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The Defining Issue: Not Government’s Size, but Who It’s For

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By Robert Reich

The defining political issue of 2012 won’t be the government’s size. It will be who government is for.

Americans have never much liked government. After all, the nation was conceived in a revolution against government.

But the surge of cynicism now engulfing America isn’t about government’s size. The cynicism comes from a growing perception that government isn’t working for average people. It’s for big business, Wall Street, and the very rich instead.

In a recent Pew Foundation poll, 77 percent of respondents said too much power is in the hands of a few rich people and corporations.

That’s understandable. To take a few examples:

Wall Street got bailed out but homeowners caught in the fierce downdraft caused by the Street’s excesses have got almost nothing.

Big agribusiness continues to rake in hundreds of billions in price supports and ethanol subsidies. Big pharma gets extended patent protection that drives up everyone’s drug prices. Big oil gets its own federal subsidy. But small businesses on the Main Streets of America are barely making it.

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When the End of Life Is Not.

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By Marya Zilberberg

So begins this New York Times essay by Peter Bach, MD, where he talks about the inadequacy of resource use at the end of life as a policy metric. Now, I am not very fond of policy metrics, as most of you know. So, imagine my surprise when I found myself disagreeing vehemently with Peter’s argument. Well, to be fair, I did not disagree with him completely. I only disagreed with the thesis that he constructed, skillfully yet transparently fallaciously (wow, a double adverb, I am going to literary hell!) Here is what got me.

He describes a case of a middle-aged man who was experiencing a disorganized heart rhythm, which ultimately resulted in dead bowel and sepsis. The man became critically ill, the story continues, but three weeks later he went home alive and well. This, Dr. Bach says, is why end of life resource utilization is a bad metric: if this guy, who had a high risk of dying, had in fact died in the hospital, the resources spent on his hospital care would have been considered wasted by the measurement. And I could not agree more that lumping all terminal resource use under one umbrella of wasteful spending is idiotic. Unfortunately, knowingly or not, Peter presented a faulty argument.

The case he used as an example is not the case. Indeed it is a straw man constructed for the cynical purpose of easy knock-down. When we talk about futile care, we are not referring to this middle-aged (presumably) relatively healthy guy, no. We are talking about that 95-year-old nursing home patient with advanced dementia being treated in an ICU for urosepsis, or coming into the hospital for a G-tube placement because of no longer being able to eat or drink. We are talking about patients with advanced heart failure and metastatic cancer, whose chances of surviving for the subsequent three months are less than 25%. And yes, we are also talking about some middle-aged guy with gut ischemia, sepsis and worsening multi-organ failure whose chances of surviving to hospital discharge are close to nil; but in his case, instead of being clear from the beginning, the situation evolves.

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The States: Friends With (Essential) Benefits

By Linda Bergthold

Since the passage of health reform (Affordable Care Act), many have wondered what would be covered in the benefits offered through the State Exchanges. We have been reassured that the benefits that are “essential” would be comprehensive yet affordable. But essential to whom? What is an essential benefit and who gets to decide? Tough questions. No easy answers.

Last week HHS released a bulletin punting part of the issue to the States. States will have more “flexibility” to determine what is in the essential benefit package. Of course, not complete flexibility. These benefit plans MUST include, at least, the ten categories of benefits that are defined in the law. Those categories include:

Section 1302(b)(1) provides that EHB include items and services within the following 10 benefit categories: (1) ambulatory patient services, (2) emergency services (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care.*

Here are some questions that you might want to know about what is unfolding:

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12 Common Medicare Scams

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By Richard Reece, MD

“To scam Medicare is not to give a damn for taxpayers. Money is money whether you earn it or steal it.”

– Anonymous

Christine Seivers of medicalbillingandcoding.org sent me the following list of common Medicare scams. I have edited and shortened her copy to fit my blog.

1. The Poser Scam

One common way to scam Medicare is to pose as a Medicare employee, a practitioner, or insurance representative. These fraudsters call, email, or send letters asking for personal information that includes bank, Social Security, and Medicare numbers.

2. The Healthcare Reform Scam

Healthcare reform is on the lips of everyone these days, and scammers are using it to cash in. Many adults don’t know what the new health care legislation actually entails. That’s just the way criminals want it. It makes many Americans easy targets for scams, like those that claim to sell “healthcare reform insurance” that purportedly protects seniors from any losses to their Medicare or any fines they make incur from not meeting guidelines.Continue reading…

mHealth: Seemingly Stuck in Neutral

By John Moore

As many readers know, Chilmark Research has been a strong proponent of mHealth for several years. Despite this enthusiasm, we sometimes come away from a conference, such as this week’s mHealth Summit, with the feeling that the only ones making a living with mHealth are conference organizers. Maybe it was the format of this particular conference – too many presentations that were not well vetted for relevance and content. Maybe it was the lack of exhibitors – where is the rest of the legacy HIT market who are all claiming to be bringing mHealth solutions to market? Maybe it was hearing too many mHealth vendors with weak value propositions asking the Feds to step in and jump start this market. Or maybe it was the over reliance on government presentations and an ill-fated alliance with HIMSS, who sponsored less than visionary sessions. Hard to point to any single thing that contributed to this ho hum feeling, so let’s just chalk it up to all the above.

That being said, however, the mHealth Summit, now in its third year, is the best conference one can attend in the US if one wants to get the global pulse on all things mHealth.

From its humble beginnings where the first conference was quickly over-subscribed and held in a small DC amphitheater, this year’s event drew over 3,000 attendees to the massive Gaylord Resort outside of Washington DC for three days of countless sessions running concurrently covering every aspect of mHealth one could imagine. While most sessions were structured as panels with several short presentations, one was thankful that presentations were indeed short for few had substance. But nearly every session had one stellar presentation that kept one hopeful. Those were the gems of this event and like any event, the networking that occurs in the halls.

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Florida’s Problem: Cutting Medicaid May Cost More

By David Williams

Florida is concerned that it spends too much on Medicaid. Unfortunately for policymakers, proposed cuts to Medicaid are likely to be self-defeating according to an Orlando Sentinel article. They may result in more spending as well as boosting the number of people with no coverage – especially children. Components introduced under the guise of personal responsibility –such as charging $10 per month per beneficiary or $100 for non-emergency use of the emergency department– have great intuitive appeal to taxpayers and legislators, yet can backfire in practice.

Experience from Oregon suggests that even modest, sliding scale premiums result in huge drops in coverage. A report from the Health Policy Institute at Georgetown University suggests 82 percent of those who leave coverage would be children, of whom 98 percent would be below the poverty level.

There are clear examples of emergency room overuse, but what’s crystal clear in retrospect is not always evident up front. In any case, hospitals can do their part with effective triage that sends patients to lower acuity settings or back home when patients who shouldn’t be there show up.

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Hobson’s Choice

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By David Dranove

I recently moderated a Crain’s Business Breakfast. The panel included four highly respected Chicago-area hospital CEOs. I questioned the panel on a wide range of topics, from near term operational issues to long term public policy concerns. One expects well-rehearsed answers from senior executives so I was pleasantly surprised by the thoughtfulness and thoroughness of many of their comments. I was rather looking forward to how they would respond to this question, which they had been told in advance:

“Secretary of Labor Hilda Solis recently commented that the healthcare sector continues to be a bright spot for job creation. How is the nation to reconcile the desire for “job creation” with the desire for cost containment?”

First, some background. Secretary Solis is correct – the healthcare sector is a jobs engine. In just the past year, healthcare has added about 325,000 jobs, accounting for perhaps a third of total U.S. job growth. By way of perspective, the rapidly growing energy sector creates about 100,000 jobs annually. Job growth is great, but more jobs in health care means more spending on health care. Despite the technological imperative that propels the system, healthcare remains a labor intensive business. Half or more of hospital spending goes to labor, not including physician expenses. Labor expenses dominate home health and long term care. It is nigh on impossible to reduce healthcare spending without reducing labor spending. Thus, job creation and cost containment are enemies.

I put the ball in the hands of the panelists: do you favor job growth or do you favor spending cuts? The panel punted.

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Can Hospitals Exist Without Doctors?

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By RICHARD REECE, MD

“One cannot run a hospital without doctors, and one cannot run one with them.” – Peter F. Drucker

Yesterday Kaiser Health News ran a piece titled “Hospitals Clash with House Republicans on Medicare Cuts.”

The article revived these questions:

·Are hospitals friends or foes of independent physicians?

·Will the future of hospital-doctor relationships be one of cooperation, collaboration, or cooptation? (On the last bullet point, “cooptation” means hospitals take over the practice of medicine).

·What is the role of hospitals in health reform – hospitals after all have already agreed to $155 billion in Medicare cuts under Obamacare?

But I digress. What is the hospitals’ problem with the Republican legislation? What is the big deal? The Senate will probably not even take up the bill up anyway.

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Medicare Advantage Quality, Savings, Access and Satisfaction: Can We Have It All?

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By AL LEWIS

Imagine a Medicare Advantage (MA) policy which increases the quality of health care for seniors, saves the government money, brings MA to the few remaining places that don’t have it, and puts checks in the hands of senior citizens. What you are about to read should do all that, in theory. However, I’m sure there are practical issues that I am overlooking, and I am hoping to attract comments noting those issues that, as Woody Allen once said, can take this from being a notion to an idea, and eventually a concept.

First, each county would have a “default” plan that would automatically enroll people on their 65th birthday, rather than have the traditional plan serve as the default option. (Those of us already in an HMO with a Medicare option can stay in it, seamlessly, rather than join the default plan.) Anyone could still opt out into the traditional plan or another MA plan, of course, at any time.

The default plan is chosen based partly on its Stars rating, but partly on a bid process, in which plans offer to pay the government for the right to be this default plan. The payment would be substantial for three reasons:

1. In some highly populous counties, MA is profitable enough to support fifteen or twenty plans, far more than would survive in a competitive market with market-based pricing. Much of this “excess profit” would be bid back to the government by the default plan, in exchange for access to many more enrollees;

2. Member acquisition costs for the default (“opt-out”) plan would be a small fraction of the $500- $1000 that a new member costs in today’s opt-in MA environment. Much of this savings would be included in the bid;

3. The bid would be calculated not based on just on one year’s profit, but rather on the expected lifetime value of a member, taking into account projected member retention and any scheduled or anticipated relative reductions in reimbursement.

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Seven Reasons to be Thankful for Health Reform this Holiday Season

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By LINDA BERGTHOLD

This holiday season you may be surprised to find some gifts from the Affordable Care Act (aka health reform) in your stocking. I say “surprised” because a recent Kaiser Family Foundation poll found that the American public still doesn’t know what is in the health reform law and what is not.

If you haven’t been sick this year or are not included in the following categories of people who are benefiting from health reform, it makes sense that you won’t have paid much attention. You may not experience concrete benefits until it is fully implemented in 2014. But just in case you know someone in these categories, here’s the list of health reform “gifts” available this year (see my blog on the Health Insurance Resource Center for more details):

1. If you are 65 or older — (and eligible for Medicare) — seniors who are enrolled in Medicare Advantage plans (that’s Part C or the managed care part of Medicare) may have seen their premiums reduced this year. Some may even have access to ZERO premium health plans. Seniors also now receive free preventive treatments and a rebate of $500 if their drug coverage hits the “donut hole” in 2011.

2. If you haven’t turned 26 yet — you may have been able to stay on your parents’ health plan this year, even if you are working or don’t live at home. 1.8 million young people had access to this benefit. And 90,000 children under the age of 19 could not be denied coverage because of a pre-existing condition due to a change that was implemented in 2011.

3. If you needed preventive care (or had the good sense to get it) — you had access to it this year without a co-payment or deductibles.

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