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Tag: Policy/Politics

POLICY/POLITICS: Our fearless leader demonstrates his vast understanding of the health care system

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Here’s the man himself interviewed in the run up to the State of the Union by the the friendly WSJ:

The Wall Street Journal: Thanks for taking the time for us. We wanted to think forward to the State of the Union a little bit, next week. Obviously, health care is something that has moved back to the top of the agenda. You’ve got employers and employees both equally concerned about cost and availability. What’s the approach going to be this year, philosophically and specifically?President Bush: The government must work to reduce costs through the spread of information technology, which many in the health field say will help reduce the rising costs substantially; litigation reform to prevent these frivolous lawsuits from running up the cost of medicine, either through the practice of defensive medicine and/or premium increases, and actually drive good docs out of business. I’m particularly concerned about OB/GYNs; we have an OB/GYN crisis in states because of these lawsuits. The patient-doctor relationship is a crucial relationship in helping control the costs of medicine. The more transparent pricing is and the more opportunities patients have to make decisions in the health-care field, the more likely it is costs will not increase as dramatically as they have in the past.I believe in the expansion of HSAs [health savings accounts]. I will talk about my philosophy for health care in the State of the Union. I will specifically address issues that I want the Congress to take up over the course of this month, including how to expand HSAs to make them achieve an objective, which is to have a patient-doctor relationship that will have market forces within the decision-making process and the pricing of medicine; as well as have a system that’s portable for our workers, to recognize that we are a society which has significant job turnover, and therefore one of the uncertainties in a society in which there is job turnover is whether or not health care will go from one job to the next.As well, HSAs, in my judgment, as well as other innovative programs, like association health plans, will enable the small-business sector of the economy, in which there’s a lot of working uninsured, to be able to more likely afford health care. That’s what I’m going to be talking about.WSJ: How do you turn that into a bipartisan movement?Mr. Bush: The question going into the ’06 year is how do we take health care or entitlement reform, or all these issues, into something that the country really wants — which is a bipartisan look at issues, as opposed to what many interpret to be needless politics, so whether it be in health care or in a variety of issues we’ll be discussing. And that’s the challenge of the ’06 year.One big issue is competitiveness, of which health care is an important component. If our health-care system is such that small businesses, for example, can’t afford to stay in business, it’s going to obviously hurt our people, but it’s also going to make our country less competitive. The war on terror is a big issue. And I will continue to talk about a bipartisan approach to beating the terrorists. So whether it be in health care or these other issues, it’s, no question, a challenge.

So that’s it. 45 million uninsured, crisis at every level in the health care system and even rich people in Florida scared about the future and Bush believes that we going to solve it all by using IT to save money and sticking it to those blood sucking attorneys. Then of course we’re going to use the easily available transparent pricing to beat providers to death with market forces.  Finally, he thinks the remaining solution is HSAs, which any analysis shows cost the system money overall. At least that’s apparent to anyone who can do basic math, a group which doesn’t seem to include Bush or virtually anyone in his party.

OK. What’s actually going to happen? Not much is my guess. The House is in disarray since Delay’s indictment, and the Senate is in some risk of going back to the Dems in the November election, and the biggest health care story — Medicare part D — is shaping up to be a disaster for the Administration. So why would any Republican in a position of influence get behind these ideas? Especially as most of them are actually counter to the interests of the big contributors at the AHA, AMA and AHIP.

Oh, I know. It’s because health care is just another form of terrorism, and that demands bi-partisan cooperation. Yup, the important thing is to link the two. Only Bush and PhRMA can manage to do that.

POLICY: Over at TPMCafe, Medicare Part D

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I have joined in a coversation about Part D with some other old farts and a couple of young punks (but very smart young punks — I was strugling to learn how to pick my nose at their age, and they’re health policy whizzes!) at TPMCafe. The section is called Drug Bill Debacle

Also don’t miss this cracker from a surgeon, Me and my HSA in which she shows why it’s great for her, but terrible for America!

POLICY/POLITICS: Ezra Klein skewers the HSA, Joe Paduda skewers the CDHP, with UPDATE

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(This entry bumped up to top because of fun UPDATE)

Apologies for my later start this morning, those of you who follow my knee problems will perhaps be as pleased as I am to know that I spent the weekend snowboarding with apparently no ill effects on it! But it mean that there’s only limited fodder for THCB written over the weekend.

The good news is that while I’ve been slacking, over at Tapped, Ezra Klein skewers the HSA, reminding us that it’s a destruction of the risk pool. I suspect that educating Bush about health care is like the story of David Stockman trying to explain the budget to Reagan, and realizing that he never had a clue about the difference between real and nominal dollars. One of Ezra’s commenters also points out the obvious–that the HSA will do nothing to reform the underlying problems of the system’s cost explosion, and so is by definition a temporary fix.

Last year, when I bought health insurance for my law firm (me, my family, my paralegal and my secretary) I could get coverage with a five hundred dollar annual deductible for $1,900 a month. I looked through all the options and saw that a plan with a $5,000 annual deductible was $1,200 a month. If there was one with a $10,000 deductible it would maybe cost maybe $900 a month (guessing). With health-care inflation running at 8-10% a year that policy with a $10,000 deductible would soon be prohibitively expensive.

Meanwhile over on his Managed Care Matters blog, Joe Paduda skewers the CDHP, with a big assist from Alain Enthoven. Remember kids, the CDHP is the bastard child of a one night stand between a benefits consultant with nothing to sell and a right-wing think tank that can’t do basic math.

CODA: In the transcript of the debate between Enthoven and Reggie Herzlinger on the KaiserNetwork site, Reggie’s comments have all been excised. I wonder whether there’s censorship of some kind here, or whether she was so embarrassed at what she said that she asked for them to be pulled…anyone who knows the truth please get in touch!

UPDATE: Reggie apparently did ask the Kaiser people not to publish her remarks. So was she chicken embarrassed, or was it a bad hair day, or was she selling her schtick to someone else for an exclusive?

PHARMA/POLICY/POLITICS/PHYSICIANS: Tierney with some optimism on the DEA’s war on doctors

Writing (unfortunately behind the fire-wall) in the NYT, John Tierney attacks the Republicans as being the Party of Pain. With their attempts to stop the Oregon assisted suicide law, and the relentless attack of the DEA on pain doctors, the Republican conservative Christian establishment that captured the DOJ in 2001 continues to defy rationality. Tierney is hopeful, however, following the Supreme Court’s ruling in Oregon’s favor.

Of course we never needed to engage in this ridiculous vendetta against pain doctors anyway. In his harrowing long and excellent issue brief on the subject Ron Libby at Cato points out that Oxy wasn’t that big a deal anyway

A final problem with the DEA’s claims of an OxyContin epidemic is the agency’s inflated estimate of risk of death. In 2000 physicians wrote 7.1 million prescriptions for oxycodone products without aspirin or Tylenol, 5.8 million of them for OxyContin.55 According to the DEA’s own autopsy data, there were 146 "OxyContin-verified deaths" that year, and 318 "OxyContin-likely deaths," for a total of 464 "OxyContin-related deaths."56 That amounts to a risk of just 0.00008 percent, or eight deaths per 100,000 OxyContin prescriptions 2.5 "verified," and 5.5 "likely-related." Even those figures are calculated only after taking the DEA’s troubling conclusions about causation at face value.

So this is just a classic case of the DEA acting like the drunk looking for his keys under the lamp-post because that’s where the light is. And who suffers? Obviously the doctors in jail or ruined. And it’s not a issue for just a few pain doctors. Libby points out that between one in five and one in three pain doctors has been investigated by the DEA or local authorities. Would you keep doing your job if there was a one in three chance that you’d be investigated, maybe have your assets seized, and possibly be sent to jail for very long time just for doing it?

And why is it being done? Well the DOJ and local police departments get to keep all the money from asset forfeiture. In other words this is essentially theft with patients, doctors and the taxpayer picking up the tab

Tierney hopes that there’ll be a resolution to this:

The Supreme Court’s decision is a victory for patients and their doctors – including, I hope, some of the ones in prison for violating the federal legal theory that has now been rejected by the court. The doctors should go free, and Republicans in the White House and Congress should restrain the drug warriors who locked them up. When this year’s budget is drawn up, it’s the D.E.A.’s turn to feel pain.

These loonatics need to be stopped and whatever my political differences with Tierney and the Cato crowd I applaud them for getting this in the public eye. Unfortunately I think he’s being far too hopeful that any good will come of this given the number of theocratic fascists social conservatives  still in the Administration and heading to the Supreme Court, and the current DOJ attempt to promote laws already overthrown by a (slightly) more liberal Superme Court.

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

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/POLITICS/QUALITY: Supreme Court upholds Oregon physicians and patients rights

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Some slightly good news in the DEA and DOJ’s continued campaign to get into the practice of medicine in the guise of preventing “drug trafficking”, or more accurately imposing the extreme morals of the religious right on the rest of us.

The Supreme Court upheld Oregon’s one-of-a-kind physician-assisted suicide law Tuesday upheld Oregon’s one-of-a-kind physician-assisted suicide law Tuesday, rejecting a Bush administration attempt to punish doctors who help terminally ill patients die. Justices, on a 6-3 vote, said that federal authority to regulate doctors does not override the 1997 Oregon law used to end the lives of more than 200 seriously ill people. New Chief Justice John Roberts backed the Bush administration, dissenting for the first time.

Of course the dissenters were Scalia and Thomas, both unreconstituted theocratic & social fascists conservatives. They were predictably joined by new Chief Justice Roberts. It’s no secret that Alito would have voted with them had he been confirmed. And this is for something the voters of Oregon have passed twice by large majorities. In other words the will of the voters is irrelevant in cases where social conservatives want to restrict freedom, including the freedom of physicians to practice in the way they like. And after Alito is confirmed, this will happen more and more…watch out Roe vs Wade.

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.

POLICY/PHARMA/PHYSICIANS/POLITICS: Some more publicity about the awful state of pain medication

Finally there is some word getting out about the reign of terror the DEA has been running against pain doctors and its awful impact. This article, called Let’s Get Serious About Relieving Chronic Pain picks up from the NEJM article I wrote about last week. We have known at least since the HHS report in the early 1990s that pain medication is massively under-prescribed. In this article, Jane Brody notes that :

"Pain is a common symptom in patients nearing the end of life," with up to "77 percent of patients suffering unrelieved, pronounced pain during the last year of life," Dr. Timothy J. Moynihan wrote in The Mayo Clinic Proceedings in 2003.

But the news is that the DEA, on its messianic quest to prevent us all going to hell or whatever the theocratic fascists think they’re doing, is not only wasting our time and money, and condemning innocent doctors and patients to prison.  They are also helping most people to suffer in their last year of life. Well I’m sure the DEA think it’s a deal worth taking, but I can’t believe any rational person does. If there’s one government agency that ought to be abolished and have all its employees sent to fill in prairie dog-holes in Nebraska (or wherever), it’s surely the DEA.

PHYSICIANS/POLICY/POLITICS: What else are they going to do?

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THCB contributor, radio talk show host and occasional orthopedic surgeon Eric Novack (just kidding, Eric!) sent me this story about the problems that Medicare recipients will  be having getting access to doctors in California if the projected cuts in Medicare reimbursement for Part B actually materialize. So far the cuts for this year have been rescinded by the Senate and the arguing is still going on in the House. Eric has written on THCB recently about the possible bad effects on patient access from cutting physicians fees, and I do agree with him that it’s unjust that only physician fees get cut when hospitals and managed care companies get an increase.

But the problem physicians face is that they don’t really have an alternative. Sure some will retire early, some will move to cash only practices. But given that Medicare is about a third of the money in the system, realistically they can grumble all they like but they’ll end up taking it, and of course doing more things to those patients to make it up on volume.  And that’s not just my opinion, it’s the findings of this five year study by the HSC folks. After all, they went to medical school and residency for all those years, what else are they going to do? There’s only so much room on the poker circuit and only so many of them can run health plans.

That’s why I say that physicians should be figuring out how they collude with government to reduce overall spending while maintaining as good a position as they can. That’s what’s happened in other countries, and one day it’ll happen here. Of course there’s lots of time for gnashing of teeth and entrepreneurial end-arounds before then.