By Brian Klepper

HWR has clearly arrived, at least in the sense that all KINDS of
columnists are clamoring to be read here. More than thirty submissions
arrived in my inbox, a collection of the utilitarian, the thoughtful
and sometimes the downright ridiculous. Given only so much space for an anthology, I set aside more
than a few. Some were simply plugs, or not directly relevant to a blog focused on
health policy and market dynamics. Others were merely good.

But the twenty remaining posts were, I thought, exceptional
contributions from writers who continually plug away, asking themselves, “What
really matters and how can I talk about it?” As ever, you’ll find a
potpourri here of expert observation, analysis and commentary from
every part of health care. It’ll take a little effort wading through
it, but I promise you an illuminating and entertaining time.

Ah, a warning. One of these posts is for April Fools. Keep your eye out!

On to The Review! Enjoy!

Overcoming the Frailty of AgingMike Magee MD, at Health Commentary, discusses how the frailty of age-related disease and infirmity – a condition that affects in four of five of us in the US by age 80 – may be preventable. The key appears to be awareness of and attention to critical time-related health markers that are the seeds of disabilities and aspects of the aging process. An intriguing and well-researched post.

Consumers Caught By Balance BillingOver at Health Access California, Anthony Wright describes the wrangling in that state over balance billing, a growing problem around the country. Patients are caught between payers and providers, and some have had their credit jeopardized. Governor Schwarzenegger’s Department of Managed Care has proposed regulations that would ban doctors and hospitals from balance billing patients for services rendered under an in-network health plan arrangement. Those of us ancient enough to remember the beginnings of managed care remember that the elimination of balance billing in indemnity health plans was one of HMOs and PPOs big attractions. Who knew that it would return? Anthony is clearly right here, Consumers have suffered abusive practices because the health plans and providers can’t come to terms, and they deserve the State’s protection.

Tying Health Costs To IncomeIn a companion post, Anthony’s colleague Hanh Kim Quach notes that, while Senator Clinton has proposed that health insurance premiums should be tied to income levels and capped, the new minimalist health plans that are now everywhere have out-of-pocket requirements that can be prohibitive, especially for lower income families. She argues that both premiums and out-of-pocket costs should be capped.

Managing An Employer-Sponsored Health PlanLynn Jennings, writing on The Health Care Blog, lays out practical principles for employers trying to maintain a balance of good care and reasonable cost for their employees‘ health plan. Given the array of conflicted interests bent on increasing their take and the difficulty of obtaining good information to manage, this is not trivial. Lynn is a longtime health care finance professional, a stop-loss underwriter, a former third party administration firm manager, and a former President and current Board member of the Self Insurance Institute of America, all of which lends this perspective particular weight.

Virtual Office VisitsAt the Disease Management Care Blog, Jaan Sidorov MD reports on what’s actually known about the efficacy and utility of virtual office visits, and concludes that they’re probably less than advertised. Even so, on balance he’s in favor of them, with some sensible stipulations.

Health ConsumerismOver at Health Populi, the ever-reliable (and charming) Jane Sarasohn-Kahn reviews new health consumerism data from the Employee Benefits Research Institute/Commonwealth Fund. Enrollment in Consumer Directed Health Plans (CDHPs) is slight but growing, from a mere 1 percent of people with private coverage in 2006, to 2 percent in 2007. (It’s worth mentioning that EBRI and TCWF define High Deductible Health Plans (HDHP) as identical to a CDHP, except with no Health Savings Account, and find that more than five times as many Americans have these. In other words, they have high deductible plans but nobody is funding an HSA.) Contrary to the hopes and rants of the ideologues on the right, it turns out that the enrollees in these plans tend not to be born-again uninsureds, but the healthy and wealthy. And still, a lack of information that can provide decision support to these enrollees remains a problem.

Professional RigorOn the Health 2.0 Blog, the always-entertaining veteran health care commentator and Quality Grand Poo-Bah Michael Millenson takes us on a ride that forces some introspection. In the extremely complex world of evolving health information on the Web, do we health observers drink our own Kool-Aid? “Are we open to objective data about what we do, or do we prefer to publicize only affirming anecdotes?” Its an uncomfortably reasonable question, and a fair warning.

Financial ConflictOn Health Care Renewal, Roy Poses MD does another one of his wonderfully in-depth exposes on the financial conflict that pervades nearly all health care, this time pulling together a wide variety of sources surrounding the lung cancer screening research scandal that involved academic researchers, a prominent university, a foundation that was a front for tobacco money, and a major medical journal. The amazing thing here is that nearly everyone involved keep insisting there’s no, or nearly no, impropriety.

I love this summary line near the end of Dr. Poses’ long, detailed piece. "Conflicts lead to confused thought, speech, and action. One cannot tell
what interests lie behind the speech and actions of the conflicted. So
clinical research designed, implemented, analyzed, and discussed by the
conflicted, rather than leading to further clarity about how to care for
patients, just leaves us in a fog of doubt."

Policy: The Candidates and ReformBob Laszewski points us toward the fact that key Democrats have asked the General Accounting Office (GAO) for a review of the individual health coverage market and state high risk pools, and asks whether this might be a way to shine a light on the holes in McCain’s health policy platform. Bob’s Health Policy and Marketplace Review consistently provides clear, succinct non-partisan analysis of the obvious and covert goings-on in health policy, and this post is a great example of his insight.

Breaking NewsJoe Paduda at Managed Care Matters is known for being a step ahead of the rest of us in the breaking news department. On the 1st, he was first out with the bulletin that Warren Buffett is acquiring Wellpoint. One can only imagine how that will play out. Whew!

On Patient TranslatorsOn InsureBlog, ruminating on a Harvard study finding that health disparities are more common for non-native English speaking immigrants, Bob Vineyard takes umbrage with the investigator’s suggestion that "health care providers should incorporate translation services into their practices."

Doctors on Single PayerAt Colorado Health Insurance Insider, Louise, an (unlikely) fan of single-payer national health coverage, reviews data showing that a high percentage (59%) of American physicians support this approach. (Has anyone told the AMA?) The numbers are even higher among Emergency Physicians (69%), who treat an unending, unfiltered flow of humanity in their daily work, and Psychiatrists (83%), who as all Republicans know, are crazy anyway. Louise wonders about the one-third of physicians that don’t support national health care, and what kind of medicine they practice. It’s a fair question.Old Drugs, New InsightsDov Michaeli MD PhD is, without question, hands-down, the best science writer I’m aware of. A biotechnology basic researcher by day, he writes column after column over at The Doctor Weighs In, explaining the marvelous intricacies of nature and discovery in a captivating style. (Which is unnerving. English isn’t his first language.) Take a look at his post describing how new insights into the long-known drugs aspirin and DEET have uncovered tremendous new possibilities. This is the stuff that got so many of us interested in science in the first place.

Health DisparitiesAt the Medical Humanities blog, Daniel Goldberg ponders the deep meaning of a NY Times article citing continuing evidence that wealthier people have fewer health problems than poor people, and the relationships between issues like this and the humanities. He observes that perhaps there are other ways, beside wealth redistribution, to reduce class-related health disparities.

Worker’s CompTom Lynch at Workers’ Comp Insider has written a nice overview of both the US health care and workers’ compensation systems, concluding that “bleak as that portrait is, the situation with health care costs in workers compensation is even more dire.” Tom proposes “A caring, aggressive, systemic, performance-oriented and measured program” focused on injury/illness prevention and on rapid-return-to-work. An interesting and important comment.

Health Care ITAt the eCare Management Blog, Vince Kuraitis and David C. Kibbe MD MBA collaborate on a fascinating description of how the Feds have begun a potentially powerful public-private collaboration, involving Microsoft, Google and Dossia that could tie the National Health Information Network (NHIN) to the Personal Health Information Network (PHIN). These two observers are among the best in the industry, and this example of their work shows why.

CostIn a typically thoughtful piece on GoozNews, Merrill Goozner hits one out of the park describing how reform schemes that would base their savings purely on better pricing are doomed to failure, and how meaningful reform will require changes to the ways health care is supplied and delivered. The point, he concludes, is that it’s price AND volume.

Barriers To EMR ImplementationMy favorite cynic, Richard Reece MD at MedInnovation is rife with wit, knowledge and homespun practicality. In The EMR Funk, Dr. Reece lays out some of the reasons, some of them impossible to deny, that its been so hard to get EMRs up and running in American practices.

Generic BiologicsWriting at Brass and Ivory, MS patient Lisa Emrich brings together an impressive array of information to show that the Biotech Industry Organization’s efforts to block bio-generics, with arguments backed by Congressional contributions, has paid off for them at the expense of affordable solutions for patients. It’s yet another excruciating demonstration that American health care’s first focus is on long term protection of enterprise, rather than a balance between innovation and patient interests. (Bravo, Lisa!)

Obstacles To ReformMaggie Mahar, writing at HealthBeat, describes how the different sensibilities inherent in America’s social class structure are a major obstacle to meaningful political reform. Maggie’s a rigorous researcher and great thinker, and its always a pleasure to watch her weave her arguments. She makes a compelling case that the challenges facing reformers are not merely from business’ domination of Congress, but from a lack of social solidarity and shared desires. Another excellent piece.

The Corporatization of Primary CareFinally, here at THCB (and elsewhere), I dive into Walgreen’s recent acquisition of the top two worksite clinic firms, working through the primary care crisis, the disconnect between primary and specialty care, the rampant waste in the specialties, medical homes, retail clinics and worksite clinics, to show that a new corporate medical model is emerging: the worksite clinic as medical home. The vacuums created in the health care market by a medical community that has insisted on remaining a cottage industry, and by rampant cost growth, could be seized upon and filled by corporations that have become expert at standards, tools, and management systems.

It’s worth mentioning that, in response to this piece, Maggie Mahar and I produced a follow-on exchange. She wrote an impassioned argument against for-profit health care, which was published as its own post, and I replied, arguing that the problem is not with for-profit or not-for-profit organizations, but in our failure to force them to adhere to a discipline that aligns with the common interest.

This has been a pleasure. Hope it has been for you as well.