The New York Times is shocked, "shocked!" to find that a senior administration official is going to retreat to a bigger salary in the private sector. Even more amazingly the official concerned is Tom Scully the head of CMS. Frankly I think the NYTimes is stretching it to put this on the front page. Scully was the Washington guy for the for-profit hospital chains before running HCFA/CMS and was in the Bush pere White House before that. He’s not exactly the first official or Congressman to jump over to the "dark side" and, let’s face it, there’s barely a door to revolve through these days–it’s more like a transparent shower curtain. Anyway did the Times really expect him to sit around at CMS and implement the mess the Congress just left him?
Above the Fold
QUALITY: Helmet doesn’t save young skier
A 13 girl died this weekend after skiing into a tree at Alpine Meadows near Lake Tahoe. I’m a very keen skier and snowboarder and, although I wasn’t close to dying, I tore 3 ligaments in my knee after snowbaording into a tree last year. So I have a deep personal interest in the subject and have been evaluating knee guards as I get back onto the slopes. What surprised me is that the girl was wearing a helmet. You’ll find that many skiers are wearing them these days, but apparently they don’t help in every case.
INDUSTRY: Who’ll make money in Medicare?
Just to quickly point out that the boost for health plans in the Medicare bill goes into effect next year rather than in 2006, so as the LA Times notes in this article called Medicare Reform May Be a Tonic for HMOs, Pacificare and the others that have been pulling out of Medicare+Choice may be diving back into it. The list of the other potential segment winners in the Bill is discussed in this wire article from Dow Jones.
QUALITY: Kaiser cheaper and better than the NHS, says NHS
A study in the BMJ said, apparently with the approval of the UK health minister John Reid, that Kaiser Permanete provided better care than the UK’s NHS at better overall value and similar cost! This follows an academic report that suggested that UK care standards should become more like American ones. No, they’re not thinking of importing our insurance industry, but this is suggesting that length of stay in the UK is too long and should be brought in line with best American practices. That’s not too far wrong in my view. LOS over here is too short, forced that way by per admission DRGs, but not grossly so. Whereas LOS in most other countries is 2-3 times as long and lowering it would mean that care could be better delivered in the community at lower cost–rather than in a SNF at higher cost as is often the case in too-early discharges here. (In Uwe Reinhardt’s argument this leads to higher than necessary average inpatient costs as the first day in a SNF actually costs more than the last day in a hospital). I know something about international comparisons (as well as something about Kaiser and the UK), and there is a nugget in here which I’ll bring out more in the future.
Meanwhile, think about this on the macro level;, the Brits are looking for ways to cut cost in their system and they’re spending less than half what we do! And consider one more thing–costs in Florida are twice what they are in Minnesota, so we could do the same thing if we wanted (and could be bothered to read Wennberg’s stuff).
Hat tip to the wonderful MedPundit for this story, although why is a good free-marketeer like Sydney trolling the news outputs of a nationalized monopoly business like The BBC? Maybe there’s something to that socialism thing after all??
PHARMA: Statins good but no better than aspirin?
Today’s NY times gets very excited about the ability of statins to lower cholesterol and therefore reduce the risk of heart disease. In particular they cite the improvement you get from getting LDL below the consensus "normal" levels. Of course as the article called Just how low can you go? points out, this is great news for the statin makers. Only around 10% of those who seem to be indicated for statins are actually taking them. On the other hand scaremongers (i.e. this blog and others) keep pointing out that there can be side-effects from statins, which include severe muscle pain and some say long-term amnesia. While it’s OK for the NY Times to act as Pfizer’s PR company on occasion (and this may actually be one of them), and to correctly point out that the incidence of side-effects is very, very low, they might have noted another study out yesterday. That study, in the British Medical Journal suggested that a new blockbuster drug you may have heard of called aspirin was found equally efficacious and far more cost-effective in preventing heart disease than statins. And not just a little more, but by a factor of 20.
The full paper admits that aspirin use does have side-effects (usually stomach bleeding), but obviously, as in the case of the Cox-2 inhibitors, the patients could be started on that regimen and switched to statins if they can’t handle the aspirin. Overall this study should give pause to the statin manufacturers. In the UK where the government already concedes that its paying too much for statins and is trying to move them OTC, this could be the start of a movement to replace them with a rather more mature and much cheaper product! In the US where cost-effectiveness is not a recognized concept, don’t expect too much attention to be paid. But as we eventually (i.e in ten years time) move into an era where the government and public starts to expect value for money from drug companies as well as miracle cures, this type of analysis will become more common and more important.
TECHNOLOGY: Medicare Bill’s impact on ePrescribing
Jane Sarasohn Kahn’s column in iHealthbeat about the impact of the Medicare bill on ePrescribing shows her being a touch cynical about the political process. But don’t worry about it affecting her analysis. Jane explains in detail why nothing will really happen in terms of Federal ePrescribing before 2009, with only passing reference to the AMA, luddites and dinosaurs. She also has some interesting takes on activities on the state level, particularly in Massachusetts. I do think that its overly optimistic to think that this kind of voluntary effort can get more than a few cities or states well on the way to ePrescribing. However, we should have some good answers within 18 months as to whether these efforts really save money. If they do, pressure will increase on other providers to adopt ePrescribing too.
INDUSTRY: Better fewer, but better!
This barely needs repeating but, just in case you weren’t sure, the New England Journal of Medicine article called Surgeon Volume and Operative Mortality in the United States confirms that the more surgery surgeons do, the better they are at it. And of course the less likely their patients are to die. Medrants has some opinions and comments about this, but it’s worth remembering that to my knowledge the Brits and the Canadians (and probably others) keep their number of surgeons and specialists artificially low. This has the side-effect of keeping them very, very busy. Given this report that appears to be a feature rather than a bug.
PS Small non-cash prize awarded to reader who can identify the author of the original title of this post. (Be honest now, NO Googling please!)
POLICY: Malpractice reforms–coming up next, maybe.
Fresh from triumph in the Senate if not in Baghdad, Bush went out next for medical malpractice reform. This goes along with the Republican ideology of sticking it to those Democrat-lovin’ trial lawyers improving the climate for business. However, the businesses who tend to get their issues on the front burner with these Republicans are a little more influential to the President’s core base (anyone for energy?) than the AMA. And the physicians just got a Medicare raise out of the recent bill. While the actual words malpractice suit stick in the throat of any self-respecting doc like an unswallowed fishbone, there are two cautionary thoughts they might have:
One, malpractice isn’t that big a deal. It’s been a while since I looked at this but by my recollection malpractice costs in all its forms add a trivial percentage to overall health care costs. And a study about a decade ago showed that there was more malpractice than malpractice suits (even though half the suits were about care that wasn’t malpractice). With the IOM reporting on quality in health care not being as amazing as the AMA would have you believe, this is not a shut and dried case in the doctors’ favor.
Two, getting this type of reform passed is very hard. It just died in Pennsylvania despite the governor’s promise, and the level of political capital required for national reform is unlikely to be expended by the Administration before their 2005 inauguration (which in turn depends on their winning the peace, or lack of it, in Iraq). But that’s not too bad for the Republicans. As Jeanne Scott knows, a lawyer joke always covers an embarrassing pause on the hustings. Of course, you may have noted that one of those potential Presidents on the other side may perhaps also have an interest here!
POLICY: Medicare morning-after round-up, with update
So a plethera of information about the Medicare bill emerges after the long weekend. The weekend instant pundit talk shows that I saw claimed it was a triumph for the President, with the odd real conservative crying into his egg-nog. Bush though decided that going on a lay-over at Baghdad would be more helpful to his re-election, and I think the Prez got the issue right (if not the policy–but this is a health care blog, Matthew!) Meanwhile, Milt Freudenheim in the NY Times reminded everyone that the competition aspect of the law is mostly irrelevant and elsewhere they found a ton of seniors in Florida who think they got stiffed. Over at Democrat blog DailyKos the previous ignorance of and about the bill has been replaced by a bitter screed showing that the rural care aspect of the bill takes money from big-city hospitals (serving Democrats) to rural ones (serving Republicans). While you should take a pinch of salt with that analysis, you should also consider what happens if the AAMC gets riled. Those big-city academic names have a lot of clout in American health care.
Elsewhere Forrester research (log-in as a guest allowed) believes that the bill will have immediate consequence in three other areas
- More drug discounting via new discount cards. Why? Medicare PBMs wanting to get going in 2006 will give deep discounts now to learn seniors’ online behavior, demographics, and drug history. Allow me some doubt on this one, as the PBMs have shown only moderate interest in cash pay cards so far and seniors have little interest in letting them know about those issues! And even if they knew, where in the bill does it say "restrictive formulary" or "co-marketing arrangement".
- Redefine the market for hospital services as Medicare requires more quality data. Forrester says this will change hospital behavior and help healthcare IT firms. Maybe. But quality measures have been around and been meaningless before and its the IOM rather than politically maleable CMS that tends to drive this, albeit slowly
- Not slow the development of specialty hospitals despite the 18 month moratorium. Agreed.
- See a boom in health savings account (HSAs) and CDH. I’m still very unconvinced that employers are biting at this. And remember that MSAs (same as HSAs) cannot logically contain enough health care spending to be effective in restraining health care costs, whatever optimistic conservative theorists believe. It’s called "insurance" for a reason even if you are a self-insured employer.
Still, while I often find Forrester over-optimistic on the pace of change, they are doing the right thing, which is looking for wrinkles in the Bill that will start changing behavior of market players. So keep looking into the folds of the bill’s flesh both politically and business-wise.
UPDATE: Harvard Professor Bob Blendon (health care’s leading political analyst) gives his take on NPR. Overall, young people like what they’ve heard; seniors hate it, but it won’t matter politically until 2005.
POLICY: Medicare round-up around the blogsphere
My take on the Bill remains the same. The details will see it losing support among seniors, but probably not enough to matter politically. Paul Ginsburg sees it differently and thinks that there might be another 1989 style repeal on the way. Some first comments on senior support that I’ve heard in the media seem to match this article which has feelings among seniors very mixed. Don’t forget that the most politically influential seniors already have drug coverage–they’ll only get really mad if they see their employers dropping coverage and forcing them into the Medicare plan (which is after all voluntary). That’s why there’s so much money in the plan to bribe what Don Johnson is calling "Old America" (employers who offer pensions) into keeping their pharmaceutical benefits alive for now. The rest of the NYT article that quotes Ginsburg suggests that employers will tread gently in moving retirees over to the Medicare drug program, and of course they can’t before January 2006. Some of you following at home might notice that there’s an election some 13 months before that. Curious, eh, that the program doesn’t start immediately after the election or even just before it? The original Medicare program went into operation in less than 9 months! (You’ll notice that I’m in flippant holiday mode today!)
Frankly I don’t think anyone else in America cares too much about this bill. Hence this huge change in the second biggest government social program has relatively little impact on the news, and even less around the non-health care blogsphere. (One article in the last three days on Andrewsullivan.com and that one shorter than his post on England’s win in the Rugby World Cup . Not one that I can find on the DailyKos. These are, I believe, the two most visited "right" and "left" blogs in the US).
Talking of Don, he has an interesting piece at The Business Word about how the bill is a response to demands from the "market". His assessment is bang on, although he shares Karl Marx’s rather than Adam Smith’s definition of a "market" (Betcha no one’s called you a commie before, eh Don?!). Don also links to non-HC blogger Daniel M Drazner (who claims to be a libertarian Republican–and you thought there were none left!), who has a post with multo-comments from his mainly right wing crowd on the issue.
Elsewhere DB’s Medrants has both a cut down but useful explanation of the details and his own comments which are largely centrist in the "we were never going to get the perfect bill, but this is a workable start" vein. He promises to add more over the weekend (and all you’ll be doing is eating left-over turkey sandwiches!).
Russ at the Bloviator doesn’t hide his true feelings. He believes that this Bill is a) responsible for the death of Medicare as we know it and b) that this is a very bad thing. I would slightly agree with him on the death issue other than it is only at the very start of a long slope towards the TDOMAWKI (pron. Tee-Dom-Or-Key), and that the Medicare program will inevitably get some huge dose of reform anyway some time between now and 20010-2 as the baby-boomers move towards it.
Otherwise that seems to be about it for the Medicare postings. I’ll inevitably get stuck into some of the nuances of the business and political implications next week.
Have a great Thanksgiving holiday.
