Monday, February 22, 2010

The President’s Health Care Proposal

There is not much I can add that has not already been said today about the White House proposal for health reform. The Kaiser Health News summary is posted here and a nice side-by-side comparison is here.

The indefatigable Ezra Klein summarizes it well over at his blog at WaPo:

But the real story of the bill is as it's always been: This is an effort to build a working health-care system in this country, and though people talk about the bill's complexity, it's really based on four simple elements: hundreds of billions of dollars in subsidies so people can afford insurance; regulations so that insurers can't deny people insurance and create a situation where only the healthy have coverage; a mandate so that people have to purchase insurance and can't create a situation where no one purchases coverage until they're sick; and exchanges so that there's a working market where people can buy their insurance and be confident in the product's quality.

As far as Medicaid is concerned, many of the provisions affect Medicaid in one way or another but the most important piece is that it has the Federal government pay for 100% of Medicaid expansion. That, coupled with some provisions that improve the fairness of the tax system (e.g. Medicare taxes will now be collected on investments and other nonearned income), will actually reduce the Federal deficit over the next 10 years.

These changes, in addition to HHS’ recent rebates (i.e. reduction in “clawback” payments) as highlighted by Health News Florida mean that a significant amount of the recent dire predictions - that states would need to make cuts all the way to the bone regarding social safety net programs - will turn out to ring hollow. ~BAA

Thursday, February 18, 2010

Health Wonk Review: “The Relationship Rescue” edition


Many of the most thoughtful comments one hears in life do not come from books but rather, in passing, from relative strangers. For example, while at a friend’s wedding ten years ago, the father of the groom offered this bit of wisdom, “In a marriage, you can either chose to be right or you can choose to be happy.”

I have to admit that the vast amount of wisdom contained in that little phrase initially escaped me and it only really sunk into my consciousness after about 24 hours of discussion and reflection with my wife.

Our country rises to the occasion when it has an external threat but when external threats don’t exist, we tend to gravitate toward one or more of the seven deadly sins (e.g. article today from the Daily Beast declaring that the U.S. is the laziest developed country in the world).  Even more, when a threat comes from within, eating away like a cancer, the two ends of the political spectrum withdraw behind their “walls,” throw stones at each other, and generally exhibit a very ugly form of American Exceptionalism. The pragmatic middle, which is barely ever heard of in the media except through surveys, has made it clear that it wants Congress to work together to solve real problems.

Watching politics right now is like watching the intimate moments of a dysfunctional relationship. One person groping for the other in a very awkward way and the other disengaged with their back turned and suffering from the imaginary headache. These partners could be Democrats and Republicans or the governing and the governed – it does not matter…all of our political and policy relationships need a relationship rescue.

As Dr. Phil counsels in his Prologue:

This is not about power to take things from people so that you have more for yourself. It’s about the power to give and to lift up those around you.  [Page 3]

Yes, it is hokey and simple but we need to transcend the political rhetoric, the turf protectors, the moneychangers, and the too-smart-by-half people in and around D.C. Remember, smart people created the mess in the first place. Maybe, if we had started with simplicity and self-awareness instead of self-righteousness, health reform would be in a better place right now.  With that said, let’s see how the thoughts of my fellow bloggers support the wise counsel of Dr. Phil.

Chapter One - Its your time; Its your turn

In this Chapter, Dr. Phil starts out with a self-revelation:

My profession’s advise was all well and good if life was an ivory tower…but it did little for those relating in the real world with real problems, real children, real financial demands, real competition for affection, real stress…clearly, pleasant and generic instructions on how to “communicate” better or theoretical musings…about relationships just weren’t going to cut it.  [Page 6]

He goes on to describe how there are very few true victims in the world (i.e. we are all products of our choices) and as I type, I can hear his comment in my head “Well, how’s that working for you?”

As a country, we have to “start getting real” and relative newcomer Brad Wright over at the Wright on Health blog leads us off with his post Doing the Right Thing. In it, he points out that when the 1964 Civil Rights Act was signed by President Johnson, he remarked “I fear that we have lost the South for a generation" and he was right. Brad aptly notes that sometimes leading means putting politics aside and doing the right thing. So true.

At the other end of the accountability scale, we have a nice post from Joe Paduda over at Managed Care Matters titled Have their cake, eat it too, and have someone else pay for their gluttony. He finishes with one of my favorite quotes from HL Mencken that “People deserve the government they get, and they deserve to get it good and hard.” Dr. Phil would applaud the sentiment.

It appears that all of us need a little self-reflection to confront the harsh realities of our relationships - even Kermit the Frog.

Chapter Two – Defining the problem

In this Chapter, Dr. Phil advises us to accurately diagnosis the problems with our relationships:

The worst thing you can do is to draw faulty conclusions about the cause-and-effect aspects of the problems in your relationship. To rescue your relationship, your job is not only to thoroughly and accurately diagnose what it is that needs to change, but then implement the correct intervention strategies that will make change happen.  [Page 24]


DrPhilBrad Wright contributes again with his post, Newsflash: Health Care Is Too Expensive, where he explains that the problem is costs and he states “anything that is done to fix the economy will see its gains unraveled in the near future if we don't also fix health care.” Included in Brad’s post is a link to an excellent interview Ezra Klein had with Rep. Paul Ryan (R-WI). The best quote from Rep. Paul was “…if Ron Wyden and I were in a room, we could hammer out a deal by tomorrow.”

Speaking of costly, the 39 percent rate hike proposed by Anthem Blue Cross of California for their individual policies due to ‘adverse selection’ and the response from the Secretary of HHS was a hot topic this past week and is reflected in a post by Bob Vineyard at Insureblog. In it, he states:

Seems to me it is evidence that Blue is doing something right. In contrast, the folks in Washington can't balance a budget. So who are they to be giving financial advice on how to run a company?

Coming at the same issue from a different angle, Anthony Wright posts How to Beat the Blues at The New Republic where he lists the five specific ways that the current health reform legislation would help consumers (and insurers) slow down and stabilize premiums. 

Over at the newcomer health AGEnda blog, Chris Langston reminds us in his post, Why We (Fight) Write, that the country’s health system ranks thirty-seventh (37th) in the world and is even worse when it comes to the care of the elderly. He notes that:

Even though Americans are becoming increasingly aware of the need to improve care for people with chronic disease, the fact that chronic disease, and particularly multiple chronic disease, is disproportionately a problem of older adults seems lost on most people and even many health care professionals. 


Thank goodness for Tom Lynch et al at Workers Comp Insider’ because that part of the health care system is even more opaque than the rest. In his post, The Medicare Secondary Payer Statute: In Search of Ariadne’s Thread, Tom points out that Workers’ compensation medical care is now getting whipsawed by two powerful and unstoppable forces: the Medicare Secondary Payer Statute (MSP) and the inexorable aging of the baby boomer generation and he goes on to compare MSP to the 50s horror movie The Blob. Now that’s an indelible image.


Over at the Incidental Economist, a guest post by J. Michael McWilliams titled Letting Perfect be the Enemy of Good? takes issue with a recent article in Atlantic Monthly that questions the accepted relationship of insurance with mortality and morbidity. He asks:

How many lives would universal coverage save each year?  A rigorous body of research tells us the answer is many, probably thousands if not tens of thousands.  Short of the perfect study, however, we will never know the exact number.  In the meantime, we can let perfect be the enemy of good.  Or we can recognize the evidence to date is sufficiently robust for policymakers to proceed confidently with health care reforms that promise substantial health and financial benefits for millions of uninsured Americans.


phil_imageAnd no “keeping it real” conversation would be complete without a post from Roy Poses over at Health Care Renewal. In it, he continues to rightly question the cushy and unaccountable world of health care executives. He cites the specific example of the recently fired CEO of Kansas City University of Medicine and Biosciences and he wonders aloud “why should anyone wonder why health care is so costly, inaccessible, and mediocre when its leadership seems so ill-informed, ethically challenged, and devoted to self-interest?” Now, tell us how you really feel, Dr. Poses…

Chapter Three – Blowing up myths

In this Chapter, Dr. Phil advises us to throw out much of what we have learned about relationships:

There are rules that, at face value, sound pretty logical – and you naturally come to believe that if you’re not following them, then you’re screwing up. But that would have been your first warning sign: logic, right? Applying logic to the emotions of love and romance doesn’t work. [Page 46]

The number one myth that should be blown out of the water is that health care is a marketplace. Yes, as Rep. Ryan points out in the interview above, there are pockets that act like markets but all-in-all, health care does not act like a market and as long as we have a shared public/private system, it will stay this way.

In a post by Jay Norris over at the Colorado Health Insurance Insider, he blows up the myth that anyone should listen to Rush Limbaugh when it comes to health care, especially when he advises listeners to go without health insurance. Jay’s post reminded me of a segment on the Daily Show where they profiled the care Mr. Limbaugh received from Hawaii’s universal health care system (go to 2:58 in video). 

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Another myth that should be disposed with is that greedy health insurers are the root of all evil. Sure, they play a role but so do providers.

Here at Medicaid First Aid, in a post titled Squeezing the Balloon on All Sides (the provider vs insurer smack-down), I discuss the new report  commissioned by the Massachusetts attorney general's office, which concludes that differences in hospital prices in that state aren't correlated to quality of care….or anything else for that matter, except for market leverage. As a solution, I discussed Maryland’s unique payment system for acute hospitals and tee up an analysis much more comprehensive than mine over at Maggie Mahar’s Healthbeat (see here, here, and here for her three part series).

David Harlow, over at Healthblawg, analyzes the same report in his post and tries to place it in the greater context of Massachusetts politics:

…Governor Deval Patrick seems to be distracted by health reform's implications for his political future.  Instead of waiting for a reasoned outcome of the deliberative process set in motion two years ago (well, as reasoned as possible, given the heavy-duty political and economic interests at stake here), he has leapt into the fray with what looks like an ill-conceived bit of political grandstanding: a bill that would give the state insurance commissioner the authority to cap health care price increases.   

Chapter Four – Eliminating your bad spirit

In this Chapter, Dr. Phil advises us not to let our inner demons sabotage our relationship.

Every one of us has an irrational and destructive emotional side to our personalities. There is a part of each of us that is immature, selfish, controlling, and power-seeking…Just as you can send your down a dead-end road by falling for myths that are misleading or unimportant, you will send your relationship right over the cliff if you start letting your bad spirit – your dark side – sabotage your attempts at intimacy and peace. [Page 76]

Well, no posts came in for this topic so instead, I will list some of Dr. Phil’s list of destructive behaviors:

  • You’re a scorekeeper
  • You’re a fault finder
  • Your way or the highway
  • You turn into an attack dog
  • You are a passive warmonger
  • You resort to smoke and mirrors
  • You will not forgive

Chapter Five – Reclaiming your core

drphil1 In this Chapter, Dr. Phil puts the period at the end of the self-help sentence when he says “If you aren’t constructively contributing to your relationship, then you are destructively contaminating it.” He goes on to say, among other things, that you have to own your relationship, show some vulnerability, focus on friendship, make yourself happy rather than right, and transcend turmoil. Easy right?

Chapter Six – The Formula for success

In this Chapter, Dr. Phil puts the analysis into action.  He states:

there are no quick fixes for relationships: that’s just one more myth that has led so many people down the wrong road. Make no mistake. If you really want different results from your relationship, then you are going to have to devote meaningful and substantial time and effort to it.  [Page 146]

Our bloggers also proposed some variables and formulas for success.

Over at the Health Affairs blog, they included a professional and informational dialogue (see here, here, and here) on the provisions of the Senate-passed health reform legislation concerning workplace wellness programs. The back and forth between HWR regular Dr. Jaan Sidorov and Alan Balch highlighted the opportunities for workplace wellness programs to both help and potentially harm employees.

To me, anything that aligns incentives is a good thing but I share Mr. Balch’s concerns that it is a slippery slope from workplace wellness incentives to workplace discrimination.

Furthermore, I understand the acceptance of employer-based insurance. People like that their employers do most of the heavy lifting and that they do not worry about pre-existing conditions. I get that but feel that the negatives of continuing an employer-based system outweigh the positives of moving to some sort of voucher system like that proposed in the Wyden-Bennett bill.

This is because people do not tend to stay at jobs long enough for employers and insurers to reap the return on their wellness investments and the system hinders the flow of human resources to where they achieve their greatest value.   In a Time magazine article last year profiling the worker of the future, it pointed out that the traditional employee-employer relationship was changing, that more and more knowledge workers will become “independent contractors,” and that this change will provide additional flexibility to companies and workers that will, in turn, grow the economy and improve worker satisfaction. My question is “how does an employer-based system support this economic shift?”  The answer is, “it doesn’t.”

Over at the Users Guide to the Health Reform Galaxy, Bruce Siegel, director of the RWJ’s Aligning Forces for Quality initiative recounts in his post how a big health care purchaser applied its considerable leverage to insist on public reports about hospital performance and how this increase in expectations and transparency has made an impact. It has also implemented value-based insurance design. How much impact did it have? Ted Rooney, the project director for Aligning Forces for Quality in Maine, offers this assessment: “When the state of Maine started to tier primary-care practices in 2007 based on quality, it put the whole system on steroids.”

The AF4Q initiative is truly, one of the brightest beacons of light in health care improvement and works primarily because it sets high expectations and builds strong relationships.  

Jason Shafrin over at the Healthcare Economist offers up his post, Did Pay-for-Performance work in the UK? In 2004, the “socialist” National Health Service of the UK adopted a P4P program entitled the Quality and Outcomes Framework (QOF). Jason highlights a recent research paper that claims the QOF improved health care outcomes without sacrificing quality of care in the areas of care that were not measured (a common criticism of poorly designed P4P programs).

From John Goodman’s Health Policy Blog, we have a post that offers us the John Goodman / Newt Gingrich framework for health care reform. Though some of framework reads like the talking points of a particular party, neither political party has a monopoly on good ideas and this framework is a good starting point for a reconciliation (no, not that reconciliation, the other one).

Speaking of reconciliation, that is a perfect lead-in to our last Chapter.

Chapter Seven – Reconnecting with your partner

iStock_000003169694XSmall-1 From Dr. Phil:

So far everything you’ve done has been intrapersonal, or completely within you. But now it’s time to go interactive. It’s time to bring in your partner. And that means it’s time for you to become a leader.

And that brings me to one of my favorite posters, Dr. Jaan Sidorov, with the perfect closing post titled The February 25th Healthcare Summit: Time for Yes We Will. He points out that:

This could turn out to be grand political theater at its dysfunctional finest. Yet, while the DMCB is fed up with all the Machiavellism, it thinks the Feb. 25 meeting is a necessary evil. It could turn out to be the dark before the dawn - the cloud behind the silver lining…So, watch the Feb. 25 meeting. If there are no plans to a) continue meetings b) in a televised manner, the DMCB will fear that health reform will truly remain in disarray. If there are plans for additional meetings and they fall off the news-cycle radar screen, we may have a chance at actually accomplishing something. This is how we'll know if the Obama Administration is stuck in campaign mode or is really interested in serious policy accomplishments.

And with that, I bid adieu. The next Health Wonk Review will be hosted on March 4th by Brad Wright at Wright on Health.

P.S. Don’t tell my wife I read parts of Dr. Phil’s book for this post, she might actually expect me to follow it. Thanks. ~BAA

Thursday, February 4, 2010

Health Wonk Review: Sleeping Beauty Edition (02/04/10)

sleeping_beauty_4The newest edition of the Health Wonk Review is hosted by Joe Paduda over at Managed Care Matters. For those of you that don’t know, Joe is one of the best bloggers around and was one of my early inspirations.

Anyone who says that, as a society, we can not have a civil discourse featuring differences of opinion and anger management should just read Joe’s edition. Maybe there is hope for us yet.

Speaking of slumber, it is good that I awoke from mine because the next edition of HWR is hosted by yours truly in a fortnight. Enjoy. ~BAA

Squeezing the Balloon on All Sides (the provider vs insurer smack-down)

DSCF1778After going back and reading my last post, I realized that my statement that Congress’ intent to repeal of health insurer’s anti-trust exemption was “much a-do about nothing” needed some clarification. I had planned to write a long narrative on the topic but thankfully, the St. Louis Dispatch and some fellow bloggers saved me some typing with their timely insight.

As an appetizer, the Dispatch’s article titled “Paying for Quality Health Care, But Not Getting It,” states:

A new report commissioned by the Massachusetts attorney general's office concludes that differences in hospital prices in that state aren't correlated to quality of care. They don't correlate with the severity of patients’ illnesses, or how many Medicaid and Medicare patients a hospital treats.

Price differences aren't even correlated with hospital costs, the report found. Facilities with the highest costs aren't necessarily those with the highest prices.

So what explains hospital price variations? Market leverage. Hospitals that had the most clout in the marketplace were able to charge the highest prices. And they did.

For the main course, Maggie Mahar has an excellent analysis over at the Health Beat blog (complete with a link to the Massachusetts report). And for desert, Austin Frakt has an excellent post, “Antitrust and Health Reform,”  over at the Incidental Economist blog.

In Maggie’s post, she rightly points out that today, we have behemoths (providers and insurers) battling it out through contract negotiations (hence, the rock’em sock’em robots in the picture). Many of these behemoths have near monopoly power in their geographic area and by weakening one side of the equation, the system will be out of balance. And when the system is out of balance – we all pay. So, what do we do?

Image10_thumb[3]Well, what we need to do is to squeeze the balloon on all sides. If we weaken one side, we also need to make sure the other side does not take advantage of this fact. This is exactly what they did in the State of Maryland.

Fun fact: Maryland is the only state where Medicare makes payments to acute-care hospitals at a rate other than the normal Medicare rate.

From Maggie’s post:

In Maryland, hospital prices have been regulated since 1977. An independent agency sets rates for all patients, including Medicare beneficiaries, at Maryland’s acute-care hospitals.

Adjustments are made for hospitals located in cities where the cost of labor is higher, as well as for hospitals that care for sicker patients and/or train medical students.

Private insurers, Medicare and Medicaid all must pay the prices set by the commission. Medicaid cannot underpay hospitals—and private insurers cannot over pay, or negotiate side deals and discounts with certain hospitals while paying others a premium for their brand name. Hospitals also cannot charge uninsured patients more.

In 1976, before regulation began, Maryland hospital costs were paid 25% more per case than the national average. By 2007 Maryland's costs were 2% less than the national average. And , according to a recent article in the Wall Street Journal Maryland’s hospitals are seeing small, but predictable profit margins.

Go figure, a standard rate for a procedure regardless of who pays the claim. This simplicity and transparency is refreshing. Yes, “price controls” are counter-intuitive to basic economic sense but as we have stated before, health care is not a well functioning market. Some hospitals in Maryland do not like the system because they feel it constrains their growth but all-in-all, the model works and has been in place for over 30 years. Let providers and insurers focus less on price negotiations and more on quality of care. That said, the only thing I would add to the Maryland model would be incentives for quality and the achievement of local public health objectives.

Maybe the various states dealing with serious budget shortfalls or access issues should give the Maryland model some consideration. The model may cause some shrinkage in hospital growth (i.e. jobs) but the price stability and improved business climate will lead to expansion of the other parts of the economy. ~BAA

Tuesday, February 2, 2010

Killed with a Smile

It is good to be back from hiatus (even my children grew tired of seeing Mr. Krabs at the top of the page). A lot (or nothing - depending on how one counts) has happened since my last post, which is part of the reason I needed a break.

Being an analytical and policy person by nature as well as an optimist, I tend to look for solutions to real problems and try to move the ball forward, so to speak. But the whole health reform effort crossed a line with me and started tugging at my emotions as opposed to my intellect.

It all got me thinking back to the video below, which I originally saw on the show Planet Earth (one of the reasons I got an HD television). In the video, the male bird does the most amazing dance with the most amazing plumage I have ever seen (look for the smiley face).  I kept having that video pop in my head every time a congressional or health industry leader pointed to why they should be treated differently. Or every time a state senator talked about sedition or stood by at check signings for things they did not support. Since when did we become a country of whiners and posers? How can Congress expect providers to work together in interdisciplinary teams and accountable care organizations if it is unwilling to do the same?

Yes, I know I am beating my head against a wall because this is the way things work in DC and state capitals, but that does not make it right.  And I believe this feeling permeates the country, albeit from different angles.

Personally, I support many of the provisions in the various health reform bills. Truth is, 75 to 80% of the bills are not really debatable and have been supported by both sides of the aisle at one time or another.  But leaders and the media flubbed on communicating what was actually in the bills and how they would affect normal people (kudos to other  bloggers, KFF, NPR, and Health News Florida for trying to fill this void). Add that to the fact that for every good provision, there seemed to be a cockamamey proposal that sucked all the oxygen out of the room. For example, the anti-fraud provisions added in the recent manager’s amendment are a major move forward to streamline and solidify the government’s efforts to deter fraud. Nobody every heard about them. What they did hear about was the other item Senator Leahy worked on, abolishing the anti-trust exemption for health insurers. Problem is, repealing the anti-trust exemption for health insurers will do nothing to improve care and will probably increase costs. It is one of those things that everyone hears about because it makes intuitive sense but healthcare is not intuitive because it not a marketplace.

Same goes for the Republican proposal to sell insurance across state lines. Sounds great right? Problem is, we’ve seen this before with credit cards and corporations where companies flock to the state with the most lax standards. Is that what we really want? I don’t think so. Oh, and did anybody even mention that the Bill passed by the Democratic Senate will allow insurance to be sold across state lines, either in regional compacts or based on meeting a nationwide standard? Nope.

But it is comforting to know that Congressional leaders are considering a method of paying for reform first proposed by Merrill Goozner and myself on the same day last August that actually improves the fairness of the current tax system. But that is cold comfort given the current state of affairs.

Will health reform survive? I do not know. Should it? Yes, but I have to admit there are many times I wish we had started from the center with a bipartisan proposal like the Wyden-Bennett bill but that is a post for another day this week. I have always tried to be true to the saying, he/she governs best who governs from the middle. Maybe it is time for Congress to do the same. ~BAA

Thursday, October 15, 2009

What we can learn from Mr. Krabs


Anyone who has young children is familiar with Sponge Bob Square Pants. Well, one of the recent episodes touched on health reform (apologies to hospital administrators everywhere) and is too good not to share. Enjoy the video below. ~BAA


Health Wonk Review: the Lean, Mean, and Clean edition (10/15/2009)

Hank Stern hosts the current edition of the HWR over at Insure Blog. Go take a look at the newest health policy posts from the blogosphere. ~BAA