremes on TV?
The Supreme Court is a fancy place. They do things with a strong sense of tradition and that most definitely applies to how they hand down their opinions and what information is made available to the public. It is relatively recently that they began releasing time-delayed audio recordings of oral arguments. Television cameras remain a no-no. I suppose the idea is that they want to be able to hear cases and deliberate without feeling scrutinized. Introducing the real-time effect of television could produce some sort of Hawthorne Effect. If the Justices know that America’s watching, perhaps they’re worried that they’ll rule differently than they otherwise would.
I have mixed feelings about this. On the one hand, I believe in preserving traditional institutions, and I don’t think that anything and everything needs to be televised. On the other hand, the outcome of this case has the potential to affect many Americans who are unlikely to ever read a majority opinion from the Court, but would certainly catch snippets on the tube.
Perhaps that’s why so many groups are asking the Court to allow television cameras in the courtroom for the first time. There’s the Association of Health Care Journalists, C-SPAN, the Radio Television Digital News Association, the New York Times, and most interestingly, Iowa Republican Sen. Chuck Grassley. My hunch is that their requests will be denied, but I hope I’m wrong, because I’d watch this case around the clock like it was the Casey Anthony trial.