THCB

Categories

Above the Fold

QUALITY: The VA, Managed Care and care management

Navigate your way over to DB’s Medical Rants to read Robert Centor on the VA doing better than managed care plans in a study of care for diabetics. Here’s the AP Version and the study abstract. Essentially back in 1998-9 the VA’s diabetics got statistically better quality care than a matched selection of patients in managed care plans. This tends to make me believe that there’s still not that much care-management going on in the general “commercial” population.

Now the “managed care” population is not a homogeneous blob. You can’t tell which plans these patients were in from the article, but some were in Hawaii and Northern California (where Kaiser is 50% & 30% of the whole market respectively) while others were in Indiana, which basically never had any managed care. So my suspicion is that the rates of care is a factor more of the delivery environment than the type of insurance coverage. But nonetheless, hats off to the VA for this care. (Right, that’s enough praise for that evil socialized medicine….)

However, some of the uglier traits of “Managed Care” (such as utilization review and physician hassling) which were dying out in the late 1990s (the time analyzed in the study) are apparently making a slight comeback, according to this recent HSC report in Health Affairs. There’s even the odd case of care denial that makes me fell that we’re back in 1996, such as Cigna recently doing a flip-flop after denying payment for an experimental procedure. I’m almost expecting $93m judgments against Healthnet with Mailk Hassan making cameo appearances in stretch limos and Time magazine.

I just get the vague sense (based only on anecdotal observation) that the DSM/care management trend is becoming slightly more important again for health plans. But it’s nowhere near as important as getting rid of the bad risks up front, as Aetna has shown its shareholders. Is there a real trend towards care management from health plans? Or is it just medical directors talking shop over at the DM Forum? Comments on a postcard please!

HEALTH PLANS/POLICY: CDHPs, HSAs, and what’s wrong with employer-provided insurance? With contribution from Atlas

The LA Times has an article about CDHPs which is called more choice, at a cost. This article baffles me. A pregnant couple is wondering what services (such as pre-natal ultrasounds) to buy and what not to buy. They need to get a clue. Within say six to nine months (and my sources tell me that it’s unlikely to take much longer!) they are going to bust out of their deductible (and probably also their out-of-pocket) payments for the year, so it doesn’t matter whether they save money on an unnecessary ultrasound or not–their total bill for care will be the same.

CDHPs only puts the onus on saving money on those people who aren’t going to spend beyond their deductible, or in other words those who don’t need much care. Of course in health care overall 80% of the money is spent on people (like the couple in the story) for whom it’s the dollars over $10,000 a year that matter, from which their catastrophic insurance completely inoculates them.

But I can say that until I’m blue in the face and no one pays any attention. It is a little different when someone else from the right side of the political spectrum notices and new-ish contributor Atlas does. He understands that there are some people who are going to cost much more than others, and he has a suggested solution–turbo charging the largely dormant state based risk-pools. It’s not my preferred solution but at least it acknowleges what’s been completely ignored in the CDHP and individual insurance market debates–some people are going to need expensive care and how we organize that care is going to impact how much it costs. Here’s Atlas:

Seekers of the truth have always been challenged by the healthcare field, as healthcare is used as a lever to power by public and private sector players alike. But it seems to me that the employer based model has some flaws that need to be addressed. In today’s world, loss of job often means loss of health insurance, which even to the libertarians among us may be too high a price to pay. In an attempt to aid a few friends in such straits, I have found that there are somewhat affordable policies available for those who don’t qualify for public assistance. But individual underwriting is a challenging barrier to access. Some sort of public pool seems to be the solution to that problem. I believe it exists in several states but a well publicized federal solution has merit.

Which leads to the next thought–the hypocrisy of public officials who write checks which they can’t cash for programs like Medicaid are the cruelest sort of joke on people who understandably don’t have a sense of humor. Those in the throes of poverty exacerbated by illness are least equipped to cope with misinformation, disinformation, and Kafkaesque demand deflators. If we’re going to have programs for the poor, they should be adequately funded and pro-actively promoted.

The overarching problem, though, is cost. My understanding of the economic rationale of consumer directed health plans is to force those happy, company insured campers to feel the pain of rising costs so as to exert market forces upon them as close as possible to the real world consumer pressure that has given us $25 bicycles at Wal-Mart. The high deductibles prevent the excesses of pure market dynamics–e.g., you can’t run up so much healthcare debt you declare bankruptcy because you have catastrophic coverage. Yet you get socked hard enough with the high deductible that you start to complain, which triggers the providers to respond by easing the sting.

If this contributes to overall cost reduction, I think it is positive for most if not all parties involved, even the uninsured. Lower premiums resulting from lower overall costs may make insurance more accessible to those in the uninsured zone–above the threshold for Medicaid coverage and yet not wealthy or wise enough to buy coverage.

The “if” which starts the last paragraph is of course the $1.7 trillion dollar question. Whether CDHPs will have anything to do with saving overall costs I find to be most doubtful. But at least Atlas has some concept that throwing people onto the individual market with no way of ensuring access to insurance for those less-than-desirable risks is not good public policy.

TECHNOLOGY: Personal Health Records (or the story of my continuing poverty…)

Harris Interactive has a new study on the use of personal health records. Around 42% keep personal health records with people tending to do it more the older they get. However, the most interesting part of the study was when they asked people how they kept those records.

Of the 42% who keep those records, (with multiple answers allowed) 86% keep paper files, 15% keep files on in a formal paper record, 13% keep it on a computer. Of those 13%, 11% keep it in their own electronic files, while only 2% purchased a specialised computer software to record their information while just 1% use a web site to keep those records.

Assuming these numbers are about accurate, this suggests to me that the health care business has got a serious problem on its hands and a real opportunity. Buried in this article about online banking fraud is this estimate:

According to Gartner, 45 percent of the 141 million U.S. adults who use the Internet pay bills online. Consumers like the convenience and banks like the operating savings.

The Pew Internet research project has some slightly older numbers

Online banking increased by 127% — more than any other activity about which we asked 2000 and 2002. In March 2000, just 15 million had tried some form of online banking, but by October 2002, 34 million had done so.

It’s a good bet that online banking is now up in the range of 50+ million Americans. And where do they keep their financial records? On the bank’s web site, of course.

So can you keep your health records on your health plan or your physician’s site? In general no — (unless you live in certain parts of Boston, Utah, or Seattle and have the right healthplan). I sort of have an online record, in that I have some information stored in RelayHealth‘s messaging service which my doctor is supposed to be (but isn’t actually) using in conjunction with Blue Shield of California. But for the vast majority of Americans, there is no easy way to get access to your health information and store it. And despite going on 8 years of the Internet revolution, essentially very few health care organizations seem to think that it’s important to provide their members or patients with that service.

Oh, and yes I’m bitter. If you don’t know why, the short version is in the last paragraph here. The longer version is buried in this rather fun article I wrote for iHealthbeat in 2002.

BLOGS: Off-topic, THCB predicts future! Craigslist….

A few weeks back I suggested that eBay or Knight-Ridder may be concerned about the way Craigslist is eating small ads. Last Friday eBay bought 25% of Craigslist. So my “prediction” was in some ways correct. Interesting deal though. Craigslist is basically an anarcho-syndaclist commune posing as a small privately-held company, and they have made only a very little attempt to cash in on their success (the only charges are for job ads in SF, and NYC). So in a sense it’s a success story of the old Internet strategy of “get the eyeballs then ramp up the prices,” without ramping up the prices much–although my sources there tell me that they get so swamped with New York apartment brokers that they might be next ones to get a bill! The deal came about because a partner and minority owner no longer working there wanted to cash out, and rather than get a new minority owner who they didn’t like, the management team basically steered the deal to the (hopefully well-behaved!) eBay. BTW Happy birthday Jim, and thanks Susan.

PHARMA: More on the ethics of reimportation and all that, with new contributor Atlas and a cameo from The Veteran

Well the radical communist moderate social democrat nature of this blog has been somewhat shattered by recent contributors, and this post continues that trend. Mark McClellan (the ex-FDA commissioner and now CMS head), Cato and more radical wingnuts libertarian think tanks like the Institute for Policy Innovation (founded by ex-House GOP leader Dick Armey and funded by corporations, the Scaife family and the rest of Hillary’s VRWC) continue to think that the problem is that drugs in the rest of the world are too cheap. IPI’s latest press-release claims that prices in Canada ought to be 82% of the US level but in fact they’re only 59%. So they think of course that Canadians should voluntarily increase their payments by some 35%. I assume the IPI also thinks that WalMart should start paying its suppliers a ton more every year, or is using your purchasing power only OK if you’re in the private sector? For that matter I don’t think WalMart lets its suppliers get away without innovating, but they certainly don’t let them raise prices to do it!

While espousing the same general view, new THCB contributor Atlas turns his rather entertaining guns on the motivations of Marcia Angell and her colleagues at the New England Journal:

Marcia is no angel when it comes to this. She and fellow traveler Arnold Relman have been biting the hand that fed them for years. The NEJM, unofficial voice of Man’s Best Medical School (Harvard) and Man’s Best Hospital (Mass. Gen.)(reference: Samuel Shem, House of God) is perhaps the only paid subscription medical journal with a circulation of 130,000 plus physicians. However it has for many years accepted pharmaceutical advertising support. Yet somehow it has managed to maintain Brahmin-like integrity and the respect of physicians worldwide. So it is for many of the physicians condemned by Angell. If not, why publish them? Shills don’t make it through peer review. If the pharma companies don’t subsidize these studies, who will? The government, of course. Talk about mega conflict of interest! What incentive will a weasly, rationing American National Health Service as Angell and Relman and fellow Brahmin Kerry advocate have to publish objective research about costly new therapies? and how will NEJM keep its sub price affordable when the only ads they get are PSA’s from their new patron, Uncle Sam?

Ah, the road to serfdom is paved with fool’s gold, and Ms. Angell and Mr. Relman are skipping along it hand and hand, off to meet the Wizard in the worker’s paradise. Wait until they meet the man behind the curtain. He will make Big Pharma look like Dicken’s old Fezziwig compared to Uncle Scrooge

.

Now Atlas points out a very big dilemma–how can journals remain objective while taking money from those they are reviewing. Really only Consumer Reports (with its no advertising, subscription only model) can claim that level of objectivity. Funnily enough the issue is one that I found in an email sent to me from The Industry Veteran late in 2003 (hitherto unpublished in THCB). Concerning the then controversy about Crestor and The Lancet, and in response to a suggestion that the Lancet was attacking A-Z’s Crestor purely on the desire to cuddle up to Pfizer The Veteran wrote:

I don’t for one minute think that the Lancet’s editors are impervious to the pressures of their publishers, and Reed-Elsevier’s business ethics are similar to Tony Soprano’s. Saying that, it remains a fact that only a fool would believe an unscrupulous company always takes the rotten course of action. If the editors are mere henchmen for a corrupt publisher, then I have to question why a company with so many business entities dependent upon the promotional spending of pharmaceutical manufacturers would go out of its way to antagonize a drug maker with an announced $1 billion promotional budget for its Crestor launch. Prestige journals such as Lancet and the New England Journal, and thought leaders in academic medicine, earn their money in the manner of whores by going to bed with every big spender they can. Reed-Elsevier can squeeze more ad pages out of Pfizer for Lipitor and Caduet (as well as Merck/Schering for Zocor-Zetia) in the event of a lavish Crestor splash rather than in the absence of one. Of course Noam Chomsky (and David Hume way before him) is correct in pointing out that the media manufacture consent. That just means we have to rely on diverse outlets and know how to read them instead of thinking reflexively and without context.

The careful TCHB reader may notice a strange confluence between Atlas’ and The Industry Veteran‘s views on medical journals. I assure you that these are two very different people but it warms the cockles of my heart to see that cynicism is very much alive on the right as well as on the left!

TECHNOLOGY: New Health Care IT booster groups popping up all over the place (and news from Manhattan on eRx)

There’s a real mood of boosterism following Stalin’s Brailer and HHS’ 10 year plan to get health IT up and running. First a group of technology companies including Microsoft, Cisco, Allscripts, NDCHealth, HP and industry alliances Surescripts, RxHUB & NCPDP all herded by consultants CapGemini have formed a booster group for ePrescribing called CafeRx.help physicians get access to EMRs and presumably put its nose under the tent for any Federal dollars that may be available to help.Manhattan Research about ePharma docs. They now estimate that:

Next, the AAFP, the EMR project of which Star Wars fans may remember I wrote about a while back, has joined with a bunch more medical societies to form the Physicians Electronic Health Record Coalition which will ostensibly

While I may sound a little cynical about all this, it’s actually good news as it indicates that something may really be happening. Of course we saw some level of this activity in the 1990s with WEDI and the IOM’s CPR report and not much came of it. But the idea of EMR’s seems to be one that’s time has finally come.

To that end, it’s worth looking at the new research out from survey wonks

According to the study, the ePharma Physician market has grown to 379,000 practicing physicians, representing 64% of all U.S. practicing physicians today. Physicians are using online technologies for a broad range of purposes: to find information about drugs and treatment options, participate in electronic detailing for pharma sales, prescribe medications, streamline information at point of care, communicate with colleagues and others, and pursue continuing medical education (CME). About 40% of survey participants were primary care practitioners; 60% were specialists. Requirements for study participation included 1) issuing over 40 prescriptions per week and 2) currently using, or very interested in using, PDA, e-detailing, eCME, and/or pharmaceutical information online.

Over a six-month period, ePharma Physicians visited a variety of sites for health and medical information. Sites were used to research 46 conditions, from acid reflux to erectile dysfunction, hypertension to weight management. Sites most often visited included WebMD,Medscape, Medline/NLM/PubMed, MDConsult, and Merck Medicus. Most ePharma Physicians—87%—report that the Internet is a critical resource for information on prescription drugs and other treatment options. This percentage is a 15% increase over the previous year’s response. Information obtained online can lead to a change in course: Over three-quarters of those surveyed said their behavior sometimes or often changed as a result of what they found online.

Over half of ePharma Physicians find certain online offerings more effective than traditional offline marketing. These offerings include websites with disease information offered by a non-pharma/biotech company, online CME, and sponsored sites with disease information provided by a pharma/biotech company.

Most ePharma Physicians (79%) responded favorably to the concept of physician-targeted customer service portals offered by pharma/biotech companies. The top five services of greatest importance to respondents include links to medical education, disease information directly on the portal, links to CME resources, patient education materials, and links to disease information. Compared to last year’s study, a 28% increase was noted in ePharma Physicians who expect online customer service from the pharma and biotech companies they regularly deal with.

While most of these nerdy eRx docs are probably just using ePocrates’ downloadable PDR for actual clinical tools, it’s a start on the eRx front. And where eRx goes I believe the EMR will surely follow.

QUALITY QUICKIE: Seniors on the wrong drugs–Medicare & doctors on the wrong incentive plan

Two amazing articles in the NY Times in recent days show that–as John Mattison from Kaiser told me in 1996–although we know what to do we don’t know how to do it. First off a study of a PBM’s database containing all prescriptions written in 1999 for 765,423 patients over 65 found that 21 percent of the patients had at least one drug on a list of drugs potentially dangerous for seniors, and that half those prescriptions were for drugs considered to have the potential for serious adverse effects. (Here’s the California Healthline link with more details).Then we come to Thursday’s NY Times article about the long-term failure of what appeared to be a successful disease management project in Washington state–again because the incentives were in the wrong place. I think that the way Medicare (and other insurers) set up their incentives is mostly to blame. But The Industry Veteran has a more familiar foe in his sights:

Now believe it or not, fixing this isn’t that hard. In the bad old days of HMOs–the early 1990s–Friendly Hills medical group and others in southern California would get all their senior patients into a brown bag lunch, tell them to bring all the pills they were on, and then pharmacists would basically go around the getting the patients off all the drugs they shouldn’t have been on at all or ones that counteracted each other. And this was prior to computerized pharmacy records! Why hasn’t this spread (other than Caremark/Medpartners buying and destroying Friendly Hills in the mid-1990s)? Well Medicare doesn’t reward that activity, but it does reward the multiple visits to doctors to get multiple scripts. And even though doctors know that this is both bad medicine and a safety risk, there’s been no national movement to do much about it.

The subdued, temperate mice in healthcare analysis (I think he means me!–Ed) consider me entirely too hostile because I refer to physicians as Mafiosi and whores, but here’s an article from Wednesday’s NY Times that should elicit temperate responses only from corpses and theocratic fascists. Written by Gina Kolata, a groupie for anything in a lab coat, the article discusses a pilot program, called a "shared care plan," that Medicare ran in Washington state among people with concomitant diabetes and CHF. The program has two components: greater access to medical records via IT and the use of non-physician, clinical care specialists.

To paraphrase the gist of the article, physicians, patients and their families have access to a patient’s computerized medical records. This allows patients to note changes in their reactions to medications. Every physician in the geographic area can access the updated medical records. Then the clinical care specialists serve as personal assistants to severely ill patients, going with them to doctors’ offices, being available by cellphone to answer questions, and teaching them to manage their diseases. The program has reduced doctor visits and medical complications. Patients with diabetes have lower glucose levels, those with congestive heart failure have remained stable instead of getting worse, and third-party payers such as Medicare save money. Therein lies the rub. Participating in the program costs each doctor in the group $500 a month over four years for the electronic medical record system while other innovations, such as group office visits and e-mailing with patients, receive poor reimbursement, if any. As a result, physicians say they will refuse to participate in the program after the pilot ends.

Hell, we don’t need John Kerry to replace George Bush, we need Harry Truman to draft these Mafiosi physicians into the Army. Then they’ll comply!

As you know as a subdued temperate mouse I’m a sucker for those nice doctors but on the other hand, doing demonstrably the wrong thing because it pays better doesn’t appear in in the version of the Hippocratic oath I remember. So this is a clear case where Congress needs to step up, and in a bi-partisan fashion institute both pay-for-performance for Medicare to get us away from the FFS treadmill and hold hearings to shame the AMA and the rest of the "Mafiosi" into doing the right thing, right away. It’s been long enough.

BLOGS: Happy 1st Birthday to THCB and Hi to Genny

One year ago today I started THCB not knowing what to expect. The first post was about What’s wrong with Medicare and it still rings true one year, and one massive political fight which resulted in the MMA, later. In fact yesterday’s article in the NY Times about the failure of a "successful" Medicare disease management experiment in Washington state confirms my very first post’s contention that financial incentives in Medicare are set up the wrong way. More on that tomorrow.All these improvements are the work of Genny Pham-Kanter, who is THCB’s first ever blogmeister. Genny is a very talented PhD candidate in Economics and Sociology at the University of Chicago, who just to make sure that she’s really overqualified also has graduate degrees from both Cambridge and Harvard. As she gets the site under control you’ll also be seeing posts from her, and she’ll be taking over some of the back and forth with contributors. So please make her feel welcome!

I’ve enjoyed writing the blog and most especially have enjoyed meeting via email (and in real life in some cases) a whole group of new collaborators and sparring partners. Thanks for reading, thanks for emailing, and thanks to everyone who contributed. I’m looking forward to another year.

And in that new year I hope THCB will continue to improve. You may have noticed a big improvement in the layout in recent days, and there’s more to come in making the site more user-friendly and easier to navigate. Included in these improvements, and coming soon (at long last) will be a topic index which will make it much easier to find particular posts, or all posts under a certain heading. If you have any suggestions please email me.

PHARMA: A riposte to my crack about pharma, software and auto R&D, by Terry Nugent

• 1

Terry Nugent, who’s a frequent contributor to the Pharma-Marketing list serv was not too impressed by my recent post about Cato and how pharma companies might have to live in a world where their margins were much smaller but they still had to do real research: He writes:

Ironically, Cato has hoisted the industry on the Republican free trade petard. However, there are a few caveats to your comparison to the high tech and auto industries. In the case of the former, copyright protection is a powerful moat to competition (e.g., Microsoft: there’s no generic Windows to separate Bill Gates from our $50 billion). In the latter instance, what’s missing is profits (as evidenced by the dismal PE ratios of auto stocks). The automobile business market is almost as unsustainable as the airlines’.

Unrestricted reimportation has some substantial downsides, including the inevitable counterfeiting that has already come to light to an extent that surprised even industry friends and allies. The pharmaceutical industry is probably the best generator of the high wage, high tech jobs its critics claim to champion, which reimportation will in effect outsource.

Profit diminution will inevitably reduce investment capital in what is a notoriously risky business. Already, pharma PE ratios are lower than their historical levels due to shortened patent windows, litigation exposure, and a clear and growing public policy hostility that amazingly lumps the cure with the cause by putting big pharma in the same docket as big tobacco, hounded by the dogs of demagoguery and the trial bar.

Prices may go down, but at what price to our progeny, much less ourselves? Our unborn children will be the ones to suffer from the absence of undiscovered drugs, aborted by the shortsighted "savings" that are the price of populist politicians’ purchase of power.

Believe it or not I’m not entirely unsympathetic to the pharmas on this issue. They live in an odd industry, where production costs are low and market entry is relatively cheap once the IP is known and exposed (unlike autos), installed bases don’t count for much (unlike operating systems) and where they do only have a few years to make the huge profits before those revenues go away (a la Claritin whose demise almost destroyed Schering Plough). But over the last decade the bigger pharmas via mergers have become more like other corporations that have the diversity to survive the disappearance of one product line or another. And their profitability is such that it can’t go up much more, and their sales and marketing expenses can certainly come down. And like it or lump it that will have to happen, lest they provoke that excessive demagoguery that Terry fears or worse that intervention from populist politicians.

And I tried to promise Terry that I wouldn’t mention the fact that the auto manufacturer’s profits would be much higher if they were paying Canadian prices for their employees’ drugs. But I failed!

HEALTH PLANS: HIAA, while not existing anymore, beats drum for CDHPs–while its successor AHIP misrepresents KFF study about individual insurance

Last year the Health Insurance Association of America (HIAA), the trade group of small health plans that created the "Harry and Louise" commercials which helped torpedo the Clinton health plan, merged with the Association of American Health Plans (AAHP). At the time AAHP supported the Clinton plan. The new happy family is called AHIP (America’s Health Insurance Plans). But even though HIAA doesn’t officially exist any more, it doesn’t seem to stop it putting out its own press releases.they have a survey to prove that they’re wanted and needed! Here are some choice excerpts from the article called Receptive Market Among Individuals-Employers For Consumer Choice Health Plans:

In this case they are backing consumer-directed health plans, and

Almost half of those surveyed said they would consider switching to a new consumer choice health plan if given a chance, despite their satisfaction with their current employer-sponsored health insurance, results of two new surveys released by the Health Insurance Association of America (HIAA) found. And more than half of the businesses asked said they either currently offer a consumer choice health plan or intend to offer one sometime in the next five years, the survey conducted by Public Opinion Strategies found.

"This study clearly shows that consumers are ready to look at new alternatives for healthcare financing," said HIAA President Dr. Donald Young. "We expect consumer choice health plans will quickly and dramatically increase in acceptance over the next five years." The survey found that 67 percent of the people who have health insurance benefits through their jobs expressed satisfaction with their current coverage, up slightly from previous years. But 44 percent of those surveyed said they were at least somewhat likely to switch to a new consumer choice health plan. Those less satisfied with their current coverage and those with high deductibles or premiums expressed a greater likelihood of switching, according to the results.

Funnily enough these findings basically contradict what HSC and Kaiser FF have reported about CDHPs–which is that employers aren’t that keen on them and that they are just cover for cost shifting to employees. If you hadn’t guessed by now Public Opinion Strategies is a Republican polling firm –there are of course Democratic equivalents like Hart Research. Public Opinion Strategies has been accused of push polling (a venal sin amongst real survey researchers) and also was heavily involved in the 2002 Saxby Chambliss campaign in Georgia, the one that played fair and nice by comparing triple amputee and Vietnam war hero Max Cleland to Osama Bin Laden.

While this type of poll is clearly for sale, it even confirms that those most interested in CDHP’s are those who already have high deductibles and generally crappy benefits. In other words,

if you’ve got good coverage at work now, you are very unlikely to want to change it

. Several polls of employees show that to be true, and anyone watching the California grocery employees or the SBC unions know how important (even irrationally important) health benefits are to employees. But of course if HIAA/AAHP members can walk into their customers with this poll to talk about and a nice new set of shiny products to sell, then their trade association has done (at least some of) its job.

Meanwhile AHIP’s headline in their press release about last week’s Kaiser FF study on the health insurance market shows that spin from the AAHP side of the organization is very much alive and well too– and that there’s no tax in Washington on lying. Their

press release

is titled (I kid you not) Individual Insurance Market Study Finds Americans Have Access to Affordable Individual Health Insurance. AHIP President and CEO Karen Ignagni is quoted as saying that "This new study provides further evidence that millions of individuals have access to affordable and flexible individual health insurance." However, if they’d bothered to have someone stroll down the street in DC and listen in to the press conference they’d have noticed that the study explicitly was only looking at what was available and what was being bought in the market, predominantly of course by the 80% of healthy people in the population, and did not have any data on what was available to everyone in the market–including of course those people who are sick and might actually need health insurance. This of course is like saying that 80% of Iraq is peaceful, so despite the war raging in Najaf the place is in good shape.

On a minor historical footnote, some years back (in 1997 I recall), while fighting a losing battle against the demonization of managed care, AAHP put out a study claiming that managed care plans had saved the economy billions of dollars in comparison to what people would have spent on health care had the rate of premium increases in the mid-1990s been the same as it was in the late 1980s–when they were going up three times the rate of inflation. That was such a crappy piece of "research" that I wrote a special article for my corporate clients explaining why, and suggesting that they never allow this kind of stuff to get out with their name attached to it. Well with this latest press release it seems AHIP is at it again. Meanwhile I’m still waiting in vain for the AHIP study showing how much their members have cost the economy in the last five years by allowing health care costs and premiums to increase by over four times the annual rate of inflation!

assetto corsa mods