For those of you curious about the AMA’s recent “Girls Gone Wild” survey, some interesting stuff from Mystery Pollster. Here’s Part 1 and here’s Part 2. If you look deep in the comments about Part 2 you’ll see my cynical viewpoint.
Hat tip Health Business Blog
THCB regulars know that we love Michael Millenson, even if he is a swiftboater! Like some of these very vigorous THCB commenters, he’s been thinking a little about transparency!
News item: The Bush administration says it will publish the prices Medicare pays for common procedures in order to encourage comparison shopping. A private Web site immediately began posting some hospital prices. Mr. McClellan, is it? You’re here for the… ….colonoscopy. The Internet Special. I believe it’s $1,299.95 through the end of this week.
Quite right. As I’m sure you know, many people are still a bit squeamish about the idea of a tube being inserted up their…lower intestine, so we’re offering a real “bare bottom” price, if you get my drift. Before we begin, though, there are a few questions I need to ask. First of all, would you like anesthesia?
Don’t I need anesthesia? Mr. McClellan, we don’t believe it’s our role to dictate to consumers what they “need.” Should you wish to decline anesthesia, we will provide you with a set of headphones, loud music and a shiny new bullet to place between your teeth. However, in that case, we recommend strongly that you select the “extra-narrow gauge” endoscope equipment package. Endoscope? The tube that we put up your… Umm, I get the picture. But I’m still a little confused about the anesthesia not being included.
When you fly coach, Mr. McClellan, do you still expect the airline to provide you with a lavish meal? Our hospital will never compromise on your safety, but surely you cannot expect that in today’s competitive environment we will subsidize your comfort. I apologize for even mentioning it. How much does anesthesia cost? That depends on how long you would like to be sedated. We have very reasonable prices on “deep-sleep” packages that come in 15-minute units. You the empowered consumer decide how long you want to be sedated. We also offer the “all you can sleep” option, where we keep you sedated from just before the procedure starts until your doctor is totally finished. We think of this as being analogous to buying the full tank of gas at the car rental counter. Most of our customers believe the peace of mind this option provides is well worth the small extra expense, particularly if their colonoscopy takes longer than expected. I certainly agree with that. By the way, how long does a colonoscopy take? It varies, but with Dr. Hoover, about forty-five minutes. Dr. Hoover? Dr. Hoover comes standard with the colonoscopy package you selected. Quite frankly, since he retired from full-time practice a couple of years ago, the other physicians have found it close to impossible to match his fee. Naturally, at this price we can’t allow any substitutions. Now, if you don’t have any questions you’d like to ask me, I think we can begin. I do have just one question. If during my colonoscopy Dr. Hoover discovers a suspicious growth that might be cancerous, what happens next? Unfortunately, our hospital has found that it isn’t really profitable to get involved in the “post-surgical” part of the business. However, one of our customer service representatives will be delighted to provide you with some shopping tips on “pathology labs.”
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Copyright 2006, Michael L. Millenson. Michael is an author, health-care consultant and visiting scholar at Northwestern University’s Kellogg School of Management. He can be reached at: m-*********@**********rn.edu <b<
There’s been some fuss about the recent grading of America’s mental health care “system”. Dr. Deborah Serani who’s usually to be found over on her Psychological Perspectives blog, explains what the new NAMI grading is all about, and no we don’t look good:
The National Alliance on Mental Illness (NAMI) the nation’s voice on mental illness, presented the first comprehensive state-by-state analysis of mental health care systems in 15 years in March 2006. Every U.S. state was scored on 39 specific criteria resulting in an overall grade and four sub-category grades for each state.
Nationally, the mental healthcare system is in trouble. It’s overall grade average is a "D". Five states receive grades in the B range. Eight receive F’s. None received A’s. And several states obtained a grade of "U", indicating an unresponsive score to the research data.In recent years, most =U.S. states either have reduced funding of services for people with serious mental illnesses or have level-funded these programs. The impact of inadequate funding has been devastating – we now see overflowing emergency rooms with no place for people to go, increased numbers of people with serious mental illnesses in jails and prisons, and large numbers of people without access to desperately needed services.Research shows that treatment works — if you can get it. But in America today, it is clear that many people living with the most serious and persistent mental illnesses are not provided with the essential treatment they need. As a result, they are allowed to falter to the point of crisis. The outcome of this neglect and lack of will by policymakers is catastrophic.The 230-page report, including individual state narratives and scoring tables, is available on-line at www.nami.org/grades.
To find my mots de raison today, you’ll have to click over to Spot-on where I’ve been intruiged by the little legal challenges that Wellpoint’s now facing and spent some time thinking about Yin and Yang – The wonderful world of health insurers. Going back to read The Soul of an HMO article was indeed a trip in more ways than one.
As ever you can come back here to comment.
The recent RAND study that suggested that there were few or no differences in the quality of treament of minorities when they got into the US health system has not been taken lying down by those who believe that there are great differences, and that ignoring them to look at the bigger picture, as the RAND researchers suggested, is not the way to go. Brian Smedley, the research director at The Opportunity Agenda wrote this opinion piece criticizing the RAND study for THCB:
Ask anyone who’s worked in, received treatment in, or studied American hospitals and health care systems, and you’ll find broad agreement: U.S. health care systems are beset by quality problems. Information systems don’t "talk" well with one another, medical errors remain all too common, and many patients don’t receive the types of treatments and services that they should.
Recently, a new study expands on these problems, finding that treatment is mediocre at best for all patients, regardless of race, ethnicity, gender, or income. This study, published March 16 by physician Steven Asch and colleagues in the New England Journal of Medicine, finds that, on average, patients receive a little more than half of the care recommended by a set of "gold standard" guidelines. And even though few patients are well-served, women and minorities were found to fare better than whites and men in receiving recommended care.
This finding wouldn’t be so shocking to most Americans, who tend to believe that health care is fair for all groups, even if less-than-stellar. Many Americans tolerate (and therefore tacitly accept) that fact that minorities are more likely to be uninsured or underinsured, or to live in communities that lack high-quality primary and specialty care, access-related problems which have profound implications for quality of health care. But once patients are in the health care system, we believe, race or ethnicity doesn’t matter.
This view, however, squarely contradicts what the vast majority of research studies have found for decades – that some patients, most notably African Americans, Latinos, those who don’t speak English well, and in some cases, women – receive a lower quality of health care than their counterparts, even when they have similar health insurance and are treated for the same health conditions in the same hospitals. This applies across the gamut of health care, ranging from basic services such as screening and immunization, to primary care, to more expensive, high-tech, specialty procedures.
These are the conclusions of literally hundreds of studies published in peer-reviewed journals over the last two decades. And while a few studies, such as the Asch study, find that disparities are diminishing or that all groups receive equal (albeit poor) treatment, their findings must be considered relative to the massive volume of evidence to the contrary. Even the U.S. Department of Health and Human Services’ National Healthcare Disparities Report, released in January and which represents the most comprehensive survey of its kind, finds that, despite some areas of improvement, racial and ethnic healthcare disparities persist, and are worsening in some areas. For example, the NHDR found that Latino patients with diabetes are receiving poorer quality care today than they were even a few years ago.
Importantly, the Asch study confirms that quality problems abound. But the authors’ conclusion – that "quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care" – unfortunately presents a false choice. Policymakers are not confronted with the question of whether to prioritize efforts to reduce inequality, or efforts to improve overall quality. Rather, these problems are inextricably linked. The persistence of healthcare disparities is a clear warning that systemic problems plague our health systems. Moreover, many of the same interventions that will reduce disparities – such as promoting the broader use of evidence-based guidelines and public reporting of hospital quality scores by patient race, ethnicity, and primary language – will help to improve quality for all patients.
Progressive health care advocates should seize upon health care disparities as a key political issue and an argument for stepped-up quality improvement efforts. Unequal health care is not only wrong, it’s one of many signals that American health care is reeling from systemic problems that hamper the best efforts of hard-working physicians, nurses, administrators, and others to provide the best quality care. Our concern and focus should be on raising the quality of care for everyone, with particular attention to those who are least well served.
And if you hadn’t had enough of Part D at THCB today, I’m also up with a brief article about it at TPMCafe’s Drug Bill Debacle site called Putting out fires
After all the yarling and snapping of the introduction of Part D, there was a curious article in the New York Times on Sunday suggesting that "For Some Who Solve Puzzle, Medicare Drug Plan Pays Off." Of course this is not exactly news. Several of us said at the time that the plan would improve the financial well being of lower-income people not poor enough to Medicare who were heavy Rx users and would now have catastrophic coverage. A real study funded by Kaiser FF said exactly that in 2004. In fact it’s headline was
LOW-INCOME MEDICARE BENEFICIARIES CAN EXPECT SUBSTANTIAL HELP FROM
PRESCRIPTION DRUG LAW, BUT OTHERS WILL GET LESS ASSISTANCE
And that report’s summary said:
Low-income people with Medicare
who sign up for new Part D drug plans and receive the additional subsidies – an
estimated 8.7 million people – are projected to pay 83 percent less for
prescription drugs in 2006 than they would have spent if the Medicare drug law
had not been enacted, according to a new report released today by the Kaiser
Family Foundation. Those who enroll in the new drug benefit but do not receive
the low-income subsidies – an estimated 20.3 million people — are projected to
pay on average 28 percent less out of pocket for their prescription drugs as a
result of the new law, the analysis finds.
Of course that all was based on a higher forecast of enrollment than it looks like we’re currently seeing. But that means that if you enrolled and you fit into that category, then you will be paying less. In fact an independent pharmacist quoted in the NY Times article gets it basically right.
Todd E. Pendergraft, owner of a Medicine Shoppe pharmacy in Broken
Arrow, Okla., outside Tulsa, said the new drug coverage was
"significantly beneficial" to one-third of his 750 Medicare patients,
"marginally beneficial" to half the patients and "no benefit at all" to
the remainder.
Because it’s of no benefit to most, and will eventually mean a reduction in employer retiree benefits, on a purely political basis I advocated Kerry running heavily against the bill in 2004. While he never really mentioned it (and my meager attempts at the time to get Democrats to pick up on it were ignored), it’s still a hot issue in 2006, and one that now will be picked up on politically. Of course because of the incompetence shown during the transition to the new program, it’ll be run on in the Katrina/Iraq incompetence meme, rather than the "destruction of Medicare" meme.
But the flat answer is that, yet again, because not everyone is put in the same pool (i.e. seniors are not forced to buy into Part D) there will be adverse selection amongst those who do. That adverse selection is coming from the people who are now better off (because they wouldn’t have bought it if they didn’t think they would be). Eventually in a couple of years the PDPs will start losing money, jacking up their rates and upsetting their senior customers — and the subsidies hidden in the bill for those PDPs start reducing at around the same time. Just as happened with Medicare HMOs in the late-1990s.
If you really wanted to run a proper drug benefit using private plans, you ought to force everyone to join so that you have a universal risk pool. But of course Congress would never dare have done that politically after the experience of Medicare Catastrophic in 1988 nor would they have forced the employers to pay into the pool for their retirees. So we get the hodge-pot we’ve got, with all the confusion and angst it’s caused amongst seniors.
And of course we’ve got two calendar issues coming up. The first formulary switch and the first donut hole "approachees".
Beneficiaries could face new problems in coming months. Insurers can
impose stricter limits on access to certain drugs after March 31, when
a 90-day transition period ends. In addition, some beneficiaries will
have to pay more at the pharmacy counter, because most drug plans have
a gap in coverage after a person’s total drug costs reach $2,250. The
gap lasts until the beneficiary incurs total drug costs of $5,100.
Beyond that point, Medicare pays about 95 percent of the cost of each
prescription.
The argument in favor of the formularies is that this is how private sector drug plans work. But CMS isn’t going to make much headway with the line that "formulary restrictions are how the private sector PBMs work" because seniors are rather more interested in their health care than working-age Americans. Somewhere at the end of this calendar is an election, I recall. And I can see the Ad now "Part D is worse than Medicare and those Republican bastards forced me into it."
And did you know that the very law creating Part D bans Medicare from negotiating with those evil bloodsucking pharma companies, even though the VA is allowed to? I suspect you did, and if you don’t you will by November!
CODA: You might want to see my other post this morning for a link to much more discussion about Part D.
UPDATE: And then there’s the power of the headline. Of course the entirely disinterested AHIP Solutions SmartBrief newsletter puts a slightly different spin on the story:
 |
More praise from Medicare drug program beneficiariesDespite reports of some problems with the Medicare prescription drug program, some customers say the benefit was worth the sometimes confusing and complex process of enrolling. People in places such as Tulsa, Okla., who were more removed from the political debate about the program, say friends and family helped them with the choices and the outcome is satisfying. |
A long transcript from a conference full of health care journalists (hat-tip Kasier FF) in which Leslie Norwalk from CMS proves that she’s very brave, or maybe even foolhardy. And apparently Medicare Part D was all Al Gore’s idea….. Bob Hayes from the Medicare Rights center, Susan Jaffe, from the Cleveland Palin Dealer and Stuart Gutterman from Commonwealth, don’t exactly agree.
Well worth a quick flip through.
There’s also one on the uninsured which is horribly transcribed, but suggests that some of the reporting about Dirigo care in Maine has been wrong, including one that I picked up on in my Spot-on piece on why we need ONE insurance pool.
Here’s what Joe Ditre, executive director, Consumers for Affordable Health Care, says about the WSJ opinion piece and it does indeed sounds as though the insurer-backed Council for Affordable Healthcare which wrote the articel with a local right wing think-tank has been caught with its hand in the statistical cookie jar:
the Main Heritage Policy Center and they put out this piece that basically said that in the state of Maine that the Dario Program had …only twenty two-percent of all enrollees were previously uninsured. The fallacy is that they based that statistic on one quarter of enrollment which did not include the individuals who enrolled. Again, Dario covers small businesses and individuals, so they focused on the very first quarter of the program’s operation in which no individuals were allowed to enroll because they had to enroll in the second quarter. So they took that percentage, twenty two-percent and what did they do they applied it across the entire enrollment for the first year only sixteen hundred people were uninsured. Now, that’s problematic from any point of view but it is the story that has stuck in the state but one the government didn’t respond quickly enough to basically take away or say that’s false but too, these mouthpieces have been able to get this story, it was in the wall street journal, if you saw that story, and it was printed up on the Kaiser website, I mean on their you know their coverage of the when they do that sweep of the national stories it gets repeated everywhere and it’s false.The real number of uninsured is forty four-percent of them are uninsured overall, within the individuals it’s fifty-percent,– of the ten thousand forty four-percent overall are uninsured, were previously uninsured
Looks like the power of Health Care Renewal (and THCB) is proved again. (Ok, OK kissing…) But after featuring the story about Donna Shalala and the Univ of Miami janitors who didn’t have health insurance, apparently the university has caved. Correspondent JC reports:
Well, Shalala finally came to her senses (actually, her political senses). In addition to providing a 25% pay raise to the janitors (they are technically still not formally organized), they have agreed to offer health insurance coverage for $13 a month to employees. The janitors are to become effective 4/1. If interested, I’ll let you know how it goes.
The interesting thing, is the publicity has put pressure on other entities. A couple of other local universities (public and private) are beginning to feel the pressure to provide coverage to hundreds of uninsured low-wage workers. It is a positive ripple effect.
Despite the risk of upsetting Jonathan Cohn — who I think is great — I take a little dig at his mother ship over at Spot-on. My piece is called Politics, religion, The New Republic, and health care, and it’s just a matter of timing.
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