Stewart Simonson, the Bush administration official currently in charge of pandemic preparedness could be another Michael Brown, say critics. Perhaps they’re just being mean.
Above the Fold
QUALITY: DM has been counting it wrong but Al Lewis sets it straight
Over the last year or so the DM listserv has been buzzing with the concept put about from Al Lewis, Ariel Linden, and Ian Duncan that to this point ROI for disease management programs has been calculated wrongly. But in an interview with Managed Care magazine Al explains how to get it right, and also predicts that this will help DM finally take off.
My cynicism has been detailed — and refuted — before in THCB, but at some point getting DM right will make sense. My fears of course revolve around problem that the the incentive for a insurer to get rid of a sick member is much greater than the incentive for them to manage that member well, and it’s a damn site easier to do the former.
PHYSICIANS/POLICY: Malpractice explained
Susan Sheridan, whom I wrote about last month, is even more famous. She and her son Cal who has kernicterus syndrome are the hook for a piece in The New Republic by Robert Berenson. (You may only be able to get to the first page…) It largely tells the truth about malpractice, but just to reiterate, my reading of the data is that:
1) The tort system only picks up about half of malpractice2) The medical system barely ever apologizes (Susan never got an apology), but when it does law suits are much less likely3) Too much of the money goes to lawyers and expert witnesses, and lawyers and Democrats don’t want to change that, but as they don’t hold power–so what.4) Doctors, whose Republican allies now do hold power, are only interested in reducing caps on damages, which may reduce their rates a bit but does nothing to help severely injured victims of malpractice and more importantly nothing much to reduce medical costs for the rest of us. (I live in California where we have the MICRA caps and my insurance premiums ain’t going down — sufficient proof to me that the Republican talking points about this are bunk).5) Defensive medicine makes the system and the doctors more money and until they stop getting paid for it, the whole "8-10% savings" concept is a myth6) Special courts, non-binding arbitration, apologies, openness, and a near-miss reporting system are all good ideas and are the eventual solution, but the AMA won’t back them, and their Republican allies won’t either. Why not? For them tort reform has nothing to do with patients, and not much to do with doctors, but much, much more to do with stopping what are mostly legitimate lawsuits against malfeasant corporations — and it’s much better if that all gets mixed up with an evil lawyer suing Marcus Welby MD in their PR campaign.
So unless there is some real concession from organized medicine, we’ll keep what we’ve got and it doesn’t work. The "good" news is that it’s only a minor issue compared to the complete morass of the rest of the health care system.
(Hat-tip to Brian Klepper for the article)
HOSPITALS: Sutter and Kaiser getting pissy, and fiddling while Rome burns
Just to follow up on the recent "SEIU hates Sutter but loves Kaiser" piece, this morning I was up at CPMC as a patient, having a doctor looking at my bum knee in the medical office building next door. (And no, I didn’t cross a picket line as the doctor I was seeing was in a medical group that’s not owned by Sutter, at least I think it’s not and it wasn’t being picketed). The pickets were out in force with a SEIU RV parked outside.
Meanwhile, on the issue of giving free care to the uninsured (or not, as the case seems to be) Sutter is now pointing out that it thinks it gives lots of charity care because it "writes off" some $40m a year in discounts that it gives Medicaid and Medicare off its charges. After you pick yourself up from rolling on the floor laughing about that one, there is the slightly more serious issue that they raise which is that everyone else does it (or actually, doesn’t do it). "Everyone else", in this case, of course means Kaiser.
This is an old and perhaps even valid meme, in that Len Schaeffer brought it up years ago when he noted that Kaiser gives very little charity care at its hospitals, which he too converted into the concept that Blue Cross was paying for the "extra" charity care delivered at non-Kaiser hospitals, because of some mystic cross-subsidy from the care that Kaiser wasn’t giving.
So what’s the solution? Well of course it’s to form a committee, provided that Blue Shield’s Foundation comes up with $75,000 to pay the committee. Yup that’ll solve the uninsurance problem overnight.
However, if I was in Sutter’s position, I might just be trying to get my head a little lower out of the firing range and not just using the "Officer, everyone else was speeding too" excuse.
THCB: Email problems
Some a-hole spammer is spoofing ATmatthewholtDOTnet as their outbound address, luckily so far without the correct first name. The result is that I’m getting hundreds of bounce-backs with "undeliverable" email (you know, the MAILER DAEMON ones), as all emails to matthewholtDOTnet by default go into my main account. Not that it’s their fault in the first place but my email and web-hosting service has been unable to figure out how to block them all and just let the correct email go through (i.e. the ones sent to my correct email address).
Worse, this morning some bright spark at my hosting company switched off my incoming email all together, including the proper address. It’s back on now, but if you sent me an email between 1 am and 9.30 am PST, please send it again.
And any advice about dealing with this would be appreciated!
TECH/BLOGS: HISTalk nails it again
Mr HISTalk and I have a mutual love affair with each others blogs, and his news sections are always gems. Today he has a story that I’ve missed about a payroll system in Ireland (no jokes from you Brits), and a great remark about RHIOs — both total classics. Go over there and read them.
POLICY: Employer health insurance and stuttering efforts to delude the public
In The New York Times Milt Freudenheim reports a little too gushingly about the attempt by a number of big companies to let the part-time employees that they don’t cover buy into their health insurance programs.
The companies are taking a small first step toward slowing the spiraling growth of the uninsured, who now number more than 45 million. They acknowledge that the program is far from an overall solution, but they are addressing a challenge that government officials have largely ignored, said Steven M. Coppock, a senior actuary at the Hewitt Associates benefits consulting firm, which is helping the association with the program.
Surprise, surprise there’s a benefits consulting firm selling yet another new idea here. I’ve started describing CDHPs as the bastard child resulting from a one night stand between benefits consultants with nothing new to sell and a libertarian think-tank that can’t do basic math. This pretty much comes into the same category.
There are some good things about this program, in that it allows the uninsured to buy into the benefits of a big group program, at the same rates that the company is paying for its "real" employees, and not having to worry about pre-existing conditions. Of course, this won’t do a whole lot to solve the uninsurance problem for two reasons. One, the vast majority of the uninsured don’t work for these big companies (or if they do they work for companies that pretend that they’re not big, like the franchised outlets of the fast food restaurants). Two, the problem of the majority of the uninsured is not just that they don’t have access to insurance, but that they can’t afford it. There are some people who are priced out of the individual market by medical underwriting who can buy a much better product in the group market, and for them this is a good option — but that’s a low number. In general you might get a better rate (in terms of premium per benefit rather than straight premium cost) from a group plan, but if you can’t afford an individual plan of any kind you probably couldn’t afford this either.
Unless I’m really missing something there are three blindingly obvious statements to be made about this effort.
1) Part of the way employers have got out of offering benefits is by asking employees to contribute for their dependents’ costs. The numbers of employees who are offered benefits (especially for dependents) but don’t take them up is high and increasing, (although that only accounts for about 1/4 of the uninsured–the rest just don’t get offered insurance by their employers). This program is really just an extension of that, and regular employees must be feeling that they are not so far away from being told that like the part-timers, they too must start paying for their care. That’s the trend that the NY Times should be writing about. While it’s not what they are writing about, plenty of others have noticed. (Note that employees remain highly opposed to losing health benefits because they understand the grimness of the alternative).
2) As the Progressive Policy Institute and many others have suggested, if we are to allow people to buy into group programs, the logical way to do it is to open the FEBHP to everyone. Of course all buying groups like this will attract poorer risks who can’t get a better deal from the cream-skimmers in the individual market — but the FEBHP might just be big enough to let them all in and deal with it, and of course it has the heavy hand of the Feds behind it to spank any health plan that starts playing games. Of course letting everyone into Medicare is a further logical extension….but let’s not get too far ahead of ourselves.
3) Given how ineffectual this is going to be, why is the NY Times covering it?
Coda: By the way I’m pretty unimpressed with the HR people at big companies. I talked to a group of VP plus level HR people last year, and I gave them a hard time about how they were allowing the health care system to run them around. A number of them said, "but we do so much more than we did five years ago". I asked them which of their other suppliers had they allowed to hit them up with 15% annual increases for the past five years running, and not one of them had a word to say.
HOSPITALS: How to play nice with workers, and how not to
If you hadn’t noticed, the next round of unionization will come in the big service industries. This is going to build over time, but health care services will be the biggest push because (with the obvious caveat about overseas surgeries) it’s hard to move health care jobs off-shore, and it’s hard to replace labor with technology in those jobs (though lots of people will be trying!). So if you’re a hospital chain how do you handle the fact that the SEIU is targeting your industry? You basically have two choices. Enter into a partnership agreement with the unions and hand over a small slice of the vast profits you are making as an organization to your workers. Or tough it out, continue to make as much as you can, and let the unions eat cake.
In Northern California we have both examples. Sutter is deciding to essentially risk its non-profit status by being not only the consistently most expensive provider chain, but having a nasty fight with the SEIU at its most profitable hospital, Cal Pacific. And of course the unions are highlighting the amount of money they’re making and helping get the Department of Justice to investigate.
Kaiser Permanente on the other hand has a big deal with its unions in which everyone gets a decent pay rise (at a time when KP is making bank, one might add) and about which the unions are deliriously happy. Here’s what the union rep said.
"This is the best (union) contract in the country," said Sal Rosselli, longtime president of SEIU’s Oakland-based United Healthcare Workers West and its predecessor, Local 250. "It’s the best contract we’ve ever reached with a hospital system." Praising Kaiser for including workers in every stage of planning, Rosselli called it "the opposite extreme" from Sutter Health, which runs California Pacific Medical Center in San Francisco, now in the third week of a bitter UHW strike. "Kaiser is serious about being the health-care provider of choice," he said, "and to do that it needs to be the health-care employer of choice."
Given that there is a huge connection between employee satisfaction and patient/member satisfaction, Kaiser might be on to something. Either way, at its current rosy spot in the revenue cycle, it’s a little odd that Sutter is drawing such a strong line in the sand. Perhaps someone wiser than me can explain why.
TECH: IDX and GE in a lovefest–We’ll see
IDX was being shopped earlier this year as its founder Rich Tarrant wants to run for a Senate seat as a Republican in Vermont where Bernie Sanders will probably enjoy pointing out how much money he’s got and how he got it. Now that its been sold apparently it thinks that GE is a perfect match. It certainly seems so for IDX’s shareholders, as it was basically going nowhere with somewhat older hopsital technology, and having trouble getting outside the business of big (usually academic) medical groups with its physician systems. Plus there was the UK fiasco. And getting a 25% premium makes for a very nice exit.
The whole thing is somewhat curious. Other than Epic is not available, Cerner was too expensive, and IDX was being shopped, why did GE buy it — and why did they pay so much? As has been pointed out at length over at the HISTalk blog, IDX has a mixed product line and a mix of customers. Even more weirdly they have a deal with Allscripts (that makes ambulatory EMRs) that is responsible for a decent chunk of Allscripts customers, and even if Glenn Tullman (Allscripts CEO) made nice noises about it, it’s hard to see why GE (which owns the Logician EMR product which its renamed to Centricity in the brochure, but still not renamed on the screen) wouldn’t start favoring its own product — unless it buys Allscripts next and merges the two ambulatory EMRs into one. Perhaps then they’ll bother with at least a comsetic veneer of pretending that its all one product line.
What’s really going on here is the confusion amongst the big FDA-regulated imaging device guys (GE, Siemens, Philips, Toshiba) about how this IT stuff is playing out. They know that their hospital clients are slowly integrating the IT and Med Tech side of their houses, and they face the fear that if they can’t supply both ends of the chain, then they may lose business on their more profitable med tech products to a rival (i.e. Siemens) that can cut the customer a deal on the other end. But there is not really a good HIT candidate to buy, so maybe a mere $1.4bn on a not-so-good one is enough for now.
My guess is that the integration of Med Tech and IT as a serious business effort is ten years away. By then the leading IT systems (e.g. Cerner and Epic) risk being out of date. At that point maybe Siemens Soarian (or its successor) or whatever GE is building with Intermountain, or whatever McKesson ends up doing, or maybe whatever Oracle builds in 2007-9, will be the hot newly rearchitected product that will dominate the hospital IT market — which by then may be much bigger than the med tech market. But that’s all speculation as to how it will shake out longer term.
For now it strikes me that GE will sit on IDX for a while, try to figure out how to sell more of some EMR (probably Logician) into its physician practice customers, and milk the revenues from its bigger hospital clients, while it talks to them and sees if it can get them interested in whatever great new products that it may develop some time down the track. It’s kind of a tweener strategy which is, as has been said, not like GE. But they’ve seen Siemens fall somewhat flat with its SMS acquisition, and they’re make a decent amount off PACS (although a whole lot less than the Healthcare Informatics Top 100 has been reporting until this year when it corrected its standings). So the IDX acquisition gives their IT guys more products to sell, a decent customer base, and won’t probably screw-up their lucrative imaging business too much.
But still paying 25% over what the market thought IDX was worth strikes me as being a little odd.
CONSUMERS: Medicare Part D … as in Detail by Mr Jib
The Sacramento Bee has a good article which exposes a little detail which may be important to people who are thinking about signing up for Medicare Part D. It turns out that people who are in managed care plans and sign up for a free standing drug plan with a different company may find their existing coverage terminated. According to the Bee:
Seniors who are members of managed care health plans and then enroll in a drug plan offered by another organization could be dropped from their health plan, according to health plan and Medicare officials. Marketing campaigns for Medicare’s new prescription drug benefit plans are set to start Saturday. Advocates for seniors are worried that the benefits will be attractive enough to get seniors to sign up without first calling their HMOs.
From the managed care plan’s perspective, signing up for a drug plan offered by another managed care plan is seen as a decision to leave…
Oh. And Medicare Part D. marketing starts Saturday.
Go read the article.
— Mr Jib
