Matthew Holt

Expect to hear a whole lot about this…

Seniors care about death panels (apparently) but they usually really care about drug prices and costs. Part of the political rationale for the Republicans passing Medicare drug coverage in 2003 was to deny the Democrats the ability to bundle seniors’ desire for drug coverage with a universal coverage bill. So far the Republicans have to say the least muddied the waters as to whether universal coverage is a good thing for Medicare recipients—or at least the ones that don’t care about their kids or grand-kids.

But there’s one minor trick. The deal with big Pharma that’s part of HR 3200 cuts the donut hole in half. That’s real money for seniors.

And when the cuts to Medicare Advantage become apparent, that donut hole is going to affect many more seniors who now are getting good benefits from Medicare Advantage and are pretty unaware about what’s about to happen to those benefits, according to this recent Silverlink/Suffolk University poll. (Hint, many Advantage plans will get much less generous).

In that case, knowing that there is something in the bill that helps them might change some seniors’ minds. Right now the Silverlink/Suffolk poll does not make happy reading for the Administration:

The survey also polled Medicare recipients on healthcare reform. Despite high levels of satisfaction and relatively strong amounts of optimism, nearly half of Medicare recipients polled (48%) say they do not believe the Obama administration is looking out for their best interests when it comes to healthcare reform. The remaining are split, with 28% believing the administration is looking out for them and 24% unsure.

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  1. Margalit,
    I am agreeable to your suggestion that those who opt-out of offering to donate their organs would fairly be denied an organ themselves despite their time of need. At some point, we have to recognize that men are not Gods, the world is not perfect, and hard problems will require uncomfortable solutions at times. Good idea, in my opinion.

  2. John B,
    No calculation was necessary to evoke your response. Such discussion is a clear tiptoe on the slippery slope toward a eugenics view of society. Show Emmanuel’s view to most Germans (of which I do have heritage) and they will be apalled. It takes no imagination to draw the line. Once we decide that we, as humans, should systematically choose on a societal scale who is more worthy to be treated than another, we have lost our humility and dignity. I am a physician who would be satisfied to draw straws for my organ…I don’t want a bureaucratic or even a medical panel to make that judgement. I’m glad you asked what metric we should use for providing scarce treatments. How about a lottery? Your suggestion of luck is the most fair of all. The result is clear and human judgment is not involved in such case. This is clearly the most “equitable allocation system”.
    Furthermore, if we are offended that those with more assets may get more care (which is a reasonable position), it would be better in my view to not have the treatment available at all than to distribute in an unequitable fashion.

  3. Margalit,
    Regarding organ transplantation, I actually agree completely with your proposal that anyone should be able to opt-out of the organ donor system, with the consequence that they not be eligible to receive an organ in that case. I’m on board. A good solution.

  4. Not naughty, my friend…
    “on average” is the key line — the millions of seniors who do not spend much on prescriptions will see a net increase…
    add to the that the millions of non-Medicare customers in the system with subsidized care from an individual mandate…. the final result being more money in the pockets of PhRMA companies… thus their $150 million in advertising support.
    So, you are correct, if Mrs, Jones was spending $10,000 per year, she will see (eventually) a decrease (assuming that the plan is not altered by Congress before full implementation that decreases the financial benefit).
    But Mrs. Smith, who spends $1000… would see a net increase.

  5. naughty naughty Eric. Selective quoting means that you missed the most important sentence in the CBO draft IMMEDIATELY after the one you quoted, and when you quoted it you didn’t indicate that you’d made such a cut. You wouldn’t be scared that other readers wouldn’t come to your conclusion.
    I’ll let THCB readers come to their own conclusions about what they CBO meant by this sentence:
    “However, beneficiaries’ spending on prescription drugs apart from those premiums would fall, on average, as would their overall prescription drug spending (including both premiums and cost sharing).”
    But somehow I can see the Democrats turning this into a “win” for seniors, if they don’t screw it up. 🙂

  6. Payment reform, payment reform payment reform. Everything begins and ends with payment reform. Without payment reform their is no health care reform.
    Fee-for-service and pay-per-pill are the root cause for all of our health care problems. A public option will not correct the problems. Supposed competition will not correct the problems.
    Fee-for-access corrects the problem. Pay upfront (like we do now) and access the health care system for free. No copays for anything including: doctor visits, hospital stays, medications, etc.
    Doctors, Pharma and hospitals get paid when you pay. They get paid upfront (unlike now) before you access the system. Doctors get retainers. Hospitals get maintenance fees. Pharma sells bundled medication licenses for access to a suite of medications.
    Fee-for-service and pay-per-pill reward the health care system for delivering quantity of care. Fee-for-access rewards the health care system for delivering quality and efficient care.
    With payment reform everybody wins except for the current Health Care system exploiters. Seniors in particular will see high value for their fixed income dollars.

  7. “…since when are humans fit to make the judgment that one man at age 35 is more valuable than one at 65? How does one judge disabled people against those who are not. What about people who are high functioning with multiple medical problems? Should they have less access to necessary treatments?”
    Fascinating string of fear-inducing questions, not calculated, I’m sure, to evoke the worst outcomes of eugenics and campaigns for racial purity, but just enough to nourish those long-exploited generic fears. By what metric does Mark propose we answer them? Age? Political affiliation? Net worth? Luck? Citizenship?
    Wait! I know the answer: ROI. Where to the greatest returns lie? Don’t forget, a living patient with good coverage is worth a lot more over time than someone without, particularly if a large net worth gets added in for security when caps are met. That settles it.
    Silly me. I thought they were trick questions.

  8. Mark,
    Dr. Emanuel’s Lancet article is NOT talking about “expensive” treatments. It is talking about allocation of VERY scarce medical interventions, such as organ transplants. No matter how much you are willing to pay, there are not enough organs to go around.
    Organ transplants are allocated today based on different factors. Dr. Emanuel is merely proposing a more equitable allocation system. Are you disagreeing with the particulars of his proposal? Do you prefer the current organ rationing system?
    Do you have any suggestions to make organ transplants a non-scarce intervention? I do, but I don’t think you’ll like it. Let’s make the organ donor status an opt-out system. So when you go to renew your driver license, you’ll have to click the box if you don’t want to be a donor, in which case you will forfeit your right to be considered for a transplant should you need one in the future. I bet it will alleviate the scarcity issue quite a bit.

  9. Wake Up America! The stimulus hid ominous healthcare provisions!!! Information technology providers from ambitious startups to the behemoth GE have been waiting for the opportunity to grab a big piece of the health care dollar in America. They found their perfect partner in the federal government this year. In the innocent guise of cost savings, the Obama Administration has plans to use computerized health information to gain federal control over all of health care. This is no hyperbole. This very significant health legislation was hidden, placed quietly within the stimulus bill (rather than including it in other health care reforms being discussed). This was a reckless and dishonorable move, in my estimation. See if you agree.
    The legislation compels physicians and other healthcare providers to adopt information systems which must be comprehensive enough to satisfy ill-defined future standards of the federal government. If providers don’t do this, they will be fined incrementally until they do. As a “carrot”, the legislation suggests a general goal of partially reimbursing physicians for computerization costs (in several years) if they meet an arbitrary “meaningful use” threshold for computerization. The vagueness is no doubt intentional. In fact, the government clearly states that it plans to tighten the standard over time until all aspects of care are computerized. With the federal government already being involved in payment of over 46% of healthcare funding, changes in government standards will soon apply to all health care in this country. The law acknowledges that all Americans will be affected. Our government will claim and receive unconstrained access to our personal health information. Once this standard is set, the private insurance sector will utilize it and take advantage of the power of personal data collection. One breech of such a system could compromise private information for millions of us. And, as some have already experienced, there is no recovery from a breach of health information.
    Given the boldness of the Administration, certain that the computerization of health care is necessary (especially with the inherent security risks), certainly there must be excellent evidence that such pressure should be put on health care providers to computerize all of our personal health care information. Well, take a look at the conclusion paragraph of the “Meaningful Use Workgroup” report to the Health IT Committee of the federal government as recently as June of 2009 (long after the stimulus bill with health IT provisions was passed).
    “In identifying potential criteria for “meaningful use” of an electronic health record, it became apparent that there are considerable gaps in EHR-generated measures available to monitor key desired policy outcomes, (e.g., efficiency, patient safety, care coordination). While these measures will not be required for Medicare and Medicaid incentive payments until 2013 , the Workgroup is seeking feedback on how to best frame these measures including measurement of key public health conditions, measuring health care efficiency, and measuring the avoidance of certain adverse events. These comments will be used to help revise the recommended measurement strategy to include more extensive and refined outcome measures for “meaningful use” in 2013 and beyond.”
    In fact, they have no idea if or how this huge undertaking will benefit our health care. Essentially, the message is, you are required to give us your health care information…we don’t know whether we need it, or if we can use it, but don’t forget we can also do what we want with your information later (if we decide it is for the greater good). They make no mention of any serious potential drawbacks, risks, or potential unintended consequences of this regulation. Nonetheless, be assured, healthcare providers will be spending their own money (costs passed on to us, of course), putting our health information, mine and yours, on a centralized IT network in short order.
    We have all heard the big selling point on health care computerization that it will save money.
    The Congressional Budget Office, the most trusted entity for objective government spending predictions, projects that these new health provisions will result in INCREASED cost, not decreased. Dr. John Halamka, Chief Information Officer at Harvard Medical School and supporter of computerization said in an NPR interview that this will require at least 200,000 new IT jobs (adding cost to our health care). Now that’s stimulus!
    Earlier in the same report cited above, the stated priorities being used to form the “framework for meaningful use” of an electronic record were the following:
    … Among these priorities were patient engagement, reduction of racial disparities, improved safety, increased efficiency, coordination of care, and improved population health.
    Cost, the most obvious and urgent need of our health care system is not emphasized at all. That’s because objective opinion is that costs will go UP. No statistics or actual evidence of the claimed benefits of this project are mentioned in the report. Instead the report speaks in general terms about its utopian “north star” (or ultimate goal) of improved access, elimination of disparities, real-time access, and tools to help insure the quality and safety…. We all want to have fairness and to reduce disparity in care. This and reducing cost are the obvious and urgent needs of our health care system in this country. Unfortunately, that’s not what this legislation is about.
    You will want to look at the most shocking and unconscionable plans of this administration. Ezekiel Emmanuel, MD, the brother of Rahm Emmanuel (President Obama’s Chief of Staff) is Obama’s “Special Advisor for Health Policy”. It is reasonable to believe that his opinions and advice are close to those of the President. Dr. Emmanuel is not silent on his opinions.
    Emmanuel recently authored an article in the medical journal Lancet describing how health care can and should be rationed. The article is, “Principles for Allocation of Scarce Medical Interventions.” He makes no bones about the fact that he believes health care should be rationed not on need and consent, but rather based on what has been called the “complete lives system” (already sounds like a euphemism, doesn’t it?). He believes scarce resources for health care should be rationed based on principles such as:
    • Young adults get priority for scarce or expensive treatments.
    • Those with a good prognosis (the healthiest) get priority for scarce or expensive treatments.
    • Others should receive scarce or expensive treatments based on a lottery system.
    • Resources should be used to save the most lives possible.
    To call this socialized medicine is generous. He acknowledges that we are not quite ready to follow these principles, suggesting that with coming changes in the health care system, this policy of rationing is desired and recommended. But, since when are humans fit to make the judgment that one man at age 35 is more valuable than one at 65? How does one judge disabled people against those who are not. What about people who are high functioning with multiple medical problems? Should they have less access to necessary treatments? The results of such rationing will necessarily result in arbitrary and bad decisions causing physical harm and demoralization to many and a collective crisis of conscience for our society. In the future, no doubt, we would regret ever having started such thinking. In fact, were this principle to be suggested in Germany (even being a rather liberal society itself), surely eugenics and the Nazi years would come to mind and prevent any consideration of this scheme whatsoever. This is plain lunacy. Social engineering presumes that humans can and should control the destiny of those who may not be useful for the goals of a society. Who of us will be the undesirables and who has the audacity to start this ball rolling down this slippery slope. Apparently your present government, that’s who. Political leaders; you are intelligent, you are attorneys, you are educated. History tells us, this is NOT a good idea.
    So, to where does all of this lead us. Well, for sure we are headede for a computerized health care system where all information, all diagnoses, all vices, all family history (eventually all genetic information) will be accessible in seconds to those deemed authorized to obtain it. Given this access to data, as I remarked, The Special Advisor for Health Care to this Administration clearly states that we should ration care in a way which does not respect the dignity of individuals. The government will decide for us who we will let down. The unintended consequences will be unimaginable (and unpredictable) today, but necessarily we will see a devaluation of some segments of our society in all aspects of life. I don’t think any of us will want our children to have to live in that world. It’s as simple as that.
    Most of us surely believe that we should pursue tirelessly the availability of healthcare for all. In fact, in our new President, Barack Obama, we have hoped for him to have proposals he promised which could serve to cover all of us and better contain costs. Unfortunately, without communicating with the people, without debate, serious (and likely irreversible) health legislation was passed, placed with quiet calculation into the stimulus bill. The urgency of the banking crisis was a perfect distraction for sneaking through this significant health legislation. Few of us were aware that this had occurred. For whatever reason, major media sources have also clearly dropped the ball on this story.
    Wake up America! Control of your health is slipping away from you, your family, and your doctor.

  10. Matthew — sorry you missed the CBO publication on Friday on this issue…
    “Overall, CBO estimates that enacting the proposed changes would lead to an average increase in premiums for Part D beneficiaries, above those under current law, of about 5 percent in 2011. That effect would rise over time and reach about 20 percent in 2019. Beyond the 10-year budget window, the premiums would increase slightly more until the doughnut hole was eliminated in 2022; beyond that point, enrollees’ premiums would grow along with the cost for covered drugs. As already noted, the proposed changes would also reduce beneficiaries’ average cost sharing and their average total drug spending. The net effect on drug spending would differ among beneficiaries depending on the amount of their purchases in a year.”
    Since the administration and nearly every member of Congress is both unable and unwilling to speak about very specific provisions of the bill (like the House health bill provision allowing the gov’t to ‘outsource’ the public plan to private health insurers!), my sense is that the more the details fully emerge, the lower the poll numbers will go.

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