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Tag: Policy

POLICY/INTERNATIONAL: Canadians somewhat grumpy about waiting, but not waiting that long

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How bad are those terrible waiting lists in Canada? Well if you hang with the loonies at Fraser and PRI they average 10 months for a typical pregnancy and care for everyone else is delivered only by morticians. On the other hand, StatCanada (the official government body, and this one I believe is an independent bunch of civil servants rather than the US variety who’s reports are re-written by 23 yr old Republican staffers) is out with some real data.

What’s the conclusion? Canadians have to wait a little bit, and they’re pissed off, but only a little bit

Results for 2005 indicate that waiting for care remains the number one barrier for those having difficulties accessing care. Median waiting times for all specialized services have remained relatively stable between 2003 and 2005 at 3 to 4 weeks, depending on the type of care. There were some differences noted in selected provinces. Most individuals continue to report that they received care within 3 months.

Similarly, patients’ views about waiting for care have remained  fairly stable between 2003 and 2005. While 70 to 80 percent indicated that their waiting time was acceptable – there continues to be a proportion of Canadians who feel they are waiting an unacceptably long time for care.

And how bad did that wait make them feel? Well most didn’t seem to worry at all but some were pissed off.

The proportion of patients who felt that their waiting time was unacceptable was highest among those who waited for specialist visits (29%) and diagnostic tests (21%) and lowest among those who waited for non-emergency surgery (16%) (Chart 2 ; Table 9) even though individuals are more likely to wait longer (i.e. > 3 months) for non-emergency surgical care compared with other specialized services (Table 7).

And for some the wait involved real inconvenience and pain. But that was less than 20%.

Approximately 18% of individuals who visited a specialist indicated that waiting for the visit affected their life compared with 11% and 12% for non-emergency surgery and diagnostic tests respectively. (Table 10)

And most of that was stress related rather than actual pain, although there was some of that too with about half experiencing pain. (These are proportions of those who experienced adverse effects from waiting)

Most of those who were affected reported that they experienced worry, stress and anxiety during the waiting period: ranging from 49% among those whose lives were affected by waiting for non-emergency surgery to 71% among those affected by waiting for a diagnostic test. (Table 11) Between 38% and 51% of individuals waiting for specialist services experienced pain and close to 36% of those who were affected by waiting for non-emergency surgery indicated that they experienced difficulties with activities of daily living. Approximately 28% of those who were affected by waiting for a diagnostic test indicated that it resulted in worry, stress and anxiety for their friends and family.

But of course what this doesn’t tell you and what the myopic Canada bashers like Gratzer, the PRI crowd and the AMA guy all fail to point out is the other half of the equation.

Even if every single American never had to wait for any care, there is considerable the impact because of our system on the financial health of poorer Americans, and there is also consequent impact on those poorer Americans’ access to care services. Below is a chart from the 2004 Health Affairs report which shows that on a raft of issues, like not getting care from a doctor, skipping recommended care, and not filing prescriptions, the direct cost of care here impacts people just as much, if not more so. And of course some substantial number of Americans (whichever side of that argument you believe) are going bankrupt because of it.

Schoen_primarycarehltsystemperf_itlchart

Yes there are problems with the Canadian system. Yes there’s room for honest debate about it.

But take the veil of ignorance test John Tierney uses in his columns in the NY Times. If you didn’t know you were going to be born or become rich, which system would you rather be in given the realistic chance that you might end up poor? The one that will get to you if you’re prepared to wait a few months, or the one that you won’t ever get to because you can’t afford to, and that might bankrupt you if you really need it? I bet you nearly half Americans would change places if they knew.

HEALTH PLANS/POLICY: eHealthinsurance still skipping stats 101

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eHealthinsurance is out with its annual report of what premiums are in different cities and they’re still comparing the price of rotten month old apples with sweet juicy, juicy mangoes. And amazingly enough they’re different. Basically some states ban underwriting and therefore have insurance which is more expensive. So what I said last year when they said that prices were going down still applies—

On further review there are more questions than answers. Who got insurance? Was this group more underwritten (i.e. healthier) than the previous year? And what benefits were they getting compared to last year?  And were there changes in deductibles, co-pays and out of pocket maximums?

Just saying that the premium went down is a bit like saying the average price of a BMW 3 series is less this year on average because more people are buying them without the fully loaded options. And if it’s really true that apples for apples the premiums went down why didn’t eHealthinsurance.com put that information in the report?

Although last year apparently “prices went down” and this year they didn’t say that, so it’s pretty damn likely that if you compared apples to apples of the stripped-down underwritten plans they’re looking at, prices went up.

Of course in practical terms this report is useless. I’m a great example in that I applied for two identical policies from different carriers on eHealthinsurance—both quotes about $100 a month for a $2500 deductible plan. But when the underwriting was done, one was still $100 a month and the other wouldn’t take me at all and suggested I went in the guaranteed issue pool at $400 a month for a $4000 deductible. So quoting price without knowing what the individuals concerned need to go through to get the insurance and therefore knowing the actual price is useless.

I do note one little thing in their report. They say that St Louis Missouri has the cheapest children’s insurance premiums ($29 a month) and yet there are 119,000 uninsured kids in Missouri. In other words very cheap—or even free given the numbers who don’t sign up for the SCHIP programs—isn’t cheap enough to get kids (and adults) insured. eHealthinsurance seems to be surprised about this.

The only logical conclusion is that health insurance needs to be compulsory and automatic (although not of course free to those who can afford it). And in fact even eHealthinsurance could do OK in such a system, although the logical ramifications of it would be horrendous for many of the plans they broker for.

POLITICS/POLICY/HEALTH PLANS: On the Blues’ political giving & CDHP complexity

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Says here that Blues Plans Favor Republicans With Their 2006 Campaign Contributions. But I think what it means is that they’re favoring incumbents. Having said that and reading the polls and the tea leaves, I think the Blues might think about evening up those contributions given that the Congress is as likely to flip over his year as any since 1994, and that the Blue Dog Democrats are the crowd most traditionally aligned with their interests.

Meanwhile, Joe Paduda is showing that the CDHP is even more confusing to consumers than ordinary health plans. Well, when United bought the shysters at Golden Rule, you didn’t actually think that they were going to reform them, did you?

 

POLICY/THE INDUSTRY: Nice work if you can get it

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So for rewriting Alain Enthoven’s lectures from the late 1980s and missing the main points, apparently Michael Porter is being paid $50,000 a day, and that is a discount from his apparently usual fee of $100,000! Damn, that’s nice work and yes I am very jealous. Hopefully I’ll soon have his co-author Elizabeth Teisberg on THCB to explain what I don’t understand about their book which I’m chunking through at the moment.

When I said he was sinking in the health care quagmire, I should have said that he would be rolling in it.

HOSPITALS/POLICY: Unhealthy & unhappy Returns from BillMon

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I missed this but last week my favorite writer on the entire Internet, Billmon at the Whiskey Bar, wrote about health care. 99% of his posts are about foreign policy, from an extremely cynical point of view. But this time he looked at the capital problems facing hospitals and his extrapolating guess is that to maintain the profitability of hospitals we will soon be allowing emergency rooms to turf people out to die in the streets. His piece on the future of EMTALA (not that he uses the term, but he clearly understands it) is called Unhealthy Returns.

PHARMA/POLICY: Medicaid gets screwed over on best price, Ignagni fibbing again.

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A little while ago I sat through a webcast starring my favorite factually challenged health plan lobbyist. Karen Ignagni said this about the costs of pharmaceuticals for Medicaid that are now bought instead by the private plans working under Part D:

"I’m hearing shock from (state) Medicaid directors that we’re getting better prices than they are"

At the time I postulated this

Ignagni is either lying here
(or massively overstating the truth from a few anecdotes), or going to
find a few men in sharp suits from the rich part of K street funded by
big Pharma coming down to see her carrying baseball bats.

You see, Medicaid plans get from pharma manufacturers
what’s known as “best price”. In other words if they give a better
price to another customer, they also have to give that price to
Medicaid. Medicaid is still of course buying its drugs for its
non-Medicare dual eligible population. The drug companies know this, so
I doubt that what she’s saying is true. But if it is true that
Ignagni’s health plan members are getting a better price than the
states are, then the states can go back to the pharma manufacturers to
get a better rebate — oh, and also prosecute Pharma companies for fraud
over not giving them best price, as has happened many times.

And today writing in the New York Times Milt Freudenheim has picked on the issue, which he calls  a Windfall From Shifts to Medicare. So was Ignagni telling the truth? Were the prices that Medicaid is now paying for its drugs via Part D lower than they were paying under the best price regime? Well take a wild guess.

Under that program, as it turns out, the prices paid by insurers, and eventually the taxpayer, for the medications given to those transferred are likely to be higher than what was paid under the federal-state Medicaid programs for the poor.

McLellan is also quoting the line that Part D is getting better prices, but the article has a raft of evidence suggesting that the drug companies think they’re doing better, and the states are being asked to return more under the "clawbacks"–the amount they are being billed as they no longer have to provide drugs for the dual eligibles–than if they’d maintained their own programs. Several states are suing the Feds about that.

Meanwhile, I still think that they ought to be able to go to the drug companies and get "best price" for the rest of their Medicaid drugs (unless someone can tell me they have an exemption under the law). Which I guess in the end may make this a wash, if the drug companies have to provide even cheaper Medicaid drugs.

But for now it’s just more evidence that Part D is a windfall for drug companies and health plans, and that AHIP’s President has been caught being extremely economical with the truth. Not exactly news, I know.

TECH/POLICY/RANDOM: Monday update

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Apologies for the quiet start today. A few things to keep you going with while I work on some other stuff off-line

MyMedwork is a MySpace/Linked in for physicians which has funding from a business accelerator started by bunch of big name mid-west medical orgs (including the Cleveland Clinic). Hey I (re-)met my fiancee on Linked-In so there must be something to this social networking stuff?

The first rumblings in the real business of health care—how much Medicare pays for what—are starting up. CMS is rattling the saber, and somehow managing to divert the attention onto 3M which is attempting to redesign DRGs and getting it in the neck for its troubles, apparently. Of course this is the beginning, not the end of a very long and ongoing process. The same thing is going on on the physician side around changes in the RVS system. The health plans have been muddying this water for some time, as I noted in my article about the punking of Milt Freudenheim back in June.

I’ve been having some fun backchat with Michael Cannon at Cato (the thinking man’s libertarian think-tank) over his riposte to my piece about Medicare HSAs. Well worth reading his response. More on that when I get my act together to edit our emails…Meanwhile over at Cato’s blog you should read anything Radley Balko’s written. He’s doing the best job in America about tracking the western liberal Democracies’ almost imperceptibly slow movement towards becoming authoritarian states. Did you know that “swearing” in public in the UK can now warrant a $130 on the spot fine at the sole discretion of the police?

Finally, working on some stuff on the new San Francisco health plan, which will emerge at Spot-on soon—now that I’m banned from writing about soccer for quite some time!