Thursday, October 1, 2009

Health Wonk Review – The Boys (and Girls) of October Edition

Boys of October 1975Health policy is a funny thing. Since major health reform passes about once a generation and since it is so personal, it often conjures up spirits of the past. For me, one of those spirits is the 1975 Boston Red Sox.

For those who did not live through the 1970s, let me set the stage from Doug Hornig’s intro to The Boys of October, “in the summer of 1975, the nation was exhausted, adrift, in the doldrums. A palpable “malaise,” as Jimmy Carter would later describe it, had settled over the land like a cloud of noxious, yellow industrial smog.

2007_1026_0001_carl_yastrzemski_77_1080The intro goes on to describe how the nation was reeling from the sight of helicopters leaving the embassy in Vietnam with people desperately clinging to their struts, the abuses of the Nixon Administration, and an economy in a seemingly never-ending recession. Thankfully, I was young enough in 1975 that I did not deal with these difficulties personally and I only have vague memories of the TV reports but I do remember one thing starkly – the 1975 Boston Red Sox.

I do not pay much attention to baseball anymore as the game has lost much of its luster but back in the 70s, I knew the stats for just about every player as baseball trading cards were as hot then as Pokémon cards are for children today.

jim-rice-77The Red Sox team was an interesting mix of players from different eras and different backgrounds. On the one hand, they had grizzled veterans Carlton Fisk and Carl Yastrzemski and on the other, they had promising youngsters Fred Lynn and Jim Rice, and then they had the unique “Son of Havana,” starting pitcher Luis Tiant. They were a hodge-podge of players who were gathered to try and excise the 50 year curse of the Bambino. The thing that was special about this particular team is best described by Hornig’s subtitle, “the 1975 Boston Red Sox Embodied Baseball’s Ideals – and Restored our Spirits.”

Currently, our country is dealing with similar, yet different challenges as 1975. But one thing is the same - we can use an example of people coming together for the greater good in a way that can inspire the country. We need something, hopefully meaningful health reform, to pull us out of our “doldrums.”  

Now, with that little bit of history as a set-up and in honor of the impending 2009 playoffs, let’s so how our various posts fare in a hypothetical American League pennant race.

AL EAST (posts on significant parts of current health reform bills) 

Jason Shafrin of The Healthcare Economist – Jason evaluates the Chairman’s Mark put forth by Senator Baucus and states “by building on existing infrastructure, what he will do is basically expand the same health care system–that everyone is now complaining about–to more people.” So true. Jason also notes that he does not favor an individual mandate, is interested in exchanges but is wary of their effects on innovation, and does not agree with one of Baucus’ primary financing mechanisms - the taxing of “Cadillac” insurance plans.

Alain C. Enthoven at the Health Affairs Blog – Alain also comments on Baucus’ funding mechanisms. First, he discusses a proposed tax on health insurers that excludes insurance provided by employers who “self-fund.” Since most large employers are self-funded, he states that this means the tax would fall heavily on small employers and individuals who purchase their own insurance. He then goes on to support the excise tax on high-cost insurance because it “would motivate people to look for less costly alternatives, thus encouraging the development of less costly systems of care.”   

Louise at the Colorado Health Insurance Insider – Louise comments on the proposed individual mandate to have insurance and whether any penalties for not having insurance amount to a tax or a fine. She brings in a helpful corollary of speeding and notes that if one chooses to speed and that choice is wrong, the price is often borne by others. In this sense, speeding tickets are a fine paid for those who make bad choices to guard against the greater good. Why not the same for health insurance?

Jeffrey Seguritan at Nuts for Healthcare – Jeffrey also takes on the excise tax on “Cadillac” plans. In a very thoughtful post, he notes that while President Obama and health economists agree that this tax discourages wasteful health spending, many Democrats are pointing out how the tax would easily hit the middle-class because of (1) high regional costs, (2) dangerous jobs, and (3) coverage of early retirees. He believes that this issue touches on the greater problem of our highly regressive and unfair tax subsidy on health benefits, and as a revenue driver, this tax actually helps to diminish its regressive nature (only if the tax can be reconfigured to elude the middle-class).

Ken Terry at BNET Healthcare – Ken discusses employees' rapidly rising cost of healthcare and how that is related to the challenge of the individual mandate in the health reform bills. He notes that insurance companies are upset that Baucus cut the fine on consumers who do not buy insurance from $3,800 to $1,900. He states insurers fear many individuals, faced with a relatively small fine or a large insurance bill, will choose the former. And he calms those fears by pointing to Massachusetts, where many individuals had the same choice, and they chose the latter.

Anthony Wright of the Health Access Blog – Anthony brings some light to the obtuse term “actuarial equivalence” and asks “if we are going to have ‘universal coverage,’ you need to define ‘coverage’ as to be meaningful.” He notes that some senators wanted to allow greater choice by allowing plans with lower equivalence and Baucus responded by calling those plans “pseudo-insurance.” Anthony then notes “the need for a balance between the affordability of the premium on front end, and meaningful coverage on back end.” He notes that just like investments, people will weigh the short-term and long-term costs and benefits and choose different plans “but below a certain point the premium no longer becomes worth it, and the coverage is just providing a false sense of security.” To help put things in perspective, he says to “think of the plans near the 65% minimum as subprime coverage and the ‘junk’ plans below 65% actuarial value as predatory lending.”

[Editor’s note: “actuarial equivalence” means many things to many people – see recent American Academy of Actuaries’  briefing on the Hill titled Demystifying “Actuarial Equivalence.”]

Merrill Goozner of Gooznews and Brady Augustine of MedicaidFirstAid – I am using my editorial license here since Merrill did not submit this post that he updated last week but on the same day, back in August, the two of us posted on the same topic. Basically, we both proposed to finance a large part of health reform by extending the employee portion of the Medicare Part A payroll tax to non-wage income like capital gains. According to Mr. Goozner, this option would raise more than $500B over 10 years and according to my post, this tax would be progressive, fair (especially in light of the causes of the current recession), and would not negatively impact total tax revenue, including the capital gains tax.

AL CENTRAL (posts on health system reform) 

David Harlow of HealthBlawg – David has an excellent interview with Dr. Paul Grundy on the Patient-Centered Medical Home. David notes that Dr. Grundy stresses the need for “transformational change in the nature of the covenant between doctor and patient -- not simply a reformation.  In his view, reformation without transformation creates as many problems as it solves: e.g., the primary care shortage exacerbated by increased insurance of the population at large in places like Massachusetts.” I know a good analogy when I see one, so I’ll post a good one from Dr. Grundy’s here in its entirety:

That’s why we are twice as expensive as anybody in the world. One part of the reason, it's kind of like the Olympics a few years ago, where we got the very best players in the world and we have a really good, well-trained physicians here.  We have really excellent hospitals, medical schools etc., and we put them on the court, the basketball players, and we got whipped – right? – by somebody, I can’t remember who it was, but mainly the fact was we didn’t play together as a team, we couldn’t throw the ball.  I mean, that’s what happens every day in our health care delivery system, we have nobody, nobody, coordinating care.  I mean somebody can have five specialists and you know one’s doing the exact opposite of what the other is doing and nobody is talking to each other, right?; it’s really dangerous.

Joe Paduda at Managed Care Matters – Joe gives a very nice narrative on how the world for Coventry (but he might as well be speaking about many other health insurers) will change if health reform passes. Joe notes “They are a pricing arbitrager and risk selector…They have not ever claimed to be expert in managing the medical costs themselves…I still don't think we'll get comprehensive reform this time around, and if we don't Coventry may think they've dodged a bullet. But sooner or later reform will happen, and those health plans that aren't very good at managing medical are going to be toast.” Only thing I would add is that managing medical in a value-based world will mean turning the current insurer-provider relationship inside-out.   

Jaan Sidorov at the Disease Management Care Blog – Dr. Jaan aptly notes that we should apply the wisdom of Socrates when it comes to health reform. You know, the man who stated that one is truly wise when they admit they know nothing. Which brings me to one of my favorite cartoons.

Panel of Experts

We have to remember that experts got us into the mess in the first place. As usual, Jaan is correct in that we should place less value on the “conclusions” of experts, politicians, and the media and place more value on empowering thoughtful people who are less tied to dogma and more tied to playing nice with others, admitting mistakes, making changes, and moving forward. Anybody remember the book All I Really Need to Know I Learned in Kindergarten. For those who don’t, here’s a basic refresher and a good quote:

Think what a better world it would be if we all - the whole world - had cookies and milk at about 3 o'clock in the afternoon and then lay down with our blankies for a nap. Or if all governments had as a basic policy to always put things back where they found them and to clean up their own mess.

Joanne Kenen at the New America Foundation (also see part 2) – Joanne highlights the work of Dr. Doug Eby, medical director of the nonprofit Southcentral Foundation nonprofit health system, which has transformed care in the challenging rural setting for Alaska natives. He notes “In our system, every bit of outpatient care is delivered through an integrated primary care team…The team has access to ‘immediately available advice and support’ from cardiologists or other specialists…Specialists do see the patients, of course, when needed, but at about one-fourth the rate elsewhere. And when a patient does need to see, for instance, the cardiologist, he or she is seen that day or soon after. No weeks of waiting. It's fast and convenient.” The list of measurable improvements brought about by the program is impressive. Truth is, brave communities across the country are improving their efficiency and quality – regardless of the incentives to do otherwise.

Bruce Siegel at the The Users' Guide to the Health Reform Galaxy – Bruce, who is director of the Robert Wood Foundation’s successful Aligning Forces for Quality (AF4Q) initiative, notes “as we work to reform our health system to improve care for all, we need to ensure that our health care organizations are actively collecting information on our patients’ race, Hispanic and granular ethnicity, and language needs…with better information, health care organizations can better understand the populations they serve, detect disparities in care, design actual solutions to improve care and evaluate progress.” He then goes on to cite successful projects where the ability to reduce disparities began with the knowledge gained through effective data collection.

Margaret Stanley at the The Users' Guide to the Health Reform Galaxy Margaret, who is former executive director of the Puget Sound Health Alliance, sounds like the adult in a room of pre-schoolers in her post on local alliances [Editors note: I had to say pre-schoolers because I stated above that everything we need to know, we learn in kindergarten]. She states “from what I can tell, it may be easier to achieve true consensus around health care reform at the local level.  That’s why much of my hope for a real health care overhaul rests on the power of local organizations.” But, maybe the most important aspects she describes are often the most elusive – leadership and commitment. Her post reminds me of one of my favorite quotes:

All of the great leaders have had one characteristic in common: it was the willingness to confront unequivocally the major anxiety of their people in their time. This, and not much else, is the essence of leadership.  John Kenneth Galbraith

AL WEST (other health policy posts) 

Karl Kronebusch at the Health Affairs Blog – Karl reminds all that “a careful reading of today’s main Democratic bills reveals, to a surprising degree, a set of policy approaches that were at the core of mainstream Republican proposals a few decades ago, which focused on employer-provided health insurance, private sector insurers, and market competition as an alternative to a national health insurance program run by the federal government.” He goes on to point to Senator Olympia Snowe, the moderate Republican Senator from Maine, who may wind up casting a crucial vote for health reform. He states “she herself is conscious of the ideological and policy shifts [of republicans] over time, telling the New York Times’ John Harwood: “I haven’t changed as a Republican.” Instead, she said, “I think more that my party has changed.”

Joe Flower at The Health Care Blog – Joe states that current health reform bills do little to “bend the cost curve” and he predicts “the way things are trending right now, Obama and the Democrats will succeed in getting a reform bill - and it will cost them the Congress in 2010 and possibly the presidency in 2012. Why? Because it will be ineffective at bringing most voters any tangible benefits soon, and ineffective especially at bringing down the cost of health care.” In the mark-up sessions this week, Senator Baucus hinted that national health reform may have to go the way of Massachusetts, coverage first and costs later. The reform bills do include some good policy (the 80% we keep hearing about) and as a wise man once told me about marriage “You can be right or you can be happy.” Maybe in this case, the democrats will choose to do the right thing, even if it will cost them down the line.  

Glenn Laffel at EHR Bloggers – Glenn squarely takes on the issue of malpractice reform and states “Max Baucus’ decision to release his solo album…was timed with the precision of a 4th grade marching band.
Physicians could live with that, but the bill contained gornisht [i.e. nothing] means on tort reform and not much more on Medicare reimbursement. Seeing that, the Long White Coats reacted like they’d just spied a chunk of earwax on their stethoscopes.” But after venting a bit on behalf of the Long White Coats, Glenn notes “but credit Obama for understanding that the Feds can’t implement tort reform all by themselves, so long as states maintain jurisdiction in malpractice litigation and set insurance premiums. If we’re ever going to get the tort reform physicians so desperately want, Washington is going to have to work with the states, like it or not.” Malpractice is as visceral a topic as exists in health reform and as usual, the truth is probably somewhere in the middle. There are some recent pieces on the state of malpractice reform here, here, and here if anyone wishes to learn more.

Roy Poses at Health Care Renewal in his post, Roy takes on one of my favorite topics – good governance. He highlights a recent article on how the governance of many not-for-profits has degraded. He notes their findings suggest many reasons for this change, chief among them the infusion of for-profit executives into Boards and the resulting focus on money at the expense of mission. Roy reminds us all that certain issues need to be addressed to make governance more accountable, transparent, ethical and honest and he recommends that anyone who cares about how health care organizations are run ought to read the article and apply its lessons.

Tinker Ready of Boston Health News and Merrill Goozner of Gooznews -  Both Tinker and Merrill take on another good topic – conflicts and transparency. They highlight an article from the Boston Globe that revealed “At least 60 Massachusetts doctors collectively have earned more than a half-million dollars this year as speakers paid by pharmaceutical giant Eli Lilly & Co. - including two Boston Medical Center physicians whose participation is being reviewed for possible violation of a hospital policy against marketing activities by its doctors.” She goes on to note that Eli Lilli believes the new law will hamper innovation and that certain clinicians believe the law will limit valuable medical education funding. Merrill adds that “here's a story we should see in abundance if Congress passes the Physician Payments Sunshine Act, which is in the House and Senate versions of health care reform legislation.”

Julie Ferguson of Workers’ Comp Insider – Julie posts about the recently released NY State Workers' Compensation Board 9-11 report on 45,000 World Trade Center cases. She states that the report is significant because “the data is a significant historical record and analysis of the largest single workers compensation event in insurance history.”

Now, one more bit of editorial license. We hear a lot about how Medicare is poorly run and bankrupt but after working there for over 6 years, I can say that the Agency is filled with many good scientists and policy-makers. If anyone wants to see why Medicare has a hard time controlling costs, just take a look at Merrill Goozner’s post What ReGen Tells Us About Health Care Reform. That is an example of why many policy makers support the “MedPAC on steroids” proposal and why many of the states with the best-run Medicaid programs are run by independent, stand-alone authorities.


AL East - Jeffrey Seguritan at Nuts for Healthcare

AL Central - David Harlow of HealthBlawg

AL West - Karl Kronebusch at the Health Affairs Blog

Wildcard - Margaret Stanley at the The Users' Guide to the Health Reform Galaxy

BostonRedSox6575 In this playoff, since I tend to pull for underdogs (and am a sucker for all things teamwork and leadership), the AL Championship goes to:

Margaret Stanley at the The Users' Guide to the Health Reform Galaxy.  


IMG_0216 The one bit of information I intentionally left out of the intro is that the 1975 Red Sox did not break the curse of the Bambino and actually lost what is described as one of the greatest World Series of all time. The curse was not broken until the Red Sox won the World Series in 2004, one generation later.

Though they did not win it all, the 1975 Red Sox were still champions and inspired a nation. At worst, the same can be said of health reform. Truth is, health care will improve with any bill that passes and reformers, though disappointed, will recite the baseball mantra “until next year” or in the case of health care (or the Boston Red Sox) “until next generation" - if we’re not broke first. Enjoy. ~BAA


Jaan Sidorov said...

Outstanding HWR as usual Brady! You've outdone yerself!

While I know nothing about baseball history, readers may or may not be interested in knowing that the Vietnam exit pic referred to in the 3rd paragraph was not of the embassy but of CIA headquarters. It's trivia, but also tells you who was really helping to run the war.