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POLICY: For Make Benefit Glorious Nation of California By John Irvine

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The first shots in the fight over California Gov. Arnold Schwarzenegger’s health care reform proposal were fired last week. The Los Angeles Times reported that a team of advisers is working to develop the proposal, which will probably be unveiled during Schwarzenegger’s state of the state address in January. The news had led to a pretty serious hoo ha.  Liberals are worried that the plan will look a lot like the helpful proposal drafted by America’s Health Insurance Plans. Conservatives, on the other hand, are concerned that Schwarzenegger could get carried away in his enthusiasm to appeal to moderate voters and end up producing something that could hurt California’s businesses.

What should we expect? The backgrounds of the advisers who are helping Schwarzenegger produce the plan may give us some hints. As it turns out, three of the four are Democrats. One recently left his position at McKesson government relations. In his piece this week, the California Health care Foundation’s George Lauer described the makeup of the team:

Richard Figueroa, former
legislative director for Insurance Commissioner John Garamendi and
former aide to former Gov. Gray Davis (D).

John
Ramey, former executive director of the Managed Risk Medical Insurance
Board, deputy secretary and assistant secretary of the Health and
Welfare Agency, and chief of staff for the Department of Health
Services. Since 2000, Ramey, a Republican, has been principal and
partner of Ramey, Macomber & Associates a Sacramento firm
specializing in health care and health insurance contracts.

Herb
Schultz, former deputy director of the state Department of Managed
Health Care, most recently vice president of government programs at
McKesson Health Solutions. Schultz also served as acting director of
the California Employment Development Department and acting secretary
and undersecretary for the Labor and Workforce Development Agency.

Daniel Zingale, chief of staff for first lady Maria Shriver and former director of the Department of Managed Health Care.

A lot of people have focused on the possibility that the plan will look a lot like the proposal produced by former Massachusetts Gov. Mitt Romney. The critics say the idea probably wouldn’t replicate well in California for many reasons. (Short explanation: California is a lot bigger than Massachusetts.)  Adopting a variant of the Romney proposal would also be a form of endorsement for Romney, who plans to run for the White House in 2008.

Continue reading…

TECH: HealthCamp

There’s a meeting called HealthCamp about Health2.0 in San Francisco on Saturday. Many of the usual suspects will be there, but I suspect there’s room for lots more. You can add yourself to the list at the wiki.

BLOGS: A great Health Wonk Review

Michael Cannon is hosting Health Wonk Review #21 up at the Cato@Liberty blog. And unlike some HWR hosters (i.e. me) Michael does a great job of not only steering you to the posts, but summarizing them and giving you his views on the legitimacy of the arguments.  And just because he’s wrong most of the time, doesn’t mean that he’s not doing a fabulous job! This is one of the best HWRs yet. (And apparently I’m James Brown!)

And if you’re not reading the Cato blog regularly you’re missing out on among other things a) some of the best argued views from free market advocates on health policy (which I usually disagree with), b) drug policy and human rights (which I’m with all the way), and c) traffic (which will at the least surprise you in a Heinlein fashion, and those ideas comes from those terrible socialists in Europe!)

QUALITY/POLICY/TECH: Quick notes from the road

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Apologies to those who’ve missed me. I’ve been lost in the mid-west taking part in some scenario planning about the big picture future of health care. I can’t give you any details (at least not yet) but it did involve me spending lots of time with a bunch of business association lobbyists who’s views on health care, shall we say, the average THCB reader wouldn’t expect me to share.

In the informal conversations, across the board there was, however, one huge topic of agreement amongst the boomers I met. They wanted themselves and their parents to die at home with palliative care; they felt that current end of life care verges not only on the irrational in terms of resource use, but also on the inhumane. And they think that within a decade, we will be having that conversation and forcing that set of opinions onto our medical providers. Who presumably will be rather more willing to hear us out, rather than insisting on engaging in those heroic measures that, the group felt, todays providers feel they must perform.

One other quick thing. Wednesday, Intel, BP and WalMart announced a PHR initiative, which I believe is being largely led by JD Klienke’s group in Oregon. On that topic I’m giving a talk to HIMSS N.California in San Ramon on Tuesday on the topic of PHRs. Also talking will be Kate Christensen from Kaiser Permanente, and Holly Miller from the Cleveland Clinic. I personally think this should be an interesting opportunity to hear a range of views and understand some developments in major PHR deployments from providers (and of course I’ll be witty and brilliant, just as soon as I’ve put my talk together). But apparently according to at least one other blogger, I’ve misunderstood it all, and really I’m just being a PR flack for the devil worshipers at KP central. I’ll report back as to whether the place still smells of sulphur.

 

POLICY: New York Trans Fat Debate Heats Up

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The Wall Street Journal reports that McDonalds and other
fast food businesses are engaged in a last minute drive to convince health
officials in New York City to “soften” the proposed ban on trans fats in restaurants
in the five boroughs. According to the Journal, McLobbyists have approached city council member Peter Vallone and asked him to sponsor a competing measure
that would give the industry more time to make the switch over to healthier
cooking oils. Quoting from WSJ’er Janet Adamy’s piece:

The city’s board of health is scheduled to vote Tuesday on
whether to force city restaurants, from fast-food outlets to servers of haute
cuisine, to eventually remove all but a trace of artery-clogging trans fat from
the food they cook. It’s not certain yet how the board will vote, but people
following the process say the board appears likely to approve the measure.

A New York City ban would place the most significant
restrictions yet on trans fat in the U.S. since health officials began warning
of its dangers years ago. Restaurant chains will feel pressure to more quickly
replace oils in their outlets across the country, since the companies get the
most efficiency and consistency by cooking with a single recipe. Other cities
probably would follow New York.

          — John Irvine

HOSPITALS: Panel Said to Call for Closing 9 New York Hospitals

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Somehow I think this will be rather difficult! Panel Said to Call for Closing 9 New York Hospitals

Welcome to the governorship, Mr Spitzer!

UPDATE: Anonymous Coward writes in to say: "The Commission’s proposals actually serve as political cover for the all but certain cuts to Medicaid, and this is actually a good thing for Spitzer.  The closing recommendations have to be approved as a whole (or rejected as a whole, unlikely) before he’s even in office.  Also, dealing with cuts through a more rational, analytical framework, actually enables the new governor to stay completely out of the business of closing hospitals, and to scale back on what otherwise would have been more devastating cuts to Medicaid for all hospitals.  The public relations around this are tricky, but the process is already being closely watched (and followed) in other states."

UPDATE 2: You can read the actual report here. (pdf) Check the New York State Commission for Health Care Facilities in the 21st Century web site for additional materials.

ED’s NOTE: Link fixed to NYT piece.

PHYSICIANS: Pity the poor radiologist

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They are “frustrated” by Liability and Lifestyle Issues, only 7% them are truly happy—although 70% would do it all over again if they had the chance (more than most other doctors). And only 25% of them make more than $400K a year and 40% have to struggle by on less than $300K.

But pretty clearly these are the good old days for radiologists. Methinks that if they don’t like it now, the average radiologist may be in for a rude shock in the next decade or two, as technology will make their skills increasingly exportable to other cheaper radiologists abroad and replaceable by computers reading images. Of course, they’ll not be quiet in defending their lucrative turf, and demand for imaging will just keep going up, so their future isn’t quite that of the steel worker in the 1980s.

But this is one place to watch in the coming years.

CONSUMERS/POLICY: Real people really travelling

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Via HISTALK, a really interesting column about people traveling to India for surgery. Essentially the total cost slightly exceeds the co-insurance for those with insurance and of course the cost is remarkably lower for the uninsured. The people featured are those in the 50-65 age group who are pre-Medicare and finding it harder and harder to get health insurance are the obvious candidates.

And of course they are the ones for whom the health insurance crisis is biting home, and the ones who will be the swing voters about this issue. I for one cannot believe that this group of Americans will accept that they all need to travel to India and pay out of pocket, over and above whatever catastrophic coverage they are also buying. So when a politician comes up with a believable universal solution, this type of story will be behind what gets it through the Congress.

QUALITY: The herniated disk story

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Medpundit has a pretty good explanation of the recent study about herniated disk surgery. Basically it works, but if you wait two years, then the results are about the same as non-surgical treatment—roughly 70% of people get better, and there doesn’t appear to be any long-term harm from delaying surgery. As I have someone very close to me with a current case of extreme back and leg pain from a herniated disk, I’m very interested in the study, and actually more inclined to suggest surgery (especially arthroscopic) sooner rather than later. But in this case the patient, doctor and other advisors are more in favor of waiting it out.

So on a global level it’s more cost-effective not to do the surgery. But on an individual level it probably lessens the pain—and the pain is close to unbearable, and if you have to put up with it for several months, then surgery is probably an option the patient will want.

Note that this is only the case for herniated disks and not lots of the other back issues for which surgery is probably ineffective–but still done at a very high rate.

The good news is that ten years after AHCPR (the forerunner to AHRQ) was decimated by daring to discuss back surgery, we’re getting studies out about this type of issue. Even, as Medpundit points out, it’s not a great study and it’s very, very hard to do studies about this type of intractable medical problem.

CODA: One slightly disquieting anecdote. I asked a local back specialist (non-surgeon) what the best way of doing surgery was (open or athroscopic). He said that the choice depended mostly on the training of the surgeon! Er…shouldn’t the surgeon be trained in the most advanced manner? (I expect those who know to chime in here)

POLICY/POLITICS/PHARMA: PhRMA sends the D out on the field

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Even thought the White House will likely veto any change to Part D, the WSJ has started playing desperate defense on behalf of PhRMA.

Apparently if we impose government price controls, it’ll cripple R&D and no new drug will ever be developed. On the other hand, they also trot out the “fact” that Part D as constructed now means that the private sector has the ability to lower prices below those that the government could get. Of course we’ve heard all this before, and we all know who wrote Part D and in whose interests it was written.

But what I wonder is how can the WSJ’s Jane Zhang hold those two contradictory thoughts in her head without smoke coming out of her ears?

Meanwhile, here’s the NY Times on big Pharma’s attempts to buy its way out of the problem. It’ll certainly make some former Democratic staffers much richer!

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