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Contradictions in Massachusetts

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By PAUL LEVY
Paul Levy 1

I have written before
about the strange things going on in the Massachusetts health care
insurance market. For those from out of state, here are some quotes
that will give you a sense of the contradictions in the public policy
arena.

They are, respectively, from two stories that appeared on
the same day in the Boston Globe:
"Rate
cap for insurer overturned" and "Officials
give up cutting health perks."

(1) An insurance appeals board yesterday overturned the state’s
cap on health premium increases for small business and individual
customers covered by Harvard Pilgrim Health Care . . . [finding] that
rate increases Harvard Pilgrim initially sought in April are
reasonable given what it must pay to hospitals and doctors. That ruling
trumped the Insurance Division’s earlier finding that the requested
increases were excessive.

(2)
The state’s public employee unions won a major victory this week when
the Legislature abandoned efforts to allow cities and towns to trim
generous health care benefits enjoyed by thousands of municipal
employees, retirees, and elected officials.

You can read
the rest and related stories, but what is most disturbing is that the
spirit of cooperation and compromise that existed when Massachusetts
approved its health
care reform law in 2006 has broken down. Part of the reason is
that commitments made at that time have not been delivered upon. For
example, the state had promised to lift Medicaid payment rates to
something closer to the cost of delivering that service. Once the
economy sank and state budgets were stressed, that was not possible.
This left providers needing to collect more of their income from private
insurers.

Continue reading…

WIHI On Imaging Practices

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By PAUL LEVY
Paul Levy

Here's a notice about an upcoming WIHI program.

The Image of Better (Radiation) Imaging Practices

Thursday, June 17, 2010, 2:00 PM – 3:00 PM Eastern Time

Guests:
James R. Duncan, MD, PhD, Associate Professor of Radiology and Surgery, Washington University School of Medicine, St. Louis, Missouri.

Richard T. Griffey, MD, MPH, Associate Chief for Quality and Safety, Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri.

Imagine an electronic card that has all your vital medical information on it. Not too farfetched. Now, imagine that this same “smart card” also contains your radiation exposure history. Who needs to know, you ask? Well, a growing number of global patient safety experts believe this is precisely the type of information patients and medical providers should be tracking to help prevent unnecessary CT scans and the like, especially as evidence mounts that all these tests begin to add up in ways that that can endanger people’s health. Cancer is being studied the most, which is of course ironic since powerful and advanced radiation imaging is what also helps diagnose cancerous tumors at their earliest and most treatable stages.

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In Defense of Paul Levy

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By ROBERT WACHTER

Picture 7

Paul Levy, the blogging CEO of Boston’s Beth Israel Deaconess Medical Center, found himself in hot water last

month over an inappropriate relationship with a female subordinate. While some of the details of the transgression remain sketchy, I think I now know enough to opine on it. To my mind, Paul has been an extraordinary healthcare leader, and – while the episode represents a lapse in judgment that deserves censure – he should not lose his job.

Let’s start with some background. Paul took the helm of BIDMC 8 years ago. At the time, the hospital – which operates in the shadow of its more storied Harvard cousins, Brigham and Mass General – was in crisis: its staff was dispirited, it was losing a million dollar a week, and it was still reeling from the challenges of blending the cultures of its two recently merged progenitor hospitals, Beth Israel and Deaconess. (Hint: the religious mismatch was only the start of the tsuris.)

Paul was an unusual choice for the position of CEO. BIDMC CEOs have historically been physician-leaders, whereas Paul’s major prior roles had been to teach Environmental Policy at MIT and to lead the Massachusetts Water Resources Board, where he spearheaded the cleanup of Boston Harbor. Some folks wondered whether he was up to the task of being CEO.

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Half full. Half empty.

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By PAUL LEVY
Paul LevyAt a recent presentation, a respected doctor expressed some frustration with the criticism that is sometimes directed towards the medical profession. He pointed out that the medical community has actually done a very good job taking care of serious illnesses in the population. He noted that this is because doctors really devote their lives to improving patient outcomes.

To support this point, he presented the chart above from the AHRQ Center for Delivery, Organizations and Markets (full study here) that demonstrates improvement in hospital risk-adjusted mortality for important diagnoses and procedures. Whether you have a heart attack or pneumonia, or whether you have an aneurysm repair or a hip replacement, your chance of dying in a hospital has gone down over the years. (I know this data ends in 2004, but I would be confident that the trends have held.)

Continue reading…

VAT On the Horizon

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By PAUL LEVY

Several months ago, a friend met with a high government official and expressed concern that the new health care bill would be more expensive than people were saying.

“Oh yes,” said the official, “In several years, the United States will pass a value-added tax.”

After the bill passed, Charles Krauthammer wrote this column in the National Review saying the same thing:

American liberals have long complained that ours is the only advanced industrial country without universal health care. Well, now we shall have it. And as we approach European levels of entitlements, we will need European levels of taxation.Continue reading…

The Laboratory of Democracy

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By PAUL LEVY

Paul levy People from other states would be wise to watch the sequence of events happening here in Massachusetts with regard to health insurance rates. As I described below:

Things are playing out just as one might predict in the Massachusetts small business and individual insurance market. The Insurance Commissioner turned downproposed rate increases, the state’s insurers appealed to the courts, and now they can’t write policies.

Now, Rob Weisman at the Boston Globe reports on yesterday’s hearing in Suffolk Superior Court. The insurers argue that the action by the Insurance Commissioner is arbitrary and capricious, the traditional standard used to overturn a decision by a regulatory agency. The Division of Insurance argues, in part, that the insurers have not used up their administrative remedies before the agency, another traditional argument. A ruling is expected on Monday.Continue reading…

It’s Easier to Beat Up the Insurers

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By PAUL LEVY

Things are playing out just as one might predict in the Massachusetts small business and individual insurance market. The Insurance Commissioner turned down proposed rate increases, the state’s insurers appealed to the courts, and now they can’t write policies.

Meanwhile, policy-makers ignore the underlying causes of the problem:

Just a few weeks ago, the Attorney General issued a report, after months of study, that explained that insurance price increases in the state were the result of two factors, the underlying increase in health care costs and a disparity of reimbursement rates that paid some providers substantially more than other providers.

As noted by my colleague Ellen Zane, in remarks consistent with the findings of the AG, “The funneling of dollars disproportionately among hospital and provider groups serves to warp the overall system balance.”

Taking a page from the debate on national health care, local officials seem to have decided that it is easier to beat up on the unpopular insurance companies rather than address the root cause of the problems. Here, though, the insurers are non-profits. If they are forced to charge prices below those that are based on actuarial determinants, there are no shareholders to absorb the losses. The most direct result is a reduction in capital reserves, a key metric the Division of Insurance is statutorily charged to protect.

Should We Let The Death Issue Die?

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By PAUL LEVY

Paul levy

Did you read yesterday’s New York Times article by Anemona Hartocollis, entitled “Helping Patients Face Death, She Fought to Live“?

It was about a palliative care doctor who faced her own end-of-life issues in a very different manner from the way she would have advised many of her patients.

An excerpt:

[A]s the doctors began to understand the extent of her underlying cancer, “they asked me if I wanted palliative care to come and see me.”

She angrily refused. She had been telling other people to let go. But faced with that thought herself, at the age of 40, she wanted to fight on.

While she and her colleagues had been trained to talk about accepting death, and making it as comfortable as possible, she wanted to try treatments even if they were painful and offered only a 2 percent chance of survival.

It is never right to be judgmental about these matters. Each person faces this kind of situation in his or her unique way, and we have no right to dispute the choices people make.

But I was struck by how this doctor personified the public policy debate that surrounds terminally ill patients. Here’s a an example of that kind of discussion from Canada (single payer, government run system!):

The high cost of dying has more to do with soaring health care costs than the aging population does, according to the Canadian Institute of Actuaries. In its submission to the Romanow commission on the future of health care, the institute said that 30 to 50 per cent of total lifetime health care expenditures occur in the last six months of life. Noting the sensitivity of the subject, the group suggested greater use of less expensive palliative care and living wills.

Dr. Pardi’s experience shows how hard it is to go from a policy-level discussion of such matters to the decisions made by individual patients and their families. Without giving credence to the nasty and politically inspired debate about “death panels,” the ambiguity in such situations suggests the difficulty in adopting formulistic approaches to the decisions around end-of-life care.

Besides abortion, it is hard to think of a part of medical practice that is more likely to be politically divisive and personally uncomfortable. Given that, is it worth the debate? Alternatively, how can we best have a productive discussion about it?

Price Controls Do Not Work

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By PAUL LEVY

Paul levy

If there is anything about economics that has been proven over and over, it is that price controls do not work. The unintended consequences are usually worse than the problem that led to the solution in the first place.

Massachusetts legislators, feeling the frustration of higher insurance premiums, are now considering a bill to limit doctor and hospital reimbursement payments to 110% of Medicare rates, or perhaps some other percentage of Medicare rates. The problem with this is that Medicare rates are not fully compensatory to doctors and hospitals and have contributed to the increase in private insurance company rates. This was one of the conclusions reached by the Attorney General in her extensive investigation of these matters.Continue reading…

Crowd Sourcing Comes Through Again

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By PAUL LEVY

Paul levy I have written before about the incredible power of crowd sourcing, using the reach and scope of social networking on the Internet to solve a complex problem. Here’s a play-by-play about a difficult question. It demonstrates how the asynchronous participation of many participants inevitably converges on the right answer in less than 24 hours. You just have to be patient and let the truth emerge.

I posted the following problem on Facebook:

Query — what makes some Facebook status updates stay put on the top of your page until cleared, while others appear as one-time updates? (Yesterday at 12:22pm.)

Luba:

I think it’s an algorithm that has to do with how often you comment on other people’s posts. Facebook tries to be smart about which people you actually care about seeing. I often find it wrong and look at both top stores and most recent to get a full picture of what is going on.

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