Tag: Policy/Politics

POLICY/POLITICS: Let them eat cake

Remember pre-election 2000 when Bush said that we shouldn’t balance the budget on the backs of the poor? He was of course joking (and not just about the balancing part), as Bob Herbert points out in his article — The Machete Budget.

Contrast the cuts in Medicaid that are in the latest budget with the $10m spent on a bahmitzvah party by a defense contractor who made $70m last year supplying apparently faulty flak-jackets to our troops. And they claim that there’s no war profiteering. Of course in WWII a real American hero, Harry Truman stopped that stuff dead in its tracks.

PHYSICIANS/POLICY/POLITICS: Is cutting Medicare Part B fees a good thing? by Eric Novack

THCB’s favorite orthopedic surgeon Eric Novack is grumpy about Medicare’s proposed cuts in physician reimbursement, which are still up in the air as I write. Not sure how much support he’ll get over here on THCB, but it’s ironic that $10 billion is being set aside for health plans and PBMs to reimburse them for possible losses for their role in Medicare Part D, and hospitals are getting a raise. If we are going to cut Medicare, wouldn’t an across the board cut be fairer? Here’s Eric’s thoughts:
Unless Congress acts in the next week, reimbursement to physicians for services provided to Medicare recipients will be cut by 4.4%. The government’s formula for determining the payment rate does not take into account the increasing costs of healthcare delivery. Rather it is based upon such factors as the cost of prescription drugs and general economic factors over which doctors have no control. The reduction is not merely a reduction in the rate of growth of spending. Payments of $100 will become $95.50. And if the Congress’s inaction continues, payment will be less than $75 by 2011. No adjustments for inflation or cost of living are included.
Is all Medicare spending being cut? No, only payments for outpatient services- Medicare Part B- are affected.
Hospital care, paid under Medicare Part A, will get a pay increase of about 4.8%. Managed care plans that get paid by Medicare for managing Medicare HMOs will also get a raise. In both cases, the government’s formula for payment is based upon the medical economic index, which takes into account the costs of health care delivery.
Other than doctors, why should anyone care that reimbursement is going down? What options do patients and physicians have? Doesn’t more affordable mean more accessible?
Nearly 97% of US doctors participate in Medicare. This means that the doctor has signed a contract to accept the rates that the government says it is willing to pay for services. Doctors cannot be selective. They must accept the rate for any and all services that Medicare offers. They cannot tell patients that they will accept the contracted rate for one service, but not another. For example, doctors are not allowed to accept the Medicare rate for knee replacements, but not for hip replacements. This is especially an issue when it comes to the care of very complex conditions, as the level of expertise, time necessary, and potential liability is significantly increased, whereas payment is often only minimally higher than for the care of much simpler cases.
Physicians have several ways to deal with the Medicare cuts. They can retire and stop practicing medicine. Some will. They can see more patients each day, spending less time with each patient. Some will. They can stop practicing medicine and pursue other careers. Some will. They can limit the number of new Medicare patients they will see. Some will. They can drop out of Medicare altogether, requiring Medicare patients to pay completely out of pocket for healthcare services. Some will.
Patients have few, if any, options under the current structure of Medicare. Seniors cannot opt out of Medicare and find private insurance to cover care.
Government fixing of healthcare prices below reasonable market rates will create the medical equivalent of the gasoline crisis of a generation ago. The planned and projected Medicare cuts will have exactly the opposite of the intended effect: seniors throughout the United States will have less access to doctors and healthcare services.

POLICY: Ignorance is not bliss

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.

PHARMA/POLICY/POLITICS: Medicare Part D–A mess that will need fixing when the grown-ups get back into power

Last week the most convoluted program in the history of Medicare began. I’ve heard comments from friends, neighbors and people in the press saying that they can’t make heads or tails of the new drug benefit. The Washington Post piled in on Saturday with yet more about how confused seniors are.

Whether you like it or loathe it, there are some interesting parts of the Medicare Modernization Act, including the HSA provision and the disease management provisions. But the main event–drug coverage–is neither rational nor ideologically consistent. It’s a dog’s breakfast put together to ensure that the PBMs and some private health plans have something extra to sell, and so that the pharmaceutical companies don’t have to deal directly with the government on pricing.

Now seniors are going to have to deal with a donut hole, out-of-pocket costs, in-network and out-of-network pharmacies, and deciding whether their employer-sponsored coverage is going to stay around. No wonder they’re confused.

And despite all this, the cost to taxpayers is going to be double what Congress was told it would be. Drug coverage for everyone (especially seniors) is needed. But the only prediction I can make is that a more fiscally and socially responsible government–should we get one–will be forced to re-sort this mess in the very near future.

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POLICY: Yet more Dartmouth proof about doing too much

We’re almost at the point that you know exactly what any study from the Dartmouth group is going to find before it’s published. Following the assessment last year that showed that the nations “Top 100” hospitals show a wide variety of difference in procedures in their ICUs, for no apparent difference in outcomes, the same result comes up again.  This time (with Stanford’s Lauren Baker playing a starring cameo) Wennberg, Fisher et al looked at Medicare spending on patients in the last two years of life in hospitals in California and once again geography is destiny. (Health Affairs article here)

The study found that reimbursements ranged from $19,745 per Medicare patient at Redwood Memorial Hospital in Humboldt County’s Fortuna to $88,661 at Garfield Medical Center in Monterey Park in the San Gabriel Valley

Sacramento was cheaper than the Bay Area which was in turn cheaper than Los Angeles.  And of course the outcomes were similar in all places and had little relation to the costs. Interestingly, hospital chain is also a predictor. Sutter, which isn’t exactly known by California’s health plans as being a low cost operator, did way less than Tenet. (although I don’t know if Redding Medical Center skewed the data by itself!)

Medicare spending was also higher in some large hospital systems. Sutter Health, which operates 27 hospitals in Northern California, spent $30,814 on average per Medicare patient in the last two years of life, compared with $46,323 at Tenet Healthcare Corp.

Given that these are the most expensive patients (the 10% that cost 50% of all dollars), and moreover “it’s my money dammit”, you’d think that our so-called conservative leaders would be seizing on this to try to do something about the practice variation problem. But it just seems to be accepted as some type of unintelligent design.


POLICY/POLITICS: Health Reform may be back on the national agenda

Here’s my editorial from FierceHealthcare this morning.

This week may or may not have been a political harbinger for the coming years. Following a disastrous year for the Administration, Democrats have been claiming victory following wins in Virginia, New Jersey and California. Meanwhile, voters in California and Washington rejected measures that would have limited the activities (and incomes) of drug companies and trial lawyers. In Massachusetts, there may be the start of a compromise designed to get universal insurance (of a sort) for the state, and several other states are looking at the issue. Of course, nationally this will only mean something if the Democrats really carry their (so far modest) victories into the Congress next year and the White House in three years. That of course is a long time away. But health care is fast becoming the number one domestic issue and a Democratic majority will feel compelled to have another crack at it.

PHARMA/PHYSICIANS/POLICY: Oncologists getting paid for reporting data they should report anyway, by Gregory D. Pawelski

Congress has authorized the payment for oncologists reporting whether their treatment adheres to guidelines. Greg Pawelski, who follows the oncology market very carefully, was not too impressed.
When Senate Finance Committee Chairman Chuck Grassley found out that the value of the approximately $300 million-a-year medicare chemotherapy demonstration project to report on a patient’s level of nausea, vomiting, pain and fatigue was for nothing (providers were being paid $130 to simply forward the data that is already collected), they hoodwinked Congress into additional reimbursement to oncologists that report whether their treatment adheres to practice guidelines published by either NCCN or ASCO.

Looks like cancer patients will have to continue overpaying their oncologists and not have access to cutting-edge cancer treatments, and continue to suffer side-effect consequences and even death. The system will continue to serve the clinical investigators and the clinical oncologists, but not serve the best interests of cancer patients.

I think that the concept that some "authoritative" organization (made up primarily of practitioners and researchers with built in conflicts of interest) should determine the "correct" approach to cancer treatment has been very harmful to progress.

PHARMA/POLICY/POLITICS: Slick Willie syphons off big Pharma

Today is waste of money election day in California, brought to you mostly by the soon-to-be terminated Governor Arnold. But there are two other props on the ballot on which PhRMA has dropped more than $80 million to muddy the already muddied waters. It looks like Prop 78 which is nominally the one big Pharma "wants" to win and Prop 79 which is the one they actually want to lose (and the reason 78 is on the ballot) are both going down to defeat. Nonetheless I’ve had a voice message from someone claiming to be a surgeon in Fresno telling me to vote yes on 78, paid for by a host of drug companies (and admitting it as such, which is why I don’t think they want it to win).

But of course the really smart people in this state are extracting as much green from big Pharma as they can. The smoothest political operator of them all, former Speaker of the State House and former Mayor of San Francisco and the man whom is surrounded by but never touched by corruption Willie Brown, has successfully put some $500,000 of big pharma’s money in his pocket. Apparently he’s got the trial lawyers to stay neutral and conned some of the NAACP (who also know which way their bread it buttered) to actually support it. Way to go Willie! Sadly that gravy train will be over after today.


Politically this has been quite a week. Don’t you think that John Kerry just wishes that we had five year Presidential terms and that he was going into the election this November, rather than a year ago? This week even the great flip-flopper himself came out with a plan as to how to get our troops out of Iraq. Pity he laid off all the attacks till the election was over (and same with Al Gore too!). Bush keeps ranting on about final victory in Iraq as if he had any idea what the hell he was talking about, and that he hadn’t declared Mission Accomplished two years ago. Now he finds that most of the cabal running the country’s foreign policy for the past 4 years are on their way to disgrace and/or jail, and that his incompetence in choosing a secret wingnut instead of a well-known one for the O’Connor seat on SCOTUS has lost him (at least temporarily) the support of the loony right.

What has any of this got to do with health care?

Well as they say on The West Wing, there are a couple of stories sitting in my backlog that I want to throw out in the trash. First BusinessWeek had a profile of David Brailer, stressing that he honestly believes that there’s a free-market solution to interoperability in our current health care system. Well he’s even lost Neal Patterson on that one (and yup last year Patterson spent a fortune failing to get his wife elected to the House as a Republican). Meanwhile, another leading health care IT exec who wants to get himself elected to Senate as a Republican (Rich Tarrant of IDX) is sounding somewhat like a commie in his support for Medicare and Medicaid. (Hat-tip Don McCane) Finally there was an extraordinary long interview in the New York Times with the founders of AFLAC (itself a pretty useless insurance product) in which they showed that you can make a duck famous while having absolutely no idea about how to fix the US health care system, even if you vaguely understand the problem.

All of this leads me to believe that the business class that runs the country is somehow getting around to this problem, and that they might not object to it being solved. If the Administration’s problems continue to pile on for all the crimes and cock-ups they’ve caused us in the last five years, then next October we might, just might, get a change in the Congress and put us on the road to a Democrat in the White House in 2009. If that happens (and I know this is all speculation) then health care will have to be the first issue on the domestic burner — which is a little sooner than I’d predicted. All pure speculation just now, but this week might be the turning point.


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