Susan Blumenthal, M.D. has updated her exhaustive (and exhausting) list of the Presidential candidates’ health care proposals You’ll find the Side-by-Side Comparisons on the The Huffington Post
Above the Fold
POLITICS: The Crystal Ball – Healthcare reform in California
I’m up over at Spot-on discussing why the opinion of 32 corn farmers in Iowa may not matter quite as much for health insurance as what’s going on in my fair state. The piece is called: A Californian Crystal Ball.
As ever come back here to comment.
Pretty much anyone interested in U.S. politics is focused today on
what 32 corn farmers in the middle of the country have to say about the
20-some people currently hoping to run the world by becoming President
of the United States.And while health care concerns have figured in many of the
conversations the U.S. political press has had – or overheard – with
Iowa Caucus voters, it’s been a wild holiday season for California’s
health care system. The impact on what type of health care reform
legislation will eventually come to national attention is probably just
as great.On Christmas Eve a California appeals court unanimously decided that
the way insurers have been practicing in the state for many years is illegal.
The case involving retroactive cancellation of policies was one that
the nice well-behaved non-profit California Blue Shield had fought in
the courts while its aggressive for-profit competitor, Wellpoint’s Blue
Cross unit, had settled.Blue Shield maintained it had the right to retroactively cancel
those insurance policies for which it says that policy-holders had lied
on their applications. At first the series of stories, which started coming out last year and ended up making an appearance in Michael Moore’s Sicko,
seemed cut and dried. People who’d received expensive care were having
their insurance canceled for pre-existing conditions that they’d either
clearly disclosed on their applications, or couldn’t possibly have been
expected to remember. Meanwhile the behavior of the health plans was
shown to be particularly cynical, with one, HealthNet, actually paying out bonuses to staff doing "recissions" based on how many expensive policy holders they kicked off their rolls.Continue reading this post o ver at Spot On.com
THCB Reader Mail: Maggie Mahar On That Checklist Decision
Frequent THCB contributor Maggie Mahar did a little detective work on the Office of Human Research Protection’s (OHRP) mysterious decision to suspend a trial designed to reduce medical errors by requiring that hospitals follow standardized safety and infection control procedures, a story that Atul Gawande wrote about over the weekend in an op-ed piece for the New York Times.
The logic behind the ruling – namely that patients should have been required to provide their express written consent before participating in a clinical trial, even one involving hospital staff and not some radical new experimental drug or treatment – struck Maggie as slightly, shall we say, strained. Particularly for an administration which boldly ran for office on a campaign platform of vanquishing bureaucratic incompetence and embracing scientific innovation. Maggie writes:
I read the letters that OHRP sent to Johns Hopkins and Michigan. They are dense with bureaucratic language, but make no sense whatsoever. So then I looked into OHRP and who runs it.Continue reading…
The Politics of Publicly-Funded Health Care – Brian Klepper
Over at Health Care Policy and Marketplace Review, the always insightful Bob Laszewski walks us through the mechanics of the just-passed federal budget and its health care financing implications for SCHIP, physicians, hospitals, Medicare Advantage plans. This clear, common sense analysis is a must-read for anyone interested in how the budget process actually works.
The final bill had 12,000 earmarks,
testimony to continuing special interest domination over the public interest. Everyone facing
a cut got a reprieve, but all the same issues (and cuts) will be on the
table in the near future. Here’s one of Bob’s summary paragraphs.
Late in 2008, the docs will be facing
a 15% Medicare fee cut on January 1, 2009, SCHIP will be out of money a
few months later on March 1, 2008, the extra payments to Medicare
Advantage plans will present the same plump target, and we will know
who won the November elections.
So the cuts were held off. Nothing really changed. And once again,
our Congressional representatives on both sides of the aisle made
decisions that accrued much more to the interests of their contributors
than those they claim to represent.
THCB Reader Mail
In response to Matthew’s take on California Governor Arnold Schwarzenegger’s Massachusett’s-style plan to require that all state residents purchase insurance ("California Not Really Uber Alles" 12/26 ) contributor and friend of THCB Jeff Goldsmith writes:
"Isn’t it interesting that the projected California budget deficit
and the cost of the health reform program are both about $14 billion.
So to fix both of them would thus requires the state to find a mere $28
billion? That’s the real reason it isn’t going to happen, not provider
lobbying or employer intransigence. No state can really do something
like this by itself without wrecking its economy. It is what we have a
national government for.It isn’t really that hard conceptually to construct an affordable
benefit. Remember the large majority of the uninsured are young people.
A stripped down package which covered primary care MD services, dental
care, chronic care type drugs like insulin, and catastrophic
hospitalization coverage (w/ some type of negotiated deep discount for
the patient’s part of the hospital bill) would do the trick.The problem is stopping one’s ears for all the sob stories from the
chiropractors, podiatrists, aromatherapists, etc. who want to force you
to insure for their services. Your suggestion that the real problem is
retaining employer based coverage still dodges the question that
somehow, somewhere, a legislative body still has to define what
coverage is mandated.Why do you think employers are so resistant (a 7.5% payroll tax
might be part of the explanation)? It is because thirty years of
legislative history suggests our elected representatives, like that
easy woman in the musical Oklahoma, "cain’t say no". Mandated in vitro
fertilization, breast reconstruction after cancer surgery, etc. – all
worthy goals in a resource unlimited world, but death to an affordable
universal benefit.Oregon’s John Kitzhaber, an emergency physician by training, seems,
so far, to have been the only political leader of either party to have
figured out that making these types of hard choices is the real problem
in health reform- not "play or pay", tax deductions or hard subsidies,
employer or individual mandate, or all the other comparatively trivial
choices. Listen to all the pervarication from the Presidential
candidate poseurs on what actually gets covered. It’s enough to turn
you into a New Zealander."
EDITOR’S NOTE: Jeff Goldsmith is the president of Health Futures Inc. From 1982 to 1994, Jeff served as National Advisor for Healthcare
at Ernst & Young. From 1980 to 1990 he was a lecturer at the
Graduate School of Business at the University of Chicago. He currently
serves on the editorial board of Health Affairs. His past pieces for THCB have included "The Perpetual Healthcare Crisis" and "Employers’ Health Cost Growth Continues to Moderate: Ain’t It Awful?"
Matthew’s end of year letter
My personal end of year letter which details the causes and charities I support is up over on my almost defunct personal blog. Please take a look if you’re feeling in the mood!
Pilots Use Checklists. Doctors Don’t. Why Not? By Maggie Mahar
Frequent THCB contributor Maggie Mahar returns today with another of her no-holds barred pieces on the practice of medicine, examining the the controversey over checklists for doctors. Many physicians are opposed to the idea on general principles, arguing that checklists "dumb down" medicine and remove the "art" from their craft. Outside observers disagree, noting that there is room in medicine for an approach that has helped make airline travel safe and improved efficiency in countless industries. If you enjoy this piece, you’ll find a wonderful collection of similar pieces tackling the inner workings of the healthcare system over at HealthBeat, Maggie’s blog at the Century Foundation.
Pilots Use Checklists. Doctors Don’t. Why Not?This is a question Dr. Atul Gawande explores in the December 10 issue of The New Yorker. “The Checklist”is a shocking story, it’s an important story—and it’s also very long. I, of course, would be the last person on earth to criticize someone for “writing long”but it occurs to me that many of HealthBeat’s readers may not have the time to peruse the full nine-page story, so I decided to offer a capsule summary here. (To read the story in its entirety, click here).
Gawande is the author of one of my favorite healthcare books, Complications: A Surgeon’s Notes on an Imperfect Science, and he writes wonderfully well. This piece begins with a riveting tale of a three-year-old who falls into in icy fishpond in a small Austrian town in the Alps. "She is lost beneath the surface for 30 minutes before her parents find her on the bottom of the pond and pull her up.”By then“she has a body temperature of 68 degrees—and no pulse.”A helicopter takes her to a near-by hospital. There a surgical team puts her on a heart-lung bypass machine. She now has been lifeless for an hour and a half. Gradually, the machine begins to work. After six hours, her core temperature reaches 98.6 degrees, but she is hardly out of the woods. Her lungs are too badly damaged to function, so the surgeons use a power saw to open her chest down the middle and sew lines to and from an artificial lung system into her aorta and beating heart. “Over the next two days, all of her organs recover except her brain. When a CT scan shows global brain swelling, the team drills a hole into her skull, threads in a probe to monitor cerebral pressure, and adjusts fluids and medications to keep her stable. “
Slowly, over two weeks, she comes back to life. "Her right leg and left arm [are] partially paralyzed. Her speech [is] thick and slurry. But by age five, after extensive outpatient therapy, she has recovered her faculties completely. She [is] like any little girl again.”
Look at How Safe [Fill in the Blank] Is by Bob Wachter
But is it as simple as that really? Perhaps not. In the commentary that follows, Bob Wachter has a very different take on the airline analogy. Analogies are useful things, true, he argues. But perhaps not as useful as the cure-healthcare-by-adopting-model-posed-by- [ insert industry / EU member state here ] might have us believe. Who should you believe? That’s up to you. You’ll find more of Bob’s excellent commentary on quality and patient safety in the THCB archives and on his blog, Wachter’s World.
The rate of fatal domestic airline crashes has fallen by 65% in the past decade – from an amazingly low rate of one fatal accident in about 2 million departures in 1997, to a breathtakingly low rate of one in 4.5 million departures this year. Flying just keeps getting safer and safer.
Beginning with the 1999 Institute of Medicine report on medical errors, aviation has become the poster child for patient safety. In fact, it was an aviation analogy – the translation of the 44,000-98,000 deaths per year from medical errors into “the equivalent of a jumbo jet a day crashing” – that jumpstarted the patient safety field in the first place.
On the whole, I like the aviation analogy, because it energizes us and helps illustrate the need for certain safety-oriented practices, such as standardization, simplification, simulation, teamwork training, and effective reporting systems and regulations. It is also uniquely accessible: who would ever fly electively if a big plane went down every day in the U.S.? Yet hundreds of thousands of people check into hospitals and clinics electively daily.
But lately, I’ve sensed gathering pushback against the aviation analogy – as well as against analogies from other industries. “This has nothing to do with us,” I hear from colleagues sometimes. “Healthcare is so different.” And they’re partly right. For example, we have learned that dampening down authority gradients on a med-surg ward is orders of magnitude harder than doing so in a cockpit. Here’s why: to prevent another Tenerife disaster (the horrific 1977 runway incursion/collision of two 747s, ostensibly caused when the flight engineer – who suspected there was a large airplane blocking the way – felt uncomfortable speaking up to his boss, the pilot), aviation had to transform its culture.
BLOGS: Out Lindsaying Lohan
And in your Friday irrelevancy….
I love those “Top 10 most emailed or read” lists and I’m hoping that Typepad will one day let me get one on THCB. Until today the most ever I saw was 3 of the top 10 in the LA Times being on Lindsay Lohan when she crashed her car into a rehab facility (or something like that).
But what beats Lindsey? It’s When Animals Attack
This is a screenshot from the most read articles on the SF Chronicle’s web site. Tatiana the man-eating tiger is the top two and four of the top seven!
Bhutto’s death can only make 5th place…
California not really uber alles
Late last week Brian Klepper stirred things up around here calling California’s health care bill Business As Usual. Over at Spot-on earlier this week I was a little more simplistic. I call the California approach The Last of the Old Solutions, largely because it keeps intact the employer-based health insurance system and doesnt include an effective individual mandate because that needs a real tax increase. (My original title of "California not really uber alles”was somehow vetoed over there—but here I’m in charge!)
As I say over there
If the goal is universal coverage, the pay-or-play system in which employers have to offer coverage sounds good – as well as familiar – but it doesn’t really get us there. Hawaii passed something similar in the 1970s and several other states have tried some variant and still no one’s really got close to universal coverage.
Please go there and read the rest and come back here to comment if you’re feeling bored at the end of the year!
