Tag: Health Care Reform

Separating Fact from Fiction and Health from Health Care

Aug 31, 2009• 23

By JAMES S. MARKS, ROBERT WOOD JOHNSON FOUNDATION

In an editorial on Wednesday, The New York Times debunks the often-cited claim that America has the best health care system in the world. For the politicians who routinely use this as a plank in their efforts to stifle reform, the Urban Institute study (disclosure: this study was funded by the Robert Wood Johnson Foundation) is an objective rebuke. The U.S. health care system is not the best – far from it. And Americans, with a life expectancy that still trails many other countries, are not the healthiest people in the world.

Clearly, this country desperately needs health reform. But the study, the editorial, and the entire current discourse around health care neglect an important truth about reform: fixing the health care system alone will not significantly improve Americans’ health.

For example: medical spending consumes 16 percent of the U.S. GDP and is projected to reach a staggering one dollar for every five earned by 2018. And yet, only 10-15 percent of preventable mortality is linked to health care. This and our terribly poor international rankings in length of life are telling signs that our tremendous investment does not do enough to address the factors that make us sick in the first place.

Our current national debate must look beyond health care – the so-called repair shop of our health system – and focus on our health. Fixing health care will require insurance reform, cost containment and sound economic policy. Fixing health will require us to look at our neighborhoods, our schools and our workplaces. From our earliest years of life, these are the places that determine how long and how well we live in America. The recommendations of the Robert Wood Johnson Foundation Commission to Build a Healthier America, which identify pockets of success where programs are making a real difference in people’s health, provide a useful place to start.

In schools, where obesity threatens the current generation of children with sicker and shorter lives than those of their parents, solutions are critically needed. By guaranteeing daily physical activity in schools – which fewer than 3.8 percent of elementary schools provide – and linking federal funds for school meals to their nutritional value, we can reverse the epidemic and help our children grow up healthy.

In our neighborhoods and communities, we must consider the health impact of investments and development to ensure that they help promote physical activity, make healthy foods more readily available and lay a foundation for prosperity. With public-private partnerships, we can bring grocery stores and nutritious food into underserved neighborhoods and help both the stores and the neighborhoods thrive. By incorporating bike lanes, sidewalks and trails into our transportation planning, we can help make the daily lives of Americans more physically active.

All of this amounts to a change in the way we think about health in this country. Health care reform, while critically important, will not avert the crisis of poor health that we’re facing. The Times editorial and Urban Institute study shine an important light on the dubious claim that we have the best health care system in the world, but they don’t go far enough. It’s time that we debunk the larger myth, that Americans are the healthiest people in the world, so all of us – from the halls of Congress to the family dinner table – can start working to improve the health of the country we love.

Dr. James S. Marks, M.D., M.P.H., senior vice president at the Robert Wood Johnson Foundation and director of the Foundation’s Health Group. Dr. Marks oversees all of the Foundation’s work in childhood obesity, public health and vulnerable populations. Prior to RWJF, Dr. Marks was an assistant surgeon general and director of CDC’s National Center for Chronic Disease Prevention and Health Promotion.

Advice For State REC Planners

Aug 31, 2009• 6

By DAVID C. KIBBE & BRIAN KLEPPER

On August 20th, HHS Secretary Kathleen Sebelius and ONC head David Blumenthal announced $598 million in grants to set up about 70 “regional extension centers” (RECs) that will help physicians select and implement EHR technologies. Another $564 million will be dedicated to developing a nationwide system of health information networks.

The RECs are based on the example of agricultural extension offices, established over 100 years ago by Congress, which offered rural outreach and educational services across the country. These extension services made America’s agricultural revolution possible, dramatically increasing farm productivity. By analogy, the Administration hopes that on-the-ground health IT trainers and implementation experts can facilitate small medical practices’ adoption of EHR technologies, especially in rural and under-served areas, enhancing care quality and efficiency around the US.

The comparison between RECs and agricultural extension offices is probably a good one, and we applaud this effort. But there are some striking differences between agriculture and health IT. For one thing, many best farming practices were well known by the early days of agricultural extension services. The road map under ARRA/HITECH for successful small medical practice health IT acquisition and use is still under development, and remains full of tough questions and unknowns.

In fact, under Dr. Blumenthal’s leadership, the government is now crafting specifications for Meaningful Use, HHS Certification, security, and interoperability. It’s not yet clear what “meaningful use of certified EHR technology” means. So we could be in a cart-before-the-horse situation. It might be a little premature to set up technical assistance programs if we can’t provide specific guidance on how to assist. Even fully CCHIT-certified comprehensive EHRs can’t meet the Meaningful Use criteria today, so the REC’s geek squads will have their work cut out for them.

However, a body of knowledge and experience already exists about successful health IT system implementation in small primary care and specialty practices. For several years, one of us (DCK) worked under the auspices of the American Academy of Family Physicians (AAFP), helping family physicians’ practices prepare, select, implement, and maintain information technology offered by EMR and EHR vendors. The AAFP’s current Center for HIT staff has expanded this effort, assembling an impressive body of resources and tools. It was augmented as well by the work of the Quality Improvement Organizations (QIOs) that participated in the Doctors Office Quality-Information Technology (DOQ-IT) programs between 2006-2008.

Some of this knowledge is anecdotal, and should certainly be revised in light of the definitions and specifications that the ONC will issue later this year and likely finalize by spring of 2010, according to Dr. Blumenthal. But the AAFP’s and QIO’s hard-won lessons may be useful to those who are planning the new effort.

Here’s some broad guidance for state planners who are applying for these grants and who hope to set up their RECs by early 2010.

Keep your advisory services simple and targeted on solving actual problems. Hire people with hands-on medical practice experience, who will carefully listen to what physicians and practice managers want the EHR technology to do for them and their patients. Physicians in small practices generally will use EHRs in caring for patients and for managing office accounts. Overwhelming change won’t be welcomed. Instead, focus on incremental implementations that try to solve information management problems without interrupting work flows.Start with one system or workflow area, gaining success and then moving on to another. For example, some practices may be ready to implement ePrescribing, but are not ready to replace paper records with an electronic documentation system. Many practices have found that Web portals facilitating patient communications are a good EHR starting point, because they let doctors and patients exchange information online and asynchronously, easing telephone line congestion.

One size does not fit all. General IT skills are useful. New rules will soon specify how physicians and hospitals can qualify for the HITECH incentive payments and which products will be certified. Even so, there may be many different routes to successful EHR use. A flexible perspective is paramount. Favor advisers with generalized health IT system knowledge, rather than expertise with a particular vendor’s product.Some medical practices will choose a single-vendor EHR with all the added features, but others will mix and match modular applications that together create can minimum system capability needed for HITECH meaningful user status and incentive payments.
Similarly, some practices will prefer to locate data servers inside their practices or at the community hospital. Others will opt for Clinical Groupware, web-based and remote services EHR technologies that offer less hassle and expense for maintenance and security. Recognizing and differentiating between EHR technology offerings is going to be a major challenge for REC personnel in the near future.

Skate to where the puck will be. The old paradigm of health data management tried to collect a patient’s complete data in a single database application, owned, maintained and controlled by a particular organization. However, throughout other disciplines, information management has become Web-centric and based on meta-data searches augmented by real-time communications and shared group activities. Think Wikipedia, Google docs, Microsoft Sharepoint, the Apple iPhone, and, yes, even Facebook, as representative of where health IT is migrating over the next few years.Eric Schmidt, CEO of Google, and a member of the President’s Council on Science and Technology, PCAST, recently urged President Obama and David Blumenthal to consider Web-based technologies as the basis of the national health information network. He warned that “the current national health IT system planned by the administration will result in hospitals and doctors using an outdated system of databases in what is becoming an increasingly Web-focused world. The approach will stifle innovation.” Mr. Schmidt’s advice, and similar advice from Craig Mundie of Microsoft, is coming from within the Administration, not from outside it. In other words, it’s much more likely to be heeded than if were it coming from the opposition.
We hope that ONC’s specifications, issued as guidance to the RECs by mid-2010, reflect market-driven innovations that can reduce the cost and complexity of EHR technology acquisition and use. Otherwise we’re in for a national exercise in chaos.

Don’t waste time re-inventing the wheel. Every REC should network with every other REC, regardless of location or stage of development, to share lessons and experience, and to avoid wasted effort. In the past, for example, regional helper organizations – some QIOs and medical societies – independently formed exclusive contracts with one or two EHRs vendors, hoping these arrangements would simplify choices and implementation. These proprietary relationships were invariably unsuccessful for the helper organization and for the practices.Physicians and their organizations want to make health IT selections based on their own situations and needs. But almost always, they will seek the same kinds of IT support during implementation: e.g. networking, set up, Internet connectivity, security, and basic computer skills training for staff and physicians alike.
RECs should collaborate on tools and instruction kits where ever possible: each REC doesn’t need to develop its own HIPAA privacy and security guide book, for instance. Remember that peripheral devices, such as printers, fax machines, and modems, are part of every office’s set up, and that these items can be troublesome to set up and use.

Come to the task understanding that successful HIT implementation requires fundamental process re-design. We’ve learned this the hard way. Unless health IT helps re-design practice work and information flow processes so they can be more efficient and quality-promoting, then the IT is simply an expensive appliance. Process re-design also can determine whether the EHR technology deployment produces a return on investment (ROI). For example, re-designing the documentation process to reduce or eliminate dictation transcription services, relying instead on EHR data entry by office staff and the physicians themselves, can save money and lead to an ROI within 12-24 months. We have seen this occur frequently. On the other hand, practices that continue dictation at the old levels are simply adding new data capture expense, making it harder to justify the investment.

States are hurrying to get access to this stimulus money. Many organizations aspiring to be RECs are focused on the rapid grant/award cycles. But its critical for planners to focus on what it will take to get the job done, and setting the groundwork for effective regional centers that can offer thousands of practices the help they need.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies. Brian Klepper PhD is a health care market analyst.

Here We Go Again – Again

Aug 29, 2009• 17

By RICK PETERS

Last Friday morning, delirious, wasted, bone tired, driving home from the Emergency Room at 8AM in my beat-up little truck with only one speaker working. Amid all of us awash in the blogosphere thank the stars for NPR and professional journalism. Steve Inskeep, from Morning Edition was interviewing Angela Braly, CEO of Wellpoint. Perfect! Wellpoint is the largest health insurer in the U.S. in terms of covered lives. Also, Wellpoint, the former non-profit Blue Cross of California converted into a very profitable for-profit corporation, represents the epitome of for-profit medicine.

Mind you I’ve already thrown in the towel. Any meaningful reform seems well past doomed. Harold and Louise are already back channeled through Newt and Sarah, and fringe lunatics are getting airtime, calling Obama a Nazi because they cannot understand the difference between National Socialism and Medicare. It would be comedy writ large if not for the gullibility of the American electorate. Oh well, here we go again.

The trouble is that our problems are so deep and fundamental that any sort of government driven health reform is destined to have limited impact despite the best intentions. That’s what was so painful and profound about Inskeep’s interview with Braly.¹ If we are going to even start to move this mountain we are going to have to foster change from within the system. That change is going to have to come from all of us as a society and as patients, families, health care providers, health care organizations, and influential health care managers and executives.

Newt and Sarah know the game they are playing – they’re politicians. Their party is out of power and they are using opposition to health care reform to rebuild their base by any means necessary. Braly and her compatriots are a whole different animal. They know exactly what is at stake. Listening to the interview you might wonder how this ditzy soccer mom every got recruited to run a major corporation. It’s uncanny. She does not answer a single question. What she does do, however, is illustrate what will essentially kill not only health reform but also real change. What Braly does is deflect responsibility to everyone else in the system and not once acknowledge that not only do we have a problem but that we all share the responsibility for getting here – Wellpoint, Braly, and every one of us in health care included.

Braly’s no fool. She is the third highest paid health insurance executive having been compensated $9,844,212 in 2008 by Wellpoint.² Only Ed Hanway, CEO of CIGNA, and Ron Williams, CEO of Aetna, were paid more. Wellpoint’s profit in the last fiscal year was close to 4% as even Braly admits, which is equal to or greater than the entire administrative cost of the Medicare program. Inskeep calls Braly on virtually every statement she makes but as a pro, Inskeep just lets her dig herself in deeper.

I think I fainted. I crawled out of the car and went in to go to sleep with it all blaring in my head. My patient with gallstones diagnosed a month ago now with elevated LFTs and awaiting an ultrasound wanting to know if she could just go out a get a carne asada burrito and then come back for the test. The Alzheimer’s patient who could not walk or feed himself or recognize anyone who fell out of bed and broke his hip and needed a hip replacement not only because he was full code, but because it is the only humane thing to do. The health information systems we struggle with feigning silence when we know they are archaic and are killing our efficiency. The practice variation and flaunting of evidence every one of us is guilty of as physicians. The elderly couple with the husband with pneumonia who has to be admitted to the ICU with the wife pleading with us that the hospital copay will ruin them this month. The healthy forty year old female executive demanding a bone density test because she ‘paid for her insurance.’ The 340 pound 53 year old diabetic back again with an ischemic leg status post three resuscitations this year alone and over $125,000 in fully covered medical expenses now headed towards $175, 000.

Ms. BRALY: Our profit is in the 3-4 percent range – I think this year, around 4 percent. When you look, though, across health care, there are profit margins in a number of sectors around health care that are three, four, five times ours. If you look at biotech margins or pharmaceutical companies or device manufacturers, they’re three, four, five, six times the margin in the health insurance business. And the irony of that is it is our job to get to the efficiency of health care.

INSKEEP: There might be another irony there, as well, because if it’s your job to make things efficient and the cost of doing business keeps going up year after year after year, doubling in five years, as the president says, somebody might suggest you’re not doing a very good job.

The key is that none of us is doing a very good job but it’s too easy to point fingers and deflect blame. I’m a pessimist about health care reform because I think the blocking and tackling have finally begun in earnest. I’m optimistic, however, about what we can and should still do even if we end up again with the status quo.

In that vein and with Matthew’s and the team at The Health Care Blog’s permission I am going to start a series of blogs called ‘Nuts and Bolts’ to talk about the incremental things we need to do no matter what happens in Washington. We need incremental changes throughout the health care ecosystem and while some need policy changes, others just need personal changes from each of us. The first installment will not be about ‘Death Panels,’ or policy, it will be about how critical it is for each of us to make our own decisions about our own lives and our own sense of death. It will be called ‘Nuts and Bolts – Advance Directives.’ Then we can go from there.

Health Reform Bills Would Be Great For the Business Of Health Care

Aug 29, 2009• 17

By ROBERT LASZEWSKI

Editors Note: This piece by veteran THCB contributor, Robert Laszewski, first appeared on Kaiser Health News. The piece is republished here with permission.

Have you noticed how none of the big health care business special
interests is running any negative health care reform ads? Why should
they when each is poised to gain billions of dollars from it?

As
President Barack Obama has said many times, any health care bill that
costs about $1 trillion would be paid for, roughly half and half, with
savings in the health care system and new revenues (taxes).

All
told, health care providers will likely get hit by $500 billion in
federal payment reductions over 10 years from what they would have
received otherwise. This is their "savings" contribution to help pay
for the overhaul effort. It amounts to no more than a couple of
percentage points less than they would have received anyway.

But
more importantly, the Congress is getting ready to spend $1 trillion
over the same 10 years mostly to expand Medicaid and provide subsidies
to the uninsured to help them purchase private health insurance and be
able to pay their medical bills. The health industry, by giving up $500
billion, gets millions more patients armed with public and private
health insurance cards. Not a bad deal—particularly when the other $500
billion needed to finance the bill comes from new levies on taxpayers,
not bigger industry cuts.

The details show an even prettier picture for the business of health care.

Innovation and Absence of Evidence vs. Evidence of Absence

Aug 28, 2009

By Joshua Seidman

Jon Gabel from the National Opinion Research Center has an excellent op-ed piece in today’s New York Times. The basic argument is summarized in his conclusion:

“The Congressional Budget Office’s integrity is beyond questioning. But the record shows that it has substantially overestimated the cost of health care reform three times out of three. As Congress now works on its greatest push for reform in generations, the budget office needs to revise the methods it uses to make predictions about costs.”

Far from being an arcane methodological debate, CBO’s approach has profound consequences for health care reform and for the long-term health and economic conditions of the country. As Gabel puts it:

“The budget office’s cautious methods may have unintended consequences in the current health care reform effort. By underestimating the savings that can come from improved Medicare payment procedures and other cost-control initiatives, the budget office leads Congress to think that politically unpopular cost-cutting initiatives will have, at best, only modest effects. This, in turn, forces Congress to believe it can pay for reform only by raising taxes, which then makes reform legislation more difficult to pass.”

The reason that CBO has underestimated savings from past reforms of Medicare is that it makes the assumption that — without convincing empirical evidence of an initiative’s cost impact — it basically “scores” it as delivering zero savings. No doubt that CBO is consistent and conservative, but that doesn’t necessarily produce the most accurate budgetary forecast.

Perhaps more so than any other area in the federal budget, there are an enormous number of unknowns in health care. CBO has historically built its model on the premise that absence of evidence equates with evidence of absence.

But there is a major distinction. “Evidence of absence” means that we have an empirical reason to believe that there is no effect of an intervention (in this case on cost). In that case, it makes sense to score zero savings.

In contrast, “absence of evidence” simply means that we do not have sufficient evidence that an intervention produces any effect. The problem is that, by definition, any true “innovation” (defined by Merriam-Webster as “the introduction of something new”) has no evidence. Which is to say: CBO has effectively ruled out scoring savings for true innovation.

Perhaps some would argue that’s an overstatement in that we certainly commonly use the term innovation to describe something that has been around long enough to be tested. Yes and no. There’s no doubt that new and innovation are relative terms, but there are still important reasons why that approach for CBO remains flawed.

First, evaluation takes time. To design a study, appropriately manage it, collect and analyze data, submit to peer review, and publish often takes many years.

Second, the level of evidence that CBO typically requires takes A LOT of time.

Third, innovation often comes from combining different initiatives and strategies that create a combined effect greater than the sum of their parts. Information therapy, patient decision aids, comparative effectiveness research, and other delivery system reforms may have a powerful impact when thoughtfully and appropriately combined together.

Fourth, the pace of innovation and the greatest innovative impacts can be dramatically robust. There is no way, in its current model, for CBO to capture those things that will have the most important effects on the federal health budget.

Like Jon Gabel, I don’t question the CBO’s integrity or analytical capacity, but I do believe that its methodological approach requires amendment. As I have written before, we — as health services researchers (and I admit to being one myself) — need to maintain our analytical rigor while being as creative in our research methods as the innovators are at innovating.

We should not shy away from the empirical idiosyncrasies that innovative care delivery initiatives create. Rather, we should rise to the challenge by employing a broader set of research and analytical skills to tackle these compelling research questions about new innovations. Indeed, the new care delivery strategies create opportunities for health services researchers to develop their own innovative research techniques.

I hope that health services researchers out there are up to that challenge.

If we aren’t, we will continue to create perverse public policy incentives.

Joshua Seidman is the president of of the Center for Information Therapy that aims to provide the timely prescription and availability of evidence-based health information to meet individuals’ specific needs and support sound decision making. He frequently blogs for THCB and the Center for Information Therapy Blog, where this post first appeared.

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Health Care Reform’s Deeper Problems

Aug 27, 2009• 59

By BRIAN KLEPPER and DAVID C. KIBBE

Congress’ health care reform debate has highlighted how American governance is broken and the difficulty of addressing our national problems.

Take, for example, whether health care is in crisis at all. Conservative commentators argue that America’s health system is fine, that our excellent care simply costs more than other countries’ poorer quality, and that most uninsureds can afford coverage. They ask why we should revamp a great system for the two or three percent of Americans who get less.

This misrepresents reality, though. Care and outcomes are often superior in other developed nations. In America, the ranks of the uninsured and under-insured have skyrocketed, from insurance costs that have grown four times general inflation for a decade. Health coverage is employers’ most unpredictable major cost, a threat to their businesses’ competitiveness, and they have increasingly offloaded costs onto employees. So while the marginalized uninsured are an important problem, declining coverage for the mainstream is the greater worry. Most know that, even with insurance, any major health problem can spell financial ruin.

As businesses and individuals have been priced out of health coverage over the last four years, commercial health plan enrollment has plummeted by as much as 20 percent, or about 36 million people. The Kaiser Family Foundation reports that 40 percent who lose group health coverage probably become uninsured.

Fewer people buying coverage means less money to pay for health care products and services, so the industry is experiencing an unprecedented financial decline. With reforms looming, it has fiercely advocated for universal coverage, which would provide stable funding for a larger patient population. Meanwhile, the industry has opposed changing business mechanisms that encourage waste, even though experts agree that one-third or more of all health care cost is unnecessary or inappropriate. But this raises an important question. Why not spend less by recovering wasted dollars, and then improve access?

The industry has pressed its goals through lobbying, which lets special interests exchange campaign contributions for policy influence. The non-partisan Center for Responsive Politics reports that, between January and June, the industry gave Congress more than $260 million. One lobbyist commented, “A person can reach no other conclusion than this is a quid pro quo [this for that] activity.”

The funds have gone mostly to Democrats, the party in power now, and are producing their contributors’ desired results. The current proposals expand coverage, but do little to reduce cost, failing to heed any of health care’s management lessons from the last 25 years. For example, they won’t re-empower primary care, which other nations have found will maintain a healthy populace for half the cost of our specialist-dominated approach. They fail to make care quality and cost transparent, which would let health care finally work as a market, and help identify the best health care vendors. They continue to favor fee-for-service reimbursement, which rewards delivering more products and services rather than rewarding results. And they all but ignore our capricious medical malpractice system, which most doctors say encourages defensive practice.

These problems and their solutions are structural, and are well understood within the industry. If reform does not pursue these structural approaches, health care will continue to drag down the larger economy. Our current problems will remain and intensify, at enormous cost.

Out of this experience, the American people should become aware of a couple of harsh truths.

First, so long as Congress willingly exchanges money for influence, American policy will favor special interests rather than the public interest. We’ll be unable to meaningfully address our national problems: energy, the environment, education, and so on.

Second, so long as partisans distort the truth to discredit their opponents, rather than focusing on our very real problems, America’s future will continue to be compromised.

Which is to say that we have deeper problems than an inability to fix health care.

Brian Klepper, PhD is a health care analyst based in Atlantic Beach. David C. Kibbe MD MBA is a physician and Senior Advisor to the American Academy of Family Physicians.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians. Brian Klepper PhD is a health care analyst.

More by these authors:

There Will Not Be Health Care Reform in 2009…

Aug 26, 2009• 27

By ROBERT LASZEWSKI

…without Republican leadership.

I will suggest that there is an opportunity for the Republicans to
score a huge political and policy win. It can be done in a bipartisan
way and it can be done in a way that does not sell out the core
principles that either Republicans or Democrats believe in.It would require a new effort—a clean sheet—this time initiated by the Republicans.The
Republicans have won August. No doubt about it. But they have “won,”
not because they actually did anything to deserve the win—they pretty
much sat back and let political gravity do all of the work.Now what? Do Republicans really think they can sit back and do nothing for three or four more months and come out “winners?”At this rate, this health care debate is headed for a stalemate that will not do the country, nor either party, any good.

Death Panels, Palliative Care, and the Dangers of Modern McCarthyism

Aug 24, 2009• 43

By BOB WACHTER, MD

It’s time to fight back. The “death panel” nonsense is not a harmless and amusing political canard – it is modern McCarthyism: the shameless, heinous use of lies and distortions to scare and confuse people. The tide will only turn if all of us begin speaking up for the truth.

Read NY Times piece on palliative care, and you get a sense of the power and beauty of the modern movement to provide patients and families with information and support at the end of life. The piece chronicles the decline and ultimate death of Deborah Migliore, a former topless dancer from the Bronx, from metastatic carcinoid, and the efforts of palliative care specialist Sean O’Mahony to support the patient and her husband through her painful final weeks. The article describes palliative care providers this way:

They are tour guides on the road to death, the equivalent of the ferryman in the Greek myth who accompanied people across the river Styx to the underworld. They argue that a frank acknowledgement of the inevitability of death allows patients to concentrate on improving the quality of their lives, rather than lengthening them, to put their affairs in order and to say goodbye before it is too late.

This has been precisely my experience working with our extraordinary palliative care team at UCSF. So I was pleased to see some support for palliative care embedded into the early versions of health reform legislation.

Then came Sarah Palin and the other hypocritical asses who have managed to take a serious, even profound, issue and turn it into a mockery. Read Joe Klein’s article in this week’s Time magazine to get your blood boiling. Klein begins with a poignant discussion of the end-of-life issues he’s grapping with for his elderly parents, but then – after the obligatory “there are still a few reasonable Republicans out there… somewhere” riff – gets to the point:

… But they have been overwhelmed by nihilists and hypocrites more interested in destroying the opposition and gaining power than in the public weal. The philosophically supple party that existed as recently as George H.W. Bush’s presidency has been obliterated. The party’s putative intellectuals — people like the Weekly Standard’s William Kristol — are prosaic tacticians who make precious few substantive arguments but oppose health-care reform mostly because passage would help Barack Obama’s political prospects. In 1993, when the Clintons tried health-care reform, the Republican John Chafee offered a creative (in fact, superior) alternative — which Kristol quashed with his famous “Don’t Help Clinton” fax to the troops. There is no Republican health-care alternative in 2009. The same people who rail against a government takeover of health care tried to enforce a government takeover of Terri Schiavo’s end-of-life decisions. And when Palin floated the “death panel” canard, the number of prominent Republicans who rose up to call her out could be counted on one hand.Continue reading…

Neither Quick Nor Easy

Aug 22, 2009• 10

By THOMAS L. GREANEY

The idea of establishing regional cooperatives, advanced as an alternative to President Obama’s public plan option, has attracted attention as a means of assuring that health reform legislation contains some means to improve competition among health plans around the nation. But the proposal, which may have superficial appeal as a “middle ground” between a public plan option and an unchecked private market, is ill-equipped to fix the key problems a public plan would address. In addition, recent experience teaches that timely and effective entry by such plans is unlikely.

The first issue is whether a cooperative, organized by consumers or other groups, can effectively deal with the shortcomings of the existing delivery system and insurance market. Thus far, the proposal advanced by Senator Conrad is pretty sketchy, but are grounds for skepticism. A central reason for having government sponsored plans is to allow the efficiencies of Medicare’s well-established administrative structure and innovative payment experiments to carry over to the private sector. Coops provide no such advantage. A second advantage of public plans is that they would likely achieve some bargaining leverage by virtue of their probable role as insurer for people representing higher risks whom private insurers find some methods to avoid. Hospitals and physicians will be hard pressed to bypass such a significant presence in the market and the public plan can thereby exert market-wide pressure to keep provider and pharmaceutical costs down. Whether co-ops will be willing to undertake the role of covering such individuals or able to sponsor innovative delivery systems to treat them is far from certain.

In any event, it is hard to envision numerous regional coops gathering the necessary data, experience and reputation to serve as a benchmark or counterweight to dominant hospitals and provider groups across the country. Further, there is a serious question regarding the independence and mission of coops. It is a mistake to assume that nonprofit entities will necessarily work to the advantage of the public. Unfortunately, our experience with nonprofit hospitals and HMOs suggest that they can easily be persuaded to play along with other providers and may not always vigorously pursue their charitable mission. Keeping cooperatives’ eye on the ball would require close attention to the control and governance of such entities.

The second objection is based on timing and practical considerations. There is ample evidence from our experience with health insurance markets that developing effective coop-sponsored plans will not come easily or quickly. It is clear that new entrants into health insurance markets face a host of obstacles. The prevalence and magnitude of entry barriers is evidenced by the dominance and profitability of existing insurance plans. One or a handful of companies dominate most health insurance markets around the country and these firms have enjoyed consistent and robust profits. Economic theory would suggest that such profit opportunities should have invited entry by rivals eager to capture some of the profits available in those markets.

Additional proof of the obstacles to entry are found in the investigations by insurance commissioners into proposed mergers in their states. In Pennsylvania for example, the proposed merger of Highmark and Independence Blue Cross would have combined the dominant insurers in two large distinct geographic regions of the state. Evidence provided to the State indicated that numerous attempts by regional and national firms such as Aetna and Coventry to enter both markets had proved unsuccessful over the years. Expert studies suggested that a variety of factors including brand loyalty, difficulties in securing physician and hospital network contracts, regulatory and information gathering costs, and obstacles created by the contracting practices of incumbent providers, thwarted entry. Newly formed coops needing to acquire expertise and develop networks will surely face enormous difficulties penetrating markets.

Professor Greaney’s is a nationally recognized expert on health care law and the Chester A. Myers Professor of Law and the Director, Center for Health Law Studies, St. Louis University School of Law. Thomas Greaney has spent the last two decades examining the evolution of the health care industry. He is also a frequent contributor at Health Reform Watch where this post first appeared. His recent testimony to the Senate on “Competition in the Health Care Marketplace” may be found here.