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Tag: Policy

POLICY: The future of retirement

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In this book review of a couple of finance books in the New York Times, Neil Genzlinger is close enough to being right to remind us why we need to figure out the underlying problems in the health care system.

But as far as radical new ideas, the visionary approach would have been the blunt one: forget retirement planning. Hakuna matata. In the future, whether you have $15 million socked away or $1,500, nothing will matter – not food, not shelter, not golf, not active-senior communities – except health care benefits. Medical science, which already offers rebuilt knees and transplanted livers and faces, will soon offer new everything, but at a staggering cost. The Health Care Cabal will issue a one-page retirement plan: “In exchange for all your assets, including your children (and all their future earnings in perpetuity), the H.C.C. agrees to replace your parts as needed, while supplies last.” And everyone will sign it, because here in the have-it-all era, death is simply unacceptable.

POLICY: Joe Paduda explains what’s wrong with Part D’s economics

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While we’ve been focused on what’s wrong with Part D’s implementation, Joe Paduda reminds us all about one of the other problems with Part D. It’s that by it’s nature a voluntary benefit is going to attract adverse selection. In other words, the only people signing up for it so far — and barring the dual eligibles who were involuntarily alloted into it there haven’t been too many, and DSS reports that there won’t be that many more — are the ones with big drug costs. So by definition eventually the plans will start losing money.

For now the PDPs are being covered against that risk, and the very generous taxpayer will make up the difference. But later on the taxpayer may not be so generous (as with Medicare Risk in the late 1990s) at which point the PDPs will start to exit.

This, by the way, is exactly the inverse of the problem with HSAs, where all the healthy people will leave the insurance pool, leaving those behind in a death spiral.

QUALITY/POLICY: Need an Organ? It Helps to Be Rich

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Were you looking for this?ABC News reporter Joy Victory found a really juicy angle on the problems of being uninsured. Her article is called  Need an Organ? It Helps to Be Rich. As you might suspect getting on the waiting list for an organ if you’re uninsured is pretty tricky. Entry to the list is controlled by the big medical centers that do transplants. Although everyone is supposed to be viewed independently of means, its totally obvious that if the patient is uninsured the hospital concerned will lose a packet on the procedure. So like every other aspect of care access for the uninsured, their chances of getting access to that list are much lower than those with insurance. And of course it goes without saying that unless they are lucky enough to be in a job offering great insurance — a number which is getting lower every day — they are not going to be able to buy insurance at any affordable price.

But the fun contrast that the article brings up concerns the other end of the transplant pipeline. Nearly 23% of those who’s organs are donated for transplantation were uninsured, who in other circumstances wouldn’t be eligible to accept their own organs! So this is a case where the haves are literally living off the have-nots.

You’d think that the advocates of universal insurance could run with this one a little?

POLITICS/POLICY/PHARMA: Compare and contrast GWB and LBJ on Medicare

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2_24_112205_teacher_sex2_smallJonathan Cohn takes a good look at the Medicare implementation now and then, in What Bush could learn from LBJ on Medicare. Not too surprisingly the current screw-up wasn’t evident in 1965, even though the Johnson Administration had only 11 months to implement an entire new program, as opposed to the Bush Administration’s 25 months to add a new one on.

It does have to be said that McClellan’s golden boy image is starting to look a little like his brother’s — he of the “I know nothing” attitude (If you don’t know what I’m talking about look under N here)

POLICY: Busboys On The Street

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I’m up at Spot-On talking about pay or play, and the San Francisco Busboys On The Street. Next week we’re taking the politico-nerds remedial education in another direction, but for now this finishes pay or play….

POLICY/POLITICS/TECH: Jon Cohn plays Gotcha on Part D

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John Cohn finds the December GAO report that says that CMS wasn’t ready for Part D’s launch, and also McClelland’s response that the GAO was underestimating CMS. Make that “mis-underestimating”, I think. 

Here’s what the GAO Report says would be some likely problems with Part D’s introduction for the dual eligibles:

For dual-eligible beneficiaries who do not have Medicare drug coverage because they were either not identified and enrolled on January 1, 2006 or are newly qualified dual-eligible beneficiaries, CMS has developed a point-of-sale enrollment mechanism designed to enable pharmacies to assist these beneficiaries in obtaining immediate Part D coverage. The agency signed a contract with a designated PDP on November 22, 2005 to implement this mechanism. Because these arrangements were completed less than 6 weeks before the transition is to occur, limited time remains to educate all pharmacies about its availability and details of its operation.

For beneficiaries who were enrolled in a PDP but do not have their PDP information, CMS has facilitated a new information-technology process, known as the Eligibility Transaction, that will allow pharmacies to identify a beneficiary’s PDP and provide the beneficiary with the PDP’s contact information. As with the point-of-sale enrollment mechanism, it is unclear to what extent pharmacies are informed about the Eligibility Transaction and will use it. Despite CMS efforts to publicize this tool to industry organizations, a pharmacy industry association representative stated that it is unclear how many independent drug stores, which dispense the majority of the nation’s retail prescription drugs, plan to use the Eligibility Transaction.

Translation: a) Pharmacies are supposed to be able to immediately register dual-eligibles if they’re not already in a PDP but that was only developed in November and wouldn’t be ready. b) GAO was unsure how many pharmacies would use the eligibility transaction system.

GAO didn’t seem to predict what apparently is the major problem — the data on eligibility from the PDP’s that the transaction database is hitting against is wrong or it’s just not working.

We will find out more, but they had two years to get this right! And it seems to be getting worse!

POLICY: Of course, you know, this means war!

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The Maryland legislature enacts a Wal-Mart specific pay-or-play bill. It says that any company with more than 10,000 employees which doesn’t spend 8% of payroll on health care benefits needs to pay into a state fund. What’s not to like about this bill? It allows attacks on the big discount retailers and the fast-food chain while leaving small and medium businesses out of the legislation.

Of course, it doesn’t really help much in terms of reducing the number of the uninsured…..but I can hear Bugs Bunny even now.

QUALITY/POLICY: Chronic care DM fails in a FFS world

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This is no news to THCB readers, but let me remind you. Chronic care is hard work. Disease management programs are only partially effective because — even if you get it right — it goes against the incentives of doctors and hospitals (to do more, more expensive procedures now) and health insurers (to get sick people off their rolls ASAP). In a long look at diabetes care, the NY Times comes up with the conclusion that In the Treatment of Diabetes, Success Often Does Not Pay.

It‘s a long article but well worth a skim for those of you wondering what’s wrong with our health care system. How can we fix it? With FFS medicine, such as Medicare and copied by most insurers, you just can’t. The only hope is an extension of Kaiser-like pre-payment, or a chronic care system mandated from the top. Pay-for-performance has some potential, but it will require structural change, particularly in terms of the types of doctors and health professionals we train and the resources we allocate to preventative rather than sick care. And of course a system that excludes the poor and the sick by making it impossible for them to get insurance is never going to get close to doing that.

And just to depress you further, one health plan that has a better record than most in promoting DM programs, Pacificare, has just canceled a demonstration project in heart failure for Medicare FFS beneficiaries because it somehow couldn’t get people involved—even thought it will mean sending money back to the Federal government!