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Tag: Policy/Politics

POLCY: HDHPs, employer insurance and regulation the Cato Way | SignalHealth

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Over at Signal Health Tom Hilliard has been having an entertaining time with Mark Pauly and the boys from Cato. Go over there and take a look at the latest round of back and forth. Suffice it to say that if Mark Pauly had to buy his insurance in the individual market rather than receiving from the Ivy League Ivory Tower he sits in, I suspect that he would be rather more concerned about the way the individual market works, particularly the 20% he acknowledges doesn’t work well.

Meanwhile, Eric Novack and I are both reading Cato’s Michaels Cannon and Tanner’s latest work which is out today. (I had planned on a pre-publication review but then again…) We’ll be discussing it in another podcast sooner or later, but you’ll get the basic idea from the SignalHealth discussion.

Meanwhile, Health Affairs has some numbers out about the rise of the HDHP and the HSA.  You can see the full article here. But here’s the abstract pull:

Almost 4 percent of employers that offer health benefits offer one of these arrangements in 2005, covering about 2.4 million workers. Deductibles, as expected, are relatively high, averaging $1,870 for single coverage and $3,686 for family coverage in high-deductible health plans with an HRA and $1,901 for single coverage and $4,070 for family coverage in HSA-qualified high-deductible health plans. One in three employers offering a high-deductible health plan that is HSA-qualified do not contribute to HSAs established by their workers.

The last line is by far the most significant (hence my bolding it).  Even though the HSA is supposed to be the employees benefit, in fact in a third of the cases setting up a HDHP is straight cost-shifting to the employee. You were getting something and now you’re getting nothing to deal with the first chunk of medical expenses. So at least those employers have figured out how not to screw over their own risk pools (assuming that they keep some of that money that would have ended up in the HSAs in reserve to cover the expensive cases). You know that the rest of them will go down that path too — in fact a survey that was covered in this THCB article confirmed it a while back. Oh, the joys of a "jobless recovery".

And of course employers are getting out of the game of providing insurance anyway.  Another Kaiser Foundation survey this morning confirms that the percentage of employers offering insurance has gone from 69% in 2000 to 60% in 2005. In effect the HDHP over time offers the employer a way to get out of the game without having to bear the shame of leaving the field completely.

This of course continues to boil the frog….

Finally, it does make me chuckle that in the comments to this post about Medicare Part D, Eric Novack is apparently appalled that a combination of lobbying from drug companies, PBMs, health plans and providers mixed in with the endemic scratch my back corruption of the current Administration and its leaders in Congress ended up with a welfare plan for them all called Medicare Drug Coverage. But it’s a little weird that he thinks that the water-carriers for the Administration over at Heritage are actually surprised. The guys from Cato might be forgiven for being true believers, but Heritage, AEI and the rest sold their souls long ago, and know exactly how they’re dealing with.

CODA: I hate to link to Tech Central Station given how dishonest it is in its lack of transparency, but if the funny Cato boys will insist on writing there, then this one from Randy Balko is worth a chuckle.

POLICY/POLITICS: Blame for Katrina–enough to go around but it’s FEMA in the lead, with UPDATE

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With all the BSing that’s gone on from the Administration about what went wrong and finger pointing, there is clearly much blame to go around. I’m impressed that New Orleans mayor Ray Nagin went ballistic when nothing was happening last Thursday night, but there are reasonable questions being asked of him by the right wing bloggers about why he didn’t or couldn’t use the city’s municipal and school buses to evacuate people in advance of the Hurricane or after it (I assume that after it he didn’t have anyone to drive the buses). Not that of course those questions are being asked in a particularly nice way, but I won’t discuss my last post or Nagin’s ethnicity.

However, even if there is local and state blame, that doesn’t absolve the Bush Administration for two reasons.  The first one is that there is a clear line of command in these situations, and this comes straight from Bush’s mouth on August 28, the Thursday before the storm.

Bushdisaster9kr THE PRESIDENT: This morning I spoke with FEMA Undersecretary Mike Brown and emergency management teams not only at the federal level but at the state level about the — Hurricane Katrina. I’ve also spoken to Governor Blanco of Louisiana, Governor Barbour of Mississippi, Governor Bush of Florida, and Governor Riley of Alabama. I want to thank all the folks at the federal level and the state level and the local level who have taken this storm seriously. I appreciate the efforts of the governors to prepare their citizenry for this upcoming storm. 

Yesterday, I signed a disaster declaration for the state of Louisiana, and this morning I signed a disaster declaration for the state of Mississippi. These declarations will allow federal agencies to coordinate all disaster relief efforts with state and local officials. We will do everything in our power to help the people in the communities affected by this storm.

In addition here’s an article which basically shows that even within all the bureaucratic BS going on, the Federal government is in charge in a disaster situation, and FEMA has the ability to do basically what it likes–which those of you hooked on The X-Files know has always been the case (although alien takeovers weren’t the issue last week)

But the main point is that, whatever the bureaucratic BS, a real leader would have got those buses into New Orleans and got the people out by Wednesday at least. That would have to be a Federal effort rounding up a few hundred buses in neighboring cities and getting them into New Orleans, while setting up tent cities to deal with the volunteers. It was this lack of action after the flood between Tuesday night and Friday morning that is the really criminal part, and even if the locals had screwed up, that does not mean that the Federal government is absolved of blame. We needed Presidential leadership, and we got little boy lost — again.

And as for health care, that goes for the evacuation of the hospitals too. It’s clear that that ended up being largely a private effort (and well down to HCA’s management which really stepped up in the crisis when it realized that the Feds weren’t helping.  Perhaps we should have completely for-profit private health care organizations so that all rescue efforts can be run out of Nashville! But if that’s not going to happen, and if every victim isn’t going to be in a hospital — as is clearly the case — then we have to depend on the Federal government.  After all this is the same Federal government that’ll move heaven and earth to make sure the sick people don’t smoke pot.

UPDATE: Brown was basically fired this afternoon–one week after Bush said "Brownie, you’re doing a hell of a job".  Odd.  Usually these incompetents get awarded the Presidential Medal of Freedom.

POLICY/POLITICS: A harrowing story from Katrina

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SignalHealth pointed the way to this story, which I’ve since found at another source by a couple of hotel guests who were basically imprisoned in New Orleans and not allowed to leave by the law enforcement and FEMA people who were supposed to be there to help them. Now before you take this entirely at face value, I’ve Googled a little bit, and found that the two authors of this account are San Francisco Paramedics who are very active in their SEIU chapter and were extremely anti-Bush, the military and police to start off with, and are posting this on an extreme left-wing (by my standards not by Fox News standards) web site.

But the problem with thinking that they’ve just made all this up is that it correlates with so much else that we know about what happened. Late on Thursday night on FOX NEWS (really!) Geraldo was in the Convention Center saying "just let these people walk out of there". They weren’t allowed to go. They were just left there. Even worse was reported by another Fox correspondent, Shepard Smith, about people just abandoned on the freeway. It seems very likely that the two SF Paramedics were among those out there. See this for the link to that piece of video.

I saw someone on CNN or MSNBC — a white man – telling his story about how the buses that they’d paid for had been commandeered (UPDATE: I’ve found the link the story about the buses for the hotel guests)– that matches the Paramedics story. This guy was taken out by a black man standing next to him, who’s name he didn’t know but whom he credited with saving his life. (UPDATE: And here’s another story from a St Louis lawyer that confirms the bus story AND the trapped on the freeway story)

Over at HIStalk, there’s a link to this incredible story about how three college kids took a whole SUV load of water and supplies into the Convention center TWICE before any real help got in there. And they had to smuggle their way in as "press".

When you start putting these pieces together, it’s clear that something went badly, badly wrong in our emergency preparedness, and how we responded to desperate people in our own country. The only people who emerge with any real credit seem to be the health care workers in the hospitals who kept their patients alive against the odds, and the people who went around the official channels to do what they could.

I would not have said anything other than on Saturday night at a dinner party, in so-called liberal San Francisco no less, one woman started explaining to us all that these were stupid people who should have a) left before the hurricane, and b) should have taken adequate supplies with them to the convention center and SuperDome, and c) were dumb and not like us because….well you can get the gist if I tell you that she was white, and in fact Irish. I lost it and pointed out that the English said exactly the same thing about the dumb starving ungrateful Irish in the potato famine. If you have time, read the whole history of that very sorry episode and weep.

I can think of no better riposte than to link to the greatest essay ever written on the topic. Go read it and marvel at how little distance we’ve come.

HOSPITALS/POLICY/INDUSTRY: Katrina and the response

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We have all been shaken by the devastation in New Orleans and the Gulf Coast. After a couple of days to reflect, three thoughts come to my mind. First has been the absolute heroism of health care workers in New Orleans, and those helping from neighboring areas. The tales of nurses, doctors and other workers keeping patients alive by hand-pumping ventilators, and performing near-miracles in conditions that none of them could have believed they’d ever have to work in reminds us that medicine and health care is a calling far more than just a job. Second, the time for investigations and blame if any will come later, but it’s beyond belief that it’s taken this long to get either food, water and medicine into New Orleans, or those stranded people out. Finally, it can’t have escaped anyone’s attention that the vast majority of those "left behind" are poor and African-American. And that’s a microcosm of what’s going on in our society and in our health care system. Hopefully this disaster may give us a chance to reflect on that and to make some changes.

I linked to the Red Cross earlier this week, but Instapundit has a long list of other charities who need help.

PHARMA/POLICY/POLITICS: FDA Official Quits Over Delay on Plan B, with UPDATE

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The FDA official in charge of women’s health quits over the delay on Plan B‘s approval. Well it’s good to see that some of the staffers left at FDA have some spine, because it’s clear that, whatever the lies being told by the Administration, this is all about cow-towing to the loonies on the Christian right rather than the science of the situation.

There are a couple of telling shots in the story. Crawford swore up and down that this was his decision and that it was a science-based one.  Not so. 

Susan F. Wood, assistant FDA commissioner for women’s health and director of the Office of Women’s Health, said she was leaving her position after five years because Commissioner Lester M. Crawford’s announcement Friday amounted to unwarranted interference in agency decision-making. "I can no longer serve as staff when scientific and clinical evidence, fully evaluated and recommended for approval by the professional staff here, has been overruled," she wrote in an e-mail to her staff and FDA colleagues"I can no longer serve as staff when scientific and clinical evidence, fully evaluated and recommended for approval by the professional staff here, has been overruled," she wrote in an e-mail to her staff and FDA colleagues.

Of course there were strenuous denials from all concerned, but what was she told?

Wood also said other FDA officials who are typically involved in important matters were kept in the dark about the contraceptive, called Plan B, until Crawford announced his decision, which she believed was made at higher levels in the administration. Wood said that when she asked a colleague in the commissioner’s office when the decision would be made, the answer was, "We’re still awaiting a decision from above; it hasn’t come down yet."

So you could argue that this was not Crawford doing what he thought the loonies wanted him to do, but instead he was actually taking instructions from Leavitt or Rove or whomever.  On this issue  they can send a sop to their "social conservative" friends. After all it’s only a small pharma company they’re pissing off here, not a big one, Just as well Lipitor doesn’t impact birth control, eh?

Meanwhile, there’s just a delicious piece of doublespeak from Leavitt that really outdoes some of the stuff we’ve had to put with from Rumsfeld over the years:

Many supporters of the Plan B application — including Sens. Hillary Rodham Clinton (D-N.Y.) and Patty Murray (D-Wash.) — accused Crawford of making a political decision that ignored science and public health. The two senators were especially angry at Crawford’s ruling because they had lifted a hold on his pending nomination based on promises, relayed by HHS Secretary Mike Leavitt, that the Plan B issue would be resolved by Sept. 1.

Clinton and Murray have accused the administration of breaking its promise, but Leavitt has disagreed. "The commitment was they would act," he told Reuters on Monday. "Sometimes action isn’t always yes and no. Sometimes it requires additional thought.

So now when you’re asked by your wife, boss, teacher, whomever why you haven’t done something you were supposed to have done (you know, "taken action") you can tell them that you were thinking about it and that is exactly the same thing! Not only that — it’s now official policy in what passes for the circus we call a government.

UPDATE: Bob Steeves points me to this quote from the spokesman for Mike Enzi (a Senator with an "R" after his name), showing that he didn’t get the Talking Points on this one and looks a little pissed:

Sen. Michael B. Enzi (R-Wyo.), chairman of the Health, Education, Labor and Pensions Committee, is considering whether to hold hearings on the FDA’s handling of Plan B, said spokesman Craig Orfield. Enzi had expected "a firm decision" from the FDA, not further delays, Orfield said.

INTERNATIONAL/PHYSICIANS: Canadian doctors going home means the US sucks, n’est-ce pas?

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This one I find hilarious and gives me great deal of personal satisfaction. The pro-American health care system, "it’s the finest on earth crowd" goes on and on about how terrible the Canadian system is and how all the doctors are leaving. In fact it was that sentiment especially from the wonderful, but confused, Sydney Smith over at Medpundit that inspired my "Oh Canada" tome.  (Actually I re-read "Oh Canada" the other day and it’s a pretty damn good piece of analysis if I say so myself).

Syd was basically saying that all the doctors were leaving cos they hated the clinical restrictions of the single payer system and wanted to move to the glorious homeland of free-choice medical practice and CABGs for 97 year olds. I showed pretty conclusively using actual real life data that a) very few doctors were leaving Canada for the US, and that b) if they were leaving it wasn’t that surprising as they get paid about twice as much by sneaking below the 49th parallel.

Well now we have more actual statistics and real data that shows that more Canadian doctors are heading back to Canada than are leaving — and this was in 2004 when hockey was on strike so there was no real reason to go to Canada! The numbers are:

Canada has seen more doctors returning than leaving for the first time in 30 years, a report by the Canadian Institute for Health Information (CIHI) shows. The report, released Wednesday, says that between 2000 and 2004,the number of physicians leaving Canada declined by 38 percent. In 2004, 317 physicians returned to Canada and 262 left. That was a drop from 2000, when 420 doctors left the country and a significant decrease from the peak of 771 physicians who moved abroad in 1994.

I’m looking forward to the barrage of articles from the know-it all alleged "free-market" crowd who get spoon-fed rubbish by Frasier, PRI, Manhattan et al offering their apologies to the Canadians and admitting that their system is better than the one down here.  After all the alleged rush of Canadian doctors to the US was absolute proof in their mind that the reverse was true.

I’m waiting, I’m waiting….

POLICY/PHYSICIANS: Is the Medicare reimbursement issue more serious this time?

This week things are starting to get a little serious regarding physicians’ Medicare reimbursement. The AMA is gearing up for a fight, trying to avoid a scheduled 4.3% cut in Medicare reimbursement. Meanwhile a survey of California doctors suggested that they would stop taking new patients at the lowered rates. Much of this is just bargaining rhetoric, but CMS is determined to start Medicare down the pay-for-performance road, and has already begun to initiate this process by paying hospitals for reporting quality measures (even though it’s less than 0.5% of their Medicare revenue).

Meanwhile Republican house rep Nancy Johnson is pushing a pay-for-performance bill which would change how physicians get paid. Anytime you put doctors, money, and quality and performance requirements in a sentence together, be prepared for at the least a vigorous debate. Medicare is still the big Kahuna, and where it goes other payers will follow — if they’re not moving there already.

POLICY: HSAs for Medicaid–cost-shifting to the poor by Theora Jones

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Policy analyst Theora Jones has been a little quiet at THCB lately, but the news that South Carolina is going to be giving all its Medicaid recipients HSAs got her a little riled up.

THCB recently pointed out that if the government could risk-adjust perfectly, we’d have no need for insurance companies, (Well I didn’t quite say that but close enough, MH) which is why this recent story from SC is so confusing–call me crazy, but I don’t think they’re out to replace the insurance industry.

So golly gee, what’s behind this? Does SC they think the private sector can control costs better? There’s no evidence of that. Do they think that people on Medicaid will get better care? Well, they’re not proposing any case management or disease management or quality measures, so…no. Wait, I think I’ve found the nut graph:

"South Carolina would cap how much it will spend on a recipient, and if health care costs more than the account will pay for, then the low-income people would have to make up the difference themselves or go without."

Ah, rationing. That’s neither new nor radical.

Please note that in order to qualify for Medicaid (2003 numbers), a mom in a family of three has to earn less than $7,510 a year. Disabled and blind folks have to earn less than $12,120 ($9k if they’re single). The old folks can pull down a cool $16,362, and kids can be covered even if their family of 3 is rolling in cash–up to $22,890! With disposable income like this, I’m SURE they’ll be able to make up the difference on that triple heart bypass. Or the asthma medication.

Legislation like this confirms my greatest fears–that HSAs are going to have a worse impact on the health care system than managed care ever did. Their effect on the health care system will be more pernicious and long-lasting–they will exacerbate the fragmentation and the injustices in the current system, and they will stymie the effects of reformers who are trying to achieve clinically focused quality improvements, greater access, and efficient financing.

PHARMA/POLICY/POLITICS: Clinical trials corrupted by Wall Street

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FrontpageThis is a doozy, and as it’s in the second first newspaper of a minor major west coast city metropolis and world class cultural center (Sorry, Ichiro & Frasier fans! See the comments, but I stand corrected!) it hasn’t quite had the attention that the front page of the NYT would give it.  Basically the Seattle Times has found a bunch of cases where hedge funds and other Wall Street brokerages found out who was running clinical trials for supposedly "double-blind" studies, and bribed the doctors (sorry, paid them consulting fees) to spill the beans ahead of the official announcement. Here’s their whole special, go punt around.

Now, insider trading happens all the time in Wall Street.  I myself have seen countless stock charts where an hour or two before an announcement the stock has gone doolally. Nothing ever seems to get done about it.  But this is a little different as it may impact the integrity of the clinical trial and the FDA’s role (not to mention the SEC).  And that tends to mean that Chuck Grassley wants in.  And he does.

For a long time people have been complaining about the fuzzy line between academic medicine and making money off it.  Apparently in several cases that line has been obliterated in a way that was not only unethical for medicine, but illegal even for Wall Street. This might, just might, be one of those trigger events that really changes how things get done in clinical trials and even biotech research. Well worth watching and kudos to the Seattle Times for coming up with it.

POLITICS: Debunking the Drug War

John Tierney has written an excellent article essentially agreeing with what I said on THCB yesterday — only he gets to do it on the editorial pages of the New York Times. This one is about how addicted law enforcement is to drugs, particularly the meth "epidemic" and it’s called Debunking the Drug War. It’s Tierney’s 3rd article on the stupidity of the drug war in less than a month.  About time someone with some national stature started raising this lunacy as a political issue — and it is a political issue, as we’ve traded in our human rights and our good sense so that law enforcement and the prison-industrial complex can take more of our money.

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