Tag: Policy

POLICY: Podcast with Jon Kingsdale, Massachusetts Connector

May 14, 2007• 6

Crossposted from the Worldhealthcareblog, this is the interview I did at WHCC with Jon Kingsdale, who created and is running the Massachusetts Connector–the organization at the center of that reform effort. Many of you have many opinions about what’s going on in that state, so now you’ve heard it from the horses mouth, feel free to comment.

Matthew Holt: This is Matthew Holt, again on the floor at the World Healthcare Blog this afternoon. Coming towards the end of the session, I have Jon Kingsdale with me. Jon is the executive director of the Commonwealth Insurance Health Connector Authority, better known as the Massachusetts Connector. This is the central body in the middle of the new Massachusetts Health Plan arrangement. And Jon gave a very interesting talk about how that is playing out in a session early this morning. So I thought I would grab him and grab a few minutes of his time. So Jon, thanks a lot for doing the conversation.

Jon Kingsdale: My pleasure.

Matthew: Let’s start in with the basics. Most people know that Massachusetts has gone in with some kind of individual combined with an employer mandate. And know that there’s some arrangement in the middle of that so people can actually buy into an affordable health plan. There’s been come controversy about what affordable means. But what’s the Connector doing in the middle of all that? What does the Connector do?

Jon: Well, we have a number of functions, Matt. One is a whole set of regulatory functions to decide some of the tough policy issues, frankly, that the legislature grappled with and decided they wanted to let the next generation of decision makers handle.

Matthew: Pass-off.

Jon: You might well say that. I wouldn’t. So those include, what is the affordability schedule? So adults in Massachusetts, starting later in 2007, need to have health insurance if they can find something affordable. Well, given your income, what is determined to be affordable? And what is the minimum amount of insurance that you would have to have? So regulatory policy decisions like that, on the one hand.

And on the other hand, we’re actually running a couple of insurance programs, one that’s subsidized for low-income uninsured. And we set the benefits and the enrollee contribution and actually enroll people, and serve as a market for them. And the other is, private unsubsidized health insurance, particularly for uninsured individuals above 300% of the federal poverty level, who are going to be buying out of their own pocket. And a big piece of what we do there is organize the market for them and try to do almost like some group buying for them. And create sort of a shopping mall for health insurance.

POLICY: Debating the Quality of VA Care By Eric Novack

May 11, 2007• 1

The many commenters and contributors
to THCB who have been touting the VA as the pinnacle of US health care—and
basing their conclusion that what we need is not ‘Medicare for All’,
but rather ‘VA Care for All’—have some explaining to do.

In this article, which reports the McClatchy
News Service’s investigation into the claims of the VA—the real
truth is not so rosy.

UPDATE: (5.11.07) Ed comments: McClatchy’s Washington bureau has set up a blog where you’ll find more detail on this story as well as related pieces on the military healthcare system.

POLICY: Freedom of Choice, Good for Education – Good for Healthcare By Eric Novack

May 11, 2007• 2

Proponents
of Sheila Kuehl’s ‘Single Payer’ health plan for California like to
lead with the argument that ‘Everybody in, nobody out’ is a good thing.
Of course, many of the same interest groups (ie. powerful lobbying
organizations in California) are vehemently opposed to school choice,
while demanding greater and greater regulations for what it means to be
a ‘qualified’ teacher.

Fascinating, then, the new study from USC’s Rossier School of Education.

The charter schools (read that to mean, more choices for students and
parents) do more with less funds, generally have fewer layers of
administration, and have fewer ‘licensed teachers’.

But it is all about outcomes these days—for both education and health care.
So how do charter schools stack up? From page 6 of the study:
California charter schools typically have smaller per-student
allocations than non-charter schools in their districts, yet charter schools have roughly equivalent levels of productivity: They get “more bang for their buck.”

Choice and freedom, and relieving the burden of excessive regulation and union
and other lobbyist control are good for education. The taxpayer
benefits. The student benefits. Society benefits.

So
why would the nurses union, whose members are on the ‘front lines’ of
healthcare, want to strip all choice and freedom out of healthcare?

H/T to the WSJ editorial page

POLICY: Communism breaks out on Wall Street? (No not really)

May 9, 2007• 6

I sat through a very interesting talk about American health care yesterday afternoon. I guess I knew all this but it was good to have it laid out in front of me. Here are my notes from the talk about the health insurance market.

The overall number of people with private health insurance has been stagnant (176.9m) since 2000 while the workforce is growing (from 137m in 2000 to 145m in 2006). The number of uninsured is growing as are those in public programs. And as a consequence the “lives” growth in the big for-profit health plans has been below Wall Street expectations. Consumer directed health plans are growing and from around 9–10m lives in 2007 may end up at as many as 25m lives in 2010 (although those projections are much lower than they were a year ago).

Margins are as high as they’ve ever been and are at the top or even higher than the top of the underwriting cycle. Is the underwriting cycle over as they’re saying? Maybe but it’s been around for 50 years, and margins in non-profit Blues (which the speaker said aren’t so concerned about profits as the for-profits, which may be news to some non-profit CEOs I’ve met!) have started to trend down, and overall premium trend is moving down. Furthermore, some competition between plans is causing overall pricing go down (although some of that may be change in product mix, as more HDHPs which have lower premiums are sold).

Then there was a great chart showing that usually medical cost trend goes up with a 3–4 year lag to overall economic growth. We’re at about 3–4 years after the start of the most recent economic expansion now. So should we expect medical trend to go up, while premiums are going (relatively) down, and so in consequence expect the financial health of insurers to be getting worse? (My note: Is that why they’re trying so hard to hang on to those “extra” Medicare Advantage payments?)

Finally, we’re seeing employer’s provision of coverage to their employees go down, unusually, in the middle of a boom (the jobless recovery is not jobless, so much as benefit-less).

What did the speaker think was the likely outcome of all this? Bad news for health plans compounded by national health reform starting in 2009 lead by a Democratic President.

And from which lefty did I crib all this insight? Matt Borsch, health care analyst at that well known group of Bolsheviks called Goldman Sachs.

POLICY/POLITICS: Wyden gets a noted conservative to join him

May 7, 2007• 2

Ron Wyden’s interesting universal health care proposal, which is essentially a variant of managed competition with an individual mandate that decouples employment from insurance is getting some support. And notably it has a major Republican, Bob Bennett from Utah, signing on. (Following is an email Wyden’s office sent out)

U.S. Senators Ron Wyden (D-OR) and Bob Bennett (R-UT) are scheduled to join some of the nation’s top CEOs at a news conference this Monday, May 7, to announce new business support for efforts to reform the nation’s ailing health care system. Wyden and Bennett are the chief Senate sponsors of the Healthy Americans Act (HAA), the first bipartisan, comprehensive health care reform bill in more than a decade to guarantee health coverage for all Americans.

CEOs and business leaders scheduled to attend the news conference with Wyden, Bennett and U.S. Reps. Brian Baird (D-WA) and Jo Ann Emerson (R-MO) include Steve Burd, CEO, Safeway Inc.; Art Collins, CEO, Medtronic, Inc.; H. Edward Hanway, CEO, CIGNA; Nancy McFadden, Senior Vice President, PG&E Corporation; Steve Sanger, CEO, General Mills; and Ronald A. Williams, CEO, Aetna Inc. Baird and Emerson announced earlier this week that they will introduce the Healthy Americans Act in the House.

Realistically this isn’t going to pass any time soon, and if it did Bush would veto it. But it does set the groundwork for a universal insurance system compromise sometime in the future and at least Aetna and Cigna think that they’ll be better off taking that compromise than the alternative!

PHARMA/POLICY: DEA insanity continues–Dr. Hurwitz Convicted

May 7, 2007• 2

I’m a little late as this happened last week, but it has to be reported even though it makes me very angry. The DEA and its poodles in the DOJ have succeeded in getting Dr. William Hurwitz Convicted on 16 Counts of Drug Trafficking. Hopefully Hurwitz will be out of jail relatively soon—although no guarantees. He’s served 2 and a half years for just being a doctor, and could serve up to 18 more.

Unfortunately the chronic epidemic of untreated pain goes on and on. As I pointed out in Spot-on last year :

45 to 80 percent of nursing home residents have substantial pain. The consequences of poor pain management include sleep deprivation, poor nutrition, depression, anxiety, agitation, decreased activity, delayed healing and lower overall quality of life. Fewer than half of nursing homes residents with predictably recurrent pain were prescribed scheduled pain medications

So we have a massive health problem, and the DEA acts like a bunch of brownshirts, going after pain doctors. Listen to Tierney’s account of one of the patients from the doctor that the prosecution used.

Then, during cross-examination by the defense, Dr. Hamill-Ruth was shown records of a patient who had switched to Dr. Hurwitz after being under her care at the University of Virginia Pain Management Center. This patient, Kathleen Lohrey, an occupational therapist living in Charlottesville, Va., complained of migraine headaches so severe that she stayed in bed most days. Mrs. Lohrey had frequently gone to emergency rooms and had once been taken in handcuffs to a mental-health facility because she was suicidal. In 2001, after five years of headaches and an assortment of doctors, tests, therapies and medicines, she went to Dr. Hamill-Ruth’s clinic and said that the only relief she had ever gotten was by taking Percocet and Vicodin, which contain opioids.

Mrs. Lohrey was informed that the clinic’s philosophy “includes avoidance of all opioids in chronic headache management,” according to the clinic’s record. The clinic offered an injection to anesthetize a nerve in her forehead, but noted that “the patient is not eager to pursue this option.” Mrs. Lohrey was referred to a psychologist and given a prescription for BuSpar, a drug to treat anxiety, not pain.“You gave her BuSpar and told her to come back in two and a half months?” Richard Sauber, Dr. Hurwitz’s lawyer, asked Dr. Hamill-Ruth. Dr. Hamill-Ruth replied that unfortunately, the clinic was too short-staffed at that point to see Mrs. Lohrey sooner. Under further questioning Dr. Hamill-Ruth said that she was not aware that BuSpar’s side effects included headaches.

Mrs. Lohrey looked elsewhere for help. Having seen Dr. Hurwitz on television _ — “60 Minutes” and other programs had featured his controversial high-dose opioid treatments — she sent him a letter describing her pain and the accompanying nausea and vertigo.“I have lost hope of retrieving my life as it was,” she wrote, because she could find no doctor to take her seriously. “I currently have a physician who has said that I am psychologically manufacturing my headaches, and that I am addicted to narcotic pain relief. This of course is not the first time that I have been treated as a ‘nut’ or a ‘junkie.’ ”

<SNIP>

“I felt that I had a duty to the patients,” Hurwitz said. “I hated the idea of inflicting the pain of withdrawal on them.” After the closure of his practice in 2002, he said, two of his patients committed suicide because they gave up hope of finding pain relief. The most moving testimony came from Mrs. Lohrey and other patients who described their despondency before finding Dr. Hurwitz. They said they were amazed not just at the pain relief he provided but at the way he listened to them, and gave them his cellphone number with instructions to call whenever they wanted.

“I felt like I was his only patient,” Mrs. Lohrey testified. “I think he truly understood the nature of what I was going through.” When she lost her health insurance, she said, Dr. Hurwitz continued treating her at no charge, and helped her enroll in a program that paid for her opioid prescriptions. After Dr. Hurwitz’s practice was shut down, she could not find anyone to treat her for seven months. Eventually, she found a doctor willing to prescribe small numbers of low-dose Percocet, but she said she was not getting enough medicine to consistently blunt the headaches.

“The last two weeks, I was pretty much in bed and sick with the headaches and the nausea and the whole nine yards,” she said, explaining that she had deliberately undergone the two weeks of pain in order not to use up any of her pills. “I had to save up medication,” she testified, “so I could be here today.”

Tell me which physician was guilty of malpractice, and why on earth one of them deserves to be in jail?

POLICY: Slagging off Philip Longman, defending Jon Cohn

May 3, 2007• 3

Up at Spot-on I’m defending Jon Cohn from a way-off topic review of his book from Philip Longman in the Washington Monthly. This is an important topic because Longman is in the “we can’t afford universal health insurance because the delivery system is inefficient” camp. He’s way wrong about that and he’s not alone. In fact his logic is backwards. We need to sort that out quickly, and I have a go at doing so in a piece called New America? Old Excuses. (The “New America” is the Foundation Longman is from which for some reason has teed off my editor over at Spot-on in the past). Here’s the intro:

Last week, I came to criticize Jonathan Cohn (for being too nice). Today, I come to defend him. Phillip Longman who hails from the New America Foundation complains in the Washington Monthly that Cohn’s new book Sick is Misdiagnosed because Cohn concentrates on the financial consequences of living without health insurance and not on the overall problems with inefficient and ineffective care in the U.S. system. He doesn’t exactly get off to a roaring start, taking Cohn to task and getting it totally wrong in the process.

Read the rest and come back here to comment

POLICY: Local health reform doesn’t work

May 1, 2007

Incremental health reform doesn’t work. Not even in Maine which is learning an "Expensive Lesson as Health Plan Stalls."

TECH/POLICY: Boston Friday dog blogging

Apr 27, 2007

This week I’ve been in Washington DC at the World Health Care Congress and I’ve talked to a lot of people–some on and some off the record. Much of that of course has been available at WorldHealthCareBlog, and some smattering of that has been seen over here at THCB from time to time. But all engrossing stuff—especially getting up close and personal with Jack Wennberg a couple of times.

I then moved up to Boston where I’ve been listening to some smart people and talking with various technology companies. You’ll hear much more about that in the coming days, including a very interesting interview with Joseph Kvedar at the Center for Connected Health at Partners. That’ll be a podcast when the upload cooperates.

POLICY: Ezra Klein’s The Health of Nations

Apr 25, 2007• 13

Now I’ve met Ezra I can stop calling him the young punk. He has written another excellent review of health care in universal coverage nations, including socialized medicine in the heart of America for our allegedly most treasured citizens.

It’s called The Health of Nations. Go read it.

It’s not entirely without flaws, almost all to do with the lack of good recent data that’s a problem with these comparisons and a need to conserve space. He skips over the UK’s private insurance system which enables the rich to trade up for elective surgery, and the recent increases in spending under Blair which have enable the Brits to buy spare capacity in private countries, (and ramped up GPs pay!). It would be nice to have Ezra do something similar on Japan and Holland (although Japan looks something like Germany plus a Canadian fee schedule, and Holland looks like an Enthoven-wet dream).

What’s also to some extent missing is the changes that have happened recently. Humphrey Taylor remarked to me on Sunday that Americans dont realize how much other systems are changing as ours essentially never does. The Brits have gone to 30% P4P in primary care; the Dutch to individually purchased insurance in a managed competition framework; the Danes and the New Zealanders have added rapid deployment of IT (100% EMR use in ambulatory care); whereas the Australians have added a private top up layer over their traditional socialized medicine system; the Swiss have their individual mandate.

Of course all of these systems have their problems and all are changing; we’re stuck in 1991. And in fact the VA system, although it works very well it about to be hit with a wave of Iraq war vets who have real problems–and is unlikely to get the resources it needs to deal with them.

And although it goes without saying to those in the know, we should keep repeating that this is the only system that visits not only ill health on the unlucky but often financial disaster too.