Paul Starr and I have been agreeing a lot lately. Not that Paul knows or cares what I think or say, but a while back we both expressed fear that private health plans will end up channeling bad risks into the public option. That time I beat him to the punch (but I happen to know his piece was on the way before I hit “publish” on mine).
This time he was out first. Last Saturday he reminded Democrats that the big deal is not what happens with the public option, but instead what matters is how aggressive and effective Federal regulation of insurance (via the exchanges) will be.
For these reforms to succeed, there needs to be effective regulatory authority to prevent insurers from engaging in abusive practices and subverting the new rules. The bill passed by the House would provide for that authority and lodges it in the federal government, though states could take over the exchanges if they met federal requirements. The Senate bill would leave most of the enforcement as well as the running of the exchanges to the states. Yet many states have a poor record of regulating health insurance, and some would resist passing legislation to conform with the new federal law.
Of course Paul was a major author/player of the Clinton plan in 1993–4, which had it been enacted would have been way more extensive and impactful than the current legislation—and in a good way. I fear that this time his influence will be equally lacking in terms of the end result. Which is a big pity.
I had an interesting call from a member of the legal profession the other day, and it got me thinking about the post-reform prospects for my own particular collection of bete noirs—the insurers who prey on desperate people in the individual market. Yes, you can expect the subject of Mega Life & Health to appear later in this article.
Now some dummies are starting to complain about what, to this point, have been broadly accepted parts of the upcoming reform legislation. Robert Samuelson is a typical advantaged recipient of community-rated insurance yet complains about the same concept being extended outside his community-rated group made up of Washington Post employees. AARP suggests in response that he should be sending (his much younger WaPo colleague) Ezra Klein a check, as Ezra is in effect subsidizing Samuelson’s health insurance.
While the political cognoscenti is struggling with the public option and payment rates to rural hospitals (and other bribes needed for DINO Senators from Nebraska & Louisiana, and the NEDINO one from Connecticut), the real issue of health insurance regulation is getting scant attention. In particular three huge issues remain to be resolved:
There’s a big to-do about whether there are really any cost-saving measures in the House and Senate bill. Most people say that the answers are “no” and “sort of”. There’ll be much more discussion about that on THCB this week, and I suspect the answer will really come down to whether or not pilot programs which have the potential to reduce costs can be both successfully piloted, then extended by CMS and then protected from Blue Dogs, reps from academic medical centers, Republicans saving Medicare and basically everyone in Congress carrying the industry’s water. So “sort of” may well mean no.
But let’s not dwell on that. Instead let’s have some fun. Regular THCB readers will know that AHIP’s Karen Ignagni has told half-truth after half-truth after outright lie to protect the position of her members. All the while somehow holding together a coalition that really should have broken apart long ago (and may yet still do that). And she gets paid very well for that role.
But today in the WaPo she told the truth:
Karen Ignagni, president of America’s Health Insurance Plans, said the Senate bill includes only “pilot programs and timid steps” to reform the health-care delivery system, “given the scope of the cost challenge the nation faces.” Unless lawmakers institute changes across the entire system, Ignagni said in a statement Wednesday, “Health costs will continue to weigh down the economy and place a crushing burden on employers and families.”
Don McCanne (who runs the Quote of the Day service from the PNHP) puts the boot in:
There could not be a more explicit admission that the private insurance industry is not and never has been capable of controlling our very high health care costs. <snip> Karen Ignagni says that the lawmakers must institute the necessary changes across the entire system (because the insurers can’t). Let’s join her in demanding that Congress take the actions necessary, and then thank her for her efforts, as we dismiss her superfluous industry from any further obligations to manage our health care dollars.
And it’s basically true. Health plans have no ability to overall restrict health care costs. And worse, because they’ve been able to charge more to their customers than the increases they’ve received from their suppliers, they do better in a world in which costs go up.
Of course Ignagni knows that gravy train can’t roll on forever, so she’s trying to craft a future in which the health plans can continue to make money, yet not bankrupt their customers outright. Whether it’s good for the rest of us remains a very open question.
Meanwhile, in another example of catching someone saying something that they don’t really understand the meaning of, Uwe Reinhardt busts Sen. Kay Bailey Hutchinson (R-TX) as saying that not having insurance coverage is rationing and shouldn’t be allowed. Well she may know have thought she was saying that, but that’s what she was saying.
In 1999 Caresoft developed a consumer web portal called the Daily Apple. The Daily Apple wasn’t all that unique or different than other health portals, until in May of 2000 they began helping consumers download their lab test results from Quest Diagnostics. Now THAT was different! A portal aggregating real clinical data on behalf of consumers, with the potential to drive personalized health information, recommendations, and alerts to the individual. “Looks like your exercise and your diet are keeping your blood sugar under good control. Great Job!” and “Your liver enzymes are elevated, which might be due to your Lipitor. You should talk with your doctor.” Now that’s information a person can use! But sometimes even the best ideas suffer from poor market timing. It was only 19 months later, in December, 2001, that the service was discontinued. Many of us on the outside wondered why such a seemingly unique and valuable service would be disabled. But whether it was the lawyers, the doctors, or the business model, timing wasn’t right.
Only a couple years later, in 2003, the Office of Civil Rights at HHS wrote the HIPAA Privacy Rule regulations, allowing consumers to access a copy of their own protected health information. But they carved out lab data as a special case. Lab data (or data governed under the Clinical Laboratory Improvement Amendments, or CLIA), was to be governed under CMS regulations that stated that lab test results could only be delivered to “Authorized Persons”, defined as “an individual authorized under state law to order tests or receive test results, or both.”Continue reading…
It’s been a fun week. After years of THCB explaining that neither could AHIP do genuine research nor could its venerable President open her mouth without lying, the rest of the world has caught on. I won’t rehash the blow by blow here—Jonathan Cohn is among many who’s done that already—but essentially AHIP commissioned PWC to include the half of the analysis about the Baucus bill that was favorable to them and leave the rest out. And the fall from grace has been particularly fun to watch. Even the whores from PWC who wrote the report criticizing the bill have been backing away from it. And some astute commentators think that the debacle has helped the likelihood of a more liberal bill’s passage.
Now to be fair (or overly fair as they’d never concede this to the other side), the insurers have a point. They loaded Baucus up with lots of cash and put a former Wellpoint exec in as his chief of staff. They romanced the White House and kept quiet when Pelosi and the rabble criticized them. The deal they thought they’d cut was that they would give up the way they currently make money by underwriting and risk skimming in individual-small group and being overpaid for Medicare Advantage, and in return they’d get 45 million more customers, all forced to buy insurance and subsidized by the government to do so.
But somehow along the way the Democrats, despite lots of tough talk about “bending the curve,” lost the cojones to find even a mere $100 billion a year to redistribute from the probably $1 trillion waste in our $2.5 trillion health care system.
At last weeks Health 2.0 Conference Maggie Mahar, author of HealthBeatBlog got more than a little feisty about Al Waxman’s suggestion that we make people with bad health behaviors pay more. She said that 95% of smokers had some form of mental illness, and therefore we were punishing the mentally ill. Really? Read on for Maggie’s explanation (lifted at her request from a comment elsewhere).—Matthew Holt
According to the New England Journal of Medicine,
“The link between smoking and anxiety also helps explain why smoking is so strongly correlated with mental illness. “smoking rates have been reported to be over 80 percent among persons suffering from schizophrenia, 50 to 60 percent among persons suffering from depression, 55 to 80 percent among alcoholics, and 50 to 66 percent among those with [other] substance-abuse problems.”
Poverty is highly correlated with smoking because poverty is stressful. U.S. soldiers also smoke in greater numbers than the population as a whole–even if they didn’t smoke before joining the army The NEJM reports:
“Serving in the military is a risk factor for smoking even for those who did not start smoking prior to the age of 18. Smoking is the number-one health problem for vets,” says Dr. Steven Schroeder, former President of the Robert Wood Johnson Foundation, where he focused on smoking cessation. “And reports are showing that many US soldiers serving in Iraq are turning to smoking to relieve their stress.”
At the Health 2.0 conference, Al Waxman asked the audience how many thought that smokers should be “penalized” for smoking, presumably by paying more for insurance. I pointed out that the vast majority of adult smokers are poor; many suffer from some form of mental illness.Do we really want to punish people who are living in poverty and are mentally ill?
A really fun piece from Keith Olbermann as he shows how the entire Gang of Six and more voted for fully socialized flood insurance and yet seem to have a problem with an independent government run public option.
Of course, now that a bill has finally left Baucus committee, our meandering towards a relatively inconsequential tinkering at the edges of the health insurance market is a little further down the path. But can we somehow arrange it that the bozos at the NY Times (yes I’m talking about Robert Pear and David Herzenhorn) please stop saying things this dumb:
the Democrats are trying to restructure one-sixth of the economy, writing a bill that will affect almost every American, every business and every doctor and hospital in the country.
The level of exaggeration in that statement is simply unworthy of the paper of record. Would that it were true.
Given that she taught me most of what I know about health IT I don’t know why I ever need reminding about how great Jane Sarasohn-Kahn is at keeping her finger on the pulse of health care, and how consistently good is her one daily post on Health Populi.
Yesterday was no different. She gave a great overview of a new PWC study on data liquidity. You’re going to hear lots from me and others in the coming days about data liquidity, substitutability, intermingling of applications, and unplatforms. But what’s happening on the edges of health care IT in the Health 2.0 movement is a combination of tools, content and transaction data beginning to flow between applications. More and more this is both enabling better management of the consumer (and clinicians) workflow experience and better ways to aggregate these new data sources for clinical decisions and research.
On day Two of the Health 2.0 Conference next week we’ll be showing this both in our panel on Data Drives Decisions, but also on the Tools panel which will feature a series of inter-operable applications sharing data. And we’ll also be showing the big players (Google, Microsoft & WebMD) as they move their offerings to a world where other service providers can use their platform.
Truly exciting times, but Jane points out that there are lots of barriers. She calls the PWC report
a sober analysis of what stands between transactions and raw data, and the ultimate goal of using that information: clinical transformation that benefits people.
And those barriers all center around the workflow, payment structure and institutional inertia of our current health care establishment.
the health industry en masse needs to shift the focus of data from transactions to quality and outcomes. This will require – surprise, surprise – incentives to, as PwC puts it, “induce all stakeholders to collect, report and use the data.”
If you want to watch the documentary Money Driven Medicine based on Maggie Mahar’s book, it’s now available for free download at moneydrivenmedicine.org (the DVD is also available for purchase). The free download is part of an ongoing “Watch-In! For America’s Health” — a national viewing party organized in conjunction with the Consumers Union.
until I found out that the people who the NY Times says are really in favor of it are Bill O’Reilly and Regina Herzlinger…
Actually I’m kidding. I knew Regi says she likes it, and Maggie Mahar ripped her position—(Herzlinger’s position being that she espouses a version of the Swiss system for the US)—to shreds a while back. But would Herzlinger really want to live in a world where there was no easy money to be made trading in the stock of health insurers who are defrauding state governments? But I’ve got to say that Herzlinger and O’Reilly make a interesting couple.…pass the falafel.