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POLICY/POLITICS: The swiftboating of single-payer?

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Here’s my FierceHealthcare editorial today

Last year the most viewed article in Health Affairs was an article suggesting that 50% of bankruptcies in America were in some part related to medical costs. The article was written by a group led by two of the intellectual leaders of the single payer movement, Harvard professors David Himmelstein and Steffi Woolhandler. This week their findings were challenged by two Northwestern-affiliated researchers, David Dranove and Michael Millenson, who reviewed their data and claimed that the number was closer to 17%. They also suggested that the not as many of people declaring bankruptcy were as solidly middle class prior to their medical catastrophe as the Harvard group had suggested. Himmelstein et al shot back saying that the Dranove and Millenson had got their math wrong, and that they were lackeys for AHIP the health insurance industry group that sponsored their study — even though it was a peer reviewed article which AHIP funded but didn’t control. Some of their supporters accused Dranove and Millenson of "swift-boating".

Why is this obtuse academic dispute so important? Whatever the facts, and facts are very malleable in our political debates, the role of the middle class in health reform is vital. There is incontrovertible evidence that lower-income Americans have disproportionately higher health costs out of pocket than poorer people in other countries. But 100 years of history shows that politically this doesn’t matter too much. If it becomes accepted that middle-class, middle income Americans are equally vulnerable to financial catastrophe due simply to bad luck with their health, then the political discussion might shift. So this is one of those occasions where, as Keynes said, the scribblings of some (not-yet) defunct economist might actually matter in terms of politics and policy.

UPDATE:  If you haven’t had a chance yet, you can listen to this week’s podcast of my converstation with Millenson on this very topic. 

POLICY/HEALTH PLANS: Shalala and the janitors (not a 60s doo-wop band)

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Over at Health Care Renewal, Tony Poses has done some excellent digging into the tale of how the University of Miami, best known for the close to criminal behavior of its football players over the years, is (by proxy of a middleman) stiffing the janitors at its hospital from getting health insurance. Meanwhile, university President and former Clinton HHS secretary — not that she did much while holding that hot seat other than make the camera pan way down when she walked in the room for the State of the Union — Donna Shalala was profiled in the New York Times for her luxury lifestyle. It’s all in the story: A Tale of Three Ironies: University of Miami’s Janitors Still Have No Health Insurance. And Roy digs up the fact that she gets a decent chunk of change for doing basically nothing by being on UnitedHealth Group’s board. ($750 for listening to a summary of a phone call? Nice work if you can get it).

Of course, compared to the average take home pay of UnitedHealth board members, that’s chicken feed. But the average is somewhat distorted by the CEO.

POLICY: Read these comments

I’m too lazy, stupid, busy to post anything here today, (although I’ll have something up at Spot-on later) but the commenters on the piece about CDHP’s that Brian Klepper wrote a few days back are kicking up a storm, and it’s interesting stuff. So please go read them instead.

TECH: High tech in health care IT? Not exactly. by Roy Johnson

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Roy Johnson is a Director of IS Applications at Children’s Hospital of Wisconsin in Milwaukee. He got a little hot under the collar after the piece I wrote on Monday about HISTalk’s post on how out of date technology was in health care IT. Here’s his take

Actually it’s worse than you think. Epic uses a Mumps back-end (the same technology IDX uses for the back-end) with a nice bright, shiny front-end and a spin-off of data to a SQL database for customer data queries (IDX is doing the same thing).  So explain to me why GE acquired that three legged, one eyed, octogenarian dog called IDX and hailed it as a great advancement???  Despite Cerner using current technology, they have interoperability and context management issues between their own modules because they were all developed separately and they seem unable to resolve them (and they have a terrible record for support).  So we’re down to Eclipsys.  Given the run up in stock price lately they are the “real deal”, at least as far as Wall Street is concerned.  But as soon as the next great software advance appears, I predict that they also will sink into the abyss of old technology because the cost of rewriting systems is too great for these companies (not just cost, time and migration issues, but also the inevitable “bugs” that they introduce and must expend efforts re-solving).Perhaps I am a bit cynical.

But we should also look in the mirror and realize that we in healthcare are also part of the cause for the lack of advancement.  After all, it isn’t as if there isn’t innovation in the world of IS. But healthcare in general is reluctant (to put it mildly) to try and to actively support anything really new and innovative in automation.  It costs too much and/or it takes too much time and/or they want someone else to lead the way.  There is no shortage of reasons why not to do something new.  For example I can’t get our finance people to seriously consider a different automated receivables system from the one they have been using for 18 years, because it works and they don’t want to risk having a new system cause a spike up in days receivable (though they would dearly love to have point and click features).

I am of the opinion that it will take a focused national effort to move healthcare out of the computing dark ages by mandate and financial support.  Without this commitment (and the current political speak commitment is meaningless) we will not find a way to achieve the envisioned national health initiative nor find a way to effectively manage costs in healthcare.

POLICY: Medical bankruptcy podcast

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This is a podcast that I’ve done with Michael Millenson who deigns to attack David Himmelstein’s hallowed article on medical bankruptcy.  We had a good time in this interview, even though I think Michael’s picked the wrong target, and he’s ever the purist.  The last couple of minutes had to be excised so that either of us might ever work in this town again….

Here it is: Michael Millenson interview

UPDATE. And here’s the Dranove Millenson article, and the reply from Himmelstein, and the retort to that reply.  And the name calling from Don McCanne.  They should have known that that Ignagni woman would be trouble!

POLICY/HEALTH PLANS: The sensible way out for the non-profit plans

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Ken Melani, who was the medical director at Blue Cross of Pennsylvania when I presented to them back last century but is now the CEO of HighMark (since BC and BA merged), points out the rational logic for private (non-profit) health plans. And that of course is to try to stay alive as a regional power that will be used by the government as a utility after the eventual inevitable government take-over:

Government expenditures for health care have taken a bigger piece of total spending every year since the creation of Medicare and Medicaid in 1965. While Republicans in Congress viewed the new Medicare prescription drug program as a way to expand the role of private companies in the massive health insurance program, Dr. Melani said the end result is a further expansion of government spending. "History has been made," he said. "If you look year after year, decade after decade, the government has been growing in its role as the financier of medical services, both through Medicare and Medicaid. We’re not growing from the private sector standpoint; we’re shrinking as a proportionate share." The key for Highmark, the region’s dominant health insurer, is to maintain and enhance its position as a regional player so that it can work as a key government contractor, Dr. Melani said.

Of course, a government-regulated utility — which Melani sees as being Highmarks’ future — will have to be managed in a slightly more sensible way than the Republicans rolled over Part D.

If the government expansion continues, the ongoing experiment with the new Medicare Part D prescription drug program provides lessons in how it should — and shouldn’t — develop, Dr. Melani said. One is that consumers like choice, but too much choice is confusing. Consumers in Pittsburgh, for example, can buy Part D benefits in more than 60 shapes and sizes, but they can’t make apples-to-apples comparisons between plans, Dr. Melani said. Another lesson is that the transition of beneficiaries from one government program to another can be difficult. For example, many low-income patients whose pharmacy benefits shifted from state Medicaid programs to Medicare on Jan. 1 were unable to access benefits at the pharmacy because of glitches.

But then again, even if the government can’t manage its own programs, insurance companies have no hope of controlling costs:

But the other key driver is technological advances in medical care, whether in the form of advanced imaging equipment, improved medical devices or new pharmaceutical products. Noting the emergence of cancer treatments that cost tens of thousands of dollars per month, Dr. Melani said insurers were nearly powerless to stem the tide."How can we afford that new technology?" he asked. "First of all, is it worth it? We won’t even ask that question, because we don’t do that in the United States. But how many of these $100,000-per-year treatments can we continue to support and survive as a country, as an economy? "You take the unit price of professional services, the unit price of technology, and we’re out of control — totally out of control."

TECH: Intel inside, but inside what?

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I spent Monday morning at a press conference where Louis Burns, the head of Intel’s health initiative, talked about what Intel is up to in health care, and Robert Pearl, the CEO of TPMG (the Kaiser doctor group), talked about their move to EMRs.

Kaiser is clearly making some progress—for instance they’ve now got messaging between physicians and patients running in N. California. Pearl repeats the line, which I buy, that the medical groups which have electronic clinical records and manage chronic care for their patients automatically will produce superior quality patient care. Unfortunately, there are two major problems. First, getting people to move to a Kaiser (or equivalent) from the disaggregated FFS doctors that 90% of Americans now use will require Kaiser to be cheaper than competitive plans (which it’s not any more) and to get employers to force their employees to move to those integrated systems. Something that has been really tricky for employers to do. Second, when I asked Pearl about it he said, speaking personally, that employers (and America as a whole) were going the wrong way by moving towards high-deductible health plans because it was a short-term way of cutting costs, and reduced the sensible use of preventative care.

Intel’s health group wants to move towards more preventative care (and less reliance on intensive acute care). They are pushing technology to create smart homes, and easier communications between patients, caregivers, and clinicians. They’ve spent a ton of effort researching all of this on an ethnographic layer, and in ergonomic use cases.

The problem is that not much seems to changed since Andy Grove’s 1996 Fortune article. Health care sucked then. Intel spent a fortune over a decade trying to change it. Health care sucks now.

So what’s Intel really doing? Well it’s helping on standards (that’s original, huh!). It’s doing lots of (free?) consulting with hospitals. And it has a new tool that looks like a more advanced version of Health Hero’s health buddy with video, and a new prototype for a portable tablet that’s designed for health care. And some snappy videos showing how it might work out. But 6 years with 200 people working away? Is that all Intel has come up with? I’m afraid it appears so.

But in some ways it’s worse; as I wrote in Spot-on a couple of weeks ago, on the benefits side it’s changing its health plan into the style that actually is pushing individuals away from integrated health plans like Kaiser. So to some extent, while they’re featuring Pearl and Kaiser, they’re not really corporately pushing the solution that would increase the adoption of the technologies they think will improve health care.

So what’s the real problem? The real problem is that America’s system is so screwed up, that just saying that “every other industry has changed and health care will” as I heard many times at the conference, is not realistic in the cottage industry that they also kept saying it was. And we’ve spent a decade of massive dislocation staying a cottage industry. And the change in the payment system required to move this is a long way away in time.

Meanwhile, Intel (as with Cisco) will continue to do fine so long as health care keeps buying new IT. But I remain confused as to what their health care initiative is going to actually do to improve their bottom line any time soon. I don’t really think that educating tech journalists about health care (which was what yesterday seemed to have been about) advances the agenda too much. And the industry-wide problems that they are recounting are well beyond Intel’s control.

I hope that I’m missing something here. As their hearts are clearly (both logically and emotionally) in the right place.

POLICY: Can Consumerism Save Healthcare? by Brian Klepper

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THCB welcomes back old friend Brian Klepper from the Center for Practical Health Reform. He’s been asked to help various newspapers through the maze of consumer-driven health care, and here’s his take on the matter. You’ll note he gives it an easy ride, in that he doesn’t descend into the mire of risk pooling. Here’s Brian’s take:

In January’s State of the Union Address, President Bush called for expanding Health Savings Accounts (HSAs) as one sensible approach to curb rising healthcare costs. An HSA is a tax-favored healthcare-dedicated savings account that a patient controls. Combined with out-of-pocket requirements and a High Deductible (also called “Consumer Directed”) Health Plan (HDHP), these financing devices can provide comprehensive coverage. Federal 2006 HDHP family coverage guidelines call for deductibles of at least $2,100, with maximum out-of-pocket expenses of $10,500. To his credit, the President also proposed tax changes that would give individuals the same advantages employers already enjoy when they buy health insurance.                                                              The main logic and “sell” of these plans is that HSAs and HDHPs give patients more “skin in the game,” more awareness of healthcare costs, and more control over healthcare spending. The increased involvement in healthcare decision-making encourages healthier lifestyles and smarter healthcare purchasing decisions. In turn, the changes in patients’ buying behaviors will drive down healthcare costs.The reality may be somewhat different.First, there’s little question that HSAs and HDHPs will become major forces in the health insurance market the same way that managed care did in the 1990’s. They’re less costly for employers than conventional plans, so there’s every reason to believe that the market will grow quickly. A recent Kaiser Family Foundation study found that 20 percent of employers offering health insurance already make HDHPs available. Nearly every major health plan now offers an HDHP. And the health insurance industry association, AHIP, claims that HDHP enrollment tripled in the last 10 months, to 3 million lives.The deeper question is why. Are HDHPs becoming more popular because they urge patients to be more sensitive to cost? Or are they successful because, as the scale of healthcare cost has grown out-of-reach, skinnier benefits and higher out-of-pocket costs constitute a lower cost insurance alternative?Both. Employers clearly see HDHPs as a less expensive way to continue offering health coverage. It’s also apparent that, when care costs employees more, they’ll ask more questions.But studies also show that half of employers offering HDHPs do not help fund the HSAs. This may not be a problem for high-income or some middle-income workers. But if you’re low-income – one-quarter of workers make less than $18,800 per year and one-third of families make less than $35,000 – the increased out-of-pocket requirement can be onerous, especially if there’s a serious medical problem. Hospitals and many doctors are already experiencing rapidly increasing bad debt associated with these plans, because HDHPs without funded HSAs are, for many people, simply coverage that can’t be accessed. How about information that helps consumers become better purchasers? There are good Web sites that help patients learn more about their conditions and treatments. But so far, even though inexpensive evaluation tools exist, consumers still can’t get much information on the pricing and performance of hospitals, doctors and drugs. It’s hard to be an effective shopper if you don’t know what things cost or how the vendors stack up. Will consumerism significantly impact out-of-control health care costs? In truth, patients’ diagnostic and treatment choices represent a tiny portion of larger healthcare cost. The real money is associated with chronic disease and catastrophes. In those cases, healthcare professionals, not patients, guide the purchasing decisions. That’s exactly as it should be. But for consumerism to work, healthcare professionals must then be publicly accountable for their financial and clinical results.More to the point, unless consumers have access to robust information about pricing and performance, mechanisms like HSAs and HDHPs won’t really impact cost so much as finance it, merely guiding how the money flows. Even Regina Herzlinger, a renowned conservative Harvard-based healthcare economist, challenged Mr. Bush on this. “Health savings accounts are being touted as a way to control costs, and I very much doubt that claim.”The real roots of our healthcare crisis reside in the ways suppliers and clinicians are rewarded to deliver goods and services that are inappropriate, unnecessary and wasteful. Most healthcare experts agree that half or more of healthcare cost is due to these factors. Making healthcare affordable, stable and sustainable once again will require the infusion of skills and tools – compatible information technology platforms, clinical/administrative practice standards, pricing/performance transparency, payment that’s tied to outcomes – that other industries have long taken for granted. No matter how it’s pitched, consumerism just won’t get us there if these other components aren’t available to support the process.When it’s more mature, healthcare consumerism will likely include the mechanisms that help patients become better buyers and impact cost. Until then, HSAs and HDHPs are less expensive, slimmed down, short-term solutions that can work well if you’re healthy or financially secure. But they’ll do little to address our rapidly collapsing healthcare system. And as a national solution, they’re inadequate and oversold.