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Tag: Policy

POLICY: Tax health care benefits, go on I dare ya!

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Hat tip to Ezra, who clearly wasn’t partying enough this weekend and read the NY Times on Sunday. In it there’s a rational argument that me, Fuchs, Enthoven and Eric Novack all agree with: get rid of the tax deductibility of health benefits.

Next year, the federal government expects to provide about $130 billion for Americans to buy health insurance. The amount is substantial: it is equivalent to about 11 percent of all federal income tax revenue and more than a fifth of federal spending on Medicare and Medicaid. And it is growing fast: the bill is expected to surpass $180 billion in 2010.

Of course, this was recently proposed  by the same panel that suggested getting rid of tax deductibility of mortgages, and immediately disowned by the politicians who set up said panel.  But linking this to the issue of the uninsured and showing that it’s unbelievably regressive on those people who buy their own insurance and don’t get the tax break can’t be a bad meme for us wonks to pursue.

POLICY/INTERNATIONAL/PHYSICIANS: It’s not just here that doctors fees are an issue

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And from the THCB Japan bureau (well actually the Yomiuri Shimbun)….

It’s worth noting that the Japanese, who have one medical fee schedule for all of their multi-payers (and also a complex system of cross-subsidization between those payers), are about to cut fees and reallocate them. In Japan private doctors make lots and lots more money than hospital-based ones, and the government is slowly trying to move the incentives away from what’s traditionally been a system with a high-volume of office visits and prescriptions of dubious benefit.

We’re about to do the same here, calling it pay for performance. Like there it’s going to turn into a fight. Joe Paduda notes today that the AMA is having some success in its attempt to stop the 4% cut that’s scheduled to come into effect for Medicare at the end of the year. And is directly linking it with a demand to stop pay for performance.

The advantage that the Japanese have got is that there’s only one fee schedule to argue about. Here we have gazillions and no one really knows what they are…

POLICY: Ignorance is not bliss

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Young punk Kate Steadman has a very interesting post about the uninsured over at Health Policy

The current display of ignorance was on the subject of being uninsured. The woman I talked with didn’t really understand what it meant to be uninsured until her housekeeper had a health problem and couldn’t get seen by a doctor.

Look down in the comments for a combination of ignorance and desperation, and you’ll see why this will end up the political topic of the next two decades, as I said in my Spot-on piece last week.

And a big Hat-tip to Derek Lowe who’s doing Grand Rounds this week.

POLICY: Another balanced debate–what did you expect from the WSJ editorial pages?

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So in this online "debate" about consumer health care called Consumer Choice: Can It Cure The Nation’s Health-Care Ills? the WSJ editorial page shows its lack of bias by having two HSA advocates, and one very tired liberal debunking them.  And Reischauer obviously couldn’t type as fast as the other two.

And no one mentioned the 80/20 rule, nor the RAND experiment that showed that needed care was forgone as often as un-needed care. And despite the fact that the two HSA loonies claim that we do not apparently ration by price, we have a huge rate of bankruptcies caused by medical bills, and huge numbers of the poor are unable to afford reccomended care or have trouble paying for care compared to poor people in other countries. But why bother using actual data published in peer reviewed journals when you can wax poetic telling lies about South Africa while ignoring what’s going on in Singapore. But it’s a "debate" so why sweat the small stuff?

BLOGS/POLICY: And over at Spot-on, c’est moi

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I have found myself another gig amongst a great group of political writers led by the intrepid Chris Nolan. Chris is a leading Silicon Valley journo and a policy wonk, and she has surrounded herself with a group of op-ed type writers whose politics are absolutely across the map, but whose writing is entertaining and incisive. She calls it “standalone journalism” and I’m happy to be along for the ride. The intention is that I do a weekly piece over there which will be a bit longer and more political than the health care wonkery you tend to see here. I hope you’ll all go over and take a look, not just at my pieces but at all of them.

The site is called Spot-on, and my first piece is called Adventures in a Health Care Nation.

POLICY/HEALTH PLANS: The perils of the individual health insurance market…revisited

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So last week arrived with bad news. For the last year and a half I have bought my health insurance from Blue Shield of California via a group called PacAdvantage. PacAdvantage is an employer-buying coalition that had its origins back in the mid-1990s as the Cal HIPC—a forerunner of the never-were regional health alliances. Still if you are an employee of a company between 2 and 50 employees you can buy from a choice of somewhat overpriced health insurance plans from PacAdvantage.  The cost is about double what it would be buying in the individual market if you are “healthy”, but about half what it would be if you’re medically underwritten against….all for the same high-deductible plan of course.

How can I as a solo operator buy into this? Well I’m a member of an association called the SF Media Alliance which as one of its side benefits allows you to buy in.  Well those of you who’ve been following at home know where this is going. All the people who buy in are of course those who can’t get it in the individual market at the “healthy” rate, so the Media Alliance as a whole is likely to be a bad “client” for PacAdvantage. So PacAdvantage is kicking Media Alliance out (I suspect there’s a lot of legal jumbo I don’t know about going on behind the scenes). But the basic reason is that there’s bound to be a lot of sicker than average people buying from Media Alliance even though I have filed zero claims in the past 18 months, nada.

So I started looking around to see what I could replace it with. One option is to pay into my domestic partner’s plan (and I may well end up doing that) but I’d rather just buy a cheaper high deductible plan like the one I have, as I don’t intend to use much care in the next year and will have a stack of cash in my HSA ready to cover any expenses if I do need it. (This is not an endorsement of a certain THCB commentators ideas, it’s just me responding to the atrocious incentives in the system).

So over the coming weeks I’ll document my experience here, remembering that yesterday AHIP was boasting about how wonderfully its members were making the whole process for the blighted consumer

I start with my first visit to the eHealthinsurance Blogshotsite.  You may note that they seem to have bought out all my Google Adwords (at least they own the whole box at time of writing). They of course are a broker not an insurer themselves, but as they are the leader in the online insurance broking space I assume that they’ve spent a little time talking with the insurers for which they act as a channel about how to “delight the customer”. (Snicker, snicker)

Continue reading…

POLICY: It’s not just me saying that the individual market sucks

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You’ve heard me saying it often enough.  And later this week I will start to tell you my new personal horror show in navigating yet another twist in the individual insurance market.  But given the lack of a rational government regulated system that anyone can access, the NY Times is right to say that Employer-Backed Health Care Is Here to Stay, for Lack of a Better Choice.

What is also clear, though, is that there are no clear alternatives. Corporate executives and many others are leery of a government solution, but no one has come up with a private-sector option that has gained significant support. Because individuals who buy private insurance on their own pay much higher prices than the group rates employers get, many people could probably not afford health insurance if their employers were not buying it for them.

And I love what Helen Darling, the voice of big employers on health care, says in this juicy quote.

"There’s no functioning individual market" for insurance, Ms. Darling said.

Too bloody true, no matter how much free-market fantasists who haven’t read their Adam Smith might wish it weren’t so.

TECH/POLICY: Steeve Kay on integrating disability via PHRs

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More from the conference. Steeve Kay is the founder of QTC, a disability company which provides outsourced evaluations. Given the problems in figuring out who’s disabled and who’s not, you can see why they care about getting these records electronic. Meanwhile, a private equity firm just bought his company, so he’s obviously convinced someone else that it’s a good business! Yet another little niche in the health care world where plenty (plenty!) of money is flowing around.

Steeve says that medical treatment is provider centric, medical disability is payer centric — and there are lots of payers. It’s about $350 bn total on the health care side (public and private) for medical care for disability, plus another $200 bn for cash payments to the disabled. There’s about 10,000 claim centers in the US who are involved in allocating money, and that includes about 250,000 people working as claims administrators (of various types) with some 10 m claims a year. (I may have that number wrong—Mapping this system is damn confusing!)

These all need evidence to process and judge a disability claim. Most of that needs to come from a medical record, and the legal custodian of the medical record for disability is the payer, while in the medical world it’s a provider. And the disability payer needs to do a bit more to make that complete.

And of course not much has been thought about how these different parties access medical records in an electronic world. His 2 key questions are can we standardize billing codes for disability? And is evaluating disability a practice of medicine.


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TECH/POLICY: Disability and PHRs

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David Stapleton (from Cornell Univ Inst for Policy Research) is here to talk about disability. He says that we spend over $200bn on disability (via Medicare, SSI, and Medicaid) and the process of getting people onto disability is totally broken (Determination takes forever, and appeals take even longer). Much of that problem is due to the fact that there is no easy access to the medical record, and then if they actually get the record, figuring out what’s in it is hard, and the information may be biased because the provider is somehow colluding with the applicant (Imagine that in health care!), or applicants may withhold information early, and then produce it later. (If you let the consumer have control of the PHR, then they’ll fix the record to make it favorable to them to qualify for SSI!)

So if there was national PHR then the applicants could give these records out and they’d theoretically be available, accurate and complete! But funnily enough he thinks that disability is not the right place to target EHR development…and given the complications in that part of the world….yup! So why is he here? This conference (and in fact the sponsor of the center) are from a disability management company, hence the role of disability is coming up more than you might suspect! Still it’s a pretty interesting part of the system that we don’t hear about much, and it takes a lot of dollars. And if there was a national, reliable PHR with adaquate rules to get into it — and people trusted the government which Helga Rippen just told us they don’t — then management of the disabled population across programs could dramatically benefit in many ways, but we’re not holding our breath!


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