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POLICY/POLITICS: Iraq, planning and the VA

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In a op-ed in the LA Times, called The battle of Iraq’s wounded Linda Bilmes points out that the number of wounded servicemen and women from the Iraq war/occupation is incredibly high relative to the 3,000 deaths. Something like 50,000. And once the current generation is discharged from the army, the VA —which is already stretched— is going to be overwhelmed.

I’ve just read Imperial Life in the Emerald City which is a mind-blowing account of exactly how screwed up the initial occupation of Iraq was. Not only was there no plan of any form before the invasion for what the occupation ought to be like, but the only people who were thinking rationally in advance about what it should have been like (in State and other departments) were forcibly prevented from getting involved. I thoroughly recommend the book (by WaPo reporter Rajiv Chandrasekaran).

But, as if you needed to know after their “preparations” for occupied Iraq and Katrina, it’s for sure that this Administration has done no planning for the wave of disabled veterans that’s about to hit the VA. Now that they finally control the purse strings, let’s hope the Democrats can do better.

POLICY/PHYSICIANS: A National Health Service for those without medical insurance in the United States by Walter Bradley

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Walter Bradley is the Chairman of the Department of Neurology at the school of Medicine at the University of Miami. He has written a long piece (available here) on how he thinks we should solve the uninsurance problem. Here’s the short version:

Introduction

We all know that the United States health care system is in trouble. The US spends over $2 trillion a year on health care, almost 17% of the GDP. By comparison, Switzerland, Germany and Canada spend about 10% of their GDP on health care, while United Kingdom spends less than 8%. Despite this, the 2005 Commonwealth Fund International Health Policy Survey of sicker adults from six countries, Australia, Canada, Germany, New Zealand, the United Kingdom and the US reported that "(t)he United States often stands out with high medical errors and inefficient care and has the worst performance for access/cost barriers and financial burdens." Moreover, the US lags well behind many other countries in indices of quality of care. In 2005 the US ranked 42nd among the world’s nations in infant mortality, with 6.50 infant deaths per 1,000 live births, behind such nations as Singapore (2.29), Sweden (2.77), France (4.26), Canada (4.75) and United Kingdom (5.16), and was 29th among developed countries in maternal mortality. In 2004, 46 million people (15.7% of the US population, about one-fifth of them children) were without any form of health insurance. Many of these have been without health care for years, though others are between jobs that provide health care coverage. In addition another 50 million people in the US have inadequate health care coverage and would be bankrupted by a serious illness.

Most people without health insurance do not have primary health care and only obtain medical care when they suffer an illness that is sufficiently severe as to take them to the Emergency Department of a public hospital. The stroke or heart attack costs the public hospital and the local taxpayers much more than would the control of blood pressure by a primary care doctor.

Health insurance premiums are skyrocketing. In 2004 the annual premium of an employment-based group plan for a family of four averaged $9,950 and workers are contributing an ever-increasing amount to these premiums. The percentage of people with employment-based health insurance in 2004 was 61 percent and is likely to fall further in the coming years as employers strive to reduce health insurance overheads.

The current system of health care for the medically indigent is fragmented, expensive and inefficient. The exact cost of health care for the uninsured in the US is difficult to assess because it is fragmented between Medicaid, the public hospitals, physicians and the insured public. In fact, the US may well be spending more per capita on health care for those without health insurance through these various sources than it does for those with insurance.

I propose a comprehensive cost-effective system of medical care for those without health insurance, the National Health Service for the Uninsured (NHSU). The creation of the NHSU would not immediately address all the ills of the US health care system, but it would provide health care for those without medical insurance, improve the overall health of US citizens, and introduce cost-saving systems that might eventually help the overall US health care system.

An integrated system of health care for the medically indigent in the United States, the National Health Service for the Uninsured.

This proposal for the provision of improved health care to those without medical insurance envisions no change in the current system of fee-for-service medical care, which would continue to provide for the 80% of the population with private health insurance or Medicare. As now, these patients would continue seeing their own doctors and the health insurance programs would reimburse the doctors, hospitals, laboratories, etc. for the medical services they provide.

The National Health Service for the Uninsured (NHSU) would replace the current fragmented "non-system" for the 16% of the US population that is currently without health insurance. The NHSU would be a comprehensive, cost-effective federal program. It would be an integrated health care system for the uninsured based on a new primary care physician network, and the staff and facilities of public hospitals that contracted to join the program. The NHSU would provide medical services from the family practitioner to the specialist, from ambulatory care and home health services to the hospital and nursing home services. It would provide laboratory services, medications and durable medical equipment, and the services of allied health professionals for all covered patients. When fully operational, the NHSU might approach revenue-neutrality for the US as a whole if it were funded centrally by redirection of monies currently going to provide inefficient and costly indigent care through federal, state and local funding. It has been suggested that the incremental annual cost to the federal government of providing health care for the medically uninsured to the level of that provided by insurance-based and government-based coverage would be $34-69 billion annually. However, the cost to Society of shorter lives and poorer productivity of 50 million people without health insurance has been estimated to be $65-130 billion per annum.

Continue reading…

POLICY/POLITICS: Health care reform all the rage

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Arnie is yakking about health care. Over at Spot-on where I’ll be penning a weekly column this year (honest!) I explain why it’s mostly much ado about nuttin’.

Well you can’t trust these people, can you? No sooner than I’d spent all last year explaining why the time wasn’t quite right for health care reform by 2008
,
then just because they eke out a small electoral win, the Democrats—and
every non-loony conservative Republican—comes out with their own health
care reform plans.The new Congress hasn’t even found out where to molest the pages and already Senator Ron Wyden has introduced a comprehensive plan to eliminate employer-based health insurance,
and transform it to a highly regulated individual market.  Not to be
beaten to the punch, AHIP, the insurance industry lobbying group, has
announced a universal insurance plan
that doesn’t get us close to universal insurance, but miraculously
involves lots of government subsidies for insurance companies. Even
more bizarrely, Kaiser Permanente, which signed on to the AHIP plan
despite the distaste with which they must view some of the other
members of the AHIP board, introduced their own separate plan for California. Continue …

PODCAST/TECH: Interview with David Blauer at Click4Care

Here’s the full transcript of the David Blauer podcast interview from December.

Matthew Holt: Well hello again. It’s Matthew Holt at THCB and it’s time for another podcast. This one is also about technology, somewhat different than some of the technology we’ve been talking about recently. We’re now back in the world of technology to help improve health and health management, in particular connecting with health plans. Today we have David Blauer who is the CEO of Click4Care. David, how are you?

David Blauer: I’m doing well, thanks. Thanks for having us.

Matthew: Great. Let’s start off with the basics. Click4Care has been around for a few years now and has been known to some of us on some sort of inside baseball view of the world in terms of what’s going on within health plans. It’s pretty fair to say you guys have been building out your product line and building out your client base without making a lot of marketing publicity splash. You coming on this show is part of changing that. Can you give me a quick background as to what the basic business problem is that Click4Care is helping to solve and how you’re solving it?

David: Sure. Our application is built on the premise that preventive healthcare is more effective than reactive healthcare. When we formed the business, we took a look at the industry. Like everybody else, I think, we noticed that if you look at any P&L for a health plan, 85% of the costs for that plan are being driven by medical costs rather than administrative costs. People had spent a lot of time, at that point, trying to refine and skinny down administrative costs as far as they can refine them. But people haven’t found technologies to address the 85% of the cost structure that comprised medical costs. When we looked further, we saw that the sickest 1% of an insured population was driving 40-50% of all those medical costs. The sickest 5% of any insured population was driving nearly 90% of those medical costs. If you continued to drill down, you found that the people responsible for those small percentages were typically moribund, chronically ill people. It became clear to us that there needs to be a technology platform that enables people to identify those risky people driving all the costs and automate the workflows throughout the supply chain to support those people who are driving all those costs in a preventative way that prevents them from incurring those costs by staying healthy.

Continue reading…

BLOGS:/INDUSTRY/POLICY A little bit of mini-forecasting for 2007

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Crystal_ball
For the first major post of the year, I usually do a forecast of the big issues that I think will be happening.  Looking back at the last few forecasts, I noticed a couple of things. First, as ever in health care things take longer and longer to become a big deal.  So it seems that people have been forecasting consumer driven health plans for a long time—in fact I wrote part of a report on consumers in health care in 1997. The same thing is true with FDA reform, Medicare disease management, and state health initiatives. Be patient.

The big difference there seems to be coming up this year is that because of the Democrats’ win in the November elections, we are now going to have some real discussion about solving the problem of the uninsured, and the implications that has for the rest of the system. I will be talking more, in a piece tomorrow at Spot-on, about the various reform initiatives that are going to be in the news in the coming months. Even our local Governator is getting into the act, both as a Governor and as a  patient.

Realistically, there is nothing that Democrats can do a national scale to improve the situation of the uninsured or to reform the system.  To get anything properly done will require 60 votes in the Senate, and Presidential help.  That’s not going to come with the current occupant of the White House, who is still living in cloud cuckoo land that a few more HSA tax reforms will send all the nation’s health care problems back beyond the rainbow. Personally I think it’s too early for the Democrats to be introducing significant legislation.  I’m not even sure that the nation will be ready for health-care reform after the next Presidential election. Victor Fuchs has many times correctly predicted the failure of national health care legislation because he believes there will need to be a significant national crisis before it gets enacted. My sense is that the ongoing slow collapse of employment-based health insurance, will produce that level of crisis, but not quite yet.

So what do I think will be a big deal this year?  Some of these are obvious, but here goes anyway.

1. Discussions of reform plans And of course secret meetings amongst health care stake-holders to figure out how to subvert those discussions.

2. Investigations of Medicare managed care. This is just too big and a easy target for Pete Stark.  The bad behavior of the management of the largest Medicare managed care plan—even if the CEO has been sacrificed—will surely come up in the conversation, as will some of the equally bad if not worse behavior by the largest for-profit Blues plan. Hopefully, some of the good parts of care management that are slowly being introduced into Medicare, will not be the babies thrown out with the bath-water.

3.Employers getting smarter. With increasing numbers of articles in the Wall Street Journal, blog postings from smart consultants, and general understanding of what the health insurance and PBM industry has been up to, it’s likely that employers will not be standing for the kind of rate increases that exceed medical trend which they have been receiving for the past five years in the next year. At least I hope they’re not that dumb.  In fact it’s likely that insurers and PBMs will try to keep prices down, and even take lower profits, so as not to raise their customer’s ire.

4.Software coming of age? This is tough to compress into one bullet point, but enough medical groups are implementing electronic medical records, health plans are introducing care management software, and hospitals are starting to use IP-based telephony and other productivity tools, that we should actually start to see some of the productivity and quality improvements this technology has been promising in the next year or two. It’s also worth noting that the numbers of hospitals with PACS systems is increasing fast, and that some of the RHIOs are distributing software as a service which is making it more affordable for small physicians’ offices and hospitals.Obviously, it’s a wise move to keep your eye on a couple of sentinel events, such as the success or failure of Kaiser’s HealthConnect, and the relative acceptance of Windows Vista in health care.

5.Health 2.0 I may have a special bias here and I know some people say this is just hype, but I believe that by the end of 2007 there will be a significant number of patients and consumers using the new software tools that are currently being developed to significantly change how they interact with both their insurers and their providers. I somewhat agree with Unity Stoakes when he says that not much has happened in the last ten years in terms of advancing the tools patients are using online. I think that there is great appetite for improved search and improved tools. Steve Case at least agrees with me!
6. More sectarian strife among providers. The latest staving off of the Medicare Part B cuts papered over the cracks for a little while, but the difference between profitability among different specialties and different hospitals is becoming really politically visible. There’s no essential reason why diagnostic radiologists should earn four times the amount of primary care doctors, for example. At some point this discussion will start, so look for inklings of it this year.

7.Patient safety and the industrial process. I throw this in just because I interviewed Brent James last month. This year a new batch of studies will come out suggesting that error rates in hospitals may exceed 30%. Michael Millenson will get very upset, and at the time when hospitals have been making record profits, questions will begin to get asked about what we’re getting for our money.

8.Pharma trying to duck under the radar. Right at the end of last year, buried in the Christmas lull, the former Pfizer CEO was revealed to have been awarded $200 million, give or take, for his performance in wiping several billion off the company’s market capitalization. This kind of thing doesn’t help when the industry is trying avoid price controls on Medicare Part D. Given that the Democrats are now in power in the Congress, it is likely that Big Pharma will spend this year keeping its head down and trying to mend fences. I also suspect that we’ll have a big merger or two as that’s the only rational way for the industry to cut its vast marketing expenses.

9. Finally, in the year’s most important news, all is not well in west London as Chelsea are only in second place in the English Premier league, and the continued absence of several key players with injury—and of poor play of several expensive new players—combined with the brilliant form of Manchester United makes a third repeat championship look unlikely. My forecast is that Chelsea will make the race tight, but will end up coming second. They will also lose in the final of the European champions league, and Jose Murinho will exit at the end of the season. Of course I hope I am wrong about that forecast!

HEALTH PLANS/POLICY: Underwriting–pernicious and ridiculous

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Lisa Girion in the LA Times kicks butt and takes names, exposing the individual insurance market for the fake gong-show that it is. She found a member of the LA insurance commission rejected by all three major health insurers in the state because of asthma. Of course THCB readers got my own extremely personal perspective on this process last year when one insurer totally rejected me, while another gave me the best underwritten rate—while both were looking at the same information!  That’s even better proof that the current system is a lottery.

We need one pool.

POLICY: Health Care Problem? Check the New York Times Psyche

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Hi, if you’ve wandered in from the Typepad blog of the day site, welcome!

Today the NYT lets its rational lefty business reporter Anna Bernasek make a rational if obvious and basic case for single payer health care, even though she quotes Vic Fuchs as if he was a leading opponent. He’s not—he’s just  a realist and he supports his own version of what the real opponents at Cato and Manhattan would call single payer.

The article is called Health Care Problem? Check the American Psyche. Of course  the real psyche that needs checking is that of whoever it is who controls (if anyone) what the NY Times writes about health care policy in its business pages. Last year they let several just appalling articles by Gina Kolata and David Leonhardt be published on health care spending—not to mention the odd op-ed by loony libertarians who think that the number of Nobel prizes for medicine awarded is a proxy for a good health care system.

And like a dog licking its own sore, they just could not stop.

Hopefully, with the debate getting real on health care, today’s article is a sign that the paper of record is beginning to be slightly less dense. And may even allow some rational voices to have a rational debate…

POLICY: Peak Oil and Healthcare by Dan Bednarz, Ph.D

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Dan Bednarz from Energy & Healthcare Consultants in Pittsburgh, PA is pretty concerned that you health care types don’t seem to be concerned about Peak Oil. What you say, you’ve never heard of Peak Oil? Better read this then!

America’s healthcare predicament will be resolved in the context of the worldwide energy emergency idiomatically known as “peak oil.” In short, the era of cheap, abundant fossil fuels is entering its twilight and medicine — virtually cut-off from this awareness—is exposed to the consequences. Like any other system healthcare requires energy and resources to function; fossil fuels, especially petroleum, provide both.

Continue reading…

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